Chemical Dependency Counseling

Fifth Edition
Chemical Dependency Counseling
A Practical Guide

Fifth Edition

Robert R. Perkinson
Keystone Treatment Center, Canton, South Dakota
FOR INFORMATION:

SAGE Publications, Inc.

2455 Teller Road

Thousand Oaks, California 91320

E-mail: order@[Link]

SAGE Publications Ltd.

1 Oliver’s Yard

55 City Road

London, EC1Y 1SP

United Kingdom

SAGE Publications India Pvt. Ltd.

B 1/I 1 Mohan Cooperative Industrial Area

Mathura Road, New Delhi 110 044

India

SAGE Publications Asia-Pacific Pte. Ltd.

3 Church Street

#10-04 Samsung Hub

Singapore 049483

Copyright © 2017 by Robert R. Perkinson.

All rights reserved. No part of this book may be reproduced or utilized in any
form or by any means, electronic or mechanical, including photocopying,
recording, or by any information storage and retrieval system, without permission
in writing from the publisher.
Printed in the United States of America

Library of Congress Cataloging-in-Publication Data

Names: Perkinson, Robert R., author.

Title: Chemical dependency counseling : a practical guide / Robert R. Perkinson, Keystone Treatment Center,
Canton, South Dakota.

Description: Fifth edition. | Thousand Oaks, California : SAGE Publications, [2017] | Includes bibliographical
references and index.

Identifiers: LCCN 2016010154 | ISBN 978-1-5063-0734-3 (pbk. : alk. paper)

Subjects: LCSH: Substance abuse—Patients—Counseling of. | Dual diagnosis—Patients—Counseling of.

Classification: LCC RC564 .P47 2017 | DDC 362.29—dc23 LC record available at

[Link]

This book is printed on acid-free paper.

Acquisitions Editor: Nathan Davidson

Editorial Assistant: Heidi Dreiling

Development Editor: Abbie Rickard

eLearning Editor: Gabrielle Piccininni

Production Editor: Bennie Clark Allen

Copy Editor: Pam Schroeder

Typesetter: C&M Digitals (P) Ltd.

Proofreader: Susan Schon

Indexer: Robie Grant

Cover Designer: Candice Harmon

Marketing Manager: Shari Countryman

Brief Contents
Preface to the Fifth Edition
Acknowledgments
1. First Contact
2. First Hours of Treatment
3. Biopsychosocial Interview
4. Treatment Plan
5. Individual Treatment
6. Group Therapy
7. Drugs of Abuse
8. Recovery Skills
9. Steps
10. Lectures
11. Special Problems
12. Adolescent Treatment
13. The Family Program
14. The Clinical Staff
15. Discharge and Continuing Care
16. The Good Counselor
Appendix 1. Cognitive Capacity Screening
Appendix 2. Short Michigan Alcoholism Screening Test
Appendix 3. DSM–5 Psychoactive Substance Use Disorder
Appendix 4. Alcohol Withdrawal Scale
Appendix 5. Narcotic Withdrawal Scale
Appendix 6. Sample Biopsychosocial Interview
Appendix 7. Chemical Use History
Appendix 8. Honesty
Appendix 9. Love, Trust, and Commitment
Appendix 10. Feelings
Appendix 11. Relationship Skills
Appendix 12. Addictive Relationships
Appendix 13. Communication Skills
Appendix 14. Self-Discipline
Appendix 15. Impulse Control
Appendix 16. Relapse Prevention
Appendix 17. Step One
Appendix 18. Step Two
Appendix 19. Step Three
Appendix 20. Step Four
Appendix 21. Step Five
Appendix 22. Adolescent Unit Level System
Appendix 23. Peer Pressure
Appendix 24. The Behavioral Contract
Appendix 25. Family Questionnaire
Appendix 26. Codependency
Appendix 27. Personal Recovery Plan
Appendix 28. Sample Discharge Summary
Appendix 29. Stress Management
Appendix 30. Hamilton Depression Rating Scale
Appendix 31. Biopsychosocial Assessment
Appendix 32. Anger Management
Appendix 33. Narcissism
Appendix 34. Honesty for Gamblers
Appendix 35. Step One for Gamblers
Appendix 36. Step Two for Gamblers
Appendix 37. Step Three for Gamblers
Appendix 38. Step Four for Gamblers
Appendix 39. Step Five for Gamblers
Appendix 40. Relapse Prevention for Gamblers
Appendix 41. Adolescent Unit Point System
Appendix 42. Results From the 2013 National Survey on Drug Use and
Health: Summary of National Findings
Appendix 43. Drug Categories for Substances of Abuse
Appendix 44. Adult Inpatient Program Schedule
Appendix 45. Adolescent Inpatient Program Schedule
Appendix 46. Adult Outpatient Program Schedule
Appendix 47. Adolescent Outpatient Program Schedule
Appendix 48. Gambling Inpatient Program Schedule
Appendix 49. Gambling Outpatient Program Schedule
Appendix 50. Day Treatment Program Schedule
Appendix 51. Pressure Relief Group Meeting and Budget Form
Appendix 52. Heroin
Appendix 53. South Oaks Gambling Screen
Appendix 54. Barriers in Thinking
Appendix 55. Psychotherapeutic Medications 2011
Appendix 56. Drug Abuse Screening Test
Appendix 57. Clinical Opiate Withdrawal Scale
Appendix 58. Adult Nurses Intake
Appendix 59. Adolescent Nurses Intake
Appendix 60. National Cancer Institute Guide to Quitting Smoking
Appendix 61. Post-Traumatic Stress Disorder (PTSD) Checklist Civilian
Version
Appendix 62. Post-Traumatic Stress Disorder (PTSD) Checklist Military
Version
Appendix 63. Alcohol Abstinence Self-Efficacy Scale
Appendix 64. Hamilton Anxiety Rating Scale
Appendix 65. Strengths, Needs, Abilities, and Preferences
Appendix 66. Daily Craving Record
Appendix 67. National Association of Alcohol and Drug Abuse Counselors
(NAADAC) Code of Ethics
Appendix 68. Gambling History
Appendix 69. Diagnostic/Integrated Summary
Appendix 70. Mental Health Screening
Appendix 71. Fagerstrom Test for Nicotine Dependence
References
Index
About the Author
Detailed Contents
Preface to the Fifth Edition
Acknowledgments
1. First Contact
Treatment Works
The Motivational Interview
How to Develop the Therapeutic Alliance
How to Do a Motivational Interview
What to Do If There Are One or More Red Flags
Natural History of Addiction
How to Diagnose an Addiction Problem
How to Intervene
How to Assess Motivation
The Stages of Motivation
Motivating Strategies
2. First Hours of Treatment
The First Hours
How to Greet Clients
Examples
Beginning the Therapeutic Alliance
The Importance of Trust
Dealing With Early Denial
Example of an Initial Contact
How to Check for Organic Brain Dysfunction
The Initial Assessment
Referral
How to Conduct a Crisis Intervention
American Society of Addiction Medicine Patient Placement Criteria
Diagnostic and Statistical Manual
Criteria for Diagnosis
Diagnosis: Substance Use Disorder
Gambling Disorder
How to Determine the Level of Care Needed
Criteria for Outpatient Treatment (Adults)
Criteria for Inpatient Treatment (Adults)
Criteria for Outpatient Treatment (Adolescents)
 Criteria for Inpatient Treatment (Adolescents)
The Client’s Reaction to Intoxication
What to Do With an Intoxicated Client
Detoxification
How Clients React in Detoxification
The AMA Threat
Example of an AMA Intervention
How to Develop and Use the AMA Team
How to Use the In-House Intervention
How to Respond to Clients Who Leave AMA
3. Biopsychosocial Interview
The Biopsychosocial Interview
How to Conduct the Interview
Summary and Impression
Diagnosis
Disposition and Treatment Plan
A Sample Biopsychosocial Interview
4. Treatment Plan
How to Build a Treatment Plan
The Diagnostic Summary
The Problem List
How to Develop a Problem List
Goals and Objectives
How to Develop Goals
Examples of Developing Goals
Examples of Goals
How to Develop Objectives
Examples
How to Develop Interventions
Examples
How to Evaluate the Effectiveness of Treatment
How to Select Goals, Objectives, and Interventions
Examples
Treatment Plan Review
Documentation
How to Write Progress Notes
Examples
Formal Treatment Plan Review
Discussion of Continuing Care
5. Individual Treatment
The Therapeutic Alliance
How to Develop a Therapeutic Alliance
How to Be Reinforcing
How to Use Empathy
Transference and Countertransference
Examples of Empathic Statements
How to Be Confrontive
Behavior Therapy
How Clients Learn
Habits
Changing a Habit
What Is Reinforcement?
What Is Punishment?
The Behavior Chain
The Importance of Reinforcement
How to Use Punishment
When a Client Breaks a Rule
Why We Concentrate on Behavior Therapy
Cognitive Therapy
How Chemically Dependent People Think
Defense Mechanisms
Applying Cognitive Therapy
Automatic Thoughts
How to Correct Inaccurate Thoughts
Interpersonal Therapy
How to Develop Healthy Relationships
Building a Relationship With a Higher Power
Developing a Relationship With Self
Building Relationships With Others
How Clients Use Feelings Inappropriately
How Clients Learn Relationship Skills
How to Change Relationships
How to Handle Grief
How to Choose the Therapeutic Modality
6. Group Therapy
Benefits of the Group Process
Preparation for the Group
The Preparation Statement
 The Agenda Group
How to Choose the Order of the Agenda
How to Give Good Feedback
How to Receive Feedback
How to Run a Group
How to Know Which Therapy to Use
The Honesty Group
Example of the Honesty Group
Uncovering the Lies
How to End Each Group
The Euphoric Recall Group
How to Uncover Euphoric Recall
How to Help the Clients See the Truth
The Reading Group
The Relapse Prevention Group
The Trigger Group
How to Uncover the Triggers
The Drug Refusal Skills
The Inaccurate Thinking Group
The Feelings and Action Group
The Lapse Group
The Spirituality Group
How to Develop Healthy Relationships
How to Develop a Healthy Relationship With a Higher Power
The Eleventh Step Group
The Meditation Group
The Childhood Group
How to Explore Early Parental Relationships
How to Begin to Heal Early Childhood Pain
Men’s Group/Women’s Group
The Community Group
The Personal Inventory Group
Skills Training Group
Assertiveness Skills Group
Skills
Problem-Solving Skills Group
Skill Set 1
Skill Set 2
7. Drugs of Abuse
 Drugs of Abuse
Central Nervous System Depressants
Central Nervous System Stimulants
The Hallucinogens
The Reinforcing Properties of Drugs
Tolerance and Dependence
Cross-Tolerance
Alcohol
Alcohol-Induced Organic Mental Disorders
Alcohol Intoxication
Alcohol Amnesic Disorder (Blackout)
Wernicke-Korsakoff Syndrome
Alcohol Withdrawal
Alcohol Withdrawal Seizures
Alcohol Withdrawal Delirium (Delirium Tremens)
Sedatives, Hypnotics, and Anxiolytics
Opioids
Cocaine and Amphetamines
Phencyclidine
Dissociative Anesthetics (Phencyclidine, Ketamine,
Dextromethorphan, and FLAKKA)
Hallucinogens
The Psychedelic State
Cannabis
Synthetic Designer Drugs
Inhalants
Nicotine
Club Drugs
MDMA
GHB
Ketamine
Rohypnol
Polysubstances
Treatment Outcome
8. Recovery Skills
The Chemical Use History
Honesty
Love, Trust, and Commitment
Feelings
 Relationship Skills
Addictive Relationships
Communication Skills
Self-Discipline
Impulse Control
Relapse Prevention
Stress Management
9. Steps
The Committee
Step One
Step Two
How to Help Clients Accept a Higher Power
Step Three
How to Help Clients Embrace Step Three
Step Four
Step Five
Step Six
Step Seven
Step Eight
Step Nine
Step Ten
Step Eleven
Step Twelve
10. Lectures
The Disease Concept
Addiction Is Not a Moral Problem
Addiction Is Not Due to a Weak Will
Addiction Has Genetic Components
Addiction Is a Social Problem
Addiction Is a Psychological Problem
Addiction Is a Physiological Problem
The Obsession
The Problems
Defense Mechanisms
Minimization
Rationalization
Denial
How to Begin to Live in the Truth
The Great Lie
 How the Great Lie Works
We Never Feel Accepted
The Promise of the Disease
Truth
A Program of Rigorous Honesty
Normal Development
The Primary Caregiver
The Struggle for Independence
The Fear of Abandonment
Learning the Rules
The Development of Insecurity
The Peer Group
Adolescence
Adulthood
Physical Addiction and Recovery
How Drugs Affect the Cell
How Drugs Affect Behavior
Tolerance
Cross-Tolerance
Withdrawal
How We Learn
Alcoholics Anonymous
A Spiritual Awakening
Two Alcoholics Talking to Each Other
The “Big Book”
The 12 Steps
Meetings
Feelings
All Feelings Are Adaptive
Assertive Skills
11. Special Problems
The Psychiatric/Psychological Assessment
How to Develop the Treatment Plan
The Depressed Client
How to Assess Depression
How to Treat Depression
Psychopharmacology
Behavior Therapy
Cognitive Therapy
 Interpersonal Therapy
Grief
Suicide
The Angry Client
How to Handle a Violent Client
How to Handle an Angry Client
Assertiveness Skills
The Importance of Forgiveness
How to Teach the Client to Recognize Anger
Disengagement
Time-Out
How to Keep Your Cool as a Counselor
The Homicidal Client
The Duty to Warn
Personality
What Is Personality?
The Antisocial Personality
A Disorder of Empathy
How to Treat the Antisocial Personality
How to Deal With a Rule Violation
Moral Development
How to Deal With the Family of an Antisocial Client
The Borderline Client
Interpersonal Relationships
Emotional Regulation
How to Treat the Borderline Client
Setting Limits
Dealing With Transference
Stress Tolerance
Dealing With the Family
The Narcissistic Client
The Anxious Client
How to Measure Anxiety
The Psychological Component of Anxiety
How to Use Relaxation Techniques
The Daily Log
Cognitive Therapy
Post-Traumatic Stress Disorder
Panic Attacks
 The Psychotic Client
Hallucinations and Delusions
How to Treat the Psychotic Client
The Family of the Psychotic Client
Acquired Immune Deficiency Syndrome
The High-Risk Client
The Client With Low Intellectual Functioning
How to Treat the Client With Low Intelligence
The Client Who Cannot Read
The Family of the Client With Low Intelligence
The Elderly Client
The Client With Early Childhood Trauma
How to Deal With Sexual Abuse
Cognitive Therapy
How to Learn Forgiveness
Love in the Treatment Center
The Importance of the Unit Rules
How to Deal With Clients in Love
The Pathological Gambler
Honesty
Gambling Step One
Gambling Step Two
Gambling Step Three
Gambling Step Four
Gambling Step Five
Gambling Step Six
Gambling Step Seven
Gambling Step Eight
Gambling Step Nine
Gambling Step Ten
Gambling Step Eleven
Gambling Step Twelve
Gambling Relapse Prevention
12. Adolescent Treatment
The Normal Adolescent
Puberty
Ages 13 to 16
Ages 16 to 19
Interesting Adolescent Facts
 The Chemically Dependent Adolescent
The Adolescent Chemical Dependency Counselor
The Point System
The Primary Elements in Adolescent Treatment
The Rules
Communication Skills
Honesty
Exercise
Fun in Sobriety
The Reinforcers
Spirituality
Group Therapy
Peer Pressure
Continuing Education
Continuing Care
The Parents Support Group
The Behavioral Contract
Phases of Adolescent Treatment
13. The Family Program
The First Family Contact
How to Handle the Early Against Medical Advice Risk
Common Family Problems
Codependency
Guilt
Loss of Control
Shame
Caretaking
Enabling
Inability to Know Feelings
Inability to Know Wants
Lack of Trust
People Pleasing
Feelings of Worthlessness
Dependency
Poor Communication Skills
How to Treat Family Members
The Family Program Schedule
How to Work With the Family in Group
The Conjoint Session
14. The Clinical Staff
The Physician/Addictionologist
The Psychologist/Psychiatrist
The Social Worker/Mental Health Counselor
The Nurse
The Clinical Director
The Clinical Supervisor
The Chemical Dependency Counselor
The Rehabilitation Technician or Aide
The Recreational Therapist
Clinical Staffing
How to Present a Client
Team Building
Commitment to Coworkers
Boundaries
Staff–Client Problems
What to Do When a Client Does Not Like a Counselor
What to Do When a Client Complains About a Rule
The Work Environment
15. Discharge and Continuing Care
Outpatient Discharge Criteria
Inpatient Discharge Criteria
How to Develop a Discharge Summary
The Discharge Summary
Saying Good-Bye
16. The Good Counselor
Good Counselors Are Caring
Good Counselors Love Their Work
Good Counselors Do Not Become Overly Involved
Good Counselors Do Not Lie
Good Counselors Are Gentle
Good Counselors Like Themselves
Good Counselors Are Supersensitive
Good Counselors Have a Sixth Sense
Good Counselors Do Not Become Overly Emotional
Good Counselors Are Active Listeners
Good Counselors Do Not Talk Too Much
Good Counselors Maintain Boundaries
Good Counselors Are Client Centered
 Good Counselors Have Effective Relationship Skills
Good Counselors Have a Sound Code of Ethics
Appendix 1. Cognitive Capacity Screening
Appendix 2. Short Michigan Alcoholism Screening Test
Appendix 3. DSM–5 Psychoactive Substance Use Disorder
Appendix 4. Alcohol Withdrawal Scale
Appendix 5. Narcotic Withdrawal Scale
Appendix 6. Sample Biopsychosocial Interview
Appendix 7. Chemical Use History
Appendix 8. Honesty
Appendix 9. Love, Trust, and Commitment
Appendix 10. Feelings
Appendix 11. Relationship Skills
Appendix 12. Addictive Relationships
Appendix 13. Communication Skills
Appendix 14. Self-Discipline
Appendix 15. Impulse Control
Appendix 16. Relapse Prevention
Appendix 17. Step One
Appendix 18. Step Two
Appendix 19. Step Three
Appendix 20. Step Four
Appendix 21. Step Five
Appendix 22. Adolescent Unit Level System
Appendix 23. Peer Pressure
Appendix 24. The Behavioral Contract
Appendix 25. Family Questionnaire
Appendix 26. Codependency
Appendix 27. Personal Recovery Plan
Appendix 28. Sample Discharge Summary
Appendix 29. Stress Management
Appendix 30. Hamilton Depression Rating Scale
Appendix 31. Biopsychosocial Assessment
Appendix 32. Anger Management
Appendix 33. Narcissism
Appendix 34. Honesty for Gamblers
Appendix 35. Step One for Gamblers
Appendix 36. Step Two for Gamblers
Appendix 37. Step Three for Gamblers
Appendix 38. Step Four for Gamblers
Appendix 39. Step Five for Gamblers
Appendix 40. Relapse Prevention for Gamblers
Appendix 41. Adolescent Unit Point System
Appendix 42. Results From the 2013 National Survey on Drug Use and
Health: Summary of National Findings
Appendix 43. Drug Categories for Substances of Abuse
Appendix 44. Adult Inpatient Program Schedule
Appendix 45. Adolescent Inpatient Program Schedule
Appendix 46. Adult Outpatient Program Schedule
Appendix 47. Adolescent Outpatient Program Schedule
Appendix 48. Gambling Inpatient Program Schedule
Appendix 49. Gambling Outpatient Program Schedule
Appendix 50. Day Treatment Program Schedule
Appendix 51. Pressure Relief Group Meeting and Budget Form
Appendix 52. Heroin
Appendix 53. South Oaks Gambling Screen
Appendix 54. Barriers in Thinking
Appendix 55. Psychotherapeutic Medications 2011
Appendix 56. Drug Abuse Screening Test
Appendix 57. Clinical Opiate Withdrawal Scale
Appendix 58. Adult Nurses Intake
Appendix 59. Adolescent Nurses Intake
Appendix 60. National Cancer Institute Guide to Quitting Smoking
Appendix 61. Post-Traumatic Stress Disorder (PTSD) Checklist Civilian
Version
Appendix 62. Post-Traumatic Stress Disorder (PTSD) Checklist Military
Version
Appendix 63. Alcohol Abstinence Self-Efficacy Scale
Appendix 64. Hamilton Anxiety Rating Scale
Appendix 65. Strengths, Needs, Abilities, and Preferences
Appendix 66. Daily Craving Record
Appendix 67. National Association of Alcohol and Drug Abuse Counselors
(NAADAC) Code of Ethics
Appendix 68. Gambling History
Appendix 69. Diagnostic/Integrated Summary
Appendix 70. Mental Health Screening
Appendix 71. Fagerstrom Test for Nicotine Dependence
References
Index
About the Author
Preface to the Fifth Edition

Things are changing in the addiction world, and the new health care parity and
Affordable Care Act should make things better. As I travel around the country
giving workshops on addictive disorders, I often have the privilege of listening to
the leaders in the field speak, and I find they are all saying the same thing.
Addiction is a brain disease that needs long-term management. For decades, the
field of addiction was living in the belief that treatment takes a few weeks. This is
not true for any chronic disease, including hypertension, diabetes, asthma, or
addiction. Addiction needs management for a lifetime. The gold standard in
addiction treatment is found in programs designed for physicians and airline
pilots. This starts off with 90 days in inpatient treatment, followed by a very
aggressive relapse prevention plan that requires telephone contact with one
random urine analysis (UA) a week for the first 6 months, then the successful
client can extend random UAs to every month and then finally every year. Random
drug screens means the client never knows when he or she will get called in for a
urine drug screen. Sometimes counselors use hair drug testing that can tell if a
client is using more often. The clients are monitored with weekly phone calls as
long as it is necessary to stabilize recovery. One 12-step meeting is required
every day for the first 90 days, and the client must acquire a sponsor. Once a year
in continuing care the client attends a weekly return to the treatment center with the
clients he or she went through the original program with, solidifying how they are
doing in recovery and discussing what worked and what didn’t work to maintain
their sobriety.

Clients who get well need to come into treatment for an individualized number of
days, weeks, months, or even years and are then followed in continuing care for at
least the next 5 years; that is when the relapse rate drops to around zero.
Continuing care should include random drug screens, therapy, motivational
enhancement, treatment for co-occurring disorders, mandatory attendance at 12-
step meetings, sponsorship, spiritual direction, lifestyle management, enhanced
recreation, support from the family, and finding new friends in recovery. There is
no easy fix or magic bullet; recovery is hard work. However, it is incredibly
rewarding. We are fortunate in addiction treatment to see our clients literally
blossom into health before our eyes. Advancements in new treatments and
medications will continue to change the field almost on a daily basis, so we must
remain open to new treatments whenever possible. In any field, change occurs
slowly in incremental steps.

Unfortunately, along with huge advancements in recovery, the field of addiction

treatment is shrinking. This is a catastrophe because millions of our brothers and
sisters will die, and millions will spend valuable time in prison. Most addiction
programs today occur in outpatient settings with an average of 6 to 10 counselors
working with 150 to 500 clients. This results in poor treatment outcomes.
Research says that approximately two-thirds of clients relapse in the first year.
Only 40% of these treatment programs offer individual sessions; they have no
medical or medication support and are overwhelmed with paperwork. The
turnover of staff is dismal—about 50% —which is as high as the fast-food
industry. Because of managed care, we have been trying to make treatment cheaper
and more effective. This has led to cost cutting and usually staff cutting, which
leads to fewer professionals working with more clients. A few hospitals such as
the Talbott Recovery Addiction Treatment Center are doing things differently.
They focus on the client first, believing that better care leads to a more stable
system, better outcomes, and greater financial rewards. They concentrate on
prevention, treatment, and continuing care.

It is possible to treat addiction the right way the first time. Most addicts come
through treatment three or four times. Most addicts eventually stop using on their
own by making a motivated, life-changing decision, usually made with the help of
someone in recovery or a health care professional (McLellan, 2006). Still, many
clients will not be able to recover without treatment. “I have spent my whole
career looking at all of the kinds of things that have been tried—at least in the
country—to reduce substance use problems, and treatment is by far the best”
(McLellan, 2010, p. 26).

Because of third-party payers, thousands of treatment centers have closed. There

are more than 23 million diagnosed addicts in the United States on any given day,
and only 3 to 10% are in treatment. Worst of all, most professionals in the field
are not using evidence-based treatments but treatments they learned in their own
recovery or on-the-job training. These treatments do not work as well as
evidence-based treatment programs. When we see a client, we want to know we
are giving that person the best treatment in the world.

For the first time, science has shown us how to keep most addicts clean after only
one treatment. If you read articles or hear speeches by the leaders in the field, you
will read about this new revolution: treatment that works developed in the
programs where the cost of treatment was irrelevant because the cost of relapse
was deadly to the public. This initially came from the work with physicians and
then branched out to other professionals such as airline pilots. No one wants a
pilot flying a plane or a physician doing surgery while intoxicated. No price was
too high to pay these professionals to stay clean and sober. These people had to
stay clean to protect all of our lives. These programs developed markedly higher
recovery rates hovering around 90%. If we develop similar programs for all
substance abusers, most of our clients will stay clean and sober. It is obvious that
this will be more effective and cheaper in the long run. Until now, third-party
payers were reluctant to pay for treatment because it rarely worked. However, the
treatment success rate in addiction is similar to the treatment of other chronic
diseases. Third-party payers should be willing to pay for treatment that restores a
client to health (Marlatt & Donovan, 2008; McKay, 2005; Skipper & DuPont,
2010; White, 2009).

There are many treatments for addiction, and most of them work, but it is
important to note that when physicians treat their own, all these successful
programs focus on 12-step facilitation and sponsorship as the core of treatment
(Skipper, 1997; Skipper & DuPont, 2010). Studies show that if abstinence is the
desired outcome, consistent involvement with 12-step meetings produces the best
results. About 76% of treatment programs use the 12 steps as their basis
(Florentine & Hillhouse, 2000).

Robert L. DuPont, MD, the founding director of the National Institute on Drug
Abuse (NIDA), said the following:

Today, I see these fellowships as a modern miracle and the key to sustained
recovery for most, but not all, addicts. . . . In fact, these programs created the
entirely new concept of “recovery,” which is much more than mere
abstinence. The 12-step fellowships support a new and better way of life.
(White, 2010, p. 43)

These programs for professionals also use evidence-based therapies such as

motivational enhancement, cognitive behavioral therapy, and medication including
disulfiram, naltrexone, acamprosate, buprenorphine, and topiramate. The change
required is an emotional, interpersonal, and spiritual shift (Earley, 2009). This
same treatment should be available for all clients.

This manual will concentrate on five evidence-based treatments:

1. Cognitive behavioral therapy

2. Motivational enhancement
3. Pharmacology
4. Skills training
5. 12-step facilitation

The Minnesota Model is the gold standard for alcohol and drug treatment. The
research evidence for this treatment says that it is a good start, but continuing care
in most programs is lacking. Two-thirds of clients going through these programs
relapse in the first year after treatment. This is exactly like the treatment of other
chronic relapsing diseases such as hypertension, asthma, and diabetes. These
chronic diseases have almost identical genetic concordance rates, about 50 to
60%; treatment compliance rates, about 50 to 60%; and relapse rates, about 50 to
60%. Health care has become an acute care business, but many chronic diseases
need lifelong management. In acute medicine, clients learn what they need to do to
stay healthy, but about half of them do not comply with treatment. Only half of
substance abuse clients are encouraged to go to 12-step meetings, and we know
that these meetings help addicts recover. Clients may be encouraged to get a
sponsor, go to some kind of counseling, and take their medications, but most of
them are not followed up, do not comply, drop out, and relapse.

This book outlines the best treatment in the world. The leading treatment centers
and addiction professionals have contributed to and approved of this text. You
might not work at a large treatment center that has all of these services available,
but the more of these components you add, the better your treatment will become.
The best treatment centers have a large, multidisciplined staff, but even these
treatment centers fail miserably when it comes to continuing care. They fail
because they are not paid for the continuing care that works. It must become a part
of your mission to change this policy. Recovery does not take a set number of
days, weeks, months, or years but usually takes a lifetime of vigilance and hard
work.

You are reading this book because you are interested in working with addicts.
Congratulations! You can be proud of yourself because addiction treatment is
effective and fun. You belong in one of the most rewarding professions in the
world. In addition, with counseling you will watch your clients change from being
at death’s door to being happy, joyous, and free. Treating alcoholics and addicts,
you will be working with some of the most caring and dedicated professionals in
the world. You will save lives, change the world, and have loads of fun. Because
of who you are and what you do, you have my greatest respect. I hope this manual,
developed by thousands of treatment programs and professionals, will benefit you
in your work.

—Robert R. Perkinson
Acknowledgments

Thousands of addiction professionals, mental health workers, and chemical

dependency counselors shaped this book. Every comment, suggestion, or question
I receive makes it better. I want to thank all of you for helping me over the years.
As a field, we have been trying to develop and maintain a treatment book that all
addiction professionals could be proud of and use every day. The work of training
new staff is exhausting for everyone, and it became necessary for the major
treatment centers to develop a standard treatment book that everyone coming on
board could read, understand, and have available for review. It had to be
practical, simple, and easy to use. It had to have feedback from the best treatment
centers in the world. The following key professionals played a major role in
developing the manuscript, sharing their training and expertise, and going over the
manual in detail. These people never stop walking in the truth, and their light
covers the earth.

Bob Bogue, Clinical Supervisor, Keystone Treatment Center

Julie Braaten, Accreditation Coordinator, Keystone Treatment Center
Bob Carr, Director, Substance Abuse Program at the VA Regional Hospital
in Sioux Falls
Carol Davis, Counselor, Betty Ford Center at Eisenhower
Michael Ford, Former President, National Association of Addiction
Treatment Providers (NAATP)
Luther Hegland, Addictionologist, Keystone Treatment Center
Marcia Nelsen, Addictionologist, Keystone Treatment Center
Michael Moeller, Psychiatrist, Keystone Treatment Center
Charles and Jean LaCour, Net Institute
Cynthia Moreno-Tuohy, Executive Director, National Association of Alcohol
and Drug Abuse Counselors (NAADAC)
Terry O’Brian, Member of Board of Directors, Hazelden
Donald P. Osborn, Past President, National Association of Alcohol and
Drug Abuse Counselors (NAADAC)
Carol Regier, Executive Director, Keystone Treatment Center
Gene Regier, Medical Director, Keystone Treatment Center
Eleanor Sargent, Project for Addiction Counselor Training, National
Association of Alcohol and Drug Abuse Counselors (NAADAC)
Nancy Waite-O’Brian, Clinical Director, Betty Ford Center at Eisenhower
Richard Weedman, President Healthcare Network, Inc.
All of the staff and clients of Acadia Healthcare and Keystone Treatment
Center
We gratefully acknowledge John Ellis of the University of Akron and Richard
Romaniuk of Case Western Reserve University for developing the eLearning
resources available on the companion website for Chemical Dependency
Counseling, 5th edition.
1 First Contact
Source: ©[Link]/KatarzynaBialasiewicz.

Someone you know and love is dying of addiction. No one, even the addict, knows
the extent of the disease that is poisoning his or her body. More than half of
Americans drink, and many of them innocently fall victim to this silent killer.
Addicts live their lives deeply alone, immersed in self-told lies. They could not
tell you the truth if they wanted to because they do not know what the truth is. They
are living in a world of carefully constructed self-betrayal: “I am fine. I can stop
anytime I want. I do not drink or use any more than my friends drink.” “Everybody
loves to gamble. It is so much fun, and I win.” “I was born to use speed.” At
times, the addicts want to cut down or stop, and they try, but they always fail—
repeatedly they fail. Addicts live in world full of self-hatred and shame. They do
not want anyone to know the terrible truth about their pain. They put on a false
front of being fine. You might suspect something is wrong, and you would be right,
but there seems to be little you can do to help an addict see the truth. Most addicts
die of their addiction. Ninety-five percent of untreated alcoholics die of
alcoholism an average of 26 years early. The death certificate might read heart
disease, cancer, or something else to protect the family, but the real reason is
addiction.

Text
Source: Created by Mervin Magus.

Addiction is more than a behavior problem. Repeated drug use causes long-lasting
changes in the brain, so the addict loses voluntary control. The prefrontal lobe of
the brain where we make decisions, plan, organize, and resist primitive impulses
goes off-line. Clients are obsessed with doing what they hate doing. The addiction
is the only way they know how to feel normal. Not to use causes withdrawal,
which causes craving, which is too painful to consider. In time, the addict’s brain
adapts to the point that he or she cannot get high and cannot get sober. This is
when addicts feel hopeless, helpless, and powerless, and their lives are
unmanageable. This is when many of them commit suicide or come in for
treatment.

In America, 51.1% of the population drinks alcohol, and a little less than a third of
them will have a substance use disorder sometime in their lifetime (Substance
Abuse and Mental Health Services Administration [SAMHSA], 2009a). In the
United States, almost 1 million people die of substance abuse disorders annually.
This does not count the people who die of diabetes, coronary artery disease, and
cancer caused by drinking, smoking, poor eating, and lack of exercising. Heavy
drinking or drug use contributes to illnesses in each of the top three causes of
death: heart disease, cancer, and stroke. At least 13.8 million Americans develop
problems associated with drinking. Over many years of following alcohol and
drug problems, studies find that 78% of high school seniors have tried alcohol.
Fifty-three percent have tried illegal drugs. Fifty-seven percent of high school
seniors have tried cigarettes, and 27% are current smokers. Addiction is one of
the most horrible plagues to attack the human race. According to the Centers for
Disease Control and Prevention (CDC), 25% of Americans die as a direct result
of substance abuse (Heron et al., 2009).

Millions of Americans are dying annually of preventable conditions. Drug

overdoses are now the leading cause of accidental death in the United States.

443,000 die of tobacco products.

365,000 die of improper diet and exercise habits.
88,000 die of alcohol abuse.
75,000 die of microbial agents.
55,000 of toxic agents.
47,000 die of adverse reactions to prescription drugs.
29,300 die of homicide.
29,000 die of firearms.
26,000 die of automobile accidents.
20,000 die of sexual behavior.
19,000 die of prescription pain reliever overdoses.
17,000 die of illegal drugs (“Annual Causes of Death in the United States,”
2014; Center for Disease Control and Prevention, National Center for Health
Statistics, National Vital Statistics System, Mortality File, 2015).
11,000 die of heroin overdoses.
Treatment Works
Most addicts will quit on their own by making a highly motivated personal choice
then working hard at recovery, usually with multiple attempts at quitting and
periods of relapse and reevaluation. Most of the people who quit on their own
have learned about treatment and recovery through someone who is in recovery, a
health care professional, or a friend. These people make the choice that the
negative consequences of continued use outweigh the rewards. They go through
the same motivational steps that a client needs to make in treatment (DiClemente,
2006b). Some clients cannot seem to quit on their own, and they need treatment.
We know from many years of scientific experiments that addiction treatment
works. For every dollar spent on treatment, the economy saves $7 in health care
and costs to society. Most clients who work a program of recovery stay clean and
sober. To get clean, clients have to come out of hiding and use their journey to
help others. By sharing our experience, strength, and hope, addicts in recovery
give others reasons to get clean. Working the program means getting honest, going
to recovery group meetings, and making conscious contact with a higher power of
their own understanding (Johnston, O’Malley, Bachman, & Schulenberg, 2008;
McLellan, 2006).

Your first meeting with a client might be accidental or it might be by appointment.

During the interview, you—if you look and listen carefully—will sense something
is wrong with this person, but you do not know what it is. You have a clinical
thermometer inside of you that you will over time learn to trust. This is more than
intuition; it is a gift. The skill is to watch the client so carefully and listen so
intensely that you pick up cues that others miss. The person might look depressed
and anxious. Her face may be red and swollen, his eyes watery and red, or the
person may be markedly thin with scabs caused by “meth bugs.” He might have a
fine hand tremor or have difficulty sitting still. Sometimes the person’s head hangs
in depression that looks like shame. Something is wrong, and it will nag at you.
That clinical thermometer inside of you feels uncomfortable, and you do not like
it.

If you are reading this manual, you have probably been a natural born healer all of
your life. When you were a little kid, you cared more about puppies and kittens
than others did. People in school talked to you and told you secrets when they
would not talk to anyone else. People recognize a healer when they see one.
There is another side of you that is very different. It has been in trouble with
clients like this before. Sometimes being a healer is not good. Sometimes you
have to tell people the truth when they do not want to hear it. They can rebel
against you and fight. You have learned that sometimes it is best to let the truth go
—or worse, lie to yourself and your clients and let them go. You hate that part of
yourself, but you have learned how to live with it. After all, you live in a world
full of litigation and managed care. Fear has overcome your best judgment many
times.

And there is that client sitting in your office, crying out for the healer in you.
Clients desperately need someone to tell them the truth. This time if you let the
problem go, if you take the easy way out, the client may die. Addiction is like
brain cancer. To let this client out of your office without confronting the truth is to
be responsible for the client’s death.

Yet you have confronted drug addicts before. Addicts seem to have two sides to
them. One side knows they are in trouble, while the other side knows they can
continue the addiction safely. You and your client are in a life-or-death battle with
the truth. The trick is to help the client win. You are up against a great enemy.
Alcoholics Anonymous (AA) (2002a) says this illness is “cunning, baffling and
powerful” (pp. 58–59).

The battle lines are drawn. The illness inside of the client is confident of victory.
It thinks that you will take the easy way out. You will handle the acute problem
and let the client go home. You will not ask the questions that could lead to the
truth. That would be too much trouble; besides, you are too busy.

The enemy does not know that you are a healer. You will not lie, and you will not
let the addict go home to die. You are going to fight. This is who you are, and it is
who you will always be. To be anything else leaves you in shame.
The Motivational Interview
So you decide to take action. Either you do this yourself, or you call in an
addiction professional to do it for you. You suspect your client is addicted. Your
client does not even want to know the reason because to know the truth confronts
him or her with change. Your job is to go with the client toward the truth. It does
no good to go against the client’s idea of himself or herself. Arguing with the
client will not work because the addict is an expert at giving every excuse in the
world for abnormal behavior. If you argue, the client will win because he or she
will leave your office convinced you are a bad person. Walk with the client
toward the truth. Listen and seek out ambivalence about the negative consequences
of continuing the addictive behavior. This is client-centered counseling, not self-
centered counseling. You must listen, so you can step into the client’s world and
connect with that gentle voice of reason inside of him or her. That healthy voice is
there, and your job is to connect with it, empathize with it, and pull for more. The
other voice in the client’s head says something else is to blame. They might have
another problem, but it has nothing to do with addiction.
Source: ©[Link]/AlexRaths.

As a professional, you are used to your clients being honest with you, but this one
is going to lie. The client is not a bad person; he or she is a good person with a
bad disease. The disease of addiction lives in and grows in the self-told lie. The
client must lie to himself or herself and believe the lie, or the illness cannot
continue. The client will have a long list of excuses for his or her behavior:

My spouse has a problem.

The police have a problem.

The school has a problem.

My boyfriend has a problem.

I have a physical problem.

I am depressed.

I am anxious.

I have a stomachache.

I cannot sleep.

The excuses go on and on, and they might confuse you if you are caught up in them.
They are all part of a tangled web of deceit. Remember, your job is to walk with
the client toward the truth, not against the client toward the truth. You are going to
spend most of your time agreeing with the client. When the client is honest, you
are going to agree. When the client is dishonest, you are going to probe for the
truth. Look at it this way: If the client is listening to you, you can work. If the client
is not listening to you, anything you say is useless.

Watch the client’s nonverbal behavior very carefully. You are a healer, and you
have the gift of super sensitivity. Your intuition will tell you whether the client is
going with you or resisting. When the client goes with you, you feel peace. When
the client goes against you, you feel uncomfortable. When the client is ready, you
will educate him or her about the disease. This is a gentle process, and it takes
time. If you are in a hurry, this is not going to work.

The client has been using the addiction for a long time to relieve pain. All
addictions tell the brain, Good choice! All organisms have a way of finding their
way in a complicated, lethal environment. They learn which foods are good and
which are bad. They find the best way through the jungle. They learn what is safe
and what is dangerous. We learn these things deep in the reptilian brain. What is
good is remembered, and if it is very good, it is remembered after one experience.
The addiction has been good to this client for many years, but now it is
destructive. The very thing that gave the client joy now gives pain. This process
fools the client. Remember, the addiction has always said, Good choice! So how
can it be a bad choice? You are fighting with the client’s basic understanding of
the world, and he or she will be convinced that you are wrong. You must help the
client see that the addiction is no longer a good choice—it is a deadly choice. The
addict cannot see this alone, but AA has an old saying: “What we cannot do alone,
we can do together.” The client cannot discover the truth without your help. You
must guide the client toward a decision he or she finds impossible. You need to
help clients see that they need to stop the addictive behavior.

What you are looking for is the truth. The client will rarely tell you accurate
symptoms. You have to look for signs of the disease. Symptoms are what the client
reports. Signs are what you see. You will continue to investigate—testing;
smelling the air; ordering laboratory studies; and talking to family, friends, court
workers, school personnel, and anyone else who can help you until you uncover
the truth.

Your client cannot tell you the truth because the client does not know the truth.
Addiction hijacks a client’s thinking; it’s a web of self-deception. Remember, you
are the healer. You care for your clients even if they hate themselves. You are
going to love them even though they are being deceptive. You are going to help
them even though they do not understand what you are doing.
How to Develop the Therapeutic Alliance
From the first contact, your client is learning some important things about you. You
are friendly. You are on his or her side. You are not going to beat up, shame, or
blame your client. You answer any questions. You are honest, and you hold nothing
back. You discuss every option in detail. You are committed to do what is best for
the client. You provide the information, and the client makes the decisions. The
client sees you as a concerned professional. You are asking questions no one else
has asked. This leads them to believe you are a skilled professional. In time, the
client begins to hope that you can help. The therapeutic alliance is built from an
initial foundation of love, trust, and commitment.

You show the client that he or she does not have to feel alone. Neither of you can
recover alone. Both of you are needed in cooperation with each other to solve the
problem. The client knows things that you do not know. The client knows himself
or herself better than anyone else does, and he or she needs to learn how to share
his or her life with you. Likewise, you have knowledge that the client does not
have. You know the tools of recovery.

The client must trust you. To establish this trust, you must be honest and consistent.
You must prove to the client, repeatedly, that you are going to be actively involved
in his or her individual growth. You are not going to argue or shame the client; you
are going to try to understand him or her. When you say you are going to do
something, you do it. When you make a promise, you keep it. You never try to get
something from a client without using the truth. You never manipulate, even to get
something good. The first time a client catches you in a lie, even a small one, your
alliance is weakened.

If you work in a treatment facility or group practice, the client must learn that your
staff works as a team. You can share with the whole team what the client tells you
—even in confidence. The client will occasionally test this. The client will tell
you that he or she has something to share but that it can only be shared with you.
The client wants you to keep it secret. Many early professionals fall into this trap.
The truth is that all facts are friendly and all information is vital to recovery. You
must explain to the client that if he or she feels too uncomfortable sharing certain
information that the client should keep it secret for the time being. Maybe they can
share this information later when they feel more comfortable.
The client must understand that you are committed to his or her recovery, but you
cannot recover for the client. You cannot do the work by yourself. You must work
together, cooperatively. You can only teach the tools of recovery. The client must
use the tools to stay clean and sober.
How to Do a Motivational Interview
In the first interview, you begin to motivate clients to see the truth about their
problem. Questions about alcohol and other drug use are most appropriately asked
as a part of the history of personal habits, such as use of tobacco products and
caffeine. Questions should be asked candidly and in a nonjudgmental manner to
avoid defensiveness. Remember that this is client-centered interviewing, not
professional-centered, and the interview should incorporate the following
elements (with the client being free of alcohol at the time of the screening)
(DiClemente, 2006a; Prochaska, 2003):

Offer empathic, objective feedback of data.

Work with ambivalence.
Meet the client’s expectations.
Assess the client’s readiness for change.
Assess barriers and strengths significant to recovery efforts.
Reinterpret the client’s experiences in light of the current problem.
Negotiate a follow-up plan.
Provide hope.

Example of a Motivational Interview

Professional: Hello, Frank, I am ___________________ (your name). Why did
you come in to see me today?

Client: My wife wanted me to talk to you.

Professional: Why did she want that?

Client: I do not know.

Professional: I talked to your wife on the phone yesterday, and she said she was
concerned about your drinking.

Client: She is always concerned about something. Her father was an alcoholic,
so she thinks everyone drinks too much. (The client looks irritated.)
Professional: Sounds like things are not going well at home? (The professional
mirrors the client’s feelings and facial expression. When you mirror a person’s
expression, you validate his or her worldview.)

Client: I do not know. It is just that she gets all worked up about everything.

Professional: Your wife said you have been drinking heavily every day. She is
afraid for you.

Client: I work hard, and I like to come home and relax with a few beers. Is
anything wrong with that? (The client is obviously irritated with coming to the
interview. So far, the client is saying, My wife has a lot of problems.)

Professional: There’s nothing wrong with relaxing. How do you relax? (The
professional goes with the client’s point of view.)

Client: I have a couple of beers. So what?

Professional: Your wife says you have been drinking a 12-pack a day.

Client: It is not that much.

Professional: Are you drinking more than a couple of beers a day? (The
professional is gently pulling for the truth.)

Client: Maybe a little more.

Professional: Is it around 12?

Client: I work hard, and I deserve to relax. (The client is resisting, and the
professional backs off a little. It is important to keep the client’s ears open. Be
empathic, tender, and understanding. Try to see the problem from the client’s
point of view. Once you enter the client’s world and understand his or her point
of view, you will get clues about what will motivate the client to change. This
client is mad at his wife, and he needs some help with that, but what is his real
problem?)

Professional: I like to relax after a hard day, too. Your wife sounds afraid for
you. What is frightening her?
Client: My wife just sits around all day and watches television, while I am
working my tail off.

Professional: So you really need to relax when you come home. Particularly if
you feel like you are pulling the load all by yourself?

Client: Yeah, she sits around and thinks about things to argue with me about.

Professional: Do you think your wife loves you? (This is pulling the client
toward the truth. Why is his wife worried about him?)

Client: Well, yeah, I think she does. (The client visibly softens.)

Professional: It is great to have a wife who loves you. Sounds like you are a
lucky man. (The professional reinterprets the client’s experience in light of the
alcohol problem.)

Client: But I am not drinking too much. I am just drinking a few beers.

Professional: You said it was 12. (The professional reminds the client what he
said earlier to cement the fact.) What is the most beer you have ever drunk in a
full day?

Client: Oh, I do not know.

Professional: Give me a guess.

Client: Well, on the weekends I can drink up to a case if I am watching a ball

game.

Professional: That is a lot of beer. (The professional determines the client is

an alcoholic but does not jump the gun; the client is not ready yet.)

Client: Not if I am drinking all day.

Professional: Did you know that if you drink more than three beers a day, more
than three times a week, your organs are dying? Alcohol is a poison. It kills the
brain, heart, kidneys, every cell in the body. If you are drinking more than three
drinks per day, you are literally killing yourself. That might be why your wife is
worried about you. (The professional believes the client’s ears are open, so it is
time to try a little education.)
I want to show you a single photon emission computed tomography (SPECT)
scan pictures of a healthy brain and a brain of someone who abuses alcohol.
More substance abuse pictures are available at [Link].

The client quickly looks away. He does not want to see a picture of his brain
dying. However, he did see it, and he could not make that fact go away. He has to
rapidly deny the professional’s statements and the pictures or admit that he has a
problem. A part of him knows he has a drinking problem, and now it is confirmed.
It is not only his wife’s opinion but now a picture and a professional’s opinion
confirm the diagnosis. He has not admitted it yet, but he knows he has been
drinking too much.

The professional begins negotiating and assessing the client’s readiness for
change.

Professional: Bob, have you ever worried about your drinking?

Client: No, honestly, I have not. (This comes across as real. When the words
and the client’s affect match, they are probably telling the truth. Most addicts
think their addictive behavior is normal.)

Professional: Maybe that is because you did not understand how much you
could drink safely. If alcohol is killing you, do you not want to know?

Client: Well, sure.

Professional: Looking at these pictures, and thinking about how much you have
been drinking, do you think you have been drinking too much? (The professional
is taking the biggest chance of all.)

Client: Maybe? (Maybe is very close to a yes. The client has admitted that he
drinks too much. That moves him from the precontemplation phase to the
contemplation phase. For the first time, he is considering the negative
consequences of his drinking. This is a huge step toward recovery.)

Professional: Did you know that 95% of untreated alcoholics die of their
alcoholism? And they die 26 years earlier than they would otherwise.
The client says nothing.

Professional: Knowing what you know now, would you like to learn how to
drink less or even stop drinking entirely? (The professional is negotiating how
far the client is willing to go to get better.)

Client: I did not know it was that bad. (Now the client is contemplating
change. We are on the road to recovery. With a gentle approach, the
professional can negotiate and listen to the client’s life from his or her
perspective, allowing the client to move toward the truth.)

Professional: Why don’t we meet again with your wife and talk about what we
can do to help you two feel better? Would that be all right with you?

Client: If you think it will help.

Professional: Most people who try to get better get better.

Client: Okay, let’s do it. (A commitment to change has occurred. Now the
client realizes he has a problem and is making plans to take action. These are
the first giant steps toward recovery.)

Questions to Ask the Adult Client

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has developed
the following low-risk drinking guidelines:

Men should drink no more than two drinks a day and no more than four drinks
on a single occasion.
Women and clients over 65 years of age should drink no more than one drink
a day and no more than three drinks on a single occasion.
Pregnant clients and those with medical problems complicated by alcohol
use should abstain completely (“U.S. Surgeon General Releases Advisory on
Alcohol Use in Pregnancy,” 2005).
We could also add that no person should ingest an illegal substance.
If a person cannot stop something they want to stop, it is an addiction.

At some time during the first interview, certain questions need to be asked to
assess addiction problems. They have to be answered honestly to give you a clear
picture of the extent of the problem. Most clients who have addiction problems
will be evasive or deny their addiction, so the questions should be asked of the
client as well as a reliable family member.
The following questions and flags are taken from the American Society of
Addiction Medicine (ASAM) ([Link]

1. Have you ever tried to cut down on your drinking?

2. Have you ever felt annoyed when someone talked to you about your drinking?
3. Have you ever felt bad or guilty about your drinking?
4. Have you ever had a drink in the morning to settle yourself down?
5. Has alcohol or drugs ever caused your family problems?
6. Has a physician ever told you to cut down on or quit use of alcohol?
7. When drinking or using drugs, have you ever had a memory loss or a
blackout?

Similar questions could be asked about gambling or any other addictive behavior.
If clients answer yes to any one of these questions, it is a red flag for addiction. If
they answer yes to two questions, it is probably addiction. Make sure you do not
just ask the client. Ask family members, friends, and anyone else who can give
you collateral information. (See Figures 1.1 through 1.5.)

Figure 1.1 Client History/Behavioral Observation Red Flags for Addiction

Figure 1.2 Laboratory Red Flags for Adult Alcohol/Substance Abuse Disorder
Figure 1.3 Client History/Behavioral Observation Red Flags for Adolescent
Alcohol Abuse

Figure 1.4 Laboratory Red Flags for Adolescent Alcohol/Substance Abuse

Disorder

Figure 1.5 Interview Questions for Suspected Addiction Among Adolescents

What to Do If There Are One or More Red Flags
Once you have one or more red flags, you have several important actions to take:

1. Advise the client of the risk.

2. Advise abstinence or moderation. Men should be advised to drink no more
than three drinks at a time and no more than three nights a week. Women
should be advised to drink no more than two drinks at a time and no more
than three nights per week. More drinking than this will result in disease.
This is a harm reduction approach where you teach a client how to drink
responsibly. This would not be appropriate for someone who has a serious
drinking problem.
3. Advise against any illegal drug use.
4. Schedule a follow-up visit to monitor progress.
Natural History of Addiction
Addiction can begin at any age, and it often occurs in individuals with no history
of psychological problems. When the addictive substance is readily available,
inexpensive, and rapid acting, the incidence of use increases. Whenever the
individual is ignorant of healthy alcohol or drug use, is susceptible to heavily
using peers, or has a high genetic predisposition to abuse or to antisocial
personality disorder, abuse may increase. This is also true if the client is poorly
socialized into the culture, or in pain, or if the culture makes a substance the
recreational drug of choice.

Risk Factors
Risk factor 1: Substance or behavior is readily available.
Risk factor 2: Substance use or addictive behavior is cheap.
Risk factor 3: The addictive chemicals reach the brain quickly.
Risk factor 4: Addiction is a pain reliever.
Risk factor 5: Addiction is more common in certain occupations
(bartending).
Risk factor 6: Addiction is prevalent in the peer group.
Risk factor 7: Addiction is preferred in deviant subcultures.
Risk factor 8: Social instability is found.
Risk factor 9: There is a genetic predisposition.
Risk factor 10: The family is dysfunctional.
Risk factor 11: Comorbid psychiatric disorders are present (Vaillant, 2003).
How to Diagnose an Addiction Problem
In the assessment, you must determine if the clients fit into your range of
experience and care. Do you have the ability to deal with his or her problem, or
do you need to refer to someone else? Does the client have a problem with
chemicals or an addictive behavior? Is he or she motivated to get better? Does the
client have the resources necessary for treatment? Is the individual well enough to
see you? For the most part, you will start by asking yourself certain basic
questions: Does this person have signs and symptoms of addiction? Does he or
she need treatment? Is he or she motivated for treatment? What kind of treatment
does she or he need? For the benefit of third-party payers, it is important to use
assessment instruments to document (1) diagnosis, (2) severity of addiction, and
(3) motivation and rehabilitation potential. Third-party reviewers will often have
more faith in a test battery than your clinical opinion.

There are a number of companies that sell inexpensive, disposable Breathalyzers

and drug screening instruments, including Prevent (1-800-624-1404); Bi-
TechNostix (1-888-339-9964); Random Drug Screens, Inc. (1-803-772-0027);
Drug Screens, Inc. (1-800-482-0693); hair screens; Pharmchec Drugs of Abuse
Patch, which lasts 2 weeks; a new GGT alcohol screen that will test for alcohol
injection for 80 hours after use; and ankle bracelets that measure alcohol in the
sweat of probationers 24 hours, 7 days a week. Order a number of these tests, and
have them readily available for assessment, treatment, and continued care
monitoring. Positive tests are only suggestive of drug and alcohol use, so before
any legal or workplace action is taken, the test should be confirmed by both an
approved immunoassay and gas chromatography/mass spectrometry, which can be
administered and analyzed by a health care provider (SAMHSA, 2007). Two
quick screening tests for alcoholism have been developed: the Short Michigan
Alcoholism Screening Test (SMAST) (see Appendix 2) (Selzer, Winokur, & van
Rooijen, 1975) and the CAGE questionnaire (Ewing, 1984; Selzer et al., 1975).
The Michigan Alcoholism Screening Test (MAST) or SMAST has greater than
90% sensitivity to detect alcoholism. It can be administered to either the client or
the spouse.
Source: From “Activation of Memory Circuits During Cue-Elicited Cocaine
Craving,” by S. Grant et al., 1996, Proceedings of the National Academy of
Sciences, USA, 93, pp. 12040–12045.

The Substance Abuse Subtle Screening Inventory (SASSI) (1-800-726-0526;

[Link]) was developed to screen clients when defensive and in denial.
The SASSI measures defensiveness and the subtle attributes that are common in
chemically dependent persons. It is a difficult test to fake, unlike the SMAST or
the CAGE. Clients can complete the SASSI in 10 to 15 minutes, and it takes 1 or 2
minutes to score. It identifies accurately 98% of clients who need residential
treatment, 90% of nonusers, and 87% of early stage abusers. This is a good test
for those clients with whom you are still unsure about the diagnosis after your first
few interviews—clients who continue to be evasive (Miller, 1985).

The Addiction Severity Index (ASI) and the Teen-Addiction Severity Index (T-
ASI) (1-215-399-0980) are widely used, structured interviews for adults and
teens and are designed to provide important information about the severity of the
client’s substance abuse problem. These instruments assess seven dimensions
typically of concern in addiction, including medical status, employment/support
status, drug/alcohol use, legal status, family history, family/social relationships,
and psychiatric status. The tests are administrated by a trained technician. The ASI
is an excellent tool for delineating the client’s case management needs (Kaminer,
Bukstein, & Tarter, 1991; McLellan, Luborsky, & Woody, 1980).

The Adolescent Alcohol Involvement Scale (AAIS) is a 14-item, self-report

questionnaire that takes about 15 minutes to administer. It evaluates the type and
frequency of drinking, the last drinking episode, reasons for the onset of drinking
behavior, drinking context, short- and long-term effects of drinking, perceptions
about drinking, and how others perceive his or her drinking (Mayer & Filstead,
1979; Mee-Lee, 1988; Mee-Lee, Hoffmann, & Smith, 1992) (1-800-755-6299).
The RAATE-CE is a 35-item scale that assesses treatment readiness and examines
client awareness of problems; behavioral intent to change; capacity to anticipate
future treatment needs; and medical, psychiatric, or environmental complications.
The RAATE-CE determines the client’s level of acceptance and readiness to
engage in treatment and targets impediments to change.
How to Intervene
No Problem Usage: If the client is at low risk for addiction, you should
provide positive prevention messages that support the client’s continued
positive lifestyle. A client with a positive family history of addiction should
be warned about his or her increased vulnerability to addiction and the need
for vigilance.
Problem With Addiction: The client who has had recurrent problems due to
addiction should be encouraged to abstain from, or at least reduce, his or her
addictive behavior. A client such as this should be strongly encouraged to
abstain from all illegal drugs and addictive behaviors. You should discuss
the biopsychosocial complications of addiction (see Appendix 8). A client
who is encouraged to cut down on his or her addictive behavior should be
provided with the brochure from NIAAA (see Appendix 9). It is essential
that these clients be reassessed frequently to monitor their ability to comply
with your recommended limits.
Addiction: Addicts need to have their diagnoses carefully discussed with
them and a treatment plan negotiated. You need to be empathic and address
the problems that seem to be caused or made worse by the client’s continued
addictive behavior. The client needs to hear that this illness is not his or her
fault and that there is excellent treatment available that will help the
individual to stay clean and sober. The client needs to hear that only 4% of
addicts can quit on their own over the course of a year, but 50% can quit
over the course of a year if they go through treatment. Seventy percent can
quit over the course of a year if they also attend AA meetings regularly, and
90% can stay sober if they go through treatment, attend meetings, and go to
continuing care once a week for a year (Hoffmann, 1991, 1994; Hoffman &
Harrison, 1987). The client should also be told about the potential benefits of
naltrexone, accamprosate, and disulfiram when used along with formal
treatment programs. Carefully discuss the ASAM client placement criteria to
help you and the client negotiate the best treatment plan possible to bring the
addiction under control. (See Figure 1.6.) The following questions may be
helpful in negotiating a treatment plan:
1. Is the client a danger to self or others (suicidal and homicidal ideation,
impaired judgment while intoxicated, or history of delirium tremens)?
2. Has the client ever been able to stay clean for 3 or more days?
3. What happened when the client stopped the addictive behavior in the
 past? How serious were the withdrawal symptoms?
4. Has the client ever been able to stay completely abstinent for long
periods?
5. Why did previous attempts at staying clean fail?
6. How does the family understand alcoholism and its treatment?

Figure 1.6 Positive and Negative Prognostic Factors

How to Assess Motivation
Constantly ask yourself about the client’s stage of motivation, and introduce
appropriate motivating strategies to move the client up a motivational level. This
book will give you many ways of doing this. No client is alike, so you must be
creative in helping the client see the inaccuracies in his or her thinking and move
away from the lies toward the truth.
The Stages of Motivation

Precontemplation
The individual is not intending to take action in regard to his or her substance
abuse problem in the near future.

Tasks: Try to increase awareness of the need to change; increase concern

about the current pattern of behavior.
Goal: Make a serious consideration of change.

Contemplation
The individual examines the current positive and negative effects of drinking
behavior and the potential for change in a risk–reward analysis.

Tasks: Analyze the pros and cons of the current behavior and of the costs and
benefits of change.
Goal: Write a list of the positive and negative consequences of continued
use.

Preparation
The individual makes a commitment to take action to change and develops a plan
for change.

Tasks: Increase commitment and create a change plan.

Goal: Create an action plan to be implemented in the near future.

Action
The individual implements the plan, takes steps to change, and begins new
behavior patterns.

Tasks: Implement change, and revise the plan as needed while sustaining
 commitment in the face of difficulty.
Goal: Develop a successful action for changing behavior, and establish a
new pattern of behavior for a significant period of time (3–6 months).

Maintenance
The new behavior is sustained for an extended period of time and is consolidated
into the lifestyle of the individual.

Tasks: Sustain change over time, and integrate the behavior into everyday
life.
Goal: Sustain long-term change of the old behavior, and establish a new
pattern of behavior (DiClemente, 2006a; Prochaska & DiClemente, 1983;
Prochaska, DiClemente, & Norcross, 1992; Prochaska, Norcross, &
DiClemente, 1994).
Motivating Strategies
Clients at different stages of motivation will need different motivating strategies to
keep them moving toward recovery, and these stages are not static. Clients can
shift back and forth through the stages for various reasons or spontaneously.
Clients in the precontemplation stage underestimate the benefits of change and
overestimate its cost. They are not aware that they are making mistakes in
judgment, and they believe they are right. Environmental events can trigger a
person to move up to the contemplation stage. An arrest, a spouse threatening to
leave, or a formal intervention can all increase motivation to change. Persons in
the precontemplation stage cannot be treated as if they are in the action stage. If
they are pressured to take action, they will terminate treatment (Prochaska, 2003).

A client in the preparation stage has a plan of action to cut down or quit his or her
addictive behavior in the near future. Such a client is ready for input from
professionals, counselors, or self-help books. The client should be recruited and
motivated for action. Action is the client changing his or her behavior to cut down
or quit the addiction. This is the client who has entered early recovery and is
involved in treatment (DiClemente, 2006a).

In the maintenance stage, the client is still changing his or her behavior to be better
and is working to prevent relapse. A client who relapses is not well prepared for
the prolonged effort it takes to stay clean and sober. All clients need to be
followed in long-term continuing care because addiction is fraught with relapse,
and clients need encouragement and support for years to stay in recovery. Addicts
typically do not have the skills to work a program in early recovery. This takes
time, commitment, and discipline, constantly trying to raise the client’s
consciousness about the causes, consequences, and possible treatments for a
particular problem. Denial is unconscious, and one must help the client raise the
material from unconscious to conscious. Clients can make a better decision
consciously than they can without automatically thinking about the consequences
of their addictive behavior. Interventions that increase awareness include
observation, confrontation, interpretation, feedback, and education, pointing out
the need to reevaluate the environment and change behavior. Encourage the client
to reevaluate his or her self-image, and explain how this is negatively affected by
the addictive behavior. Encourage the client to learn the new skills of being
honest, helping others, and seeking a relationship with a higher power
(DiClemente, 2006a).

Figure 1.7 Processes of Change for the Client in Precontemplation Stage

To help motivate clients to progress from one stage to the next, it is necessary to
know the principles and processes of change (DiClemente, 2006a; Prochaska,
2003; Prochaska & DiClemente, 1983; Prochaska et al., 1992; Prochaska et al.,
1994).

The following process should be applied to clients in the precontemplation stage

(see Figure 1.7) (DiClemente, 2006a; Prochaska, 2003; Prochaska & DiClemente,
1983; Prochaska et al., 1994), helping relationships combine caring, openness,
trust, and acceptance, as well as family and community support for change.
2 First Hours of Treatment

Source: ©[Link]/Lisa-Blue.
The First Hours
The first thing that clients need when they come into treatment is a warm welcome.
Most clients coming into treatment feel demoralized and ashamed. They feel like
the scum of the earth. These people need you to show them encouragement,
support, and praise. You show them that they are persons of worth, that they are
important, and that they matter to others. Nothing gives this feeling better than a
warm welcome. A warm welcome helps them understand that they are entering a
caring environment. They do not need to be afraid.
Source: Created by Mervin Magus.
How to Greet Clients
You need to convey to clients that you understand how they feel and that you will
do everything in your power to help them. When greeting a new client, it is as if
you are welcoming a long-lost brother or sister back into your family. This person
is not different from you; this person is you. Treat the person the same way in
which you would want to be treated yourself. The more the client senses your
goodwill and unconditional positive regard, the less alienated and frightened the
client will feel.

If you feel as though you can shake a client’s hand, then do this. Make it a warm
handshake. As you do these things, you are developing your therapeutic alliance,
and you are giving the client the most important thing that he or she needs—
acceptance.

The initial words you choose are important. Clients remember your words.
Clients come back after years and describe their first few hours in treatment. They
remember the exact things that people said. Because coming into treatment is a
highly emotional experience, they seal them inside their hearts. You want them to
remember the good things. Think of it like this: These people have been living a
life full of no love, no light, no beauty, and no truth. You are walking them toward
a new life full of love, light, beauty, and truth. Life in the darkness is lonely and
painful. As you welcome them home, the client should clearly see that he or she is
entering a new world full of hope.
Examples
Introduce yourself, and say something like the following:

“Welcome. You have made a very good choice. I am proud of you. This is a
victory not only for you but for all of the people in the world whom you will
help recover.”
“This is a new start. Good going.” (Give the thumbs-up sign.)
“Please ask us if there is anything you need. We are going to take good care
of you.”
“I know this was a difficult decision for you, but you will not be sorry. This
is the beginning of a new life you have not even dreamed about.”
“Try everything in your power to stay in treatment. If you feel uncomfortable,
tell one of the staff. We are here to give you the best treatment possible. You
will feel better every day.”

Notice how each of these statements welcomes the client and enhances his or her
self-esteem. Welcome. You are a good person. You made a good choice. We are
going to take good care of you.

Ask whether the client wants anything. How can you help? Nothing shows that you
care better than to offer to get the client something small—juice, food, milk, or
coffee. This shows that you care and, more importantly, that the client is worth
caring for. You are giving the client new ideas. Treatment is not going to hurt. The
staff is willing to respond to the client’s needs. “This treatment thing might be
okay,” the client begins to think. “I just might be able to do this.”

How to Handle Family Members

If the client came into treatment with family members, then make sure to tour the
facility with the family as a whole. This helps the client to make the transition
between the family at home and the new family in treatment. When you have all the
information that you need from the family members, they should be encouraged to
leave. To have them linger unnecessarily can be detrimental to the client’s
transition. The client needs to focus on himself or herself and to orient to
treatment. Family members who cling are rare, but they do exist. These people
need to be separated from the client and given reassurance that the client is in a
safe place. Someone in the family program might be willing to talk to the family
members for a while to encourage them and answer any questions they might have.
Remember that you are bonding with the client and his or her family members.
You want them all to see you as someone they trust.
Beginning the Therapeutic Alliance
From the first contact, your clients are learning some important things about you.
You are friendly. You are on their side. You are not going to hurt, shame, or blame
them. This is a disease like cancer, hypertension, asthma, or diabetes. People
should not be ashamed for being sick. No one wants to become addicted, just like
no one wants to have cancer.

Freely answer any questions about treatment and the treatment center. Take the
client on a tour, and introduce him or her to other clients. Be honest, and hold
nothing back. You provide the information, and the client makes the decisions. The
client sees you as a concerned professional. The client begins to hope that you can
help him or her. The therapeutic alliance is built from an initial foundation of love,
trust, and commitment.

Give the client the idea that you are going through treatment with him or her. The
client does not have to feel alone. Neither of you can do this alone. Both of you
are needed in cooperation with each other. Clients know things that you do not
know. They have knowledge that you do not have. They know themselves better
than they know anybody, and they need to learn how to share themselves with you.
Likewise, you know things that they do not know. You know the tools of recovery.
You have to share these tools and help the clients use them. This is a cooperative
effort. It is as if you are on a wonderful journey together.
The Importance of Trust
Your clients must develop trust in you. To establish this trust, you must be
consistent. You must prove to the clients, repeatedly, that you are going to be
actively involved in their individual growth. I will say this again, when you say
that you are going to do something, you do it. When you make a promise, you keep
it. You never try to get something from the clients without using the truth. You
never manipulate, even to get something good. The first time your clients catch you
in a lie—even a small one—your alliance will be weakened.

Clients must understand that you are committed to their recovery but that you
cannot recover for them. You cannot do the work by yourself. You must work
together cooperatively. You can only teach the tools of recovery. The clients have
to use the tools to establish abstinence.
Dealing With Early Denial
The first few hours of treatment are not a time for harsh confrontation. It is a time
for listening, supporting, and encouraging the client to share what he or she can
share. The great healer in any treatment is love (treating the other person like you
would want to be treated), and love necessitates action in truth. All clients come
into treatment in denial. They have been dishonest with themselves and others.
They are lying, and they will lie to you. Your job is to search for ambivalence and
inconsistencies in their stories and reveal the lies as gently as possible. Reflect
the truth. You do not want to hurt the clients or incur their wrath, but you must be
dedicated to the truth. This program demands rigorous honesty.

Clients lie to themselves in many ways. They do not want to see the whole truth
because the truth makes them feel guilty and anxious. They keep the uncomfortable
feelings under control by deceiving themselves. They distort reality just enough to
feel reasonably comfortable. They defend themselves against the truth with
unconscious lies called defense mechanisms. “As long as we could stop using for
a while, we thought we were all right. We looked at the stopping, not the using”
(Narcotics Anonymous [NA], 1988, p. 3).

Clients minimize reality by thinking that the problems are not so bad. Then they
rationalize by thinking that they have a good reason to use drugs. Then they deny
by stubbornly refusing seeing the problems at all. Treatment is an endless search
for truth.

Those who do not recover are people who cannot or will not completely
give themselves to this simple program, usually men and women who are
constitutionally incapable of being honest with them. There are such
unfortunates. They are not at fault. They seem to have been born that way.
They are naturally incapable of grasping and developing a manner of living
which demands rigorous honesty. (AA, 2001, p. 58)

Your job as an addiction counselor is to help the clients learn the truth knowing
that the truth will set them free from the slavery to the lies.
Example of an Initial Contact
Approach the client. Reach out and take the client’s hand. “Hi, Ralph.” Use
the client’s first name. “I am _________________________ [your name]. I
am going to be your counselor. How are you doing?”
The client looks at the floor and then at the wall. (You know the importance
of silence and wait.)
The client finally looks up. “I am okay, I guess.”
“The first few days are going to be the hardest. After that, it is going to be a
lot better. This is the beginning of recovery. Is there anything I can do for you
right now to make you feel more comfortable?”
“I don’t think so,” Ralph says, looking relieved.
“If you feel uncomfortable, I want you to tell the nurse or one of the staff,
okay? If you cannot find anyone else, come and see me. My door is always
open to you. We want you to feel calm and tranquil through withdrawal, not
anxious or tense. Do not try to get through this by yourself. Let us help you.
How you feel is important to us.” (The therapeutic alliance is being
established.)

The client might never have experienced unconditional positive regard before. It
might seem strange to the client. To many clients, it is unbelievable. They come
into treatment with preconceived ideas about how treatment is going to go. Many
think that they are going to be punished. When they are greeted with love and
affection, it comes as a great surprise. Your words of support and concern are as
soothing as a warm bath.

All chemically dependent clients, at some level, want to punish themselves. They
feel guilty about what they have done, and they are waiting for the executioner.
They expect to be treated poorly. When you treat them with respect, they ask
themselves why people are treating them so nice. Could it be that I am worth it?

Tell your clients that they are important. The staff cares about how they feel and
what they want. You are here to help. You want to help. You are going to respond
to the client’s needs. It might be tough for a while, but things are going to get
better.
How to Check for Organic Brain Dysfunction
Clients need to be checked for medical problems, particularly organic brain
syndrome, as quickly as possible. Some clients coming into treatment are
organically compromised and need immediate medical treatment to prevent further
damage. Clients may be intoxicated, may be in withdrawal, or may have a serious
vitamin deficiency called Wernicke’s encephalopathy.

You should be familiar with how to check a client for these cognitive problems.
The Cognitive Capacity Screening (see Appendix 1) is an excellent way of
screening for organic brain problems (Jacobs, Bernhard, Delgado, & Strain,
1977). The Mini-Mental State Examination is a similar assessment test (Folstein,
Folstein, & McHugh, 1975). Either of these tests is a brief 10-minute assessment
of how the brain is functioning. The test is simple and comes up with a score. If
the client falls below the cutoff score, then inform medical professionals of the
possible organic problems. If you notice anything unusual about how the client
moves, acts, or speaks, then tell a physician or nurse. Always count on your
medical staff or the client’s family physician. They are more skilled at these
examinations than you are.
The Initial Assessment
During the first few hours, you must determine whether clients fit into your
program. Do they have a problem with chemicals? What is their level of
motivation? Do they have the resources necessary for treatment? Are they well
enough to move through your program? The criteria for admission are different for
different facilities. For the most part, you will start by asking yourself certain
basic questions about a client. Does this person have a problem with addiction?
Does he or she need treatment? Is this person motivated? What kind of treatment
does he or she need?
Referral
The counselor will need to establish and maintain relationships with civic groups,
agencies, other professionals, governmental entities, and the general recovery
community to ensure appropriate referrals, identify service gaps, and help address
unmet needs. You will need to network and communicate with a large community
resource base. You need to have knowledge and understand the functioning of
these agencies:

Civic groups and neighborhood organizations

Health care systems
Employment and vocational opportunities
Rehabilitation services
Faith-based organizations
Governmental entities
Criminal justice systems
Child welfare agencies
Housing administrations
Child care facilities
Crisis intervention programs
Mutual and self-help groups
Advocacy groups

The counselor needs to have knowledge about community demographics, political

and cultural systems, and criteria for receiving community services, accessing
funding opportunities, state and federal legislative mandates and regulation,
confidentiality rules and regulations, effective communication styles, and
community resources for both affected children and other household members. If
you decide to refer, you must advocate for the client working with others in the
community as a team. You need to respect interdisciplinary service delivery,
respect the clients and the agency’s services, collaborate and cooperate with
respect, and appreciate strength-based principles that emphasize client autonomy
and skills development (SAMHSA, 2006).
Source: Andrea Morini/Thinkstock.
Two quick screening tests for alcoholism have been developed: the Short
Michigan Alcoholism Screening Test (SMAST) (see Appendix 2) (Selzer et al.,
1975) and the CAGE questionnaire (Ewing, 1984).

The Substance Abuse Subtle Screening Inventory (SASSI) was developed to

screen clients when they were defensive and in denial. The SASSI measures
defensiveness and the subtle attributes that are common in chemically dependent
persons. It is a difficult test to fake, unlike the SMAST or the CAGE
questionnaire. The SASSI gives the clients the opportunity to answer honestly
about their problems with chemicals, but it also measures the client’s possible
abuse using questions that do not pertain to chemicals (Creager, 1989; Miller,
1985). Clients can complete the SASSI in 10 to 15 minutes, and it takes only 1 or
2 minutes to score. It accurately identifies 98% of clients who need residential
treatment, 90% of nonusers, and 87% of early-stage abusers (Miller, 1985).

The Addiction Severity Index (ASI) is a widely used structured interview that is
designed to provide important information about what might contribute to a
client’s alcohol or drug problem. The instrument assesses seven dimensions that
typically are of concern in addiction: (1) medical status, (2) employment and
support status, (3) drug or alcohol use, (4) legal status, (5) family history, (6)
family and social relationships, and (7) psychiatric status. The ASI is
administered by a trained technician and takes about 1 hour (McLellan et al.,
1980).

The Recovery Attitude and Treatment Evaluator-Clinical Evaluation (RAATE-

CE) is a measure of client readiness. It assesses client resistance and impediments
to treatment. The instrument is a structured interview that measures five scales:
(1) degree of resistance to treatment, (2) degree of resistance to continuing care,
(3) acuity of biomedical problems, (4) acuity of psychiatric problems, and (5)
extent of social, family, and environmental systems that do not support recovery
(Mee-Lee, 1985, 1988).

As the counselor, you need to constantly ask yourself about clients’ stages of
motivation and introduce appropriate motivating strategies to move the clients up
to the next level. The manual will give you thousands of ways of doing this. No
two clients are alike, so you must be creative in helping the clients see the
inaccuracies in their thinking and move them toward the truth. The
precontemplation stage is where the individuals are not intending to take action
with regard to their substance abuse problem in the near future. Contemplation is
where the individuals intend to take action within the next 6 months. Preparation
is where the persons intend to take action within the next month. Action is where
the persons have made overt attempts to modify their lifestyles. Maintenance is
where the individuals are working a recovery plan and attempting to prevent
relapse. If you can move the clients up to the next stage, then you can be sure that
treatment is working (Prochaska & DiClemente, 1983; Prochaska et al., 1992;
Prochaska et al., 1994).

Clients at different stages of motivation will need different motivating strategies.

In the precontemplation stage, clients underestimate the benefits of change and
overestimate its cost. They remember the good things about addiction and forget
the bad. They are not aware that they are making these mistakes in judgment and
believe that they are right. Environmental events can trigger persons to move up to
the contemplation stage. An arrest, a spouse threatening to leave, or an
intervention each can increase motivation to change.

Clients in the preparation stage have a plan of action to cut down or quit their
addictive behavior. These clients are ready for input from their doctors,
counselors, or self-help books and should be recruited and motivated for action.
Action is where the clients are changing their behavior to cut down or quit the
addiction. These clients have entered early recovery and are actively involved in
treatment.

In the maintenance stage, clients are still changing their behavior to be better and
are working to prevent relapse. People who relapse are not well prepared for the
prolonged effort needed to stay clean and sober. All clients need to be followed in
continuing care because they need encouragement and support to stay in recovery.
Addicts typically do not have the skills needed to work a program in early
recovery. This takes time, commitment, and discipline.

As the counselor, you constantly try to raise your clients’ awareness about the
causes, consequences, and possible treatments for a particular problem.
Interventions that can increase awareness include observation, confrontation,
interpretation, feedback, and education. You point out the need to reevaluate the
environment and how to change behavior. Encourage the clients to reevaluate their
self-images and how they are negatively affected by the addictive behavior.
Encourage the clients to learn the new skills of honesty, helping others, and
seeking relationships with a higher power (Prochaska & DiClemente, 1983;
Prochaska et al., 1992, 1994).
Laboratory tests can be used to corroborate suspicions about excessive alcohol
use that have been generated by the history and physical. None of the tests alone or
in combination can diagnose alcoholism, but they add to the certainty of the
diagnosis and warn clients of physical complications. High serum levels of liver
enzymes can represent alcohol-induced hepatic injury. Ethyl glucuronide (EtG)
testing is the newest way to test for alcohol consumption and can detect alcohol
use up to 80 hours after drinking (1-800-724-1970;
[Link]). The problem is the test is too sensitive. It will
pick up any alcohol use, including using common products such as hand sanitizers
or aftershave. Therefore, this is not a good stand-alone biomarker to test for
relapse. Gamma-glutamyl transferase (GGT) is elevated in two thirds of
alcoholics. There are many sources for an elevated GGT, and GGT only elevates
with heavy drinking. Aspartate aminotransferase (AST) and alanine
aminotransferase (ALT) are elevated in about one half of alcoholics. Alteration of
fat metabolism causes elevated serum triglycerides in about one fourth of
alcoholics. Alkaline phosphatase is elevated in about one sixth of alcoholics.
Total bilirubin is elevated in about one seventh of alcoholics. Mean corpuscular
volume (MCV) is elevated in about one fourth of alcoholics. Uric acid is elevated
in about one tenth of alcoholics. A newer biomarker is carbohydrate deficient
transferin (CDT) and is now widely available. It has moderate sensitivity and
picks up drinking at least five drinks a day for 2 weeks. This biomarker has been
shown to be a good measure to identify relapse. The advantage of CDT over GGT
is that fewer things can cause elevation. However, CDT is not as sensitive to
heavy alcohol use, resulting in false positives. The best biomarkers for monitoring
abstinence are using a combination of urine alcohol and EtG. A follow-up test of
CDT could be used to confirm heavy alcohol use (Brostoff, 1994; DuPont, 1994;
SAMHSA, 2009b; Wallach, 1992).
How to Conduct a Crisis Intervention
Clients who are severely dependent and unwilling or unable to see the severity of
their addiction need a crisis intervention. Crisis intervention is a confrontation by
a group of concerned family and friends. This confrontation must be gentle and
supportive, and it is best to use a trained interventionist to help you develop the
intervention strategy. If you want to do the intervention yourself, first read the
books Love First: A New Approach to Intervention for Alcoholism and Drug
Addiction by Jeff and Debra Jay (2001) and No More Letting Go: The
Spirituality of Taking Action Against Alcoholism and Drug Addiction by Debra
Jay (2006). These excellent texts carefully discuss the intervention techniques.
Basically, an intervention has to be carefully organized, rehearsed, and
choreographed. Each member of the group should be a caring significant other and
not an addict. Each person writes a letter stating exactly how the client’s addiction
has negatively affected his or her life. In this letter, group members share their
love and concern for the client and ask that the client enter treatment. The client is
told it is not he or she that is the problem but the illness. It is a lethal problem, and
it needs treatment. Each person reads his or her letter of concern and love for the
client and asks him or her to go into treatment that day. Save the best letter for last.
This is someone very tender and special to the client. It might be the client’s child,
a friend, or family member. It is someone whose letter breaks your heart. The
treatment setting has been arranged, and the client’s bags are packed. The
intervention needs to be held at a neutral location when the client is clean and
sober, not in the client’s home or office, where the client may feel more
comfortable. It is difficult for the wall of denial to hold up under all of this love,
and most of the time, the client agrees to go into treatment. If the client refuses, the
truth has still come out, and this often leads to treatment later. Each participant is
encouraged to exhibit the following behaviors:

Show positive regard for the client and negative regard for the addiction.
Give specific situations where the addiction negatively affected them.
Validate that addiction is a disease, and it is not the client’s fault.
Source: Andrea Morini/Thinkstock.

Interventions and treatment are going to take time. If you are a primary care
physician, emergency room doctor, cardiologist, or surgeon, you might not have
the time to struggle with this problem. All addiction treatment is a long journey
toward the truth, and this journey is slow and painful. Clients have to face the
demons they have hidden from for years. They need to walk into the dark forest of
fear and need a trustworthy guide. They need someone with time, energy, patience,
and love, a person who has been on this journey many times and come out alive.
At some point, you need to decide if you are going to take on this problem yourself
or refer to an addiction professional. Remember that addiction is a chronic
relapsing brain disease. It is only at the 5-year sobriety point that the relapse rate
drops to around zero (Vaillant, 2003).

Therefore, if you take this battle on, it is going to be a long one. If you look at
addiction programs around the country, you will see that about half of the clients
who leave treatment stay sober for the next year. Ninety percent of clients who
work the program stay clean and sober. Therefore, if you want to take on this job,
remember that you are in a 5-year fight for the client’s life. You must do everything
in your power to make sure that the client works the program. Because of
protracted withdrawal, dual diagnoses, organic brain syndrome, and many other
factors, about half of all addicts are not able to work their program on their own.
They do not have the spiritual, mental, or physical skills necessary to work a self-
directed program of recovery. These clients may need years in a structured facility
or a highly structured continuing care program.

Figure 2.1 Example of an Intervention Letter

Sometimes you will want to refer an addict to an addiction professional. There

are excellent alcohol and drug counselors and physicians that specialize in
addiction. They are used to the battle, and they have specialized training to deal
with the special problems of addiction. A treatment facility locator can be found at
[Link] Other times, you will want to try to help the client
yourself, but remember you are in for a 5-year battle. Never forget that you are the
healer, and you will do everything in your power to keep your client sober.

Once the diagnosis of addiction has been made, you will need to decide what
level of care the client needs to get the best help possible in the least restrictive
environment. This is why the American Society of Addiction Medicine (ASAM)
developed the client placement criteria.
American Society of Addiction Medicine Patient
Placement Criteria
All clients need to be assessed constantly in the following six dimensions:

1. Acute intoxication and/or withdrawal complications

2. Biomedical conditions and complications
3. Emotional, behavioral, or cognitive conditions and complications
4. Readiness to change
5. Relapse, continued use, or continued problem potential
6. Recovery and living environment

These are the areas of assessment that have been developed by the ASAM in the
second edition of its handbook ASAM PPC-2R, ASAM Patient Placement Criteria
for the Treatment of Substance-Related Disorders, Second Edition-Revised
(Mee-Lee, 2001). All counselors need to have a copy of this document and use
these criteria in deciding which level of care clients need. (A copy of the criteria
can be obtained from the ASAM, 4601 North Park Avenue, Upper Arcade, Suite
101, Chevy Chase, MD 20815.) The manual details specific criteria for
admission, continued stay, and discharge for all levels of treatment, adult and
adolescent.

For brevity, the present book concentrates on the criteria for admission and
discharge of adult and adolescent outpatient and inpatient treatment. These are the
criteria that you, as the counselor, will use most often. The criteria are as
objective and measurable as possible, but some clinical interpretation is
involved. Psychoactive disorders are no different from any other medical
evaluation. Assessment and treatment are a mix of objectively measured criteria
and professional judgment. The six dimensions that need to be assessed are as
follows:

1. Acute intoxication and/or withdrawal complications

1. What risk is associated with the client’s current level of intoxication?
2. Is there significant risk of severe withdrawal symptoms based on the
client’s previous withdrawal history and amount, frequency, and
recency of discontinuation of chemical use?
3. Is the client currently in withdrawal? To measure withdrawal, use the
 Clinical Institute Withdrawal Assessment of Alcohol (see Alcohol
Withdrawal Scale, or Appendix 4), the Benzodiazepine Scale (Busto,
Sykora, & Sellers, 1989), the Narcotic Withdrawal Scale (see
Appendix 5) (Fultz & Senay, 1975), or the Clinical Opiate Withdrawal
Scale (COWS) (see Appendix 57).
4. Does the client have the supports necessary to assist in ambulatory
detoxification (or “detox”) if medically safe?

2. Biomedical conditions and complications

1. Are there current physical illnesses, other than withdrawal, that may
need to be addressed or that may complicate treatment?
2. Are there chronic conditions that may affect treatment?

3. Emotional, behavioral, or cognitive conditions and complications

1. Are there current psychiatric illnesses or psychological, emotional,
cognitive, or behavioral problems that need treatment or may
complicate treatment?
2. Are there chronic psychiatric problems that affect treatment?

4. Readiness to change
1. Is the client objecting to treatment?
2. Does the client feel coerced into coming to treatment?
3. Does the client appear to be complying with treatment only to avoid a
negative consequence, or does he or she appear to be self-motivated?

5. Relapse, continued use, or continued problem potential

1. Is the client in immediate danger of continued use?
2. Does the client have any recognition of, understanding of, or skills with
which he or she can cope with his or her addiction problems to prevent
continued use?
3. What problems will potentially continue to distress the client if he or
she is not successfully engaged in treatment at this time?
4. How aware is the client of relapse triggers, ways of coping with
cravings, and skills at controlling impulses to continue use?

6. Recovery and living environment

1. Are there any dangerous family members, significant others, living
situations, or school or working situations that pose a threat to treatment
success?
 2. Does the client have supportive friendships, financial resources, or
educational vocational resources that can increase the likelihood of
treatment success?
3. Are there legal, vocational, social service agency, or criminal justice
mandates that may enhance the client’s motivation for treatment?

Clients must be able to understand treatment. They must be intellectually capable

of absorbing the material. They must be physically and emotionally stable enough
to go through the treatment process. They cannot be actively harmful to themselves
or to others. They cannot be overtly psychotic. They cannot have such a serious
medical or psychiatric problem that they cannot learn.
Diagnostic and Statistical Manual
Criteria for Diagnosis
To make a diagnosis, use the criteria listed in the current edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM) published by the American
Psychiatric Association. (A copy of the DSM can be obtained from the American
Psychiatric Association, 1400 K Street, N.W., Washington, DC 20005.) A new
edition comes out every few years, so there will be changes in the criteria from
time to time. The 2013 criteria (American Psychiatric Association, 2013) are
listed in Appendix 3.

Diagnosis: Substance Use Disorder

1. A maladaptive pattern of psychoactive substance use leads to clinically
significant impairment or distress indicated by one or more of the following
occurring within a 12-month period:
1. Recurrent substance use resulting in a failure to fulfill major role
obligations at work, school, or home (e.g., repeated absences or poor
work performance related to substance use; substance-related absences,
suspensions, or expulsions from school; or neglect of children or
household)
2. Recurrent use in situations where use is physically hazardous (e.g.,
driving an automobile or operating a machine when impaired by
substance use)
3. Recurrent substance-related legal problems
4. Continued substance use despite having persistent or recurrent social or
interpersonal problems caused or made by the effects of the substance
(e.g., arguments with spouse about consequences of intoxication,
physical fights)
2. The symptoms never met the criteria for psychoactive substance dependence
for this class of substance.

Questions for You to Ask the Client

1. What are your drinking and drug habits?
2. Was there ever a period in your life when you drank or used drugs too much?
3. Have drugs or alcohol ever caused problems for you?
 4. Has anyone ever objected to your drinking or drug use?

If you are unable to diagnose a substance use disorder, then check with the family.
The client may be in denial, and you might get more of the truth from someone
else. A family member, particularly a spouse or a parent, might give you a more
accurate clinical picture of the problems.
Diagnosis: Substance USE Disorder
A maladaptive pattern of substance use leads to clinically significant impairment
or distress, as manifested by three or more of the following, occurring at any time
during the same 12-month period:

1. Tolerance, as defined by either of the following:

1. A need for markedly increased amounts of the substance to achieve
intoxication or desired effect
2. Markedly diminished effect with continued use of the same amount of
the substance

2. Withdrawal, as manifested by either of the following:

1. The characteristic withdrawal syndrome for the substance
2. The same (or a closely related) substance taken to relieve or avoid
withdrawal symptoms
3. The substance is often taken in larger amounts or over a longer period of time
than was intended.
4. There is a persistent desire or one or more unsuccessful efforts to cut down
on or control substance use.
5. A great deal of time is spent in activities necessary to obtain the substance
(e.g., visiting multiple doctors, driving long distances), to use the substance
(e.g., chain smoking), or to recover from its effects.
6. Important social, occupational, and/or recreational activities are given up or
reduced because of substance use.
7. The substance use is continued despite knowledge of having a persistent or
recurrent psychological or physical problem that is likely to have caused or
been made worse by the use of the substance (e.g., current cocaine use
despite recognition of cocaine-induced depression, continued drinking
despite recognition that an ulcer was made worse by alcohol consumption).

Specify if:

With physiological dependence: Evidence of tolerance or withdrawal

Without physiological dependence: No evidence of tolerance or withdrawal

Explain to the client that the diagnosis is your best professional judgment. It is
important that the client makes up his or her own mind. The client needs to collect
the evidence for himself or herself and to get accurate in his or her thinking. Does
the client have a problem or not? This is a good time to explain about denial and
how it keeps clients from seeing the truth.
Gambling Disorder

Diagnostic Criteria for 312.31 Gambling Disorder

Persistent and recurrent maladaptive gambling behavior is indicated by five (or
more) of the following:

1. 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)
2. Needs to gamble with increasing amounts of money to achieve the desired
excitement
3. Has repeated unsuccessful efforts to control, cut back, or stop gambling
4. Is restless or irritable when attempting to cut down or stop gambling
5. Gambles as a way of escaping from problems or of relieving a dysphoric
mood (e.g., feelings of helplessness, guilt, anxiety, or depression)
6. After losing money gambling, often returns another day to get even (“chasing”
one’s losses)
7. Lies to family members, therapist, or others to conceal the extent of
involvement with gambling
8. Has committed illegal acts such as forgery, fraud, theft, or embezzlement to
finance gambling
9. Has jeopardized or lost a significant relationship, job, or educational or
career opportunity because of gambling
10. Relies on others to provide money to relieve a desperate financial situation
caused by gambling

The gambling behavior is not better accounted for by a manic episode.

How to Determine the Level of Care Needed
Once you know that the client has a significant addiction, you must decide the
level of care the client needs. There are five levels of care generally offered
across the United States:

Level 0.5: Early intervention. Early intervention is an organized service

delivered in a wide variety of settings. Early intervention explores and
addresses problems or risk factors related to substance use and assists
clients in recognizing the harmful consequences of inappropriate substance
use. Clients who need early intervention do not meet the diagnostic criteria
of either substance abuse or dependency, but they have significant problems.
The rest of the treatment levels include clients who meet the criteria for
psychoactive substance abuse or dependency.
Level I: Outpatient treatment. Outpatient treatment takes place in a
nonresidential facility or in an office run by addiction professionals. Clients
come in for individual or group therapy sessions, usually fewer than 9 hours
per week.
Level II: Intensive outpatient or partial hospitalization.
Level II.1: Intensive outpatient treatment. This is a structured day or
evening program of 9 or more hours of programming per week. The program
has the capacity to refer clients for their medical, psychological, or
pharmacological needs.
Level II.5: Partial hospitalization. Partial hospitalization generally includes
20 or more hours of intense programming per week. This program has ready
access to psychiatric, medical, and laboratory services.
Level III: Residential or inpatient services.
Level III.1: Clinically managed, low-intensity residential services. This is a
halfway house.
Level III.3: Clinically managed, medium-intensity residential services.
This is an extended care program oriented around long-term management.
Level III.5: Clinically managed, high-intensity residential services. This is
a therapeutic community designed to maintain recovery.
Level III.7: Medically monitored intensive inpatient treatment. This
residential facility provides a 24-hour structured treatment. This program is
monitored by a physician and is able to manage the psychiatric, physical, and
pharmacological needs of its clients.
Level IV: Medically managed intensive inpatient treatment. This 24-hour
program has the resources of a hospital. Physicians provide daily medical
management.
Criteria for Outpatient Treatment (Adults)
An adult client qualifies for outpatient treatment if he or she meets the diagnostic
criteria for psychoactive substance use disorder as defined by the current DSM
and if the client meets all six of the following criteria:

1. The client is not acutely intoxicated and is at minimal risk for suffering
severe withdrawal symptoms.
2. All medical conditions are stable and do not require inpatient management.

3. All of the following conditions exist:

1. The individual’s anxiety, guilt, and/or depression, if present, appear to
be related to substance-related problems rather than to a coexisting
emotional or cognitive/behavioral condition. If the client has emotional,
cognitive, or behavioral problems other than those caused by substance
use, then the problems are being treated by an appropriate mental health
professional.
2. Mental status does not preclude the client from comprehending and
understanding the program or from participating in the treatment
process.
3. The client is not at risk for harming himself or herself or others.

4. Both of the following conditions exist:

1. The client expresses a willingness to cooperate with the program and to
attend all scheduled activities.
2. The client may admit that he or she has a problem with alcohol or drugs,
but the client requires monitoring and motivating strategies. The client
does not need a more structured program.
5. The client can remain abstinent only with support and can do so between
appointments.

6. One of the following conditions exists:

1. The environment is sufficiently supportive to make outpatient treatment
feasible. Family or significant others are supportive of recovery.
2. The client does not have the ideal support system in his or her current
environment, but the client is willing to obtain such support.
3. Family or significant others are supportive, but they need professional
interventions to improve chances of success.
Criteria for Inpatient Treatment (Adults)
An adult client needs inpatient treatment if he or she meets the DSM diagnostic
criteria for substance use disorder and meets at least two of the following criteria:

1. The client presents a risk of severe withdrawal or has had past failures at
entering treatment after detox.
2. The client has medical conditions that present imminent danger of damaging
health if use resumes or concurrent medical illness needs medical
monitoring.

3. One of the following conditions exists:

1. Emotional, cognitive, or behavioral problems interfere with abstinence
and stability to the degree that there is a need for a structured 24-hour
environment.
2. There is a moderate risk of behaviors endangering self or others. There
are current suicidal or homicidal thoughts with no action plan and a
history of suicidal gestures or homicidal threats.
3. The client is manifesting stress behaviors related to losses or
anticipated losses that significantly impair daily living. A 24-hour
facility is necessary to address the addiction.
4. There is a history or presence of violent or disruptive behavior during
intoxication with imminent danger to self or others.
5. Concomitant personality disorders are of such severity that the
accompanying dysfunctional behaviors require continuous boundary-
setting interventions.
4. Despite consequences, the client does not accept the severity of the problem
and needs intensive motivating strategies available in a 24-hour structured
setting.

5. One of the following conditions exists:

1. Despite active participation at a less intensive level of care or in a self-
help fellowship, the client is experiencing an acute crisis with an
intensification of addiction symptoms. Without 24-hour supervision, the
client will continue to use.
2. The client cannot control his or her use so long as alcohol or drugs are
present in the environment.
 3. The treatments necessary for the client require this level of care.

6. One of the following conditions exists:

1. The client lives in an environment where treatment is unlikely to
succeed (e.g., chaotic, rife with interpersonal conflict that undermines
the client’s efforts to change, nonexistent family, other environmental
conditions, or significant others living with the client who manifest
current substance use and are likely to undermine the client’s recovery).
2. Treatment accessibility prevents participation in a less intensive level
of care.
3. There is a danger of physical, sexual, or emotional abuse in the current
environment.
4. The client is engaged in an occupation where continued use constitutes a
substantial imminent risk to personal or public safety.
Criteria for Outpatient Treatment (Adolescents)
An adolescent client qualifies for outpatient treatment if he or she meets DSM
criteria for substance use disorder and the following dimensions:

1. The client is not intoxicated and presents no risk of withdrawal.

2. The client has no biomedical conditions that would interfere with outpatient
treatment.
3. The client’s problem behaviors, moods, feelings, and attitudes are related to
addiction rather than to a mental disorder, or the client is being treated by an
appropriate mental health professional. The client’s mental status is stable.
The client is not at risk for harming himself or herself or others.
4. The client is willing to cooperate and attend all scheduled outpatient
activities. The client is responsive to parents, school authorities, and staff.
5. The client is willing to consider maintaining abstinence and recovery goals.

6. A sufficiently supportive recovery environment exists to make outpatient

treatment feasible:
1. Parents or significant others are supportive of treatment, and the
program is accessible.
2. The client currently does not have a supportive recovery environment
but is willing to obtain such support.
3. The family or significant others are supportive but require professional
intervention to improve chances of success.
Criteria for Inpatient Treatment (Adolescents)
To qualify for inpatient treatment, the adolescent must meet the DSM criteria for
substance use disorder, all of the dimensions for outpatient treatment, plus at least
two of the following dimensions:

1. The risk of withdrawal is present.

2. Continued use places the client at imminent risk of serious damage to health,
or a biomedical condition requires medical management.

3. History reflects cognitive development of at least 11 years of age and

significant impairment in social, interpersonal, occupational, or educational
functioning, as evidenced by one of the following:
1. There is a current inability to maintain behavioral stability for more
than a 48-hour period.
2. There is a mild to moderate risk to self or others. There are current
suicidal or homicidal thoughts with no active plan and a history of
suicidal or homicidal gestures.
3. Behaviors are sufficiently chronic and/or disruptive to require
separation from the current environment.
4. The client is having difficulty in acknowledging an alcohol or drug problem
and is not able to follow through with treatment in a less intense environment.
5. The client is experiencing an intensification of addiction symptoms despite
interventions in a less intense level of care; the client has been unable to
control use so long as alcohol or drugs are present in his or her environment,
or the client, if abstinent, is in crisis and appears to be in imminent danger of
using alcohol or drugs.

6. One of the following conditions exists:

1. The environment is not conducive to successful treatment at a less
intense level of care.
2. The parents or legal guardians are unable to provide consistent
participation necessary to support treatment in a less intense level of
care.
3. Accessibility to treatment precludes participation in a less intense level
of care.
4. There is a danger of physical, sexual, or emotional abuse in the client’s
current environment.
The Client’s Reaction to Intoxication
Clients in these acute organic brain syndrome states can seem to be relatively
normal or extremely bizarre. They can be actively psychotic, relaxed and
comfortable, or in a panic. They can experience intense flashbacks. High doses of
amphetamines, cocaine, or phencyclidine (PCP) may produce organic delirium.
Disorganized thinking, a cloudy sensorium, and memory deficits can characterize
delirium. The client will not be able to follow a conversation. The disorganized
thinking is manifested by rambling, irrelevant, or incoherent speech. This delirium
usually is brief (less than 6 hours) after amphetamine or cocaine use, but it can
last for up to a week after PCP use (Schuckit, 1984; Spitzer, 1987).

Acute use of amphetamines, cocaine, or PCP may result in a delusional state.

Delusions are false beliefs that are intractable to logic. The client may feel that
someone or some group is out to get him or her. The client may think that he or she
has strange or unusual powers. These delusions usually are brief, lasting from
several hours to several days, but in some clients, they can last for up to a year,
even in the absence of further drug use. Hallucinogen use can result in the
development of delusions (Vardy & Kay, 1983). Brief psychotic states also have
been reported following cannabis use (Hollister, 1986).

During acute intoxication and withdrawal, it is not unusual to see clients

complaining of hallucinations. These hallucinations usually are visual or tactile
and rarely are auditory. Lights may seem too bright, or sounds may seem too loud
and startling. This is a transient psychotic state. The clients may see trailing of
objects (e.g., when the clients move a hand, they see a brief image extend behind
the solid object like a jet contrail). The walls or floor might seem to move, or the
clients might see bugs or other things that are not there. The clients may feel
something unusual on or under their skin. These hallucinations usually are brief,
but the clients will need to be reassured and supported. The clients’ brains are
chemically correcting. These negative experiences are used to give the clients
evidence that they need to stop abusing chemicals.
Source: ©[Link]/keeweeboy.
What to Do With an Intoxicated Client
Never argue with intoxicated clients. This will get you nowhere. They probably
are not going to remember the conversation anyway. Briefly introduce yourself, let
the medical staff examine and treat these clients, and let the clients sleep.
Intoxicated clients and clients in withdrawal will mainly be the responsibility of
the medical staff. These staff members will be watching the clients carefully and
monitoring their vital signs.

There is an old idea that has been floating around the field for years that clients
should hurt in withdrawal. The theory goes that this will help clients to learn that
they have a problem. To do this would be a medically unsound practice. It is
inappropriate to subject clients to severe withdrawal symptoms just to teach them
a lesson. Some of them would die. Clients should be medicated to a point where
they stay in mild withdrawal. This hurts enough.

Intoxicated clients who want to talk will have to be reassured and educated. They
are not bad people. They are sick. If they want to talk a lot, then let some of the
other clients do the talking. Join in if you must. The clients will definitely need to
trade off. This is very tiring work, but it is beneficial for them to see the
intoxicated clients so messed up. It reinforces for the other clients that they never
want to go through this again.

Clients need to be educated about withdrawal. What can they expect? The main
thing that clients need to hear is that things are going to get better. With every hour
that passes, things are going to improve. The staff is not going to let the clients feel
too uncomfortable. Things are going to feel uncomfortable sometimes, but the staff
is not going to allow the pain to reach intolerable levels.

Many of the clients’ thoughts and feelings now are chemically induced. The clients
need to understand that they are going to have some wide mood swings in acute
withdrawal. Most clients will be feeling depressed, agitated, irritable, and crabby
at various times. They need to have their fears and concerns put to rest. Let them
talk. Answer their questions. Listen. These clients need a lot of attention.
Detoxification
Except for the hallucinogens, PCP, and the inhalants, prolonged drug or alcohol
use is accompanied by the development of drug tolerance and physical
dependence. In the case of withdrawal from central nervous system depressants
(alcohol, barbiturates, and benzodiazepines), tremulousness, sweating, anxiety,
and irritability may give way to life-threatening seizures and delirium. Opioid
withdrawal is not life threatening, although the client feels uncomfortable, like
they have the flu (Group for the Advancement of Psychiatry Committee on
Alcoholism and the Addictions, 1991). Withdrawal from central nervous system
(CNS) stimulants may be accompanied by a “crash” characterized by depression,
fatigue, increased need for sleep, and increased appetite (Gawin & Ellinwood,
1988; Kasser, Geller, Howell, & Wartenberg, 1998).

Source: ©[Link]/Scrofula.

Detoxification is the gradual, safe elimination of the drug from the body. Some
drugs, such as alcohol, are detoxified quickly, usually within a few days, but the
benzodiazepines may take weeks or months (Burant, 1990; Schuckit, 1984). Many
clients are suffering from polysubstance withdrawal, and this can complicate the
clinical picture. The drugs most likely to cause serious physical problems are the
depressants. These clients can deteriorate rapidly.
How Clients React in Detoxification
Most any physical or mental symptom can present itself in withdrawal. No heavy
confrontation is necessary. These clients are sick and irritable. They are sleeping
poorly. They have powerful cravings. This is where many clients walk out of
treatment. They feel as though they cannot stand the symptoms anymore. These
clients need medication, reassurance, and support. You must be gentle. Keep
telling them repeatedly that it will get better. If they stay clean and sober, then they
never will have to go through this misery again. The correct detox medication
should keep the client in a mild withdrawal that is easily tolerated, but some
clients can’t seem to stand even mild withdrawal symptoms.

In withdrawal, clients are restless and have strong cravings. This physiological
and psychological need for the substance is the primary motivating force behind
drug addiction. The clients’ bodies are driving them to return to their drugs of
choice. The cells are screaming for relief. The clients have been in withdrawal
hundreds of times before, but they always have treated it by getting intoxicated
again. Now they are going to stick it out, striving for recovery. All of these clients
think about leaving treatment, but when they get to feeling a little better, they reach
the greatest chance of actually going out the door. You must be on top of this by
constantly assessing where the clients are both physically and psychologically.

The clients need to keep a journal of each day they are in treatment. What
happened? What did they learn? What do they need to work on? As they
journal, they need to think about their recovery skills and how they need to
use them.
The clients need to rate their cravings and try to uncover the situations,
feelings, or thoughts that trigger the craving. Clients need to keep up with
their Daily Craving Record (see Appendix 66) for at least the first 90 days of
recovery. Check this record often throughout treatment to see how the client
is doing in recovery. Identify situations, thoughts, and feelings that trigger
craving, and make a plan to cope with each trigger. Watch for triggers that
happen repeatedly because they are driven by inaccurate thoughts. For
example, the client may have a trigger that he or she calls feeling angry.
“When I get angry, I want to drink.” You know that all anger comes from hurt,
so you try to answer the questions, of how people hurt the client so often or
how other people are seen as being too aggressive. Once you pull for the
 thinking that comes before the feeling, you will get more and more data about
how to help the client see these situations and to cope with each situation
appropriately.

Detoxification should be managed in a room that is reduced of excessive

stimulation. The area needs to be quiet and without bright lights. Familiar people,
pictures, a clock, and clothes are helpful. Soft conversation that reassures clients
and keeps them oriented is best. The staff should display a positive attitude of
mutual respect. Reassuring touches, such as taking a pulse and putting a hand on a
shoulder, are helpful (Baum & Iber, 1980).

Once the acute withdrawal syndrome has passed, clients remain in a protracted
abstinence syndrome for weeks or even years. Relapse is higher during this period
of physiological adjustment. The protracted abstinence syndrome varies
depending on the drug of dependency. Typically, it is a symptom constellation
opposite of that which the client was using the drug to produce (e.g., the client
using stimulants to increase energy will experience lethargy) (Geller, 1990).
The AMA Threat
Clients in an inpatient or outpatient setting can present an AMA threat (leave
treatment against medical advice). They usually isolate themselves first from
treatment peers and staff. Addictive thinkers must lie to themselves and believe
that the lies are the truth for the illness to work. The addiction cannot exist in the
light of the truth. The disease has a much better chance of working in isolation.
That is why clients must not be left alone in early treatment until they have
stabilized.

The illness cooks a stew of inaccurate information—minimization (“My use is not

that bad”), rationalization (“I have a good reason to use”), projection (“It is not
my problem; it is their problem”), and denial (a stubborn refusal to see the truth).
All of these defenses are used to distort reality.

You may first get wind of an AMA threat as you assess a client, or you may learn
of it from another client or from a staff member. The client shares that he or she is
thinking about leaving treatment. You must intervene when you see this problem
developing. As the client tells more and more lies to himself or herself, the client
becomes convinced that the lies are the truth. The client keeps collecting
information that proves that the illness is right.

For the most part, clients’ reasons will be inaccurate. They are distortions of
reality. Clients might not be aware that the real reason why they are leaving
treatment is to use their drugs of choice. Clients delude themselves. They are
craving, but many of them do not know it. They believe the inaccurate thinking.
Example of an AMA Intervention
The intervention desperately needed here is the truth. Every time the client brings
up a reason for leaving treatment, you challenge him or her with the truth. Be
gentle. The truth is on your side, and a big part of the client wants to know the
facts. Do not talk to the illness side of the client. Talk to the side that wants to get
well.

Client: I have to get out of here. I can quit on my own.

Counselor: You have tried that before, and you have always failed.

Client: This time I can do it.

Counselor: Your meth addiction is worse now than it has ever been. It is not
better. It’s worse.

Client: I will go to meetings. That is all I need. I know how to stay off drugs.

Counselor: You may do that for a while, but it is very likely that you will begin
using again.

Client: I think I can do it this time.

Counselor: You have had that thought a hundred times before. Give the disease
some credit. It is stronger than you are. The 12-step program says that no human
power can remove our addiction. It is unlikely that you will lick this problem on
your own.

Client: I will go to church.

Counselor: I believe you need treatment.

Client: I have some marital problems that I need to work out. I cannot do that in
here.

Counselor: The best thing you can do for your marriage is to stay in treatment
and get into a stable recovery. Why don’t we call your wife and see if she wants
you to leave?
Client: I have to get out of here. I do not fit in.

Counselor: Why don’t you try to help someone else?

Client: I am not like these people. Their problems are much worse than mine
are. Some of them are criminals.

Counselor: Weren’t you arrested twice?

Client: Yes.

Counselor: But you are not like these people?

Client: No.

This conversation can go on for quite some time. The longer you expose the lies
that the client is telling himself or herself, the better the chance of keeping the
client in treatment. If you have to, see whether the client will agree to stay in
treatment for one more day or even one more hour. The longer the client stays, the
more opportunity you have to help him or her see the truth.
How to Develop and Use the AMA Team
The AMA team is a group of three or more of the treatment peers selected by the
staff to help other clients who are at risk of leaving treatment early. Have them
share their experiences, strengths, and hopes with the client. Often, this group will
be more effective than you are. It is easier for a client to trust people who are in
treatment. In an outpatient setting, if you do not have an AMA group, then maybe
one of the clients further along in the program will agree to encourage the client to
stay.

If there are any consequences that a client will face if he or she leaves treatment,
this is the time to bring these things out. The client may have been court ordered
into treatment. The client’s employment may be in jeopardy. A spouse or parent
may have given the client an ultimatum—get treatment or else. Use every angle
you can so long as it is based in the truth. The family may even have to
involuntarily court commit the client into treatment.

The client must be gently told the truth until he or she hears it. There is a healthy
side of the client—the side that is sick of this problem and wants to recover. The
truth is a very powerful tool. It is even more powerful when delivered in an
atmosphere of encouragement and support.

Some counselors believe that they have to hammer away at a client’s denial
aggressively until they literally “break through it,” but it cannot be like a war. The
therapeutic alliance builds on mutual acceptance, trust, and unconditional positive
regard. It is impossible to trust someone who is verbally beating on you. This
behavior harms your relationship and makes your job even harder than it already
is. You will get angry with clients. That is normal; everyone does. Try to treat
clients the same way in which you would want to be treated.
How to Use the In-House Intervention
If all else fails, then you might have to arrange an in-house intervention. Here you
gather the client’s family and concerned others together and have them tell the
client why they want him or her to stay in treatment.

Have each of the participants write a letter stating how the client’s addiction has
adversely affected the participant. The participants need to give specific examples
of how they were hurt. They share how they are feeling now and ask for what they
want. They write down exactly what they are going to do if the client does not
agree to stay in treatment. A spouse could state that she has been humiliated in
front of friends. If the client does not stay in treatment, then she will divorce him.
An employer could say that he is weary of the client calling in sick. If the client
does not stay in treatment, then he or she will be fired. The kids could say that they
are embarrassed by the client and want out of the home. Parents could talk about
the lies and mistrust in the home and say that they are going to withdraw their
financial support.

In an intervention, the family members are going to need a lot of encouragement.

You need to help them with their letters and practice the intervention without the
client present. Once the group is gathered, bring the client in and have each
member share his or her letter. If the client is still unwilling to stay in treatment,
then you can open the group up for discussion. Again, every time the client gives
the family a good reason for leaving, you and the family will tell the client the
truth.
How to Respond to Clients Who Leave AMA
Do everything in your power to keep your clients in treatment, but if they decide to
leave early, then wish them well, and invite them to come back if they have further
problems. Many clients will leave for a time and then return. Whatever happens,
remember that when the clients were in treatment, you told them the truth. Clients
leaving treatment are no reflection on you or your skills. You did not lose. You
planted the seed of the truth that will grow later.

Programs that are more genuinely caring will keep more clients than will
programs that are harsh and confrontational. The key balance is to confront the
clients in an atmosphere of support. An encouraging and supportive environment
is attractive, and everyone wants more. You will know that you have struck the
right balance when many of your clients are reluctant to leave treatment at the end
of their stays. They have felt so accepted, loved, and supported that they do not
want to leave an environment in which they have made major growth.
3 Biopsychosocial Interview

Source: ©[Link]/Shironosov.
The Biopsychosocial Interview
Now kick back and relax. Get yourself a cup of coffee. When the client has settled
into treatment, it is time to hear his or her whole story. This is an exciting time
because everyone’s story is fascinating, like a detective story. You are searching
for the leads necessary to develop a diagnosis and treatment plan. The
biopsychosocial assessment will be one of the most valuable times you spend
with your client. Every client is interesting and has a never-ending puzzle of
human and environmental interactions. Do not worry about being bored. This is a
great mystery, and you are the detective. You need to search out and find clues to
the problems.

The purpose of the biopsychosocial interview is to find out exactly what the
problems are and where they came from. Then you need to decide what you are
going to do about them. All diseases have biological, psychological, and social
factors that contribute to dysfunction. These ingredients mingle together, leaving
the client in a state of “dis-ease.” The client does not feel easy; he or she feels
“dis-easy.” There are no major psychiatric diseases that do not have
biopsychosocial components. All addiction affects the cells (bio from biology);
the emotions, attitudes, and behavior (psycho from psychology); and the social
relationships (socio from sociology).

To do your biopsychosocial interview, you will need the Biopsychosocial

Assessment form (see Appendix 31) and a quiet place where you will not be
disturbed. The interview will take at least 1 hour or maybe more. Many beginning
counselors are bogged down in this interview because they become overwhelmed
with information, or they try to begin treating the problems too early. This
interview is not for treatment; it is for assessment. The best way of keeping out of
these traps is to let the client do most of the talking. You ask the questions and let
the client tell his or her story, while you write it down. Ask for more information
only if you are confused or uncertain about what the client is describing. You must
understand the facts and how the client feels about the situation.

It will take you a while to become a skilled interviewer. It takes keen insight to
see the problems clearly, as they develop. You will get better at this as you
become more experienced.
How to Conduct the Interview
Begin the biopsychosocial interview by telling the client what you are going to do:
“The purpose of this interview is to see exactly what the problems are, where they
come from, and what we are going to do in treatment. From this information, we
will develop the treatment plan. You need to keep things very accurate here. Just
tell me exactly what happened.”

Now relax, and begin your interview. Do not be in a hurry. This is fascinating and
fun. Ask the following questions, and write the answers down in the blanks
provided on the biopsychosocial form.

Date:
Client name:
Age:
Sex:
Marital status:
Children:
Residence:
Others in residence:
Length of residence:
Education: Mark the highest grade completed.
Occupation:
Characteristics of the informant: Mark down whether or not you trust the
information that the client is giving you. Is the client reliable? If so, then
write “reliable informant.” If for some reason you do not trust the information
the client is giving you, then write why you mistrust it. You might want to
write “questionable informant.”
Chief complaint: This is the chief problem that brought the client to
treatment. Use the client’s own words. If someone else gives you the chief
complaint, then list that person as the informant. “What was the chief
problem that brought you to treatment?”
History of the present problem: This is everything that pertains to the chief
complaint. One good approach with histories is to say something like this:
“As they are growing up, kids have a really accurate idea when things are
right with them and when things are wrong. Go back into your childhood, and
tell me where you think things began to go wrong for you. From that point,
 tell me the whole story, including what is bringing you into treatment now.”

Let the client tell his or her story, and for the most part, you just copy it down. Use
as many direct quotes as you can. Guide the client only when you need to do so.
You want the story to flow in a rough chronological order. Most clients will do
this naturally, but everyone jumps around a little. Stop the client if he or she is
going too fast or if you do not understand something. Do not let the client ramble
and be caught up in irrelevant details. Look for the problem areas.

The history of the present problem must contain the following information:

Age of onset:
Duration of use:
Patterns of use: How does the client drink? Is this client a binge drinker or a
daily drinker? Does the client drink all day or only after work? How often
does the client drink?
Consequences of use: These are physical, psychological, and/or social
problems caused or made worse by drinking.
Previous treatment: Who did the client see? What was the treatment? What
were the results?
Blackouts:
Tolerance:
Withdrawal symptoms:
Past history: A history of the client’s life, from infancy to the present, is the
next phase of the interview. The categories include the following:
Place of birth:
Date of birth:
Developmental milestones: “Did you have any problems when you were
born? Problems walking, talking, toilet training, reading, or writing? Did
anyone ever say that you were a slow learner?” Cover developmental
problems and intellectual problems here. Determine as best you can whether
the client can understand the material presented in your program. Most
recovery material is written at a sixth-grade level. Clients who read two
grade levels below this are going to need special assistance.
Raised with: This includes primary caregivers, brothers, and/or sisters and
what it is like to live with them.
Ethnic and cultural influences: “What is your ethnic heritage?” This
includes race, sexual orientation, marital status, religious preference, culture,
disability or ability, ethnicity, geographic location, age, socioeconomic
status, and gender. An inner-city black teenager is going to be a lot different
from a Midwestern farmer. You need to know about the person’s culture and
be able to step into the person’s worldview from his or her perspective.
How does the culture relate to things such as time orientation, family,
sharing, cooperation, and taught customs that guide relationships? (For
further information on cultural differences, read the book Counseling the
Culturally Different: Theory and Practice [Sue & Sue, 1999]. This book
will help you to become culturally competent, which is essential to
understanding the client and offering good treatment.)
Home of origin: “When you were growing up, how did it feel in the house
where you were raised?”
Grade school: “What kind of a kid were you in grade school? How did you
get along with the other kids and the teachers?”
High school: “What kind of a student were you in high school? Did you get
in any trouble?”
College: “What were you like in college?”
Military history: “Were you ever in the armed services? For how long?
What was your highest rank? Did you get an honorable discharge?”
Occupational history: “Briefly tell me about your work history. What kind
of work have you done?” Include the longest job held and any consequences
of drug or alcohol use.
Employment satisfaction: “How long have you been at your current job? Are
you happily employed?”
Financial history: “How is your current financial situation?”
Gambling: “Do you gamble? Have you ever tried to cut back on your
gambling?”
Sexual orientation: “How old were you when you first had sex? Have you
ever had a homosexual contact?”
Sexual abuse: “Have you ever been sexually abused?”
Physical abuse: “Have you ever been physically abused?”
Current sexual history: “Are you having any sexual problems? Are you HIV
infected? Do you have AIDS or any sexually transmitted disease?”
Relationship history: Briefly describe this client’s relationship and
friendship patterns. Does the client have any close friends? Is the client in a
romantic relationship now? How is that going? Include consequences of
chemical use. Some helpful questions include the following: “Do you have
close friends? Have you ever been in love? How many times? Tell me a little
bit about each relationship.”
Social support for treatment: “Does your family support you coming into
treatment? What about your friends?” Thoroughly assess the client’s recovery
environment. How supportive are family and friends going to be about
recovery?
Spiritual orientation: “Do you believe in God or a higher power or anything
like that? Do you engage in any kind of religious activity?”
Legal: “Are you having any current problems with the law? Have you ever
been arrested?” List the year and cause of each arrest.
Strengths: “What are some of your strengths?”
Needs: “What are some of the things you need to do to get into recovery?”
Abilities: “What are some of your abilities that might help you stay in
recovery?”
Personal preferences: “How do you prefer to learn a recovery program,
person-to-person contact, group therapy, audiovisual material, reading, any
cultural preferences . . . ?”
Weaknesses: “What are some of your weaknesses or some of your qualities
that are not so good?”
Leisure: “What do you do for play, entertainment, or fun? What has been the
effect of your chemical use?”
Depression: “Have you ever felt depressed or down most of the day, almost
every day, for more than 2 weeks?” If the client has signs of depression, this
needs to be flagged for the medical staff.
Mania: “Have you ever felt so high or full of energy that you had little need
for sleep or got into trouble or people thought that you were acting
strangely?” Mania is a distinct period of abnormally elevated, expansive, or
irritable mood. This mood must be sustained for at least 2 full days.
Anxiety disorders: “Have you ever been anxious for a long time? Have you
ever had a panic attack?”
Eating disorders: “Have you ever had any problems with appetite or eating,
gorging, purging, starving yourself, or anything like that?”
Medical history:
Illnesses: “Have you ever had any physical illnesses—even the small ones,
such as measles, mumps, or chicken pox?”
Hospitalizations: “Have you ever been in a hospital overnight?” Write down
the reason for each hospitalization.
Allergies: “Do you have any allergies?”
Medications at present: “Are you taking any medication?” List each
medication and dose schedule.
Family history:
Father: “How old is your father? Is he in good, fair, or poor health? Any
health problems? What is he like? How did he act when you were growing
up?”
Mother: “How old is your mother? Is she in good, fair, or poor health? What
was she like when you were growing up?”
Other relatives with significant psychopathology: “Did anyone else in your
family have any problems with drugs or alcohol or any other kind of mental
disorder?”
Mental status: This is where you formally test the client’s mental condition.
Description of the client: Describe the client’s general appearance. How
would you be able to pick the client out of a crowd? Note the client’s age,
skin color, sex, weight, hair color, eye color, scars, glasses, mustache, and so
on.
Dress: How is the client dressed? Describe what the client is wearing and
how he or she is dressed. Is the client overly neat, sloppy, casual, seductive,
or formal?
Sensorium: Is the client fully conscious and able to use his or her senses
normally, or does something seem to be clouding the client’s sensorium? Is
the client alert, lethargic, or drowsy? Intoxicated clients will not have a clear
sensorium.
Orientation: The client is oriented to person, place, and time if the client
knows his or her name and location and today’s date.
Attitude toward the examiner: What is the client’s attitude toward you—
cooperative, friendly, pleasant, hostile, suspicious, or defensive?
Motor behavior: Describe how the client is moving. Anything unusual? Does
the client move normally, restlessly, continuously, or slowly? Does the client
have a tremor or tic?
Speech: How does the client talk? Any speech or language problems? Does
the client talk normally, or is he or she overly talkative or minimally
responsive? Do you detect a speech disorder?
Affect: How is the client feeling during the interview—appropriate, blunted,
restricted, labile, or dramatic?
Range of affect: What is the client’s capacity to feel the whole range of
feelings? Affect ranges from elation to depression. During the interview, you
should see the client cover a wide range of affect. Does the client’s range of
feelings seem normal, constricted, blunted, or flat?
Mood: What is the feeling that clouds the client’s whole life? The client
might be calm, cheerful, anxious, depressed, elated, irritable, pessimistic,
angry, neutral, or any other sustained feeling.
Thought processes: Does the client have a normal stream of thought? Is the
client able to come up with clear ideas, form these ideas into speech, and
move the speech into normal conversation? If the client is hard to follow,
then write down why. Describe what the client is doing that makes the
conversation difficult. Are the client’s thought processes logical and
coherent, blocked, circumstantial, tangential, incoherent, distracted, evasive,
or persevered?
Abstract thinking: “What does this saying mean to you? ‘People who live in
glass houses shouldn’t throw stones.’ ” An abstract answer might be: “Do not
talk about people because you might have problems yourself.” A concrete
answer might be: “They might break the glass.” Ask the client, “How are an
egg and a seed alike?” An abstract answer might be: “Things grow from
both.” A concrete answer might be: “They are both round.” Using such
questions, determine the client’s ability to abstract. Is it normal, or is it
impaired?
Suicidal ideation: “Have you ever thought about hurting yourself or anything
like that?” Describe all suicidal thoughts, acts, plans, and attempts.
Homicidal ideation: “Have you ever thought about hurting someone else?”
Describe all thoughts, acts, plans, and attempts.
Disorders of perception: Disorders in how the client perceives can be
assessed by asking questions such as the following: “Have you ever seemed
to hear things that other people could not seem to hear, like whispering
voices or anything like that? Have you ever seemed to see things that other
people could not seem to see, like a vision? Have you ever smelled a strange
smell that seemed out of place? Have you ever tasted a strange taste that
seemed out of place? Have you ever felt anything unusual on or under your
skin?”
Delusions: “Have you ever felt that anyone was paying special attention to
you or anything like that? Have you ever felt that someone was out to hurt you
or give you a hard time? Have you ever felt like you had any strange or
unusual powers? Have you ever felt like one of the organs in your body was
not operating properly?” A delusion is a false belief that is fixed, intractable
to logic.
Obsessions: “Have you ever been bothered by thoughts that did not make any
sense, and they kept coming back even when you tried not to think about
them? Have you ever had awful thoughts like hurting someone or being
contaminated by germs or anything like that?” Obsessions are persistent
ideas, thoughts, impulses, or images that are experienced, at least at first, as
intrusive and senseless.
Compulsions: “Was there anything that you had to do repeatedly and you
could not stop doing it, like washing your hands repeatedly or checking
something several times to make sure you had done it right?” Compulsions
are repetitive, purposeful, and intentional behaviors that are performed in
response to an obsession, according to certain rules, or in a stereotyped
fashion.
Intelligence: Estimate the client’s level of intellectual functioning—above
average, average, low average, borderline, or mentally challenged.
Concentration: Describe the client’s ability to concentrate during the
interview—normal, mild, moderate, or severe impairment.

Memory:
1. Immediate memory: Tell the client, “Listen carefully. I am going to say
some numbers. You say them right after me: 5–8–9–3–1.” After the
client has completed this task, tell him or her, “Now I am going to say
some more numbers. This time I want you to say them backward: 4–3–
9.” Clients should be able to repeat five digits forward and three digits
backward.
2. Recent memory: Tell the client, “I am going to give you three objects
that I want you to remember: a red ball, an open window, and a police
car. Now you remember those, and I will ask you what they are in a few
minutes.” Clients should be able to remember all three objects after 5
minutes.
3. Remote memory: The client should be able to tell you what he or she
had for dinner last night or for breakfast this morning. The client should
know the names of the last five presidents of the United States. The
client should know his or her own history.
Impulse control: Estimate the ability of the client to control his or her
impulses.
Judgment: Estimate the client’s ability to make good judgments. If you cannot
estimate from the interview, then ask the client a question: “If you were at the
movies and were the first person to see smoke and fire, what would you do?”
The client should give a good answer that protects both himself or herself
and the other people present.
Insight: Does the client know that he or she has a problem with chemicals?
Does the person understand something about the nature of the illness?
Motivation for treatment: Is the client committed to treatment? Estimate the
level of treatment acceptance or resistance.
Summary and Impression
Begin with the client’s childhood, and summarize all that you have heard and
observed. Include all of the problems you have seen, and give your impression of
where the client stands on each of the following dimensions:

1. Acute intoxication or withdrawal complications

2. Biomedical conditions and complications
3. Emotional, cognitive, and behavioral conditions and complications
4. Readiness to change
5. Relapse, continued use, or continued problem potential
6. Recovery environment
Diagnosis
Diagnose the problem using the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5, 2013).
Disposition and Treatment Plan
List and describe all of the problems that need treatment and how you plan to treat
each problem.
A Sample Biopsychosocial Interview
Now let us go through an actual interview so that you can see how it works. We
describe how you should be thinking as we go through the interview.

The client comes into the office. She is tall and thin and is dressed in white jeans
and a white sweatshirt. She smiles as she sits down. She makes good eye contact
and relaxes. Her face is relaxed. She does not appear to be in any acute distress.

Counselor: Give me your full name—all three names please—and spell them
all.

Client: Jane J-A-N-E Roberts R-O-B-E-R-T-S.

Counselor: How old are you?

Client: Twenty-eight. (The client seems to relax even more. She sits farther
back in the chair and crosses her legs.)

Counselor: Are you married?

Client: No.

Counselor: Have you ever been?

Client: No.

Counselor: Do you have any kids?

Client: No.

Counselor: What is your current hometown?

Client: Sioux Falls, South Dakota.

Counselor: Who lives with you?

Client: No one.
Counselor: How long have you lived there?

Client: About 5 years.

Counselor: How much education do you have?

Client: High school.

Counselor: Are you currently employed?

Client: Yes.

Counselor: What do you do?

Client: I am a self-employed beautician.

Counselor: What was the chief problem that brought you to treatment?

Client: I knew I could not go on drinking the way I was.

Counselor: When kids are growing up, they have a really accurate idea of when
things are right with them and wrong with them. Go back into your childhood as
early as you feel is important, and tell me where you think things began to go
wrong with you in your life, and from that point, tell me the whole story, including
what brings you to treatment now.

Client: I think that as a child, I do not remember an awful lot about my

childhood. I do not remember many good things. I did not have a bad childhood. I
have never been abused physically or sexually or anything like that. But I always
felt left out, abandoned, lost, alone a lot. (This is where the problems start. The
client grew up feeling left out, abandoned, lost, and alone.)
I think I knew that I was loved, but I was not shown it very much. Going to a
Lutheran school was hard on me. I never felt like I was like the other kids. (The
client continues to feel isolated in school.)
One year I was a class officer, and that made me feel very good. I was not sports
minded. I did not feel that anyone was working with me with what I could do. My
father died when I was a baby. My mother did not listen to me. I would ask her a
question, and she would just look at me. I could never get any answers. (This
seems to be where the client began to feel unheard, abandoned, and lost.) I
remember asking her about how boys and girls were different. She just said,
“Don’t you know?” I never got any information about my period. I did not get it
until I was old anyway, about 17, and by then I had to find out some things from
my friends. I read a book about how to take care of myself. (The client is angry
with her mother. This may or may not have influenced her drinking. It certainly
increased her feelings of isolation and loneliness, and it influenced her ability
to establish and maintain close interpersonal relationships.)
I hear from other members of my family that my father was strict. I did not hear
good things about him, but I did not hear bad things either. He did not like
drinking, and my mom would hide her alcohol from him. (The client seems to
long for her father. It is in the sadness of her voice. Her mother might have had
a drinking problem. It sounds as though it caused some family conflict.)
I think my mom talked to me about this. She may have had a problem. She hid her
wine bottle down in the basement. Going through school was hard because I did
not fit in with the group. I remember making up stories and trying to buy the
clothes they wore to fit in, but I never did. They all caught on about what I was
trying to do. It did not work. I could not afford many things. When I was older, I
was very glad to get out of the house. I did not date much, but when I did, I
immediately fell in love. I felt like, great; somebody likes me. When they would
go out with others, I was devastated. I kept grasping at them to come back. (These
relationships sound addictive. This is a problem. Listen to the powerful feeling
statements she makes: “When they would go out with others, I was devastated. I
kept grasping at them to come back.” The client begins to use relationships to
fill the empty void. She is trying to replace her dead father and her distant
mother with a relationship with a man.)
One day my girlfriend and I were eating lunch, and these guys came up to us. They
asked if we wanted to go out for a ride and have a few drinks with them. They
were cute, you know, so we decided to go. There was this one; he said his name
was Mark. He was older, and we got along really well. He impressed me. I could
tell he really liked me a lot, more so than anyone else I had ever dated. I ended up
going with him for quite a while. About a year later, I found out he was married.
His name was not Mark. It was Andy. He had a wife and a kid. I finally called him
up and told him that I knew the truth but that I loved him anyway. This was a very
passionate man. He loved me. He showed me he loved me. I do not care what you
say—he was able to love two people at the same time. (The client becomes
involved in another addictive relationship. This time it is with a man who is
addictive himself. The intense sexual excitement that this man offers fools her
into thinking that he really loves her.)
We continued that relationship for a long time. There was a lot of pain in that
relationship. I just broke up with him about 2 years ago.
Counselor: When did you start dating him?

Client: When I was about 21—I went with him for 4 years; 2 of those years he
was married, and 2 he was not. (This is passive and dependent? She does not
look passive. She makes good eye contact and seems to feel comfortable. We
must let the story unfold to get the answer.)

Counselor: How old were you when you first had a drink?

Client: It was in my early teens at a party.

Counselor: Did you drink much in high school?

Client: No, only very occasionally.

Counselor: Okay, go on with your story. You are going out with Andy, and
Andy’s married.

Client: We kept seeing each other. He kept promising that he was going to get a
divorce. He did not want to lose me. It kept going on for years and years. I would
get angry with him when I found out that he was seeing somebody else other than
his wife and me. I would blow up, then I would finally settle down, and we would
continue to see each other. Every time I would get frustrated with him, I would
seek someone else out.
I would find someone else who was interested in me. I had several affairs. Andy
would get very angry if he found out that I was dating someone, but I felt he did
not have the right to get angry. He was married. (There is an honesty problem
here. The client was lying to both men.)
I went out with this guy once. He was everything I had ever dreamed of. He was
tall and dark with a hairy chest. He was beautiful. I went out with him for quite a
while. He really liked me, but I kept seeing Andy. The relationship with this guy,
the new guy, Rob, began to get abusive. The relationship with Andy was abusive,
too. They would both hit me, slap me, sometimes. They both tried to choke me. A
couple of times, they raped me out of anger. Andrew was not ever a violent
person, but then all of a sudden he got violent. He put me down a lot. He put me
down all the time.

Counselor: Did he make important choices for you? (The counselor probes the
dependency problem.)
Client: No, I never did that.

Counselor: Is it hard for you to make decisions without some sort of

reassurance from someone else?

Client: No, I do not have any problem there, but I am attracted to men with
power. They can tell me anything, and I would believe it. I do not know what it is
about powerful men, but I am real attracted to that. Andy finally got a divorce, and
I lived with him. He is a banker and very wealthy. I thought things were going to
be a lot better. He was still controlling and manipulative, but I thought everything
was going to improve. I always knew that eventually I was going to be abandoned.
(Here we see the fuel for the addictive relationship. The client chronically fears
abandonment, like the abandonment that she felt as a child. This leaves her
feeling anxious and vulnerable. She will do anything to keep her man, but at the
same time, she fears that she will lose him.)
He was very demanding, but I could get what I wanted by being very diplomatic.
It took me a long time to learn how to do that. He always wanted me to do all
kinds of things. I kept the house and the grounds immaculate. I worked and kept
house and did the yardwork and worked at my job. (The client is not assertive.
She has learned how to lie and manipulate to get what she wants.)
All this time, I was drinking a lot. I was hiding my drinking. I would hide my beer
cans. Sometimes he would come home, and I would be drunk.

Counselor: How much were you drinking then?

Client: At least a six pack.

Counselor: Did you ever have a blackout?

Client: Oh, yeah, I had plenty.

Counselor: Did you ever have a real bad hangover?

Client: Yes.

Counselor: Hands ever get shaky?

Client: No, but I would be sick. I would feel terrible—headache, upset stomach.

Counselor: What happened then?

Client: I came home one night and caught him with another woman. He denied
what was going on, but I knew. I could tell from her reaction that she did not know
about me. I talked to her, and in time we both got together with him again. I swear
to God, he has the ability to love two women at the same time. I can tell he loves
me.

Counselor: Healthy relationships are based on trust.

Client: I know that. This woman and I were never mad at each other. We both
knew that he was so intense that he could love us both.

Counselor: It is not right to lie to you.

Client: I like that. That makes sense. I finally broke up with him. I did not know
anyone. It was very hard, but I did it. He was furious. That was the last time he
raped me. He was out of his mind.

Counselor: You do not rape somebody that you love either.

Client: It was finally over. I fell in love with a new guy, Dave. I fell in love so
fast. He was a dream come true. We had long talks about things. This guy did not
work out because I realized that I was doing all of the giving again. I am starting
to realize my pattern. I do all the giving, and I love men with power. It took me a
long time to realize that. He would go to my house, watch TV, and eat all my food.
He never took me anywhere. I said, “Are you getting tired of me or what?” I
realized that there was something I was not getting here. I had such feelings for
David. I cannot remember ever feeling like that. He was such a heartthrob.

Counselor: It is easy to get love and lust confused. (The counselor continues to
teach the client and to show her how she has been confused about relationships.
Notice that these interventions are very brief. This is not the time for therapy. It
is the time for assessment.)

Client: That relationship ended, and I started going out with another guy. He
was an alcoholic in recovery, so I cut down on my drinking some. I only saw him
once a week. It was nice. One night Andy just walked in on us. It was crazy. He
just came right in as if he owned the place. I had my own place then. I was finally
making the break with him, and he could not believe it. Bryan handled it very
well. Andy finally left. You know, I like a man with power. I have this thing about
a man with power. I do not know what it is.
Counselor: Well, you have felt powerless in your life. Someone with power
would make you feel safe.

Client: Yeah, a strong man makes me feel safe. Anyway, my drinking kept on
increasing, my relationships kept going to hell, and here I am.

Counselor: Anything in particular bring you into treatment now?

Client: I went out and got drunk again, and I woke up with such a hangover. I
said to myself, I have to do something about this, now. I made the call right then.
This concluded the history of the present problem. Then the counselor moved right
into the history.

Counselor: Where were you born?

Client: Livingston, South Dakota.

Counselor: When is your birthday?

Client: June 28, 1983.

Counselor: Did you have any trouble when you were born?

Client: No.

Counselor: Any trouble walking, talking, toilet training, reading, or writing?

Client: No.

Counselor: You were raised with whom?

Client: My mother and two younger sisters.

Counselor: What is your ethnic heritage? Irish? German? Do you know?

Client: I am Irish.

Counselor: Your home of origin, growing up with your mother and sisters. How
did it feel in that house?

Client: I felt alone. I did not like it.

Counselor: What kind of a kid were you in grade school?

Client: I was timid, not very outgoing.

Counselor: What kind of a kid were you in high school?

Client: I was scared, scared to relate.

Counselor: You seem to have made real progress with that timid thing. You do
not seem timid anymore.

Client: Yeah, I really have. I do not think I am timid anymore.

Counselor: Great. Were you ever in the armed services?

Client: No.

Counselor: Ever go to college?

Client: No.

Counselor: Give me a brief occupational history. What kind of work have you
done?

Client: I worked as a secretary for 5 years. I have been at my current job for
about 5 years.

Counselor: Are you happily employed?

Client: Yeah, I like my job.

Counselor: How is your current financial situation?

Client: Good. I am not rich, but I get along okay.

Counselor: Do you have any sexual problems?

Client: No.

Counselor: Have you ever had a homosexual contact?

Client: No.

Counselor: Are you currently involved with a guy?

Client: Yes.

Counselor: How long has that been going on?

Client: About 3 months.

Counselor: And how is that going?

Client: Great.

Counselor: Do your friends and family support your coming into treatment?

Client: Yes.

Counselor: Do you feel like there is any kind of a higher power or God or
anything?

Client: I believe in God.

Counselor: Do you attend church?

Client: I go to the Lutheran church.

Counselor: Are you having any problems with the law?

Client: No.

Counselor: Have you ever had any problems with the law in the past?

Client: No.

Counselor: What are some of your strengths or some of your good qualities?

Client: I am caring. I get along with people real well. I think I am intelligent.

Counselor: What are some of your weaknesses?

Client: A drinking problem.

Counselor: What do you enjoy doing for fun?

Client: I enjoy biking. I hike and jog.

Counselor: Have you ever had a period of time where you felt down or
depressed most of the day most every day?

Client: No.

Counselor: Have you ever felt really anxious?

Client: No.

Counselor: Ever felt so high or filled with energy that you got into trouble or
people thought you were acting strangely?

Client: No.

Counselor: Ever had any eating problems—gorging, purging, starving yourself,

anything like that?

Client: No.

Counselor: Are you intensely afraid of anything?

Client: No.

Counselor: Ever had any illnesses, even the small ones—measles, mumps, or
chicken pox?

Client: Measles, mumps, and chicken pox.

Counselor: Ever been in a hospital overnight?

Client: No.

Counselor: Do you have any allergies?

Client: No.
Counselor: Are you taking any kind of medication here?

Client: They have me on a Valium come-down schedule.

Counselor: For what?

Client: I have been taking Valium for about 5 years. I am withdrawing from that.
(Current problems are covered in the history of the present problem. The
counselor did not know about the Valium until now. This happens often. The
counselor now has to flip back to the history of the present problem and add
this part.)

Counselor: How much of the Valium were you using?

Client: I was using it every day for sleep.

Counselor: Did you find yourself using more?

Client: Yes, I had to increase what I took, so it would work.

Counselor: Twice as much?

Client: More.

Counselor: Did you ever stop using?

Client: No.

Counselor: How much would you take every night?

Client: I got up to about 30 mg. (Once this information was gathered, the
counselor resumed the client’s past history.)

Counselor: Okay, how old was your father when he died.

Client: In his 20s.

Counselor: How old is your mother?

Client: Fifty-three.
Counselor: Is she in good, fair, or poor health?

Client: She is in good health.

Counselor: What kind of a person is your mom?

Client: She is quiet and demanding.

Counselor: Has anyone else in your family had any problems with alcohol,
drugs, or any other kind of mental disorder?

Client: I think my mother had a drinking problem.

This concludes the past history. Now you would complete the mental status, which
we will not bore you with here, and you are ready to dictate the biopsychosocial
interview. The client has said a lot, and it was important for her to share these
things, but you need to tell the story in an abbreviated form. Keep in the main parts
of her story, but exclude all of the details. At the end of the biopsychosocial
interview, come up with a problem list and a preliminary treatment plan.

To view Jane’s biopsychosocial interview as it was completed, see Appendix 6.

4 Treatment Plan

Source: ©[Link]/ChristopherFutcher.

The treatment plan is the road map that a client will follow in his or her journey
through treatment. The best plans will follow the client for the next 5 years, when
the relapse rates drop to around zero (Vaillant, 2003). No two road maps will be
the same; everyone’s journey is different. Treatment planning begins as soon as the
initial assessments are completed. The client might have immediate needs that
will need to be addressed. Treatment planning is a never-ending stream of
therapeutic plans and interventions. It always is moving and changing. We have
written an excellent treatment-planning book and computer program that makes
treatment planning easy: The Addiction Treatment Planner (Perkinson, Jongsma,
& Bruce 2014). The book and computer program write your treatment plan with
point-and-click easiness and have been approved by all accrediting bodies.
Source: Created by Mervin Magus.
How to Build a Treatment Plan
The treatment plan builds around the problems that the client brings into treatment.
The problem list details each problem. It must take into account all of the
physical, emotional, and behavioral problems relevant to the client’s care. It must
take into account the client’s strengths, weaknesses, needs, abilities, and personal
preferences. It must address each of the six dimensions that you are following.

The treatment plan details the therapeutic interventions, what is going to be done,
when it is going to be done, and by whom. It must consider each of the client’s
needs and come up with clear ways of dealing with each problem. The treatment
plan flows into discharge planning, which begins from the initial assessments.
The Diagnostic Summary
After the interdisciplinary team members assess the client, they meet and develop
a summary of their findings. This is the diagnostic summary. This is where
members of the clinical team—the physicians, nurses, counselors, psychologists,
psychiatrists, recreational therapists, occupational therapists, physical therapists,
dietitians, family therapists, teachers, pastors, pharmacists, and anyone else who
is going to be actively involved with the client’s care—meet and develop a
summary of the client’s current state and needs. The team members discuss each of
the client’s problems and how to treat the problem. From this meeting, the
diagnostic summary is developed. This details what the problems are, where they
came from, and what is going to be done about them. It is much better to do this as
a team. As you see your team function, you will see how valuable it is to have
many disciplines involved.
The Problem List
The treatment team will continue to develop the problem list as the client moves
through treatment. Add new problems as the client continues in treatment. Nothing
will stay the same. A problem list and treatment plan must be fluid. It is modified
as conditions change.
How to Develop a Problem List
A treatment plan must be measurable. It must have a set of problems and solutions
that can be measured. The problems cannot be vague. They must be specific. A
problem is a brief clinical statement of a condition of the client that needs
treatment. The problem statement should be no longer than one sentence and
should describe only one problem.

All problem statements are abstract concepts. You cannot actually see, hear, touch,
taste, or smell the problem. For example, low self-esteem is a clinical statement
that describes a variety of behaviors exhibited by the client. You can see the
behaviors and conclude from them that the client has low self-esteem, but you
cannot actually see low self-esteem.

Problems are evidenced by signs (what you see) and symptoms (what the client
reports). A problem on the treatment plan is followed by specific physical,
emotional, or behavioral evidence that the problem actually exists. List the
problem, add “as evidenced by” or “as indicated by,” and then describe the
concrete evidence you see that tells you that the problem exists.

Examples of a Problem List

Problem 1: Inability to maintain sobriety outside of a structured facility
As evidenced by: Blood alcohol level of 0.23
As evidenced by: The client’s family report of daily drinking
As evidenced by: Alcohol withdrawal symptoms
As evidenced by: Third DWI
As evidenced by: History of third treatment for addiction

Problem 2: Depression
As evidenced by: Hamilton Depression Rating Scale score of 29
As evidenced by: Psychological evaluation
As evidenced by: Client’s two suicide attempts in the past 3 months
As evidenced by: Depressed affect

Problem 3: Acute alcohol withdrawal

As evidenced by: Blood alcohol level on admission 0.23
As evidenced by: Coarse hand tremors
As evidenced by: Blood pressure 160/100, pulse 104
As evidenced by: Restless pacing; self-report of strong craving
As evidenced by: Profuse sweating; mild visual disturbances
Goals and Objectives
Once you have a problem list, you need to ask yourself what the client needs to do
to restore himself or herself to normal functioning. A person who has a drinking
problem needs to stop drinking and must learn the skills necessary to maintain a
sober lifestyle. A person who is depressed needs to reestablish normal mood. A
person who is dishonest needs to get honest with himself or herself and others.
Writing goals, objectives, and interventions in a treatment plan is made much
easier for counselors by using The Addiction Treatment Planner or The Addiction
Treatment Planner With Disk (Perkinson, Jongsma, & Bruce, 2014) plus the
TheraScribe 5.0 computer program. These plans conform to the highest standards
set by accrediting bodies such as the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO, 1988).
Source: Jupiterimages/Thinkstock.
How to Develop Goals
A goal is a brief clinical statement of the condition you expect to change in the
client or in the client’s family. You state what you intend to accomplish in general
terms. Specify the condition of the client that will result from treatment. All goals
label a set of behaviors that you want to create.

Goals should be more than the elimination of pathology. They are directed toward
the client learning new and more functional methods of coping. Focus on more
than just stopping the old dysfunctional behavior. Concentrate on replacing it with
something more effective.
Examples of Developing Goals
Instead of: The client will stop drinking.
Use: The client will develop a program of recovery congruent with a sober
lifestyle. (The client is learning something different.) It often helps to put the
goals in the client’s own words. Client statement: “I need learn how to stay
sober.”
Use: The client will learn to cope with stress in an adaptive manner. Client
statement: “I need to learn how to cope with my stress.”
Instead of: The client will stop negative self-talk. (The client does not learn
or use something differently; the client just avoids something that he or she
already knows.)
Use: The client will develop and use positive self-talk. Client statement: “I
need to start telling myself the truth.” (Now the client learns something
different that is incompatible with the old behavior.)
Use: The client will develop a positive self-image. (The client learns
something new and more adaptive.)

The client or the client’s family must be the subject of each goal. No staff member
or staff intervention are mentioned. Identify one goal and condition at a time.
Make each goal one sentence.
Examples of Goals
1. The client will learn the skills necessary to maintain a sober lifestyle.
2. The client will learn to express negative feelings to his or her spouse.
3. The client will develop a positive commitment to sobriety.
4. The client will develop a healthy diet and begin to gain weight.
5. The client will learn how to tolerate uncomfortable feelings without using
chemicals.
6. The client will learn to share positive feelings with others.
7. The client will develop the ability to ask for what he or she wants.
8. The client will develop the ability to use anger appropriately.
9. The client will sleep comfortably on a regular basis.
10. The client will learn healthy communication skills.
How to Develop Objectives
An objective is a specific skill that the client must acquire to achieve a goal. The
objective is what you really set out to accomplish in treatment. An objective is a
concrete behavior that you can see, hear, smell, taste, or feel. An objective is
stated so clearly that almost anyone would know when he or she saw it. Goals
usually are abstract statements that you cannot actually see happen. You cannot see
someone learn or see his or her self-esteem. You can see an individual express 10
positive things about himself or herself. One way of seeing whether you have a
goal or an objective is to use the “see Johnny” test developed by Arnold
Goldman: “If you can see Johnny do it, then it is an objective; if you cannot, then it
is a goal.” (Goldman [1989] gives lessons on treatment planning in Accreditation
and Certification: For Providers of Psychiatric, Alcoholism, and Drug Abuse
Services [PO Box 742, Bala Cynwyd, PA 19004]. Richard Weedman also has
done a lot of work in this area. He wrote Client Records in Addiction Treatment:
Documenting the Quality of Care [JCAHO, 1992]. A copy can be obtained from
JCAHO, One Renaissance Boulevard, Oakbrook Terrace, IL 60181. These
materials should be read if you have problems with treatment planning.)

Remember, if you can see it, then it usually is an objective. If you cannot see it,
then it usually is a goal.

Can you see the client read about Step One in the “Big Book” (AA, 2002a)?
Yes. (Objective)
Can you see the client understand the illness of addiction? No. (Goal)
Can you see the client gain insight? No. (Goal)
Can you see the client improve his or her self-esteem? No. (Goal)
Can you see the client complete the Step One exercise? Yes. (Objective)
Can you see the client keep a daily record of his or her dysfunctional
thinking? Yes. (Objective)
Can you see the client share his or her feelings in group? Yes. (Objective)

All goals and objectives help the client change. Individuals must change how they
feel, what they think, and/or what they do. Each goal should have one or more
objectives. The best way of developing goals is to ask these questions: How can
you know for sure that the client has achieved the goal? What must the client say
or do to convince you that the treatment goal is completed?
State the goal aloud, add on the words “as evidenced by” or “as indicated by,”
and then complete the sentence describing the specific objectives that will tell you
that the goal has been reached. Each goal will need at least one objective. Each
goal and objective will need a number or a letter that identifies it. Each objective
will need a completion date. This is the date by which you expect the objective
will be completed. If the client passes this date without completing the objective,
then the treatment plan might have to be modified.
Examples
Goal A: The client will develop a program of recovery congruent with a sober
lifestyle, as evidenced by the following:

1. The client will share in recovery skills group three times when he or she
tried to stop drinking but was unable to stay sober.
2. The client will make a list of the essential skills necessary for recovery.

Goal B: The client will learn to use assertiveness skills, as indicated by the
following:

1. The client will discuss the assertive formula and will role-play three
situations where he or she acts assertively.
2. The client will keep an assertiveness log and will share the log with the
counselor daily.
3. The client will practice assertiveness skills in interpersonal group.

Objectives must be measurable. You must be able to count them. You or the client
can count all thoughts, feelings, and actions. The client can count his or her
thoughts by keeping a daily record of his or her thinking. The client can count
feelings by keeping a feelings log. You can keep a record of every time a client
acts angry around the unit.

To achieve the goal of maintaining a sober lifestyle, an alcoholic might need to

develop one or more of the following skills:

1. Verbalize that he or she has a problem, or verbalize an understanding of the

problem.
2. Develop and practice new behaviors that are incompatible with the problem.
Read the “Big Book.”
3. Practice the 12 steps of AA.
4. Go to meetings.
5. Learn how to cope with uncomfortable feelings.
6. Develop a relapse prevention plan.

All depressed clients will need to develop one or more of the following skills:
1. Learn how to say positive things to themselves.
2. Develop recreational programs to add fun to their lives.
3. Grieve and learn how to accept the deaths of loved ones.
4. Get accurate in their thinking.
5. Improve the dysfunctional interpersonal relationships with their spouses.
6. Take antidepressant medication.
How to Develop Interventions
Interventions are what you do to help the client complete the objective.
Interventions also are measurable and objective. There should be at least one
intervention for every objective. If the client does not complete the objective, then
new interventions are added to the plan.

Interventions should be selected by looking at what the client needs. They may
include every treatment available from any member of the multidisciplinary team.
They may include any therapy from any staff member such as group therapy,
individual therapy, behavior therapy, cognitive therapy, occupational therapy,
recreation therapy, or family therapy. The person responsible for the intervention
needs to be listed with the intervention so that the staff knows who is responsible.
Examples
Intervention: Assign the client to write a list of five negative consequences
of his or her drug use.
*Responsible professional ____________________
Intervention: In a conjoint session, have the client share the connection
between drinking and marijuana use.
*Responsible professional ____________________
Intervention: In group, encourage the client to share his or her anxious
feelings.
Intervention: Have the client develop a personal recovery plan that includes
all of the activities that he or she plans to attend.
*Responsible professional ____________________
How to Evaluate the Effectiveness of Treatment
In treatment, it is vital to keep score of how you are doing. It is the only way in
which you will know whether treatment is working. Feelings, thoughts, and
behaviors are counted. The staff can count them, or the client can count them. The
client must record thoughts and feelings, being internal states. Behaviors are
recorded by the client or the staff. Clients and the staff will record feelings,
thoughts, and behaviors and keep a log of these data. The log of the staff is called
the clinical record or the chart.
How to Select Goals, Objectives, and Interventions
Goals, objectives, and interventions are infinite. It takes clinical skill to decide
exactly what the client needs to do to establish a stable recovery. Every treatment
plan is individualized. Everyone is different, and every treatment plan is different.
For the same goal, you may have widely different objectives. You need to ask
yourself three questions:

1. What is this client doing that is maladaptive?

2. What does the client need to do differently?
3. How can I help the client behave in a new way?

These questions, if asked carefully, will uncover your goals. Once you have your
goals, ask yourself this question: What does the client need to do to achieve these
goals? These are your objectives. Then ask yourself what you can do to help the
client. Each client will need to do the following three things:

1. Identify that he or she has a problem.

2. Understand exactly what that problem is and how it affects the client.
3. Apply healthy skills that will reduce or eliminate the problem.
Examples
Problem 1: Pathological relationship with alcohol, as indicated by a blood
alcohol level on admission of 0.32, three DWIs, and family report of daily
drinking
Goal A: Develop a program of recovery congruent with a sober lifestyle, as
evidenced by the following:
Objective 1: Norman will identify with his counselor 10 times when
alcohol use negatively affected his life by 6-1-2017.
Intervention: Assign the client the homework of making a list of 10 times
when alcohol use negatively affected his life.
*Responsible professional _______________________________
Objective 2: Norman will complete his chemical use history and share in
group his understanding of his alcohol problem by 6-1-2017.
Intervention: Assign the client to complete a chemical use history exercise
and then have him share his answers in group.
*Responsible professional _______________________________
Objective 3: Norman will share his powerlessness and unmanageability
with his group by 6-10-2017.
Intervention: In a one-to-one counseling session, teach the client about
powerlessness and unmanageability, and then have him share what he learned
in group.
*Responsible professional _______________________________
Objective 4: Norman will share in group his understanding of how he can
use his higher power in sobriety by 6-15-2017.
Intervention: Clergy will meet with the client and explain how he can use a
higher power in recovery.
*Responsible professional _______________________________
Objective 5: Norman will take all medications as prescribed and report
side effects to the medical staff.
Intervention: Physician will examine the client and order medications as
indicated, while the medical staff monitors for side effects.
*Responsible professional _______________________________
Objective 6: Norman will develop a written relapse prevention plan by 6-
25-2017.
Intervention: In a counseling session, teach the client about relapse
prevention, and help him to develop a written relapse prevention program.
 *Responsible professional _______________________________
Objective 7: Norman will discuss his codependency with his wife by 6-
30-2017.
Intervention: In a conjoint session, help the client to discuss his
codependency with his wife and how this problem relates to substance
abuse.
*Responsible professional _______________________________

In developing goals and objectives, the client must move through the following
events:

1. Identify that he or she has a problem.

2. Understand how the problem negatively affects the client.
3. Learn what he or she is going to change.
4. Practice the change.

Let us take another problem.

Problem 2: Poor impulse control, as indicated by numerous fights,

abusiveness to spouse, and self-report that he loses control when angry
Goal A: Learn to use angry feelings appropriately, as evidenced by the
following:
Objective 1: Thomas will discuss with his counselor five times when he
used anger inappropriately by 7-2-2017.
Intervention: Assign the client the homework task of listing five times when
he used anger inappropriately.
*Responsible professional _______________________________
Objective 2: Thomas will share in group his understanding of what he
needs to do differently to cope with his anger by 7-10-2017.
Intervention: Have the client share in group five tools he can use to cope
with anger effectively.
*Responsible professional _______________________________
Objective 3: Thomas will visit the staff psychologist to learn and practice
stress management techniques by 7-2-2017.
Intervention: The staff psychologist will teach the client stress management
techniques such as progressive relaxation, biofeedback, and systematic
desensitization.
*Responsible professional _______________________________
Objective 4: Thomas will keep a daily log of his angry feelings and
 discuss the log with his counselor once a week.
Intervention: Assign the client to keep a daily log of angry feelings and to
use subjective units of distress to rate each situation on a scale from 1 to 100.
*Responsible professional _______________________________
Objective 5: Thomas will share his hurt and angry feelings in group by 7-
21-2017.
Intervention: Encourage the client to share his feelings log in group.
*Responsible professional _______________________________
Objective 6: Thomas will practice sharing his hurt and anger with his
spouse in a conjoint session by 7-30-2017.
Intervention: In a conjoint session, have the client share his hurt and angry
feelings with his wife and make a written contract to separate and contact the
sponsor or counselor when angry.
*Responsible professional _______________________________
Objective 7: Thomas will attend a violence group once a week.
Intervention: Refer the client to an anger management group, and make the
first appointment with the client present.
*Responsible professional _______________________________

Samples of a complete biopsychosocial, diagnostic summary, and treatment plan

are given in Appendix 6.
Treatment Plan Review
The interdisciplinary team reviews the treatment plan at regular intervals
throughout treatment. At a minimum, the treatment plan is reviewed at all decision
points. These points include the following:

1. Admission
2. Transfer
3. Discharge
4. Major change in the client’s condition
5. The point of estimated length of treatment

Most facilities have a daily staffing where the client’s progress is briefly
discussed and a weekly review where the treatment plan is discussed. It is at these
meetings that the treatment plan will be modified. Problems, goals, and objectives
will change as the client’s condition changes. Treatment team review is where the
staff finds out how the client is doing in treatment and what changes need to be
made.
Documentation
The staff keeps a written record of the client’s progress through treatment. This
document is called the client record, commonly called the chart. The staff keeps
progress notes that document what happens to the client during treatment. Progress
notes have to be typed or written in black ink.

Source: ©[Link]/nano.

Each progress note needs to be identified with one or more treatment objectives.
For example, a progress note on Goal A, Objective 7, would begin with the
notation A(7). This helps the staff to keep track of how the client is doing with
each objective.

Progress notes include the following data:

1. The treatment plan

2. All treatment
3. The client’s clinical course
4. Each change in the client’s condition
5. Descriptions of the client’s response to treatment
6. The outcome of all treatment
7. The response of significant others to important events during treatment
How to Write Progress Notes
Keep your progress notes short, and write with a black pen only. Progress notes
must include just enough detail to describe what is going on with the client. For
the most part, describe things in behavioral terms. Any entry that includes your
opinion or interpretation of events is supplemented by a description of the actual
behavior you observed. What did you see or hear that led you to that conclusion?
Describe exactly what the client did or said. Direct quotations from the client
make an excellent progress note.

The client’s progress in meeting the goals and objectives is recorded on a regular
basis. The efforts of the staff in helping the client to meet treatment goals and
objectives are recorded. The progress notes will be used by the staff to see how
the client is doing in treatment. A person who has never met the client should be
able to know the client’s story by reading the client record. Before you chart, ask
yourself this question: If you were a counselor just coming in to take over this
case, what would you need to know? It is a good idea to write a short progress
note on each client each day. This is not essential, but it will keep you thinking
about the treatment plan and the client’s progress through the treatment plan on a
daily basis.
Examples

6-12-2017 (10:30)
Jane discussed her denial exercise in group. She verbalized an understanding of
how denial had adversely affected her, stating, “I cannot believe how dishonest I
was to myself. I really did not think I had a problem even after all that trouble. I
lied to Andy, too, about everything.” The client was able to see how denial was a
lie to herself and to others. After the session, the client was able to verbalize her
need to get honest with herself and others. “I have been lying about everything. It
is about time I got honest with myself.”

6-14-2017 (15:15)
Jane was tearful in an individual session. She mourned the loss of her love
relationship with her past partner. The group helped her see how destructive the
relationship had been for her. The treatment peers reinforced that Jane was worth
being treated better than her partner was treating her. Jane expressed that she is
extremely angry with her mother. “I hate her. She never spent any time with me.
She only wanted me as a slave. She wanted a housekeeper, not me.” It seemed to
give Jane some relief to hear other clients express that they had similar feelings
about their mothers. “I thought I was the only one who felt like that,” Jane stated.

6-15-2017 (11:00)
Jane’s facial expression is sad. She has been isolating herself. She did not eat
breakfast. She was seen crying alone in her room. I went in, and she was able to
express her feelings. “I am so ashamed of myself. I will never be able to live this
down.” Jane expressed that she was feeling guilty about sharing with group her
anger at her mother. I reassured Jane and told her to bring up her feelings in group
this afternoon.
Formal Treatment Plan Review
Once a week, the staff will do a formal treatment team review. This requires a
more detailed look at how the client is doing in each problem area. The staff
members present must be identified along with their credentials.

6-16-2017 (11:45)
Treatment plan review: Present, Dr. Roberts, MD; M. Smith, CCDC Level II;
T. Anderson, RN; F. Mark, CCDC Level I; Dr. Thomas; M. Tobas, PhD; E.
Talbot, RN; A. Stein, LPN. The staff feels that Jane is adjusting well to
treatment. She is more talkative and seems to feel more comfortable. She has
made some friends with several treatment peers including her roommate. Her
mother came to see her on Sunday, and Jane reported that this visit went
well.
Problem 1: Jane continues on her Valium come-down schedule. She has
reported only mild withdrawal symptoms. She is sleeping well. She
continues to be mildly restless. She was encouraged to increase her level of
exercise to 20 minutes daily.
Problem 2: Jane has completed her chemical use history and Step One
exercise. She shared in interpersonal group her powerlessness and
unmanageability. She was open in group, and she verbalized that she has
accepted her disease of addiction. She was somewhat more reluctant to
accept her problem with Valium, but the group did a good job of explaining
cross-tolerance. The client should complete the cross-tolerance exercise and
report her findings to the group.
Problem 3: The client continues to take her iron supplement. Her hemoglobin
is within normal limits.
Problem 4: The client is over her cold. Problem 4 is completed.
Problem 5: The client has written a letter to her mother and father (even
though he passed away years ago), describing how she felt about her
childhood. The client shared her letter in group, and she was surprised to
find out that many of the other clients had similar experiences. The client
stated that she is feeling more comfortable sharing in group, and she appears
to be gaining confidence in herself. Jane met with her counselor, and the
counselor encouraged Jane to accept her new AA/NA group as the healthy
family that she never had. Jane expressed hope in becoming involved with
this healthy family.
Problem 6: Jane is working on the relationship skills exercise. She has been
practicing asking for what she wants. It is still very difficult for her to share
some of her feelings, particularly her anger, in group. When she shares her
anger, she tends to feel guilty.
Problem 7: Jane completed the honesty exercise and the chemical use history
that opened her eyes to how dishonest she has been. Jane made a contract
with her group to be honest and asked the clients to confront her if they felt
that she was being dishonest. Jane is keeping a daily log of her lies and when
she is tempted to lie. She has been able to identify many lies she was telling
in her life and is able to verbalize her understanding of how her lies keep her
isolated from others.
Problem 8: Jane is working on the assertiveness skills exercise. She is
practicing the assertive formula. She tends to feel guilty when she says no,
but she is getting better at it. She will say no to someone five times a day for
3 days and keep a log of how she feels about each situation.
Discussion of Continuing Care
During the discussion of the treatment plan, it is always a good idea to begin
continuing care planning. This will include a 5-year follow-up plan run by the
continuing care case manager. This is a formal contract negotiated with the client
and significant others. The plan includes an agreement that the client work all
aspects of the continuing care plan with detailed consequences if the client fails to
meet his or her obligations. The plan should include the following:

Client sends in a log of 12-step meetings by the 10th of every month. The
case manager sets the number of meetings each week.
The client will meet regularly with his or her 12-step sponsor.
Client will agree to attend all therapy recommended by the primary
counselor with a report from the primary care giver as often as deemed
necessary.
Client will agree to up to one random drug screen a week for the first 6
months and up to one random drug screen a week for the next year and a half.
The client can use the PharmChek Drugs of Abuse Patch that lasts for 7 days
or longer ([Link]) or use an alcohol ankle bracelet, the
Secure Continuous Remote Alcohol Monitor (SCRAM), which measures
alcohol from the sweat 24 hours a day, 7 days a week.
The client will take all medications as ordered.
If the client fails to meet any of his or her obligations, he or she is sent a
letter explaining the deficiency and asking that it be corrected.
If the client fails to answer the letter, an appointment will be set up with the
continuing care case manager.
If the client still fails to comply with the contract, the consequences agreed
upon are implemented. This might include contacting the client’s professional
board, employer, probation officer, drug court judge, family members, and so
on. The client has initially signed a release of information to all such
individuals and has written each of them, cosigned by the continuing care
case manager. These letters are signed, sealed, stamped, and mailed if
necessary. The continuing care manager must be very careful to design
consequences that lead the client back into treatment.
5 Individual Treatment
Source: ©[Link]/monkeybusinessimages.

All of the treatments that counselors work with on a daily basis revolve around
changing clients’ thoughts, feelings, and behaviors. People think in two ways: in
words and in images. If you close your eyes and think of the word tractor, that is
thinking in words. If you close your eyes and see some sort of a tractor in your
mind, that is thinking in images. Thoughts happen extremely quickly, so quickly
that we do not pick all of them up. Some are conscious, and some are unconscious.
There is a constant stream of thought. It never stops.
Source: Created by Mervin Magus.

Feelings give us the energy and direction for problem solving. All feelings have a
specific movement attached to them. The feeling of fear gives us the energy and
direction to run away from an offending stimulus. The feeling of sadness gives us
the energy and direction to recover a lost object. Good problem solving
necessitates using feelings appropriately.
Behavior is movement. Anytime a person moves, he or she is exhibiting behavior.
Speech is movement. Drinking is movement. Going to AA meetings is movement.
These all are behaviors. Behaviors are the easiest things to see, count, and record.
Whenever possible, conduct your treatment using the client’s behavior as your
guide. Behavior will tell you whether your treatment is working.
The Therapeutic Alliance
All individual treatment will revolve around the relationship that you have with
your clients. This is the therapeutic alliance. If the clients like and trust you, then
they will listen to you and will want to change to please you.

Source: Hemera Technologies/Thinkstock.

How to Develop a Therapeutic Alliance
The therapeutic alliance should be growing and improving from the first moment
you meet your clients. You need to be constantly encouraging and supportive. You
should give the clients the feeling that you are going to walk with them as a trusted
guide. This relationship is based on love, trust, and commitment. The clients are
afraid to tell anyone the truth. The clients probably never have told anyone the
whole truth. You are going to be different. You are going to be confidential and
consistently act in the clients’ interests. You are going to show the clients
unconditional positive regard. No matter what the clients do, you are going to be
there for them. You are not always going to tell the clients what they want to hear,
but you are going to tell them the truth, and you are going to encourage the clients
to see the truth in themselves. You are going to expect the clients to improve and
work with you. You cannot do all of the work yourself. The client has to struggle
to get clean. You are going to encourage the clients to see the fact that they can
recover if they work a program of recovery. You believe that the clients have the
resources necessary or else you would not have accepted them as your clients.
You believe that the clients can do it.

Clients will have great doubts about themselves. They have tried to lick their
addictions many times before and always have failed. Many clients have lost hope
that they can recover. Self-efficacy is clients believing they can succeed. This
confidence builds over the weeks of treatment by constantly reinforcing the clients
when they complete some small task in the program. This may be as little as
coming to group on time or as big as confronting their parents with their real
feelings.

The solid basis of a good therapeutic alliance is to constantly encourage, support,

and educate. Encourage means to reward the client when she or he tries something
new. You give the client confidence by assigning tasks that the client can
successfully complete. Support means to help clients do something that they cannot
do by themselves. The client might not be able to talk to a spouse, probation
officer, or employer at first. You might have to help him or her do that. As the
counselor, you look for good behavior from the clients. When you see the clients
doing something right, you point it out and praise them for it. Try not to miss an
opportunity to reinforce the client for good behavior. That gives the client
confidence.
How to Be Reinforcing
“Good job. I knew you could do it.”
“You are doing great. I am proud of you.”
“I am so impressed.”
“That took great courage.”
“This is going to pay off for you.”
“Keep coming. You can do it.”

These statements reinforce clients. You are going to support the clients warmly as
often as you can. Be sensitive to the clients’ needs. Constantly ask yourself this
question: If you were in this client’s situation, how would you want to be treated?
Then treat the client that way.

Make good eye contact when you give praise or make a point. Clients have
learned that they cannot trust anyone. The clients do not even trust themselves. You
are going to prove to the clients, with your actions, that they can trust you.

Be gentle. Do not hammer your ideas home aggressively. That wounds the
therapeutic alliance. Let the power of the truth work for you. A whisper of truth is
much more powerful than an angry confrontation. Your clients are injured already.
They do not need to be broken. They need to heal in an atmosphere of love and
trust.

Help the clients to move toward greater self-understanding. Help the clients to
identify exactly how they have kept themselves isolated, and teach them new ways
of reaching out to others. The clients have been hiding from themselves for a long
time. They have been feeling lost and alone. They need to come out from the
darkness created by the disease and into the light of the truth.
How to Use Empathy
Empathy is stepping into the client’s world and understanding it from his or her
perspective. Whenever you put yourself in someone else’s position, you are
practicing empathy. It often is helpful to recognize the feelings or thoughts of the
clients that stimulate something from your own experience. You do not have to
experience the same intensity of feelings that grips the clients, but you need to
relate to the feelings and understand them. Feel yourself walking in the clients’
shoes. What if this was happening to you? How would you feel? What would you
be thinking? What would you need? What would you want? Your empathic
responses will not always be correct—you can misperceive the clients—but they
will improve over time. A good test of empathy is that your comments should
deepen the clients’ narrative flow (Havens, 1978). Empathic accuracy can be
further determined by reflecting the clients’ feelings. Repeat to the clients your
understanding of what they have just said. The clients will clarify any
misunderstanding. Their words and behavior should continually deepen your
understanding of their life (Bettet & Maloney, 1991).

Be sensitive to your own feelings. How are the clients affecting you? Are some of
your own issues being triggered? How can this give you insight into yourself and
the clients?
Transference and Countertransference
Transference is clients responding to you with the same feelings, thoughts, and
behaviors that they developed for other people in their lives. Countertransference
is you responding to clients in the same way that you responded to other people.
We all have internal maps about how the world and people function. We trust
these maps to help us navigate in the world. We learned maps from our primary
caregivers and from significant others in our lives. If you had a father who was
demanding, then you learned that people, particularly men, are demanding. If you
had a mother who you could not trust, then you learned that people, particularly
women, are not trustworthy. These maps profoundly influence the client’s whole
life and therapy. Sometimes they are accurate, and sometimes they are inaccurate.
Constantly check your maps, as well as the clients’ maps, for accuracy.

There are counselors who are insensitive to themselves and others. These
counselors can do great damage to their clients. They demand immediate
disclosure before their clients are ready. They are not sensitive enough to know
that the clients are not ready to share. They need to trust you first. Clients are
making some very quick decisions about you:

Can I trust this person to try to understand me?

Can I trust this person not to hurt me?
Can I trust this person to act in my interest?
Does this person know what he or she is talking about?

Clients are given the opportunity to share. They should never be forced or
manipulated into sharing. The best intervention for someone who is keeping a
secret is to tell that person that he or she can keep the secret; that is a person’s
right. An individual does not have to share everything with everyone, but there is a
consequence for keeping secrets. If you cut someone off from the truth, then you
cut yourself off from feeling close to that person. The formula is this: The more
you can share, the closer you can get, and the closer you can get, the more you can
share. Intimacy (into-me-see) can occur only in an atmosphere of truth.

Some of the keys to developing a positive therapeutic alliance are a forward-

leaning posture, good eye contact, a reinforcing facial expression, good listening
skills, unconditional positive regard, and the skill of engaging the clients on a
feeling level. It helps if you can engage the clients using your own feelings. This
increases the feeling of intimacy.
Examples of Empathic Statements
“Bob, you scare me sometimes. I have to wonder how your wife and kids
must feel when you raise your voice like that.”
“I feel very close to you right now.”
“You seem confused. What do you want from me right now?”
“That makes me feel really sad. I am sorry that happened to you.”
“I can feel that you are angry. What happened?”
“Ralph, I am scared for you.”
How to Be Confrontive
A good confrontation is one individual stating how another person is making him
or her feel. The formula is as follows:

1. I think ________________________. (Describe the client’s behavior: “That

is the third time that you have said nothing is wrong.”)
2. I feel ________________________. (Tell the client how the behavior makes
you feel: “I feel a bit frustrated.”)
3. I want ________________________. (Describe exactly what you want the
client to do: “I want you to describe how you are feeling.”)

These actions need to be described in behavioral terms. Exactly what did the
person do to make you have a certain feeling?

“When I hear you deny you have been drinking, I feel frustrated. I want you to
look at what has really been happening in your life. Didn’t you just get your
third arrest for drunk driving?”
“I feel scared when I hear you say that you want to hurt yourself. What are
some of the other alternatives?”
“When I see you sit there with that blank look on your face, I feel really sad.
You seem to want to cry. Can you tell me what you are thinking?”

A positive therapeutic alliance fosters mutual independence. It is an intense

investment in energy. There is a lack of defensiveness and a sense of mutual
positive regard. You develop similar modes of communication. You are in accord.
You constantly affirm the client’s worth as an individual.

A Guide to Treatments That Work is a wonderful book developed by Peter Nathan

and Jack Gorman (2007). Every mental health professional should make sure that
she or he has easy access to this text. Better yet, Oxford University Press, the
publisher, has published a number of client workbooks and therapist guides that
show the client and the therapist exactly how to treat a number of psychiatric
problems. This is how you can make sure you are using evidence-based treatments
that are demanded by third-party payers. The authors found that certain
psychopharmacological and psychosocial therapies have consistently been shown
to have better outcomes.
Behavior Therapy
In treatment, counselors concentrate on change. Clients have maladaptive feelings,
thoughts, and behaviors that keep them from functioning normally. The clients are
unable to reach their full potential in life because of something they are doing
wrong. When there is something wrong with their actions, behavior therapy is
needed. All behavior is movement. Changing how clients move will help them to
function better. Clients who always lash out in physical violence when they are
mad are in for a world of hurt. They must understand how to do something
different when they are mad. They must learn how to practice new behaviors until
this becomes automatic.
How Clients Learn
To understand all types of therapy, you need to know how the brain works. The
brain is like a jungle. Imagine, for a moment, that you have crash landed an
airplane in the jungle. There are thick branches and vines everywhere. All you see
is thick vegetation everywhere. As you recover from the crash, you get thirsty. You
hear a creek running to the right of the nose of the plane. You look for the easiest
way of getting to the creek, but you only see jungle. The jungle is the same
thickness in all directions. Finally, your thirst overcomes your fear, and you strike
out for the creek. When you do, you make a pathway. It is not much, and it will not
last long, but it is there. By passing through the jungle once, you have made a
pathway of least resistance. Naturally, on the way back, you take that pathway
again. It is the easiest way. As you go through repeatedly, you make more of a
pathway until in time you have a nice, smooth trail. Every time you go to the creek,
you take the easiest way. That is exactly how the brain works, and that is how
learning takes place.

Source: Jupiterimages/Thinkstock.
Habits
Humans are creatures of habit. Habits are learned behaviors. They are easy
pathways in the brain. Habits must be practiced to remain an active part of the
person’s behavior. Suppose that someone has a drinking problem. This is a habit.
The person has this wide pathway in the brain. We could call this the drinking
pathway. When this person feels uncomfortable, he or she takes a drink. The
person has been doing this for years. We need to teach this person another way of
relaxing. The first time the person takes the new way in the brain, it is going to be
difficult. Just like the jungle, there are thick vines and branches in the way, it hurts,
and all the time the person has this other way tempting him or her back to drinking.
The old pathway is better established. As the counselor, you encourage the client
to try something new. You support the client, you reward the client, and finally he
or she tries the new way. It is not easy, but the client does it. Now you encourage
the client to try it repeatedly. The client begins to build a new pathway in the
brain, and as he or she does, the old pathway gradually begins to grow over. It
never will grow over completely. The client may think about drinking. This will
be tempting sometimes, but the more the client takes the new pathway, the more it
becomes the pathway of least resistance. Soon it will be the easiest way, and the
client will take the new way automatically.

You can see from this analogy that every time you go one way in the brain, it is
important. Each time you go through the brain the same way, you are making a
better and more long-lasting pathway.
Changing a Habit
People drink for a reason. Let us say that they drink when they feel tense. Every
time people feel tense, they reach for a drink. Once people come into treatment,
they decide that they cannot drink anymore, but they still have times when they feel
tense. They need to learn a new way of dealing with that tension. They need to
learn a new skill. They may learn that every time they feel tense, they talk about it,
they exercise, or they go to an AA meeting. The more clients practice the new
behavior, the more comfortable and habitual it becomes. Soon the new behavior
will become second nature. Every time the clients feel tense, they use the new
skill.
What Is Reinforcement?
New behavior is learned by encouraging clients to try something new and then
reinforcing them for the new behavior. Reinforcement increases the frequency of a
behavior. It increases the chances that the new behavior will happen again. A
reinforcer does one of two things for the clients:

1. It gives the clients something positive.

2. It allows the clients to escape from something negative.

Behavior does not exist, nor does it continue to exist, without reinforcement. If
you take the reward away, the behavior will vanish. It will extinguish.
What Is Punishment?
Punishment decreases the frequency of a behavior. It works in two ways:

1. It introduces something negative.

2. It removes something positive.

The best punishment for someone is to allow that person to suffer the natural
consequence of his or her behavior. For example, someone who does a poor job
of completing a step exercise has to do it over again. This usually is punishment
enough. There are some bad things about punishment, so you need to use it
sparingly. Punishment cannot teach someone a new behavior. It can only teach
them to avoid an old behavior. Punishment takes the client’s mind off what he or
she did and puts it on to what you are doing. The client can miss the point.
Treatment centers need to be set up with a clear consequence for maladaptive
behavior. The rules and the consequences for breaking the rules must be clear.
The Behavior Chain
To understand people and behavior therapy, you need to understand the behavior
chain. At every point along the chain, clients can change or can do something
differently. Treatment is learning what to do and when to do it. These are the tools
of recovery.

The first event in the chain is the trigger. This is the stimulus or event that triggers
a response. After the trigger comes thinking. Here the person evaluates what the
stimulus means. Much of this thinking is so fast that it is not consciously
experienced. The thoughts generate feelings. The feelings give energy and
direction for action or behavior. All behavior has a positive or negative
consequence. The behavior chain looks like this:

Trigger → Thinking → Feeling → Behavior → Consequence

Let us look at an example. Larry is addicted to cocaine. He is riding down the

street and hears a particular song on the radio (trigger). He begins thinking about
the “good old days” when he enjoyed using cocaine (thinking). This thinking leads
him to crave cocaine (feelings). He decides to ride over to a drug dealer’s house
just to see how his “old friend” is doing (behavior). Larry uses cocaine
(consequence).

Now let us plug in some tools of recovery. Larry is riding down the street and
hears a particular song on the radio. He recognizes this song as one of his triggers.
He tells himself that he no longer has the option of using cocaine (new thinking).
He thinks about the misery that cocaine caused him (new thinking). He
experiences some craving, so he decides to give his sponsor a call (new
behavior). He goes to a meeting with his sponsor (new behavior). He does not use
cocaine (new consequence).
The Importance of Reinforcement
Every time you encourage people or pay attention to them, you reinforce them. You
must try to reward clients only when they act in the way that you want them to act.
If possible, you must ignore, or give a negative consequence for, all maladaptive
behavior. Behavior therapy is going on constantly in treatment. You need to look
for positive things to reinforce. Reward your clients as often as you can. See
yourself as someone who is constantly looking for behavior to reinforce.

Examples of Reinforcing Statements

“I liked what you did in group today.”
“Thank you for joining in this afternoon.”
“You look better after you exercise.”
“You told the truth. That is great!”
“I saw you working on your assignments this afternoon. Good going.”
How to Use Punishment
When maladaptive behavior is displayed, the first thing you need to do is share
your feelings. Remember the formula. I feel _____________________________

When you ________________________________________.

I would prefer it if _____________________________________. This tells the

client how you are feeling, what the client is doing that is causing you to have that
feeling, and what you want the client to do differently.

“Tom, I feel frightened when you raise your voice. I would prefer it if you
speak more quietly.”
If the maladaptive behavior continues, then warn the client of an impending
consequence.
“Tom, if you do not lower your voice, I am going to leave the room.”
If the behavior continues, then administer the consequence: Leave the room.
Let us go through another example. Tim, an adolescent client, begins to throw
food.
“Tim, it makes me angry when you throw food. I would prefer it if you would
eat normally.”
Tim keeps throwing the food. He laughs with the other adolescents.
“Tim, if you do not stop throwing food, you will be restricted to your room
for 1 hour.”
Tim defiantly throws food again.
“Go to your room. You are restricted to your room for 1 hour.”
When a Client Breaks a Rule
If a rule is broken, then a consequence is given. To let the behavior slide tells the
client that rules do not count. It is a common early mistake for counselors to want
to avoid giving consequences. They do not want to hurt clients’ feelings, and they
want to be friends. If you will examine this desire carefully, you will see how
wrong it is. A good counselor does not want to teach people to do bad things. You
do not want to let clients continue their maladaptive behavior. That would be
helping them to stay sick.

Let us go through a few behavioral objectives. Remember that in behavior therapy,

you want to teach the client to do something differently.

Objective 1: The client will go to five treatment peers and share the feelings
exercise with them. (This exercise comes with a built-in reward because
sharing feelings brings people closer together. As the client shares his or her
feelings, the client draws closer to others. This is a powerful reinforcement.)
Objective 2: The client will list 10 times when he lost his temper with his
children. He or she will discuss each situation with the counselor. He or she
will verbalize other means of dealing with anger (by 9-20-2017). (In this
objective, the client also feels closer as he or she shares the truth. You also
would want to reinforce the client for being honest and ask the client how he
or she feels after the disclosure.)
Objective 3: The client will keep a feelings log for the next 5 days
(completed by 9-15-2017). (In a feelings log, the client charts his or her
feelings. This allows the client to keep up on his or her improvement. This is
a powerful reinforcement.)
Objective 4: The client will give a 20-minute speech to the group on his or
her powerlessness and unmanageability (by 9-25-2017). (Giving the group a
talk is a positive new behavior. If the client is going to teach something to
others, then the client must first learn it himself or herself.)
Objective 5: The client will meet with his or her counselor and spouse in
five conjoint sessions before the end of treatment. (During each session, you
would want to reinforce each person for building better communication
skills. When someone compromises, reinforce him or her.)
Objective 6: The client will ask two treatment peers a day for help with his
or her program. The client will record each situation and share weekly with
his or her counselor. (A client who is reluctant to ask for help needs practice
in doing so. The illness tells the client that he or she is not worth helping and
that other people do not want to help the client. Nothing works better to
dispel these inaccurate beliefs than to actually have people help the client.)
Objective 7: The client will give three treatment peers a compliment each
day. The client will keep a log of each situation and discuss with his or her
counselor (by 9-25-2017). (By having a client say reinforcing things to
others, you set up a natural reinforcing situation. You need to talk with the
client about how the other people responded.)
Objective 8: The client will keep an anger log and share weekly with his or
her counselor (by 9-30-2017). (Keeping an anger log will make the client
more aware of his or her anger. If the client is more aware, then he or she can
catch the anger earlier and use a specific skill to deal with the feeling. For
example, every time the client gets angry, he or she could back away from the
situation until the client can get accurate in his or her thinking. Then the client
can do something different such as talking about his or her anger.)
Why We Concentrate on Behavior Therapy
The reason why behavior therapy is so good is that you can see it happen. The
new behavior either occurs or does not occur. The more you reinforce a new
behavior, the quicker it develops into a habit. It is important to reinforce the
behavior as quickly as you can after it occurs. Practice is important. The more a
client practices a behavior, the more of a habit it will become. You can role-play
certain situations to solidify and practice the new skills. We ask for progress, not
perfection. Most old behaviors fall away slowly. It will be months before the
triggers stop creating old responses.

Do not drink or use drugs, read the “Big Book” (AA, 2002b), go to meetings, seek
a higher power, call your sponsor, share how you feel, ask for what you want, and
tell the truth—all of these are essential parts of the program. They all are placed
in behavioral terms. They can be changed and counted as they change. If you
monitor behavior, then you will know exactly how your clients are doing in
treatment.
Cognitive Therapy
Another essential element in addiction treatment is how people think. Thoughts
precede feelings, and feelings initiate action. Clients have to think about drinking
before they drink. People think in words or in images. If I were to ask you to close
your eyes and think about the word wagon, you could do that. If I were to ask you
to close your eyes and see a wagon, you could close your eyes and see some sort
of an image of a wagon. That is thinking in imagery.
Source: ©[Link]/track5.
How Chemically Dependent People Think
Because of the disease, clients do not think accurately. They have separated
themselves from reality. They are distorting the truth to protect themselves. Most
clients come into treatment in some form of denial:

“I do not think I have a drinking problem.”

“I never had any problems with marijuana.”
“Everybody I know drinks as much as I do.”
“My husband is overly sensitive. His dad was a heavy drinker.”
“Anybody can get arrested for drunk driving.”
“I may have an alcohol problem, but I am not an alcoholic.”

The client who said these things had a severe drug problem. All of these thoughts
were inaccurate. She was addicted to alcohol and cannabis. She was drinking and
using cannabis all day, every day.

The psychology of addiction demands repressing the truth from consciousness.

Repression is a mental process where we keep the facts hidden from ourselves.
This information is kept secret to protect us from the painful reality of our
situation. If drug addicts will see the whole truth, then they will see their
addictions. The addicts will see that they are dying from addiction. This truth
creates tremendous fear. The addicted individuals protect themselves from
experiencing this fear by not seeing reality. An addict might have gotten an eighth
DWI but still does not think that he or she has a problem. The addict might see
only half-truths. The addict might see that the police are out to get him or her or
that the addict’s spouse is overreacting. The addict does not see the whole truth or
the seriousness of the addiction.
Defense Mechanisms
The illness of addiction cannot operate without lies. Addicts must lie to
themselves until they believe the lies or else the illness cannot continue. All of the
lies are inaccurate ways of thinking. Cognitive therapy corrects the thoughts and
gets the clients accurate. Cognitive therapy is a fearless search for truth.

Minimization distorts reality and makes it smaller than it actually is. When
minimizing, the addict says, “It is not so bad.” When an alcoholic pours whiskey,
he or she does not use a shot glass; the alcoholic pours. If we take that poured
drink and measure how many shots are in it, we might find four or five shots in the
glass. To the alcoholic, this is one drink. However, it is not one drink; it is five
drinks. “I am only having three,” the alcoholic says innocently to himself or
herself. “What is the problem?”

Rationalization is a good excuse for drinking or using drugs. Probably the most
common excuse is as follows: “I had a hard day.” Therefore, for the addict,
“Anyone who has had a hard day needs to relax. Therefore, I need a few.”

Clients can rationalize almost anything. Rationalization is blaming.

“The police were out to get me.”

“My wife does not understand me. That is why I drink.”
“I have been having financial problems.”
“I cannot sleep if I do not drink.”
“My boss really gets on my nerves. I need a drink.”

The essential element here is that these clients are fooling themselves. They really
believe that their behavior is not their fault. Something else is to blame. In
treatment, these clients need to accept the responsibility for their own behavior.
Being an adult means making all of your own decisions and living with the
consequences.

Denial is the most common defense in addiction. It is primitive and distorts reality
more than does any other defense mechanism. In denial, clients refuse to
experience the full impact of reality. Suppose that you are walking downtown on a
hot summer day. Along the sidewalk, people are standing and holding buckets of
ice water. As you walk past, they throw the ice water in your face. You see the
water, and you see the people, but you do not experience the full shock of the
water. Denial is a dissociated, unreal world. A drug addict might be losing his or
her spouse, children, job, friends, money, and freedom, but the addict does not
experience the full impact of this reality. The addict does not see why everyone is
worried.

All clients who come into treatment are in some form of denial. They are not
seeing what is right in front of their faces. It is incredible how strong denial can
be. Clients can be at death’s door and still believe that they are fine.
Applying Cognitive Therapy
Cognitive therapy is correcting the lies that clients have been telling themselves. It
is the process of getting the thinking accurate. As the counselor, you help the
clients to see the truth. First, the clients need to see the lies in operation. Have a
client do the following exercise in your office or in group.

Place a chair in the center of the room, and explain to the client that he or she has
an internal dialogue going on all of the time. The dialogue is between the illness
and the healthy side of the client. The illness wants to use alcohol or drugs. The
healthy side wants to be healthy and happy. Have the client sit in one chair and
role-play the illness. Have the illness side talk the healthy side into drinking or
using drugs. It will be helpful if you model the exercise first. The dialogue will go
something like this:

“John, you have had a pretty hard day. Nobody is going to know if you have
just a couple of beers. Your wife is not going to find out. Why don’t you stop
by the bar for just a couple? It would taste good. You can handle a couple of
beers. You can stop whenever you want to. Remember all the good times we
had drinking. Remember the women. You can talk to them better if you have
had a couple of beers. You do not have to call your wife. She will not know.
You can hide it. It will not matter.”

As the client talks, you can see all of the lies he is telling himself:

1. “I have had a hard day.”

2. “Nobody is going to know.”
3. “Just a couple.”
4. “You can handle it.”
5. “You can stop.”
6. “Remember all the good times.”
7. “Remember the women. They liked you better when you were drunk.”
8. “You can talk to women better when you have had a couple of beers.”
9. “You do not have to call your wife.”
10. “She will not know.”
11. “You can hide it.”
12. “It will not matter.”

Now you challenge each of the client’s inaccurate statements.

“Do you think that having a hard day is worth risking your life?”
“When is the last time you went in a bar and just had a couple of beers?”
“Haven’t you proved to yourself that you cannot stop? If you could stop, what
are you doing in here?”
“How are you going to feel if you start hiding from your wife again?”

Repeatedly challenge your clients’ inaccurate thoughts. In treatment and in

recovery, the clients must be committed to reality. They have to live in reality and
solve problems using the whole truth.

Clients are inaccurate not only about their drugs but also about their self-images.
They might call themselves stupid, inadequate, or ugly. They might have an
exaggerated sense of their own importance. The best way of correcting these
inaccurate thoughts is in group, but individual therapy also is valuable. Someone
who thinks that he or she is worthless, helpless, or hopeless needs to see what is
real. Many clients will argue with you about these things. The inaccurate thoughts
seem to have a life of their own.

Client: I can’t live without my husband . . . Bob. I cannot.

Counselor: You cannot? What would happen to you if you were shipwrecked on
an island in the South Pacific? There was no one on this island but you. You have
plenty of food and water, but you are all alone.

Client: Oh, I would be okay.

Counselor: But Bob would not be there. Wouldn’t you die?

Client: That is different. That is a different situation.

Counselor: No, it is not. You just said you could not live without Bob. Now you
tell me you could live without anyone.

Client: Well, I do not want to live without him.

Counselor: That is better, but that is not quite accurate either. Would you kill
yourself if you did not have Bob in your life? Is it impossible to live without Bob?

Client: No, it is possible to live without Bob, but I love Bob. I want Bob in my
life.

Counselor: Good, that is accurate. You want Bob in your life. You do not need
him in your life for survival. Seeing the relationship more accurately will give you
feelings that are more accurate. If you need Bob for your survival and Bob leaves
you, then you will die. That is scary. It is too scary, and it is not accurate.
Automatic Thoughts
Thinking occurs extremely quickly. There is a never-ending stream of conscious
and unconscious thought flowing through a person’s mind. Most of this thought is
not registered on the screen of consciousness. The more a behavior or thought
process is practiced, the more unconscious and automatic it becomes. You do not
have to think consciously of each of the hundreds of little decisions you make
while driving a car. You make most of these decisions unconsciously out of habit
—how to turn the wheel, when to put on the brake, when to speed up a little bit.
These decisions are made without conscious thought.

Beck, Rush, Shaw, and Emery (1979) found out that many people who were
depressed were having certain thoughts that were leading them to feel depressed.
It was the private ways in which these individuals were interpreting events that
were critical to their uncomfortable feelings. They were thinking inaccurate things
that were involuntary, persistent, and plausible and that often contained a theme of
loss. This thinking was keeping them down. Most of these thoughts occurred
automatically, totally out of the clients’ awareness. The important thing to note
here is that these thoughts profoundly affect feelings and behavior.

Beck (1967, 1972, 1976) reported that three elements were essential to the
psychopathology of depression: (1) the cognitive triad, (2) silent assumptions,
and (3) logical errors.

The cognitive triad consists of the negative views of clients about themselves,
their world, and their future. In general, depressives view themselves, their
world, and their future as lacking something that is a prerequisite for happiness.
For example, they may view themselves as inadequate, incompetent, and
unworthy. They may view their environment as demanding and unsupportive. They
may view the future as hopeless, frightening, and full of inevitable pain.

Silent assumptions are unarticulated rules that influence depressives’ feelings,

thinking, and behavior. For example, a client may believe one or more of the
following:

“I will only be happy if I am good looking, intelligent, or wealthy.”

“When I make a mistake, people think less of me.”
“It is weak to ask for help.”
 “I have to please everyone all of the time.”

These stable beliefs develop from early experience and influence the individual’s
responses to events. They give rise to automatic thoughts.

Logical errors are the inaccurate conclusions that clients draw from negative
thinking. They can overgeneralize, drawing conclusions about their ability,
performance, and worth from one incident:

“He does not love me, so I am unlovable.”

Logical errors can magnify or minimize by exaggerating or diminishing the

importance of an event:

“The class laughed. Everyone thinks I am a fool.”

“I got all As this quarter, but 2 years ago I got a C.”
“I cannot do college work like other people.”
How to Correct Inaccurate Thoughts
Let us go through an example of how to correct automatic thoughts. The first time
that clients hear about interpersonal group, they usually feel frightened. A client
might not stop and think, Why am I afraid? They just feel scared. Feeling like this,
the clients might try to do something to prevent themselves from going to group.
They might fake that they are sick or tired.

Uncover the Thoughts and Feelings

Using cognitive therapy, you first would ask clients how they were feeling. Write
each feeling down. Then ask the following: “What were you thinking between the
time that you heard about interpersonal group and the feeling you felt? What
thoughts came to mind?” The clients might be able to respond here, or you might
have to suggest some thoughts. In cognitive therapy, you will have to suggest to the
clients thoughts that they might have been having. Do not stop until you have
brought out a short list of thoughts such as the following:

“The people in group will not understand me.”

“I would make a fool of myself.”
“This is going to be humiliating.”
“They are going to put me on the hot seat.”
“They are going to make me talk.”

Pull on clients’ automatic thoughts. Ask and then make suggestions. Remember,
these are thoughts that the clients do not try to have. They are unconscious and
happen automatically. Once you see the powerful negative message that these
thoughts give the clients, you will understand why they feel afraid.

Score the Inaccurate Feelings

It will help to have clients score each feeling on a scale of 1 (as little as
possible) to 100 (as much as possible). Let us say that a client felt fear at 90. Ask
whether the client was feeling any other feelings as well, and ask the client to
score each of these. Our client also was feeling angry with a score of 50. The
client was angry because the group was going to try to “make me talk.” The client
also was feeling sad at a score of 70 because “this is going to be humiliating. I am
going to make a fool out of myself. These people will not understand me.” If we
add up all of the negative feelings, the client was feeling 210 units of distress.

Getting the Thoughts Accurate

Now we help the client to challenge his or her automatic thinking. We know that
many of these thoughts are inaccurate.

Counselor: Your thought was that these people will not understand you. What do
you think is accurate?

Client: Well, they have the same problem as I do. They should be able to
understand me. At least they will try to.

Counselor: How about “I am going to make a fool out of myself”?

Client: I do not really think I am going to make a fool out of myself. It could be a
little embarrassing.

Counselor: Yeah, you could do something a little embarrassing. What do you

think would happen if you did?

Client: I don’t know.

Counselor: Do you think the other clients might understand and be sympathetic?

Client: I think they would try to understand.

Counselor: So, even if you did do something a little embarrassing, it would not
be the end of the world.

Client: No.

Counselor: Now what about “This is going to be humiliating”? Do you think the
group is going to humiliate you?

Client: No, I do not. I have met a few of the clients already, and they seem very
nice. I do feel humiliated, though, just being here . . . you know, in treatment.
Counselor: Do you think the other group members could relate to that?

Client: Sure.

Counselor: How about “They’re going to put me on the hot seat”?

Client: Well, they might. I have heard about the groups where they hound you
and attack you until you spill your guts.

Counselor: Let me assure you that the staff here does not work like that. We do
not have a hot seat. We give people the opportunity to talk. If they do not want to
talk, that is fine. What if it was one of those heavy, confrontational groups? Could
they make you talk if you did not want to?

Client: Probably not.

Counselor: So what is accurate here?

Client: I can talk if I want to. I really want to talk. I want to get better.

Counselor: Good. Let us go back and score your feelings again using accurate
thoughts. You hear that there is an interpersonal group at 10 o’clock. You think,
These people are nice. They have the same illness as I do. They should be able
to understand me. I want to talk and get better.

Scoring the Accurate Feelings

Counselor: Now, thinking accurately, how much fear do you feel?

Client: About 35, I guess.

Counselor: How much anger?

Client: None.

Counselor: How much sadness?

Client: 40.

Compare Inaccurate and Accurate Thoughts and Feelings

Counselor: When you were thinking automatically, you were feeling 210 units
of distress, but when you get accurate, your pain dropped to 75. That is a drop of
135 points.

Client: Amazing.

Counselor: Yes, and these thoughts go on all the time. You automatically think
the worst, so you feel bad. There is some real reason to feel uncomfortable—bad
things could really happen—but if you get accurate, you can live in reality. You
can feel the real world. You have been living and feeling in a world created by
your distorted thoughts.

Uncovering the Generalizations

As clients keep track of their negative thoughts, you will see that their thinking
ends up with certain generalizations or themes. These stable attitudes or beliefs
develop over time. They usually can be traced to early childhood experiences.
These beliefs are very tenacious. A client who believes that “I do not get along
with people” might base that belief on something that happened to him or her as a
small child. The inaccurate thinking keeps the person from seeing reality. Themes
are based on evidence that clients have collected over a number of years. The
clients act on these beliefs as if they were absolute facts. The clients no longer
challenge them. The automatic thoughts are used as evidence from which these
inaccurate conclusions are drawn. You must help the clients to uncover these
distorted attitudes and beliefs. They are not accurate, and they need to be
corrected.

Clients might believe that they are unlovable. The clients are convinced inside of
their own thinking that this is a fact—“I am unlovable.” These clients will begin to
build evidence from their experience that will support this belief. The clients will
begin to tell themselves things such as they are unlovable for various reasons—“I
am ugly,” “I am stupid,” or “I am bad.” None of these things is true, but the clients
believe that all are true. Naturally, this leads to uncomfortable feelings. Clients
who think that they are unlovable feel depressed and lonely.

In cognitive therapy, your job is to get clients thinking accurately. Most of the
clients’ thinking is automatic, and you will have to train the clients to keep track of
their thoughts. David Burns’s (1999) The Feeling Good Handbook: The New
Mood Therapy is an excellent overview of the various forms of cognitive therapy.
Reading this is a good way of beginning to think in cognitive terms. In time, you
will pick up clients’ inaccurate thinking quickly. You rarely will want inaccurate
thinking to pass by unnoticed. Stop clients at every opportunity and correct them.

Client: I have messed up my whole life.

Counselor: Your whole life?

Client: Yeah.

Counselor: Is any part of your life still intact?

Client: No. I have screwed up everything.

Counselor: You still have your job.

Client: Well, yeah.

Counselor: You still have your wife and kids.

Client: Yeah, they’re still with me.

Counselor: And your boss is supporting your treatment.

Client: Yeah.

Counselor: So, let us get accurate. You have not messed up everything. You just
feel like you have.

Client: (Laughs.) Now that I think about it, I have a few things left. I still have
my job, my wife, my kids, and my house.

Counselor: You have many things. You have not messed everything up. Why
don’t we make a list of the things you still have? Carry this list around with you,
and when you think you made a mistake, take out the list, and read it to yourself.

This is cognitive therapy at its best. The client corrects inaccurate thinking,
develops accurate thoughts, and then practices accurate thinking.

Solidifying Accurate Thinking

It is helpful to have clients carry around note cards with accurate thoughts written
on them. When they feel bad, they take out the cards and read them to themselves.
Sometimes they need to look at themselves in the mirror and read the cards to
themselves. Clients will not catch the inaccurate thinking at the thinking stage.
Thinking happens too quickly. They will have to catch the inaccurate thoughts at
the uncomfortable feeling stage and then backtrack to find out what the thoughts
were. Have clients keep a feelings log in which they jot down every time they
have an uncomfortable feeling and the situation that caused the feeling. Then have
them score each feeling on the scale of 1 to 100. Once they have a few days of a
log, call them in and begin to filter out what thoughts were occurring during the
situation.

John came in with his feelings log. On Thursday at lunch, he felt hurt and angry
when a treatment peer made the following comment about his sweater: “Where
did you steal that old sweater?” John felt angry with 70 and hurt at 80. He felt 150
units of emotional distress.

Example of a Cognitive Therapy Session

Counselor: What were you thinking when he said that?

Client: He does not like me.

Counselor: What else?

Client: That is about it.

Counselor: Were you thinking that people do not like you very much?

Client: Yeah, I was.

Counselor: Were you thinking that nobody likes you?

Client: Exactly.

Counselor: Nobody has ever liked you?

Client: (Nods his head.)

Counselor: How about nobody will ever like you?

Client: Well, I know that.

Counselor: Bob says to you, “Where did you steal that old sweater?” You think
that he does not like you, nobody likes you, and nobody will ever like you.

Client: Yes.

Counselor: Now, what is accurate? Bob says, “Where did you steal that old
sweater?” What do you think is an accurate way of thinking about that situation?

Client: Bob was just having fun and making a joke.

Counselor: So, to get you to like him, Bob tells a joke.

Client: I think so.

Counselor: Why does Bob tell you a joke?

Client: Because he wants me to like him.

Counselor: Right, Bob likes you and wants you to like him, so he tells you a
joke. He ribs you about your sweater. Your automatic thinking takes over and says
that he hates you, everyone hates you, and everyone will always hate you.
Thinking these thoughts, you feel hurt and angry. Now thinking accurately, how do
you feel?

Client: I feel good. Bob likes me.

Counselor: Right.
Interpersonal Therapy
Addiction wounds relationships. Interpersonal therapy heals relationships and
restores an atmosphere of love and trust. In recovery, clients are encouraged to
love God, to love others, and to love themselves. If one of these relationships is
not healed, then the clients will continue to feel uncomfortable and will be
vulnerable to relapse.
How to Develop Healthy Relationships
In the AA/NA program, when we are talking about relationships, we are first
talking about spirituality. Spirituality is defined as the innermost relationship we
have with ourselves and all else. The first thing that clients must do in developing
a healthy relationship is to surrender. Step One demands an admission of
powerlessness and unmanageability. Without surrender, the clients will continue to
try to control themselves and other people. This leads to disaster as the “self will
run riot” (AA, 2001, p. 62).

The next step is to believe that a power greater than ourselves can restore us to
sanity. This relationship with a higher power is an essential part of the 12-step
program. Clients must seek the God of their own understanding and establish a
relationship with that higher power.

Relationships with a higher power, self, and others are based on love, trust, and
commitment. Love is not a feeling. It is an action. Trust necessitates truth, and
commitment takes consistency of action. Action without truth is not enough. Truth
without action is not enough.
Building a Relationship With a Higher Power
In building a relationship with a higher power, clients must be willing to accept
that some sort of a higher power is possible. The best way of showing this is to
ask the clients this question: “Do you think that there is a power greater than
yourself?” For most clients, this is enough. However, for some, you have to
demonstrate by asking the following: “If you wanted to leave this room and the
group was determined to keep you in, could you leave?” The answer here is
obvious to even the most stubborn. The group has greater power.

Now, can clients begin to turn their wills and lives over to this new power? This
will start with the group. Can the group be trusted? Does the group make good
decisions? If the clients can begin to deal with doubt and faith in a group, then they
have come a long way toward developing trust in a higher power. The clients must
see the group members love each other. The clients must see the group be
committed to the truth even when it hurts.

Much later in the program, clients are encouraged to begin thinking about a higher
power. Willingness again is the key. If the clients will seek a higher power through
prayer and meditation, then they will begin to make progress in this area. Some
clients will want to do some reading about spirituality, and all of them need to talk
with a clergy person who is familiar with the 12 steps.
Developing a Relationship With Self
The relationship with self begins to heal when clients begin to treat themselves
well. They stop hurting themselves with drugs and alcohol. They stop saying bad
things to themselves. They begin eating three meals a day. They sleep properly.
They begin to get regular exercise. All of these simple skills have a profound
effect on the clients’ feeling of self-worth. People of great worth are worth
treating well.
Building Relationships With Others
Interpersonal relationships heal when a client uses good interpersonal relationship
skills.

1. The client must share how he or she feels.

2. The client must ask for what he or she wants.
3. The client must be honest.
4. The client must be actively involved in the other person’s individual growth.

If one of these skills is missing, then the relationship will be unstable. It will feel
unstable, and the individuals involved will feel frightened. Each of these skills is
developed and practiced.

Clients must practice identifying and sharing their feelings. This takes education,
individual therapy, and group work. There are only a few primary emotions.
Plutchik (1980) theorized that there are eight:

1. Joy
2. Acceptance
3. Anticipation
4. Anger
5. Fear
6. Surprise
7. Disgust
8. Sadness

Other emotions are various combinations of the basic eight. For example, jealousy
is feeling sad, angry, and fearful all at the same time. All feelings give energy and
direction for movement. Feelings motivate behavior directly related to survival.
For example, fear activates escape behavior. Escape protects the organism from a
dangerous situation. Surprise activates orienting behavior. Sadness gives the
organism the energy and direction to recover the lost object.

In therapy, you must educate clients about their feelings. For example, in many
homes, anger is an unacceptable emotion. A child learns that anger is dangerous,
so the child learns to repress anger. The child does not feel it. The child may feel
fear every time that he or she feels angry. A client needs to use all of his or her
feelings to function normally. A person who cannot feel anger cannot express
anger. A person who cannot express anger is handicapped. This person cannot
adequately protect himself or herself. Anger is necessary to establish and maintain
boundaries around ourselves. If a person cannot do this, then people will violate
the person’s boundaries and he or she will be victimized.

Have your clients list situations in which they felt each feeling and then discuss
how the clients could have responded properly. You will find that cultural
differences abound. For example, in the United States, women are not supposed to
act angry, so when they feel angry, they cry. Men are not supposed to cry, so when
they feel sad, they act angry.

As a counselor, you are teaching clients to use feelings in problem solving. When
a client has a feeling, he or she should listen to this feeling. What is the feeling
telling the person to do? The client should then consider options of action.

Client: I got so mad.

Counselor: What did you do?

Client: I just stood there. I did not know what to do.

Counselor: What were your options?

Client: I could have hit him.

Counselor: What else could you have done?

Client: I could have walked away.

Counselor: What else?

Client: I was so mad that I did not know what to do.

Counselor: Could you have told him you were mad?

Client: Oh, yeah, but he would not have cared.

Counselor: You could have told him you were mad and what he did that made
you mad.
Client: What good would that have done?

Counselor: We have to hold people accountable for what they do. Anger gives
us the energy and direction to fight for our rights. One of the best ways to use your
anger is to tell people you are angry. That holds them accountable.
How Clients Use Feelings Inappropriately
Many clients use their feelings inappropriately. They make the wrong movements
when they have feelings. People who are fearful tend to avoid fear-producing
situations. They shy away from everything. People who are angry can constantly
be fighting. They fight everybody about everything. These clients need to learn
how to use their feelings appropriately. Their feelings can get to be the problem.
Some of these clients need behavior therapy. They need to learn how to act
appropriately when they feel certain feelings. A client who was abused and
terrified by his father might respond to all people with fear. This client needs to
identify and understand how the relationship with his father influenced how he
responds to everyone. He needs to understand that most people are going to treat
him well.
How Clients Learn Relationship Skills
People learn what to expect from the world by the experiences they have had. It is
from these experiences that we draw maps about what the world is like. We learn
what to do in certain situations. Childhood experiences are very powerful. They
condition us and give us attitudes about what the world is like. The most important
relationship for us was with our primary caregiver. This person usually was the
mother, but it could have been someone else. If this person was healthy and loved
us, then we felt safe and important. We grew up feeling that the world was a safe
place. If our primary caregiver was not healthy, then we learned other things. We
might have learned that the world was an abusive or sad place. The first
relationship was very important. As the counselor, you must help clients to
develop accurate maps of the world.
How to Change Relationships
In therapy, you will see clients’ relationship maps in how they relate to you. The
clients will react to you as if they reacted to significant others in the past. This is
transference. When you react to the clients using your old maps, it is
countertransference. As the clients respond to you, watch for the inaccurate ways
in which they interpret what you do. If the clients act frightened of you when there
is nothing to be frightened about, then you can be sure that you are dealing with a
transference issue. As you treat the clients with encouragement and love, they will
have the opportunity to redraw their maps. Maybe the world is a safe place after
all. In the relationship with you, the clients will see how healthy persons relate to
each other. They will observe and be able to model after you. You will teach the
clients how to communicate and how to relate to other people with love and trust.

Clients may have a relationship problem that they will need to address with some
other person. In the family program, you will have the opportunity to work with
the family. Here you can teach all of the family members healthy communication
skills. You can teach them how to listen to each other and how to develop empathy
for each other. Have them repeat each other’s thoughts and feelings. This makes
sure that each person understands what the others are saying. Teach them how to
use “I feel” statements. Teach them how to reinforce each other. Teach them how
to inquire for more information until they understand. Burns’s (1999) The Feeling
Good Handbook has some communication exercises that can be helpful if you are
interested in pursuing this therapy further.
How to Handle Grief
Grief issues can need attention in interpersonal therapy. When clients have lost
significant others, they will have to work through the grief. The clients will have
to experience pain and say good-bye to the lost loved ones. Having the clients talk
about the good and bad times that they had with the lost loved ones is important.
Have the clients write good-bye letters to the loved ones. Have them read the
letters to you or to their interpersonal group. The clients need to gain the support
of other people. The higher power concept can be greatly beneficial here. God
knows everything, and everything fits into God’s plan. “Nothing, absolutely
nothing happens in God’s world by mistake” (AA, 1976, p. 449). The clients can
be encouraged to trust in a higher power’s judgment. Work and grief work go
together. We turn our will and our lives over to the care of God as we understand
God. Grief work is a good time to build a closer relationship with the higher
power.
How to Choose the Therapeutic Modality
Individual therapy helps to prepare clients for group work. The clients will
transfer what they learn from you in individual therapy to the group as a whole.
From the group, the clients will transfer what they have learned to people in
society. Individual therapy gives you an opportunity to discuss some things with
your clients that are not appropriate for the group. There is no need for a client to
share every intimate detail in group. Some things are best left for individual
therapy. Sexual abuse and other sensitive issues can generate a great deal of
shame, and the group might not understand. If a client decides to share something
with you but does not want to share this issue with the group, then the client is
given this opportunity, but remember that everything of importance must be
discussed with the clinical staff. The client does not have to talk to the staff, but
you do. You need the help of your colleagues, particularly in sensitive situations.

Individual therapy gives clients the opportunity to have a healthy interpersonal

relationship with another person. This is very healing. The clients finally will tell
someone the whole truth and see that person’s reaction. As you continue to care
for the clients, even when they tell you the worst, it teaches the clients something
that they never have known: They are persons of worth. Nothing battles the
disease better than this fact.
6 Group Therapy

Source: ©[Link]/PamelaMoore.

The most powerful motivation for change in most addiction programs is the group.
The group is a microcosm of the world in which the client lives. In group, there
are people who clients identify with their mothers, fathers, brothers, sisters,
friends, and enemies. Therefore, they can work through many issues by interacting
with group members. The whole group is seen as the client’s family, and the client
can learn how to resolve family conflicts by working with the group. Clients can
grow from a group in ways that they cannot grow in individual therapy. The group
serves as a healthy family from which clients can develop normal social
interaction. From the treatment center group, clients transfer relationships to their
12-step group that is by no accident called a home group. Addiction requires long-
term treatment, and this is how it occurs. Other groups such as rational recovery
or other treatment groups work just as well as 12-step groups, but some of them
are expensive. Long-term treatment is necessary for the underlying character
defects that fuel addiction. In 12-step groups, the treatment is good, it is
supportive, and it is free. The group has special characteristics that make it
uniquely effective in helping clients to overcome their problems.
Benefits of the Group Process
1. Healthier members instill hope. There are clients in the group who are
further along in treatment. These clients look better and act better. They use
effective communication skills. They do not deny their disease. They confront
other clients gently and with the truth. They encourage each other. They are
not afraid to share. This has great impact on clients coming into treatment.
They see that people get better as they stay in treatment longer.
2. Clients can model healthy communication skills. They see members sharing
their feelings and asking for what they want. Group members are not shamed
for having feelings or thoughts. The world does not end if someone gets angry
or cries. Clients watch as problems and feelings are worked through until
they are resolved.
3. Clients become aware that they are not alone in their pain. They hear the
stories of the other clients, and the stories are very similar. The group
members can laugh together about the mutual pain. No one else but fellow
alcoholics would understand riding around the block waiting for the liquor
store to open or hiding the bottle so well that even the alcoholic could not
find it. It is comforting for clients to hear someone else discuss problems that
they have experienced themselves. Clients often feel like they did the worst
thing possible, and they find to their amazement that everyone in the group
did the same thing. The clients begin to feel as though they are not bad, but
the disease is bad.
4. Information is exchanged. Clients share their experiences, strengths, and
hopes. In these stories are examples of how to handle difficult situations.
Group members learn from each other’s experiences. If members never have
relapsed, then it is informative to hear about someone who has had that
experience.
5. A feeling of family develops. The group members feel close. They accept
each other and try to love each other. Interpersonal trust and intimacy
develops. Clients carefully keep each other’s confidentiality and learn how
to watch out for each other.
6. Clients learn that they can be accepted for who and what they are. Even
when clients are at their worst, the other group members still accept them.
They are supportive and encouraging. This comes into direct conflict with
what clients always have believed—that if they told the truth, they would be
rejected.
 7. Clients learn the power of the truth. Using real feelings, in real situations,
and with real people, clients learn to solve real problems. People do not go
away from the group sulking or worse off than when they came in. They go
away feeling loved and supported. It is your responsibility to make sure that
every group ends in a positive light.
8. Clients can express their feelings freely. They can express their pain in a
supportive atmosphere. They can ventilate feelings and still feel accepted.
They can practice sharing feelings to see whether they are appropriate to the
situation. People who never have acted angry can act angry and see the
positive effect of their anger.
9. By listening to each other and sharing together, clients feel a new sense of
self-worth. They begin to feel worthy of the group’s time and energy. The
group members show each other that they all are worthwhile individuals.
10. Clients learn what works and what does not work in interpersonal
relationships. They see what brings people together. They come to
understand that the more they share, the closer they can get, and that the
closer they can get, the more they can share.
Preparation for the Group
Before each group, have someone read the preparation statement about the group
process. This sets the stage for group and prepares the members for the work
ahead. It sets a few simple rules about how the group functions.
The Preparation Statement
Interpersonal group is an experience designed to help us learn more about how we
feel, think, and act. Addiction blinds us to the truth about ourselves. It keeps us
from experiencing reality. We develop defenses that keep us from seeing ourselves
as we really are. We present to the world a false front that we ourselves believe
to be true. If we are ever going to accept ourselves and begin the process of
recovery, then we must know who we are. We can do this only by learning how
other people see us. The group members will act as mirrors, showing to us those
parts of ourselves that we do not see. They will reflect our feelings, thoughts, and
behaviors.

The spirit of this group is love. We share, care, and help each other to grow as
individuals. With all of our heart, we encourage you to share your experience,
strength, and hope. Be open to listen and talk. Our experience has shown that only
those who participate fully recover.

A main focus of the group is feelings. Many of us never have dealt honestly with
our feelings before. We know that doing this is frightening and painful, but it is
necessary. You must be willing to be yourself. It is a tremendously rewarding
experience to be accepted for who you really are.

The group has only two rules. First, there will be no physical violence. We need
to feel free to express ourselves without the fear of physical harm. The second
rule is confidentiality. What you see here, what you hear here—let it stay here. We
will now begin the session by introducing ourselves and stating why we are in
treatment.

The reader of the preparation statement gives his or her first name and the reason
why he or she is in treatment. For example, “I am Shirley, and I am an alcoholic.”
If someone in the group does not want to call himself or herself an addict, that is
fine, but that person does have to give a reason why he or she is in treatment. For
example, “I am Frank, and I got a DWI.”
The Agenda Group
As the counselor, you then have each group member choose an agenda and
someone in the group to share it with. The agenda is a current matter of concern
for the client. It has to be a real problem that generates real emotion. Some clients
will try to choose something easy, but do not let them. If they will not, or cannot,
choose something important, then choose something for them. You write down all
of the agenda items on the blackboard or a large pad for everyone to see.
How to Choose the Order of the Agenda
Once the agendas are up on the board, you choose an agenda that seems to be the
most therapeutic. Choose something that will generate emotion and will teach the
clients about addiction. The best agendas usually are those that deal with
problems the group members are currently having with each other. It is always
best to deal with the here and now rather than with the there and then.

The group members will start with the agenda item that you choose and will move
as far through the list as they can. As the counselor, you choose the next agenda
each time. You will have a good idea which agendas need to be dealt with during
a particular day. A client starts by telling a problem to the person with whom he or
she has chosen to share the problem. For example, Shirley talks to Tom about
being mad at her treatment peer. Tom answers first, and then anyone in the group
can add what he or she feels is important. You watch for and reinforce appropriate
feedback. Most new counselors talk too much. Let the group do most of the
talking, and speak only if someone is not being understood or is being hurt. Then
you clarify the issue and redirect the group toward understanding, encouraging,
and supporting each other.
How to Give Good Feedback
A person giving good feedback will do the following:

1. Talk about the specific behavior.

2. Give feedback in a caring manner.
3. Give the other person a chance to explain.
4. Avoid being judgmental.
5. Use “I feel” statements.
6. Share the positive as well.
7. Avoid giving advice.
How to Receive Feedback
To receive feedback appropriately, a client must do the following:

1. Ask for it.

2. Receive it openly.
3. Acknowledge its value.
4. Be willing to discuss it.
5. Make no excuses.
6. Indicate what he or she intends to do with it.
7. Listen to everyone.
How to Run a Group
As the counselor, you should not talk much in group. Intervene only when
necessary to keep the group moving along therapeutically. So long as the truth is
coming out and people are being accepted, the group is doing well. It is a common
early mistake for counselors to talk too much. This discourages the other members
from sharing. It is also common for the clients to get into the habit of talking only
to the counselor. When this happens, draw other people into the discussion. “John,
how do you feel about that?” is enough to take the focus off of you and onto other
group members. Let the silent periods raise the group’s anxiety. Someone will talk
if you wait. If you always talk, then no one else will.

For the most part, the clients who are doing the most sharing are getting the most
out of group. You must encourage quieter members to share. A simple question,
such as “Tom, how do you feel about that?” often is enough to get someone started.

If someone is becoming a problem in the group, then let the group handle it. Do not
try to handle everything yourself. Asking a question such as “How do the rest of
you feel about Bob right now?” is enough to let the group work for you.
Sometimes people try to monopolize the group, and they need to spend more time
listening. Look at Jane, who is talking too much and playing counselor for
everyone, and gently say, “Listen.”

You need to make sure that no one is harmed in the group process. If things are
getting too hot and angry, then focus on the client’s pain. Hurt comes before anger,
and it defuses anger to talk about the pain. If someone is getting hurt, then you must
step in and give the group direction. Statements such as “How would you want to
be treated right now?” go a long way toward giving the group solid direction.
How to Know Which Therapy to Use
Behavior, cognitive, interpersonal therapy, and skills training can all be effective
in a group setting. Your skill is to use the best therapy for the particular problem.
If a client is behaving in a way that is maladaptive, then behavior therapy comes
into play. If the client is thinking inaccurately, then cognitive therapy is necessary.
If the problem is in a relationship, then interpersonal therapy is most appropriate.
If the problem is the client needs to learn a certain skill, the skills group will be
most effective.
The Honesty Group
There are special groups that are particularly effective in dealing with specific
problems. You can plug in one of these exercises anytime you feel that it is
appropriate. The honesty group helps clients to see how they lie to themselves.
For many of these groups, as the counselor, you will model the exercise for the
group first. By being creative, you can come up with many effective groups like
this.

In the honesty group, you might say, “Today we’re going to see how the illness
operates inside of your thinking. We all have a constant dialogue going on inside
of our heads. This conversation is between the illness, who just wants to drink or
use drugs, and the healthy side, who wants to get clean and sober.” Place an empty
chair in the center of the group. “We are going to put a chair in the center of the
group. In this chair, we are going to put our illness. This side of us wants to get
high. In the chair that we are currently sitting in, we are going to put the healthy
side of us, the side that wants to stay clean and sober. Now each of us is going to
spend some time in each chair. We are going to start in the illness chair and try to
convince the healthy side of us to drink or use drugs. I am going to go first.”
Example of the Honesty Group
The counselor, Judy, sits in the center chair and leans toward the empty chair in
which she was just sitting. From the illness side of herself, she tries to talk herself
into drinking or getting high. She might say something like this:

“Judy, you are doing great. I am very proud of you. You have been sober for a long
time. You have been going to meetings. That is great. You have your life back
together.

“You know, when you feel like it, I would like to do something. I want to go for a
ride in the car, maybe on a nice spring day. I am not in any hurry. I can wait. I want
to go for a ride, relax, and drink three beers. No one is going to know. Nothing
bad is going to happen. You need to relax, Judy. You have been working too hard.
You deserve a break. Come on, it is just three beers. Remember all the good times
we had drinking. Remember how good it felt.”

Judy looks at the group. “That is how my illness still tries to get me drunk. Now, I
am going to trade chairs and answer the illness from the healthy side of me.” She
moves to her original chair and leans back. “Well, illness, you seem to forget a
few things. You always forget. You remember selectively. See, I remember the
misery. I remember trying to drink three beers and throw up three beers at the
same time. I remember losing my husband and my kids. I remember the shame of
losing my job.” She sits forward in her chair. “I also remember that we have tried
this before about a hundred times. We have tried drinking only three beers, or two,
or one, and it goes okay for a while, but eventually I get drunk, and bad things
happen. Illness, I know how good I feel in recovery. I have regained my self-
respect. I have my children back. I have a good job. I have found God for the first
time in my life. In addition, you want me to give all of this up for three beers. You
keep your three beers. I do not want to have anything to do with you.”

Now the clients should have the idea. The counselor picks someone who he or she
thinks can do a good job, and the exercise is repeated. Most of the clients will not
have as long a dialogue as the counselor, but it is important to see each person’s
illness at work. This exercise is excellent at uncovering who has a good recovery
program and who is still struggling.

Clients usually will feel more comfortable in playing the illness role. This may
show how little it is going to take the client to go back to using. The counselor
will see all manner of seductions perpetrated by the illness. It is good for the
clients to see how they have been deceiving themselves.
Uncovering the Lies
About halfway through the group, hand each of the clients a blank piece of paper.
Then tell them this: “It is important that you see how the illness works. The illness
must lie to operate. It cannot exist in the truth. You must lie to yourself and believe
the lie before you can ever go back to drinking or drugging. What we are going to
do now is uncover the lies. Every time you hear the illness lie, I want you to wave
your paper. This is your white flag of surrender. Wave it loud so it rattles.” The
counselor asks the next client to start with his dialogue.

Bob smiles at the group and sits in the illness chair. “Well,” says Bob, “you have
had a hard day.” (The group members rattle their papers.) “Why don’t you stop by
the bar and have a couple of beers? That is not going to hurt you.” (The group
members rattle their papers again.) “Your wife will not know.” (The group
members rattle their papers and laugh. Bob laughs with them.) “You can drink just
a few.” (Rattle.) “Just a couple.” (Rattle.) “Remember all the good times we had.”
(Rattle.) “You need to relax and enjoy yourself.” (Rattle.)

This is educational and fun. The clients never will forget those white flags going
up after they speak to themselves. When the clients speak from their healthy side,
the flags stay quiet. It is sobering to experience the lies try to work in front of
treatment peers.

Have the group members discuss the exercise. In which role did they feel the most
comfortable? Why? What are they going to do to keep from lying to themselves?
How can they begin to keep the illness in check? How do they feel about the
illness part of themselves and the healthy part of themselves? What is the goal of
the illness? What is the goal of the healthy side? What is it like to have what seem
to be two people in the same body?
How to End Each Group
End each group with a chance for the members to share the positive things that
they learned about themselves. Keep this sharing time positive. At Keystone
Carroll Treatment Center, we begin each group with the serenity prayer and end
with the Lord’s Prayer. The group members put their arms around each other or
hold hands as they pray.
The Euphoric Recall Group
This group examines euphoric recall and how this differs from reality. As the
counselor, you stand at the blackboard and ask each client to give an example of
what drinking or using drugs did for him or her when that person first started
using. You pull out all the positive things that the clients were getting from early
use.
How to Uncover Euphoric Recall
Counselor: Tony, what did drinking do good for you? What was it giving you
that was good?

Tony: It made me relax.

Counselor: Good. (The counselor writes “It made me relax” on the blackboard.
Then the counselor moves to the next person in the group.)
How about you, Sally? What did drugs do good for you?

Sally: It was easier for me to talk to people.

Counselor: Okay, good. (The counselor writes, “It was easier to talk to people”
on the blackboard.)

As the counselor, you go around the group at least twice. You need a long list of
the positive things that chemicals did for the group members. Do not put down the
same thing twice. You should come up with a list that looks something like this:

1. It made me relax.
2. It was easier to talk to people.
3. I felt more intelligent.
4. I felt stronger.
5. It made me brave.
6. It made me feel wanted.
7. I felt more attractive.
8. I could sleep.
9. I felt happy.
10. I could be creative.
11. My problems did not bother me anymore.
12. I could get along.
13. I was funny.
14. I felt comfortable.
15. People liked me.
16. I could talk to women.

You make as long a list as the blackboard will allow and then state, “Now, here
are some of the good things that drinking and drugs did for you. I assure you that
we could make a longer list of the good things that chemicals gave us early in use.
This is why we were drinking and using drugs.”
How to Help the Clients See the Truth
You then draw a line down the middle of the blackboard.

Counselor: Now let’s see what happened to each of these things when addiction
set in. Tony, after you became an alcoholic, did alcohol still make you relax?

Tony: I was always tense. I could not relax.

Counselor: How about it, Sally? After drug addiction took over, was it still
easier for you to talk to people, or did you feel more isolated?

Sally: Lonely. I felt totally alone.

You write down what each person says. Be sure to read off what good the client
got out of early use before asking him or her what happened when drug addiction
took over. What the group members are going to find out is that once addiction set
in, they ended up with the opposite of what they were using for. People who were
drinking to sleep cannot sleep. People who were using to be social ended up
alone. Your second list will look something like this:

1. I was tenser.
2. I could not talk to anyone. I was lonely.
3. I felt stupid.
4. I felt weak.
5. I felt inadequate.
6. I felt like no one wanted me.
7. I felt ugly.
8. I could not sleep.
9. I was very sad.
10. I could not think.
11. I had more problems.
12. I could not get along with anybody.
13. I was not funny anymore. I was sad.
14. I could not get comfortable.
15. I felt as though no one liked me.
16. I could not talk to anybody.
The group members need to take a long look at both sides of the blackboard. You
emphasize that the illness side of them will use euphoric recall to seduce them
into using drugs and alcohol again. The clients have to get in the habit of seeing
through the first use. They need to remember the painful consequences that come
with continued use. The group members discuss what they learned for a brief
period, and then you need to speak again.

Counselor: You see how the illness uses the good stuff to get you to use again.
Now, what are you going to do when the illness side of you begins to gain
strength? What are the tools of recovery that will put hurdles in the way of the first
drink?

Tony: Call your sponsor.

Bob: Go to a meeting.

Sally: Turn it over.

The counselor writes each of the new coping skills on the blackboard.

1. Call your sponsor.

2. Go to a meeting.
3. Turn it over to your higher power.
4. Get some exercise.
5. Talk to someone.
6. Read some AA/NA material.
7. Remember the bad stuff.
8. Remember how good you have felt when clean and sober.
9. Ask for God’s help.
10. Do something else that you enjoy.

Help the clients to make a long list, and then discuss it with the group.
The Reading Group
In reading group, clients read a portion of the “Big Book” (AA, 2002a) or the
“Twelve and Twelve” (AA, 1981) and discuss it with each other. It is necessary
to have a counselor present to facilitate this discussion. Gently encourage all
members of the group to share. People do not have to share, but if they do, they get
more out of treatment. The first 164 pages of the “Big Book,” and all of the steps
in the “Twelve and Twelve,” are read during treatment. There will be clients who
do not feel comfortable reading for one reason or another. Encourage all of them
who can comfortably read to do so. If a client feels too uncomfortable reading,
then he or she can pass. This material is read out loud chapter by chapter,
paragraph by paragraph, or line by line. The clients discuss the subject matter to
help them understand and internalize the material.

Source: ©[Link]/digitalskillet.
The Relapse Prevention Group
A relapse prevention group is run once a week. This group concentrates on high-
risk situations and develops coping skills for dealing with each situation. The first
group introduces relapse and concentrates on the triggers that might trigger using.
These are the environmental situations that make clients vulnerable to using drugs
and alcohol. Clients learn that there is such a thing as lapse (the use of a mood-
altering chemical) as well as relapse (continuing to use the chemical until the full-
blown illness becomes evident again). For most clients, the time period between
lapse and relapse is less than 30 days. If a lapse occurs, then immediate action
needs to be taken to prevent relapse. All clients must develop coping skills for
dealing with a lapse.
The Trigger Group
Clients tend to relapse in certain situations, which include environmental stressors
and personality characteristics. To prevent relapse, addicts need to develop
individual coping skills, self-efficacy, and lifestyle balance, which might increase
the probability of finding themselves in a high-risk situation. Relapse prevention
includes teaching effective coping strategies and enhancing self-efficacy, along
with cognitive interventions designed to prevent the occurrence of relapse
episodes. It is essential that the clients not see a lapse as a failure or a lack of
willpower but as an opportunity to learn more about the disease (Marlatt &
Donovan, 2008).
How to Uncover the Triggers
Discuss each trigger with the group. Ask the clients to list the feelings that make
them vulnerable to using. In what situations do they continue to use? How do they
feel before they use? Are they more vulnerable when they are angry, frustrated,
bored, lonely, anxious, happy, or joyful? Ask the group what they think are high-
risk situations including social pressure, interpersonal conflict, inaccurate painful
thoughts, uncomfortable feelings, low motivation for change, environmental stress,
and lack of lifestyle balance. Generally, the counselor is trying to reduce stressors
and increase pleasurable activities. Relaxation training and stress management
exercises are used to help the clients reduce their response to relapse triggers. An
environmental or interpersonal trigger throws the client into withdrawal that often
leads to craving and relapse. The trigger can set off a cascade of symptoms
including craving, inaccurate thinking, and addictive behavior, or with training it
can result in behaviors that are incompatible with relapse. A person who craves
and then goes to a meeting or calls his or her sponsor is going to have a different
outcome than someone who craves and drives to the bar.

Social pressure can occur in one of two ways: (1) direct social pressure or (2)
indirect social pressure. Direct social pressure is when someone directly
encourages the client to drink or use drugs. Indirect pressure is when the client is
in a social situation where people are drinking or using drugs (Marlatt & Gordon,
1985).
The Drug Refusal Skills
After discussing a wide variety of triggers, the group goes through drug refusal
exercises. The counselor is the role model in the situation and talks to the group
about the skills needed to say no to drug or alcohol use:

1. Refuse in a firm and unhesitating voice: “No, thank you.”

2. After refusing, change the subject. “I do not drink. How did you get here
tonight?”
3. Suggest an alternative such as having something to eat or going for a walk.
“Want to get some pizza?”
4. Avoid giving excuses: “I have got to work tomorrow.” Just tell it like it is: “I
do not drink.”
5. If the person is persistent, walk away. “See you later.”

At first, let the refusal exercises be easy, and then have more than one person
encourage the person to use. The first time that a client goes through this, anxiety
and craving usually are generated. The first attempt at refusal tends to be rather
pathetic, but with practice, the client gets better. Each client needs to practice until
he or she can say no and feel reasonably comfortable.

The group has a lot of fun with these exercises, but this role-playing delivers a
powerful message: It is hard to say no and feel good about yourself. It is a new
skill, and it has to be practiced repeatedly until it feels comfortable. The exercise
provides excellent protection against relapse if the client can continue the
exercises until he or she feels comfortable saying no. For each client, try to
reenact the exact situation that makes him or her most vulnerable to relapse. For
example, if the client is vulnerable to a sexual situation, then set up this situation
as exactly as you can. A situation in which a significant other encourages the client
to use is not difficult to set up. What is the client going to say? What is the client
going to do? What if the other person gets mad? Have the client go through each
situation until the group members believe that he or she has developed the skills
necessary to say no, and then have the group make a long list of the hurdles that the
client can put in the way of the first drink or use. What can the client do that will
prevent use even when in a high-risk situation?
The Inaccurate Thinking Group
The second group focuses on thinking. What thinking occurs between the trigger
and the feeling of craving? This is where the client’s inaccurate thinking takes
over.

“It will not hurt to have a couple of beers.”

“No one will know.”
“I can handle it.”
“I never had any problem with pot.”
“I can use a little pot.”
“I never really had a problem anyway.”
“I deserve a drink.”
“I had a hard day.”
“I would show them.”

All of these, and more, are given as examples of inaccurate thinking at work.

Have group members discuss what they think about before they use chemicals.
How is the sick part of them trying to trick them into thinking that they can still
drink or use drugs normally? Use the chair technique again. Have the clients talk
to the empty chair and talk the healthy side of them into using drugs or alcohol.
Each of these thoughts must be placed on the blackboard and exposed as a lie.
Discuss the inaccurate thoughts carefully until the clients understand that they all
are lies. Then replace the inaccurate thoughts with accurate thoughts and have the
clients practice the accurate thinking. Go over exactly what new thoughts the
clients are going to use. They are taught a sentence to plug into their thinking
whenever they feel the desire to use alcohol or drugs:

“Drinking (using drugs, gambling, etc.) is no longer an option for me.”

Have clients practice thinking this sentence several times. Have them write it
down and carry it with them. Every time they feel craving in treatment, they are to
first think this new thought and log the situation that triggered the craving. These
triggers are discussed in further groups. Every time clients are in a high-risk
situation, they will think the new thoughts and then consider the other options for
dealing with the situation. Drinking and using drugs no longer are an option, so
what are they going to do? If they are in a high-risk situation, then they need to use
their new coping skills. Have the group put on the blackboard a variety of options
available other than drinking or using. It will end up looking something like this:

1. Call someone.
2. Turn it over to your higher power.
3. Think “That is no longer an option for me.”
4. Call your sponsor.
5. Go to a meeting.
6. Think through the first use.
7. Think about how good you feel in recovery.
8. Remember how miserable you were before treatment.
9. Exercise.
10. Call the treatment center.
The Feelings and Action Group
The third group focuses on feelings and behaviors. The group members need to
know that most chemically dependent persons are particularly vulnerable to anger
and frustration. How are they going to handle these feelings in sobriety?

Feelings are used to give the clients energy and direction for problem solving.
Have the group members discuss the feelings that make them vulnerable to relapse
and come up with coping skills to deal with each feeling. Any number of positive
or negative feeling states can lead to relapse. The clients need to learn how to
cope with good and bad feelings without chemicals.

When clients are having intense feelings, they need to share these feelings with
others. This allows the clients to feel accepted and supported. They need to
develop better problem-solving skills and to practice problem solving in
treatment. The following steps need to be followed when solving a problem:

1. Stop and think. Exactly what is the problem?

2. Consider the options. What is the best thing you can do for yourself and/or
the other person right now?
3. Develop an action plan.
4. Carry out the plan.
5. Evaluate the effect of your action.
The Lapse Group
The fourth group is a lapse group. What are clients going to do to prevent a lapse,
and what are they going to do if they have a lapse? How are they going to feel?
What are they going to do specifically? What hurdles are they going to put in the
way after the first use to prevent continued use? Remember that for most clients
the elapsed time between lapse and relapse is less than 30 days.

Group members put on the blackboard the actions they are going to take to prevent
a lapse. Make a long list, and have all clients copy the list to take home with them.

1. Work a daily program of recovery.

2. Attend regular meetings.
3. Read AA/NA material.
4. Do daily meditation.
5. Have daily contact with sponsor or other AA/NA member.
6. Get daily exercise.
7. Develop enjoyable hobbies.
8. Attend church, or work on spiritual program.
9. Say daily prayer.
10. When wrong, promptly admit it.
11. Be honest. Do not lie.
12. Eat right.
13. Get enough sleep.
14. Take a daily personal inventory.

Have each client make an emergency card of phone numbers to call if he or she is
feeling vulnerable. Have the client carry this card in a wallet or purse at all times.
The phone numbers should include those of the following: sponsor, several 12-
step group members, the treatment center, the local 12-step hotline, a religious
contact, and any other person who may be able to respond to the person positively.

In group, clients should role-play calling these numbers and practice asking for
help. This is a very difficult skill for some people, and they need to be
desensitized to the situation. Have someone else in the group play the other party.
A client needs to get in the habit of calling someone when he or she feels
uncomfortable. Just out of treatment, the client should call someone every day until
he or she feels comfortable. The client should make every attempt to go to a 12-
step meeting every day for 90 days. The first 3 months out of treatment are when
the client is the most vulnerable to relapse. Every effort is made to stay sober
during these first 90 days. After the 3 months, the client can discuss with his or her
sponsor and continuing care group how and when to cut back on meetings.

Signs and symptoms of impending relapse developed by Gorski (Gorski, 1989;

Gorski & Miller, 1982) are given to a client and his or her significant others. Each
symptom is discussed so that the client understands and can identify the symptom.
These warning signs include the following:

1. Apprehension about well-being

2. Denial
3. Adamant commitment to sobriety
4. Compulsive attempts to impose sobriety on others
5. Defensiveness
6. Compulsive behavior
7. Impulsive behavior
8. Tendencies toward loneliness
9. Tunnel vision
10. Minor depression
11. Loss of constructive planning
12. Plans beginning to fail
13. Idle daydreaming and wishful thinking
14. Feeling that nothing can be solved
15. Immature wish to be happy
16. Periods of confusion
17. Irritation with friends
18. Easily angered
19. Irregular eating habits
20. Listlessness
21. Irregular sleeping habits
22. Progressive loss of daily structure
23. Periods of deep depression
24. Irregular attendance at meetings
25. Development of an “I do not care” attitude
26. Open rejection of help
27. Dissatisfaction with life
28. Feelings of powerlessness and helplessness
29. Self-pity
30. Thoughts of social use
31. Conscious lying
32. Complete loss of self-confidence
33. Unresolved resentments
34. Discontinuing all treatment
35. Overwhelming loneliness, frustration, anger, and tension
36. Start of controlled using
37. Loss of control

Clients and their significant others should be given a copy of the warning signs. It
is possible to prevent relapse. In taking a daily inventory, the clients should list
any relapse symptoms that they saw in themselves and come up with a plan for
dealing with the symptoms as soon as possible. Any symptoms resistive to change
are discussed with a client’s sponsor or 12-step group.

Clients might not recognize the early warning signs, so someone else needs to
check them. That is why a sponsor, the continuing care group, and regular
attendance at meetings are so essential. The clients need to listen to everyone. A
closed mind is a sure way of ending up in trouble.

Clients must understand that relapse is a process. It does not begin with using
alcohol or drugs. Some of the symptoms will occur long before actual drug use
begins. The one symptom that everyone should notice is a decrease in attendance
at meetings. Any decrease in attendance at meetings should be carefully discussed
with a client’s family, sponsor, and group.
The Spirituality Group
Spirituality group should be conducted once a week. This group is run by a clergy
person trained in the group process or by a member of the counseling staff who
has a solid spiritual program. At the beginning of each group, the group leader (or
someone the leader has chosen) reads the following to prepare the group for the
spiritual process: “Spirituality is the innermost relationship we have with
ourselves and all else. Religion and spirituality are different. Religion is an
organized system of faith and worship. Spirituality deals with three intimate
relationships: We will explore how to improve our relationship (1) with
ourselves, (2) with others, and (3) with a higher power. We are going to call this
higher power ‘God.’ You may call your higher power something else if you like.
We only ask that you be willing to consider the possibility that there is a power
greater than you are. We will begin the group by giving our names and the reason
why we are here.”

Source: ©[Link]/CEFutcher.
How to Develop Healthy Relationships
The first group discusses the concept of a healthy relationship. What are the
essential components of a good relationship? What are the clients’ experiences
with relationships with self, others, a higher power, and religion? What hurdles
seem to stand in the way of these relationships? What makes them worse? What
makes them better? Many clients see a higher power as punitive. They see a higher
power as they saw their fathers or mothers. These transferences, attitudes, and
beliefs need to be discussed with the group. The pastor or counselor should be
free to discuss his or her own relationships with self, others, and the higher power
of his or her own understanding.

As the counselor, you must be willing to accept how other people experience a
higher power. You will see a wide variety of individual beliefs. This is good.
Each person has his or her own understanding of what the higher power is like and
what the higher power can do. In the atmosphere of unconditional acceptance, the
group members can freely explore their own concepts of a higher power. They
must see that a higher power and religion are not going to be shoved down their
throats in this program.

It is a mistake to allow formal religious doctrine to enter into this group. Do not
allow one group member to try to convince others about some religious principle
or belief. Neither AA, NA, nor Gamblers Anonymous (GA) has any religious
affiliation. People can talk about their religious preferences, but for the most part,
they should discuss spirituality rather than religion. They need to talk about their
own spiritual journeys.
How to Develop a Healthy Relationship With a Higher
Power
The second group specifically delves into the relationship with a higher power.
The group members write letters to a higher power in which they ask for what they
want and share how they feel. Then the clients write down what they think the
higher power answers back. They may come up with questions that they would ask
a higher power if the power was sitting next to them and then write down the
answers. This makes the conversation with the higher power a dialogue rather
than a monologue. In Step Eleven, it says, “Sought through prayer and meditation
to improve our conscious contact with God as we understood him, praying only
for knowledge of His will for us and the power to carry that out” (AA, 2001). The
group members share this material with each other. The group is encouraged to
view the relationship with the higher power as essential to the program. Clients
are encouraged to share their knowledge of a higher power with each other. What
do they want a higher power to be like? What does a higher power want from
them? How can people have a relationship with a higher power?

The group needs to process through how God communicates with them. The
relationship with God needs to be presented as a simple dialogue between two
people. Clients are taught to contact God in a variety of ways. Nature, scripture,
prayer, meditation, church, and other people all are ways in which God can speak
to them. Each of these ways needs to be discussed, and clients in the group should
give examples of when they felt close to or far away from a higher power.
The Eleventh Step Group
The third group seeks ways of improving conscious contact with God. Prayer and
meditation are defined and discussed. Prayer is described as talking to God,
whereas meditation is described as listening for knowledge of God’s will. Clients
are encouraged to begin to talk to God. They need to discuss various methods of
prayer and meditation. They are encouraged to look for God in themselves and in
each other. What do they see in themselves that is good? Clients explore the moral
law. We all know what is right and wrong. Why do we all have the same laws? Is
it possible that some life force gives us these laws? If that is possible, then who
might that force be? Clients are asked to explore several philosophical questions.
If there is a God, then why did not God make himself more knowable? If there is a
God, and if God is all good, then why do bad things happen?
The Meditation Group
The fourth group does an exercise in an attempt to contact God directly. The
clients are told that God may communicate with them in many different ways,
thoughts, feelings, images, other people, scripture, music, nature, and so on. God
often communicates with them inside of their own minds. God may contact them in
words or in images inside of their own thinking. The clients are told that the group
members will try to establish a conscious contact with God, as they understand
God, and that they will try to receive a direct communication from God. It is
explained that God may communicate with them in one of three ways:

1. In words inside of their thinking

2. In images inside of their thinking
3. In no words or images, but the communication will be known

Give the group members a piece of paper, and tell them to write down any
communications they receive. Then play some soft music and take the group
members through an imagery exercise. You can take them through the exercise
yourself, or you can order a book, God Talks to You (Perkinson, 2000), and a
meditation tape, A Communication From God, on the Web
([Link]). If you want to do it yourself, then speak these words
slowly and rhythmically:

“Close your eyes and concentrate on your breathing. Just feel the cool air coming
in and the warm air going out. As you concentrate on your breathing, you will
begin to relax. Your arms and legs will begin to feel heavy and warm. There is no
right way or wrong way to pray. Prayer is just a dialogue with God. He knows
exactly what you need to experience. Say these words to God: ‘God, I am sorry I
have not treated myself the way that I should have, I am sorry I have not treated
others the way that I should have, and I am sorry I have not treated you the way I
should have. Please come into my life and make me the person you want me to be.’
Then ask God a question, ‘God what is the next step in my relationship with you.’”
Wait for 2 to 5 minutes for the answer to come inside of the clients’ mind, body, or
spirit. Then have the clients open their eyes, and have them write down what they
experienced. Go around the group, and have each person share what he or she
received. If a client received no communication, then have that person discuss
what happened when things were silent. How did the client feel? What did the
client think? What did the client see in his or her mind?

When everyone has shared his or her communication, have the group members
decide whether they believe that this communication came from God. Have them
describe the characteristics of the person who delivered the message. What was
that person like?

Most 12-step groups begin with the serenity prayer and end with the Lord’s Prayer
or the Gallic Prayer. Those clients who do not feel comfortable praying can
remain silent. At all points in spirituality group, you need to concentrate on
spirituality and not on religion. You must be willing for each client to find his or
her own unique relationship with the higher power of his or her own
understanding.

If this is done properly, then it will be the most important turning point for most of
your clients in treatment. AA (2002a) says at the end of the chapter on how it
works that

our description of the alcoholic, the chapter to the agnostic and our personal
adventures before and after make clear three pertinent ideas: (a) we were
alcoholics and could not manage our own lives, (b) probably no human
power could have relieved our alcoholism, and (c) God could and would if
God was sought. (p. 60)

Addicts who follow a genuine spiritual journey will find the peace that AA calls
serenity. They need to feel the incredible joy of a higher power’s love, which is
so much better than any drug. For more information about this procedure, I
recommend you get the book God Talks to You (Perkinson, 2000). The text will
tell you how to help clients make conscious contact with God and then to help
clients make progress along the spiritual journey.
The Childhood Group
In the childhood group, clients come to understand how they developed the
tendency to lie about themselves. They come to understand the great lie. The great
lie is that if you tell people the whole truth about yourself, then they will not like
you. The truth is the opposite of this: If you do not tell people the truth about
yourself, then they cannot like you. Most of the clients have been living their lives
as though the great lie were the truth. They need to hear that they are created in
perfection in the image of God. There is no reason for them to lie. The group
members need to see that they could not be themselves and that they pretended to
be someone else. They wore a variety of social masks and played a variety of
roles. They thought that it was the only way in which they could ever be loved.
How to Explore Early Parental Relationships
The group explores early parental relationships. The clients had to pretend to be
someone else to their parents. They knew that their parents would not love them
for who they were. This belief system resulted in the clients feeling empty and
unloved. They did not get what they wanted from their homes of origin. Addiction
is an attempt to avoid this empty feeling. Most addicted persons come out of their
childhoods feeling inadequate and unloved by parents and others.

Have the group members write a letter to their parents. This work is based on
some of the work of Bradshaw (1990). As the counselor, you introduce the
exercise like this. “Write a letter to your parents using your nondominant hand.
This makes the letter look like a small child wrote it. Write them about how you
felt as a child growing up. Tell them how you were feeling and what you wanted
that you did not get.”

After the group members write their letters, have each client read his or her letter
to the group. Then have the other members of the group respond, each in turn, as if
they were the healthy parent hearing the letter. If the client feels comfortable, then
have the group members reach out and touch the client as they respond. The group
should sound something like this.

John reads his letter. “Dear Mom and Dad. Mom, I wanted you and Dad to stop
fighting. I wanted you to pay more attention to me. Dad, I wanted you to take me
fishing and tell me you loved me. I wanted you to stop drinking. I wanted you to
tell me everything was going to be all right. I was afraid.”

Joyce, a group member, reaches out and touches John’s arm. She speaks as if she
is John’s healthy mother. “John, I am sorry your dad and I were fighting. We were
having problems. It was not your fault. I love you.”

Meg, another group member, leans over to John. She, too, plays the role of a
healthy mother. “I am sorry your dad and I were fighting. We did not mean to
frighten you. We both love you very much.”

Frank speaks as the healthy father. “John, I am sorry I was drinking. I am sick. I
am going to try to get some help. I would love to go fishing with you.”
How to Begin to Heal Early Childhood Pain
After all of the group members have read their letters, you take the group through
this imagery exercise. This exercise must be positive. It must emphasize that the
clients are now going to be their own champions in recovery. They are going to
take over the parental role. They are going to try to forgive their parents and reach
for their higher power. You should speak very slowly, pausing briefly after each
sentence.

“Close your eyes and relax. Feel yourself becoming more comfortable. See
yourself drifting back through time. See your high school. What was that building
like—was it brick or wood? See yourself walking the halls of that school. How
did you feel at that time in your life? Did you feel happy? Did you feel frightened?
Feel the feelings that you were feeling then. See your grade school. See the
playground. See a special friend. What is your friend wearing? See yourself
playing a favorite game with your friend. How did you feel in that school?
Reexperience the feelings that you were having at that time.

“See yourself walk up the street where you lived as a small child. See your house
up ahead. You walk up the front walkway and peek in your window. Which room
was yours? Go inside your house, and see yourself as a small child. How did you
feel in that house? Did you feel safe? Did you feel loved? Feel the feelings you
were feeling then. See your mother. How did you feel when she was there? See
your father. How did you feel about him?

“Walk over to yourself as a child, and smile. Imagine that the child looks up at
you. Tell the child, ‘I am from your future. I am going to be your champion from
now on. You can trust me. I am going to keep you safe. I am going to see to it that
good things happen to you. You are important. You matter to me. I want to listen to
how you feel. I care for what you want.’ Tell the child that it is time for you to
leave. You are growing up. You are not going to blame your parents anymore. That
would not do any good. They were trying as hard as they could to love you. You
pick the child up, and the child wraps his or her arms around you. You carry the
child out of the house. Your parents come out on the porch and wave good-bye.
Your higher power appears beside you. Your new AA/NA group members are
ahead. ‘Come on,’ they say. ‘You can do it. We’ll help you.’ You walk up the street
feeling confident, trusting yourself, trusting your higher power, and trusting your
new support group. You feel happy and at peace. Everyone is smiling. You and the
child are laughing together. You take the child and place him or her into your heart,
where the child will stay. You feel yourself coming back to this time, back to the
treatment center, back to your chair. Take a deep breath. Feel your toes wiggle and
your eyelids flicker. When you feel comfortable, open your eyes.”

The group then discusses the exercise. It is important that the group not delve
deeply into old childhood pain. If you keep pulling on these memories, they can
overwhelm clients. Most of these wounds are left to the second year in recovery.
Clients in early recovery need to concentrate on working a self-directed program
of recovery. Once their program is stable, usually in the second year, they can
begin to work through some of the origin issues. In early recovery, you want to
connect the clients to their feelings and not work through every issue. You want
them to feel supported by their new group and their higher power. This will give
them new hope that even the old pain can be resolved.
Men’s Group/Women’s Group
Men’s group and women’s group are run once a week. In these groups, men and
women can gather and discuss things that would be more difficult in mixed
company. Sexual issues and sexual abuse issues can be more easily shared in this
atmosphere. The special relationship of a mother to a daughter or of a father to a
son is explored in greater depth in these groups. How can you be a good mother or
father? What did you want from your parents? What did you want to say to your
mother or father that you never said? What did you want the relationship with your
father or mother to be like? What is it like to be a man? What is it like to be a
woman? What are the special problems that men and women face?

The group needs to discuss how to have healthy relationships with the opposite
sex. They need to consider addictive, dependent, and normal relationships as well
as how they differ. Women can discuss the premenstrual syndrome that may make
some of them more vulnerable to relapse. Men need to discuss anger and how to
use it appropriately. Men and women can role-play various situations. Both
groups need to discuss boundaries, past history of abuse, and how to establish and
maintain appropriate boundaries around themselves.
The Community Group
Community group is where the client population meets to discuss problems that
they are having with each other or the staff. This group usually runs first thing in
the morning and lasts for only a few minutes. Some programs run this group daily
and some weekly. A daily group is best if the clients feel supported.

A daily meditation is read during this group. Any rules of the treatment center that
have been broken need to be discussed. Have the group members join hands or put
their arms around each other and commit themselves to helping each other through
treatment.
The Personal Inventory Group
At the end of every treatment day, the clients have personal inventory group. In
this group, they evaluate their day. They need to consider how they grew in the
program and how they slipped backward. At a minimum, they need to consider
each of the following points:

1. What did I do to love myself today?

2. What did I do to love others today?
3. What did I do to love my higher power today?
4. Was I honest?
5. What uncomfortable feelings did I have?
6. What did I do with my feelings?
7. What character defects caused me problems?
8. How have I been doing in my program?
9. What am I grateful for?
10. What do I need to do differently tomorrow?

Once clients have considered their personal inventories, they need to share
positive experiences from the day. Then they need to go through a relaxation
exercise to wind down. This exercise can be taped or given by the counselor.
Have the clients sit in a comfortable place and pay attention to their breathing.
Then have them imagine a relaxing scene. They can imagine that they are at the
beach, in the mountains, down by a river, or in the desert. Take them through the
scene for about 20 minutes, and then call it a night.
Skills Training Group
The skills training group is where you teach the clients how to use skills to reduce
the chances of relapse. An excellent coping skills training manual has been
developed by Monti, Kadden, Rohsenow, Cooney, and Abrams (2002). All
counselors should read this book and bring it with them to the skills training
group. Then you can read the rationale for learning a skill, teach the skill, be a
role model for the skill, and role-play each skill with the clients. If the clients
role-play situations, it is much more likely that they will use this skill in recovery.
If the clients just hear about the skill, or watch someone else use the skill, it is less
likely that the skill will be effective. When you practice a behavior, you use sight,
hearing, touch, smell, and a variety of muscle movements. This uses most of the
brain, so when challenged, the person has a much higher chance of remembering
the skill and using it. Practice solidifies the skill until it becomes automatic. Use
the skills listed in the aforementioned book to fit your client population. Some
clients have these skills, but some need practice. We will discuss two skills
groups, but you will want to use more.
Assertiveness Skills Group
Open the assertiveness group by discussing communication skills, including
verbal and nonverbal communication. “It is important that we learn good
communication skills in treatment. This begins with nonverbal communication.
You can say the same thing a number of ways that will make the communication
different. Your facial expression, body posture, what you do with your hands and
feet, and your tone of voice are just as important as what you say. Let us say it is
10 p.m., and you have something really important to do tomorrow at school or
work, like take a test, and you need to get a good night’s sleep. In the apartment
upstairs, someone sounds like she or he is bouncing a basketball, and you cannot
sleep. You have waited for the person to stop playing, but the bouncing goes on
and on. Let me show you three ways to talk to the neighbor upstairs, and you tell
me which way is most likely to be effective.”

Have someone else in the group play the part of the neighbor. Then role-play
someone who is too passive. You knock gently at the door. The neighbor opens the
door. You keep your eyes on the floor, shuffle your feet, stumble over your words,
and make nervous gestures with your hands. You speak in a voice that is so quiet
you can hardly hear it asking the neighbor if he or she could stop the bouncing
noise. “Excuse me . . . well . . . maybe. I have got a test . . . you know an exam
thing . . . tomorrow, and I was wondering . . . if you could, maybe . . . if you really
want to . . . stop bouncing that ball or whatever it is. I cannot sleep . . . really
much . . . or at all with that . . . noise. Please, do you think you could stop? I do not
want to be a bother to you or anything. Please . . . okay . . . thanks.” Then wait for
the person playing the neighbor to respond.

Then role-play someone who is too aggressive. This time you bang on the door.
Get too close to the neighbor’s face, raise your voice, clench your fists, and act in
a threatening manner, using the word you. “Are you crazy? How do you expect
anyone to sleep with you bouncing that ball all night? This is not a basketball
court. It is an apartment building. If do not stop this racket, I am going to make
sure you get kicked out of here.”

Then role-play the same scene by being assertive. Here you stand straight, over an
arm’s length from the person, use good eye contact, and keep your voice and face
relaxed. “I live downstairs, and I cannot sleep with the bouncing ball. I have an
important day tomorrow and need to get to sleep. I would appreciate it if you
would stop bouncing the ball. Thank you. Have a nice night.”

Then ask the group which way is most effective and why. Have each member of
the group role-play the person who needs to sleep. Then ask the group to come up
with other situations that they have encountered or might encounter in recovery.
Role-play the passive-aggressive and assertive roles until all members seem to
understand the difference.
Skills
1. Personal space: Stand at over an arm’s length from the other person.
2. Facial expression: Keep everything relaxed.
3. Posture: Stay relaxed with arms to the side, hands open.
4. Tone of voice: Remain calm.
5. Hands and feet: Do not engage in nervous gestures.
6. Words: Be specific about the facts, using “I statements.” Remember the
assertive formula: I feel ______ when you ______. I would prefer it if
______.
Problem-Solving Skills Group
Life is full of problems, and many of them will show themselves in recovery.
Clients need to know the steps involved, so they can solve problems effectively. If
clients do not have effective problem-solving coping skills, they are likely to
return to their old skills, such as rage, withdrawal, or drug and alcohol abuse. If
clients have problem-solving skills, they are not left helpless to a problem; they
have precise steps that they always use when confronted with a difficult situation.
Fear, depression, or anger might start to trouble these clients, but if they become
aware of these uncomfortable feelings and shift toward problem-solving skills,
they will be on the road to problem resolution.

It is essential that the clients learn how to handle a situation where they are
encouraged to drink or use drugs. Social pressure includes being in a situation
where other people are using or being directly encouraged to use. Going into a
casino or bar is indirect social pressure, and being encouraged by a friend to use
is direct social pressure. Each of these situations can easily cause craving and
relapse unless the client knows how to deal with the situation. The clients will go
through this group again in relapse prevention groups, but they need all the
practice they can get with this one.

Begin the group by introducing the refusal situation: “Many times during recovery
you will be asked or encouraged to become involved in your addictive behavior
again. If you are not careful, this could lead to craving, inaccurate thinking, and
relapsing. We will try to avoid using people, places, and things, but it is inevitable
that at some point you are going to be encouraged to drink, use drugs or gamble,
and so on. There are three ways to act when you are encouraged to drink or use
drugs.”

1. You can answer too passively, making the other person think you are not sure
or you are conflicted or confused. This results in confusion because the other
person is not sure about your answer.
2. You can be too aggressive and make the other person afraid or angry, hurting
your relationship.
3. You can be assertive, clear, and firm about your decision not to drink or use
drugs.

Then the counselor sets up a role-play situation where he or she is encouraged to

use. “Let us pretend that we are at a family reunion. Your cousin walks over to you
holding a tray of large plastic cups. You and your cousin get drunk together every
year. He asks you if you want a drink. You could answer him too passively, look
down, make nervous gestures with your hands, speak in a soft, hesitant voice, or
make a lame excuse: ‘No . . . Thanks anyway . . . not today. I am taking some
medication, and I do not want to mix things up.’ You could answer too
aggressively: ‘If you ask me anything like that again, I am going to kill you.’ Better
yet, you could be assertive: ‘No, thank you.’ If your cousin asks you again, you say
no again and then suggest that you do something else together or say, ‘No thanks, I
quit drinking,’ and then walk away.
Skill Set 1
1. Say, “No thank you,” in a firm, controlled voice.
2. Make good eye contact.
3. Do not make nervous gestures with your hands or feet.
4. Give suggestions about something else you could do.
5. If the person keeps asking, say, “No thanks,” and then calmly walk away.

Give each member of the group an opportunity to walk through the drug refusal
exercise. Then ask the group to come up with other situations they have
experienced or might experience, and practice a few more times to solidify the
behavior.
Skill Set 2
1. Write the problem down. Be specific about exactly what happened.
2. Get accurate about the other person’s intent.
3. List each possible alternative action.
4. Consider the positive and negative consequences of each action.
5. Choose the best alternative, and carry the action out.
6. See if the problem moved toward resolution.

Then come up with a role-play situation. It could be something like this. Imagine
that you have come home from a hard day. You are exhausted, but you are an hour
late getting home. The minute you enter the door, your spouse looks at you with a
cold glare and says, “You are probably drunk. I knew you could never stay sober.”
You might want each member of the group to work through the same role play, or
you might want to make up a specific role play for each client. After each member
has tried the steps, see if the group can come up with other situations and work on
them using the problem-solving skills.
7 Drugs of Abuse

Source: ©[Link]/alacatr.
Drugs of Abuse
It is not the purpose of this book to discuss all of the drugs of abuse. This is left to
other texts such as Uppers, Downers, All Arounders by Inaba and Cohen (2014).
All counselors should keep a copy of this excellent text close by their desks.
Addicts are constantly inventing some new way to get high, so the drugs of abuse
will always be changing. The major drugs of abuse seen in treatment are
Phencyclidine, cocaine, opioids, marijuana, and methamphetamine. These drugs
are called the big five because they are the most abused, and new drugs mimic one
or more of these five drugs (Centers for Disease Control and Prevention [CDC],
2014; [Link]).

All psychoactive drugs of abuse alter feelings, thoughts, and behavior. They
directly affect the brain or the central nervous system (CNS). The specific actions
of these drugs are highly complex. Feelings are altered when the drugs affect
neurotransmitters and intercellular communications that seek a balance between
excitatory and inhibitory functions. Every organism is driven toward establishing
a balance between these two systems called homeostasis. Only humans seem to
seek drug intoxication states. Other organisms avoid altered mind states because it
makes them vulnerable to predation and death. The only way laboratory animals
can be enticed to ingest drugs of abuse is to mix them with water or food.
However, once addicted, animals use drugs compulsively to the point of choosing
drugs over food, water, or sex. An addicted brain is a changed brain forever.
Addiction is abnormal behavior that results from dysfunction in brain tissue.
Addiction is just as physical a disease as heart disease or cancer (Leshner, 1997).

The brain is the most highly complex organ in the body beginning in utero with 1
trillion neurons, and through a process called apoptosis, or cell suicide, the infant
is born with 1 billion neurons. Each neuron has thousands of connections with
other neurons using an electrochemical process. Neurons are the cells of chemical
communication in the brain. For each neuron, there are two glial cells that take
care of the neurons. The brain has the most connections when the child is age six.
Then the brain begins to prune the brain cells to foster learning. The brain
continues to make new neurons throughout a person’s lifetime (Stahl, 2008). It is
widely believed by many experts in the field that the level of drug use in the
United States is the highest in the industrialized world. An estimated 24.6 million
Americans used a drug illegally during the month prior to being surveyed in the
2013 National Household Survey on Drug Use and Health: National Findings (see
Appendix 42). Nearly half of Americans (52.1%) 12 years old or over had used
alcohol, 17.3% were binge drinkers, and 21.6% used tobacco products (U.S.
Department of Health and Human Services, 2014).

Specific drug action depends on the route of administration, the dose, the presence
or absence of other drugs, and the clinical state of the individual. In general,
psychoactive drugs can be classified by their primary action on the CNS.
Central Nervous System Depressants
CNS depressants depress nervous tissue at all levels of the brain and nervous
system. CNS depressants include all sleeping medications, antianxiety drugs (also
called minor tranquilizers), opium derivatives, cannabis, and inhalants (Hardman,
Limbird, Molinoff, Ruddon, & Gilman, 1996; Inaba & Cohen, 2014; Schuckit,
1984).
Central Nervous System Stimulants
CNS stimulants achieve their effect either by the stimulation of nervous tissue
through blocking the actions of inhibitory cells or releasing transmitter substances
from the cells or by the direct action of the drugs themselves. These drugs include
all of the amphetamines and cocaine. Nicotine and caffeine also stimulate nervous
tissue but to a much lesser degree (Inaba & Cohen, 2014; Schuckit, 1984).
The Hallucinogens
The effect of these drugs is the production of an altered perception, thought, or
feeling that cannot be experienced otherwise except in dreams. The hallucinations
usually are of a visual nature. These drugs have no known medical usefulness. The
most common hallucinogen currently found on the street is lysergic acid
diethylamide (LSD), but many designer drugs produce the same symptoms
(Carroll & Comer, 1998; Inaba & Cohen, 2014; Jaffe, 1980).
The Reinforcing Properties of Drugs
Drugs of abuse are powerful reinforcers. Animals quickly learn to self-administer
most of these drugs for their rewarding properties. Animals will press a lever
more than 4,000 times to get a single injection of cocaine. They will continue to
self-administer for weeks, alternating between self-imposed abstinence and drug
administration. These animals generally die of drug toxicity and lack of food.
They would rather use drugs than eat (Wise & Kelsey, 1998).

When given continuous access to drugs of abuse, animals show patterns of self-
administration strikingly similar to those of human users of the same drug. These
drugs are strongly reinforcing even in the absence of physical dependence. An
addicted brain is a brain that has changed in chemistry, structure, and genetics to
the point that the drug or addictive behavior undermines voluntary control.
Chronic drug exposure alters neurons in dopamine-related circuits causing
compulsive drug administration and poor inhibitory control. It is estimated that 40
to 60% of vulnerability to addiction is genetic (Thompson & Pickens, 1970; Uhl
& Grow, 2004; Volkow & Li, 2009).
Tolerance and Dependence
Tolerance and physical dependence develop after chronic administration of any
one of a wide variety of mood-altering substances. With increasing tolerance, the
individual needs more of the drug to get the same effect. Tolerance and
dependency develop as the nerve cells chemically and structurally counteract the
drug’s psychoactive effects. Tolerance is a complex, generalized phenomenon that
involves many independent physiological and behavioral mechanisms. It leaves
the chemically dependent individual physiologically and psychologically craving
the drug. The individual becomes obsessed with obtaining the drug for a sense of
well-being. The chemically dependent person becomes inflexible in his or her
behavior toward the drug despite adverse consequences. The intensity of this felt
“need” or dependence may vary from a mild craving to an intense, overwhelming
obsession. At severe levels, the individual becomes very preoccupied with the
drug (Inaba & Cohen, 2014; Kalant et al., 1978; Nestler, 1998; Wilcox, Gonzales,
& Erickson, 1994).

Physical dependence is characterized by withdrawal symptoms. Withdrawal

develops in an addicted individual when the drug is discontinued too quickly.
Physical dependence occurs throughout the entire nervous system (Smith, 1977).
The withdrawal symptoms are a rebound effect in the physiological systems
modified by the drug. For example, alcohol depresses the CNS, whereas
withdrawal stimulates the CNS. In studying the effects of withdrawal, look for the
opposite effect that the drug was used for initially. Amphetamines are used to
stimulate or to give energy, so amphetamine withdrawal causes depression and a
lack of energy. The time required to produce physical dependence can vary.
Withdrawal symptoms can develop in a day with large quantities of CNS
depressants (Alexander, 1951; Inaba & Cohen, 2014). For most drug users,
development of physical dependence is gradual, occurring over weeks, months, or
years of chronic administration.
Cross-Tolerance
The ability of one drug to suppress withdrawal symptoms created by another drug
is referred to as cross-dependence or cross-tolerance. Cross-tolerance drugs may
partially or completely remove symptoms of withdrawal. All drugs of abuse cause
intoxication and induce a psychological dependency. The individual is self-
administering the drug to change his or her level of consciousness or to increase
psychological comfort (Schuckit, 1984).
Alcohol
No one knows when alcohol was first produced, but it was most likely to be a
natural occurrence. If any watery mixture of vegetable sugars or starches is
allowed to stand for about 3 months in a warm place, alcohol will make itself.
Yeast that exists in the air everywhere will land on the juice and eat the sugar,
making carbon dioxide and alcohol as waste. The alcohol content in the juice
continues to rise until all of the yeast cells are killed. Therefore, alcohol is a
poison to all living things even to the organisms that make it. Nature alone cannot
produce anything stronger than 14% alcohol, but by distillation, the percentage can
then be increased to 93% (Courtwright, 2001).

The early detection of alcohol abuse and dependency is complicated by denial that
is found in the individual, in the family, and in society. Long-term alcohol
dependence has profound effects on personality, mood, cognitive functioning, and
a variety of physiological problems involving virtually all organ systems. The
interaction of alcohol and other drugs may lead to fatal overdoses (Frances &
Franklin, 1988).

Alcoholism is the result of a complex interaction of biological vulnerability and

environmental factors. Environmental factors such as childhood experience,
parental attitudes, social policies, and culture strongly affect the vulnerability to
alcoholism. Genetic variables significantly influence the disease. There is no
personality that causes alcoholism (Goodwin, 1985; Vaillant, 2003).
Alcohol-Induced Organic Mental Disorders
Alcohol Intoxication
Alcohol intoxication is the most frequent drug-induced mental disorder. It is time
limited, and it may occur with varying amounts of ingested alcohol. The
intoxicated individual exhibits maladaptive behavioral changes due to recent
ingestion. These changes may include aggressiveness, impaired judgment,
impaired attention, irritability, euphoria, depression, emotional liability, and other
manifestations of impaired social functioning. Although alcohol is a CNS
depressant, its initial effects disinhibit the individual. Early in intoxication, the
person may feel stimulated with an exaggerated sense of well-being. With further
use, the person may slow down and become depressed, withdrawn, and dull. The
person may even lose consciousness (Inaba & Cohen, 2014; Spitzer, 1987;
Woodward, 1994).

Source: Jupiterimages/Thinkstock.
Alcohol Amnesic Disorder (Blackout)
Alcohol amnesic disorder, or a blackout, is a period of amnesia during periods of
intoxication. The person may seem fully conscious and normal when observed by
others, but the person is unable to remember what happened or what he or she did
while intoxicated. The disorder may last for a few seconds or for days. The
severity and duration of alcoholism correlate with the frequency of occurrence of
these blackouts (Goodwin, 1971; Goodwin, Crane, & Guze, 1969).
Wernicke-Korsakoff Syndrome
Wernicke-Korsakoff syndrome is a neurological emergency that should be treated
by the immediate intramuscular administration of thiamine. The symptoms begin
with a sudden change in organic functioning. The client becomes ataxic with a
wide-based, unsteady gait. The person may be unable to walk without support.
The client is mentally confused and unable to transfer memory from short to long
term. The client may be disoriented, listless, inattentive, and indifferent to the
environment. Questions directed at the client may go unanswered, or he or she
may fall asleep while being examined. The etiology of this syndrome involves a
thiamine deficiency due to dietary, genetic, or medical factors. All clients with
compromised mental functioning or a deficit in memory need to be examined by
the medical staff as soon as possible to prevent further brain damage (Braunwald
et al., 1987).
Alcohol Withdrawal
Alcohol withdrawal symptoms relate to a relative drop in alcohol blood levels.
Withdrawal can occur when the individual is still drinking. The classic
withdrawal symptom is a coarse, fast-frequency tremor observed when the
client’s hand or tongue is extended. The tremor is made worse by motor activity or
stress. The client may experience nausea and vomiting, malaise, weakness,
elevated pulse and blood pressure, anxiety, cravings, depressed mood, irritability,
transient hallucinations, headache, and insomnia. These symptoms follow several
hours after cessation or reduction in alcohol intake and peak within 72 hours.
They usually disappear within 5 to 7 days of abstinence. The client in alcohol
withdrawal is treated with a cross-tolerant drug similar in pharmacological
effects to alcohol, usually one of the benzodiazepines. This stabilizes the client in
a mild withdrawal syndrome (Mayo-Smith, 2009).
Alcohol Withdrawal Seizures
Withdrawal seizures may occur 7 to 38 hours after the last alcohol use in chronic
drinkers. The tendency to seizure peaks within 24 hours (Adams & Victor, 1981;
Mayo-Smith, 2009).
Alcohol Withdrawal Delirium (Delirium Tremens)
One third of clients with seizures go on to develop alcohol withdrawal delirium,
or delirium tremens. This is characterized by confusion, disorientation, fluctuating
or clouded sensorium, and perceptual disturbances (Adams & Victor, 1981;
Mayo-Smith, 2009). Typical symptoms include delusions, vivid hallucinations,
agitation, insomnia, mild fever, and marked autonomic arousal. The client
frequently reports visual hallucinations of insects, small animals, and other
perceptual disturbances. The client may be terrified. The delirium typically
subsides after a few days, but it can continue for weeks (Gessner, 1979).
Sedatives, Hypnotics, and Anxiolytics
Benzodiazepines and barbiturates are useful medications with a potential for
abuse and dependence. They are medically useful for a variety of symptoms such
as insomnia and anxiety. Approximately 15% of the population uses a
benzodiazepine each year (Gottschalk, McGuire, Heiser, Dinovo, & Birch, 1979;
Inaba & Cohen, 2014). About 16% of clients abuse the sedatives that are
prescribed by their physicians (Richels, Case, Downing, & Winokur, 1983). By
1977, 18% of young adults reported nonmedical use of sedatives (Abelson,
Fishburne, & Cisin, 1977). This has increased over time until the Unites States has
lost more young adults and teenagers to prescription drug abuse than they do to
auto accidents. This is a national medical emergency. There are no sharp lines that
can be drawn among appropriate use, abuse, habituation, and addiction. Both the
client and the physician might not recognize symptoms of dependence. Both might
assume that the anxiety, tremulousness, and insomnia that develop when the drug is
discontinued are a return of the original anxiety (Jaffe, 1980). Some of these
clients have been on a succession of various benzodiazepines for years. When the
medication is withdrawn, anxiety symptoms may last for months. These clients
must be followed by someone experienced in treating anxiety disorders. The
therapist can work to reduce the anxiety symptoms while the client is experiencing
withdrawal (Burant, 1990; Dickinson & Eickelberg, 2009; Geller, 1994; Juergens,
1994).

Diagnosis of sedative abuse may prove to be difficult. The abuse can start in the
context of medical treatment for anxiety, medical disorders, or insomnia. Physical
dependence can develop to low doses over several years or to high doses over a
few weeks (Dietch, 1983). Intoxication, withdrawal, withdrawal delirium, and
amnesic disorder are similar to those found with alcohol. Benzodiazepines have a
much longer half-life, so withdrawal might not begin until 7 to 10 days after
cessation of use. The client may have a protracted withdrawal that can last for
months (Geller, 1994). Alcohol and opioid CNS depression may interact with
sedative hypnotics and potentiate the depression. Adding small amounts of alcohol
or opioids to the sedatives can quickly lead to overdose (Frances & Franklin,
1988). Treatment for sedative, hypnotic, or anxiolytic withdrawal is similar to that
for alcohol withdrawal. A cross-tolerant sedative is administered to prevent
severe withdrawal symptoms. This medication is gradually decreased until the
client is clear of the drug.
Opioids
Opium has been around since humans first discovered that the opium poppy was
not only good for food and oil but had medicinal and psychoactive properties.
During the late 1960s, the use of heroin increased in the United States. Once
centered in large urban areas, the use of heroin infiltrated smaller communities.
Members of lower socioeconomic groups continue to be overrepresented in this
client population, but the use of heroin is now observed with greater frequency
among affluent members of society. In 2013, there were 108,000 persons age 12
or older who had used heroin for the first time within the past 12 months. A survey
in 1977 indicated that 2 to 3% of young adults had tried heroin at some time in
their lives. A large proportion of the individuals recently beginning heroin use are
young. The existence of opioid addiction among physicians, nurses, and health
care professionals is many times higher than that of any group with a comparable
educational background (Courtwright, 2001; Gilman, Goodman, & Gilman, 1980;
U.S. Department of Health and Human Services, 1999).

Rapid intravenous injection of an opioid produces a warm flushing of the skin and
sensations in the lower abdomen described by many addicts as similar to orgasm.
This lasts for about 45 seconds and is known as the “kick” or “rush” (Inaba &
Cohen, 2014; Jaffe, 1980). Tolerance to this high develops with repeated use.
Physical signs of intoxication include constricted pupils, marked sedation, slurred
speech, and impairment in attention and memory. Daily use over days or weeks
will produce opioid withdrawal symptoms on cessation of use. The withdrawal
symptoms are intense but generally not life threatening. Withdrawal starts
approximately 10 hours after the last dose (Frances & Franklin, 1988; Inaba &
Cohen, 2014). Mild opioid withdrawal presents itself as a flu-like syndrome with
symptoms of anxiety, yawning, dysphoria, bone pain, sweating, runny nose,
tearing, pupillary dilation, goose bumps, and autonomic nervous system arousal.
Severe symptoms include hot and cold flashes, deep muscle and joint pain,
nausea, vomiting, diarrhea, abdominal pain, and fever. Protracted withdrawal may
extend for months (Gold, 1994b; Kosten, Rounsaville, & Kleber, 1985; Tetrault &
O’Connor, 2009).

The treatment of opioid addiction can be grouped into opioid maintenance with
methadone or buprenorphine versus abstinence approaches. Choice of the proper
treatment depends on the client’s characteristics. The course of heroin addiction
typically involves a 2- to 6-year interval between the start of regular heroin use
and the seeking of treatment. The need to participate in criminal activity to
procure the drug predisposes the addict to further social problems. Treatment
takes total psychosocial rehabilitation.

Many heroin addicts cannot or will not give up using opioids. Methadone or
buprenorphine maintenance programs can return these clients to a productive
lifestyle. Methadone substitutes long-acting methadone for short-acting heroin.
Methadone has a half-life of 24 hours, whereas heroin has a half-life of 4 to 6
hours. Buprenorphine clings tightly to the mu-opioid receptor. Research over the
past 15 years has shown that buprenorphine and buprenorphine combined with the
opioid blocker naloxone is a safe and effective alternative to methadone for
opioid maintenance therapy. Buprenorphine with or without naloxone is also used
to ease withdrawal symptoms. Levomethadyl acetate hydrochloride (LAAM) is no
longer used because of its history of causing fatal cardiac arrhythmias.
Buprenorphine has a ceiling dose, and low toxicity reduces the danger of
overdose. Buprenorphine along with the opioid antagonist naloxone also helps to
prevent the client from getting high on other opioids such as heroin during
maintenance therapy (Tetrault & O’Connor, 2009).

Worldwide opioid maintenance remains the major modality for the treatment of
opioid dependency. The research supporting methadone or buprenorphine
maintenance benefits to the heroin user are well documented (Institute of
Medicine, 1995; Lowinson, Marion, Herman, & Dole, 1992; Tetrault &
O’Connor, 2009). Methadone has been found to be medically safe even when used
continuously for 10 years or more (Leshner, 1998). Methadone is administered to
the client orally at established methadone clinics. Although a mainstay of
treatment, these programs reach only 20 to 25% of addicts, with program retention
rates from 59 to 85% (Stimmel, Goldberg, Rotkopf, & Cohen, 1977). Opioid
detoxification should be slow to avoid relapse. The drug should be removed in
weeks rather than days. Total abstinence might be the only alternative for many
clients (Tetrault & O’Connor, 2009).

Buprenorphine is related to morphine but is a partial opioid agonist that possesses

both agonist and antagonist properties. Partial agonists exhibit ceiling effects;
increasing the dose has effects only to a certain level. Therefore, partial agonists
usually have greater safety profiles than do full agonists such as heroin, morphine,
and certain analgesic products chemically related to morphine. This means that
buprenorphine is less likely to cause respiratory depression, the major toxic effect
of opiate drugs, in comparison to full agonists such as morphine and heroin.
Another benefit of buprenorphine is that the withdrawal syndrome seen on
discontinuation with buprenorphine is mild to moderate and often can be managed
without administration of narcotics (Tetrault & O’Connor, 2009). More people are
now dying of opioid prescription abuse than from auto accidents. Americans use
90% of the opioid painkillers in the world (Centers for Disease Control, 2015).
Cocaine and Amphetamines
Moderate doses of psychoactive stimulants produce an elevation in mood, a sense
of increased energy and alertness, and decreased appetite. Task performance that
has been impaired by boredom or fatigue improves. Some individuals may
become anxious or irritable. Cocaine addicts describe the euphoric effects of
cocaine in a way that is indistinguishable from that of amphetamine addicts. In the
laboratory, research participants familiar with cocaine cannot distinguish between
the two drugs when both are given intravenously (Fischman et al., 1976). Animals
use the drugs in a similar fashion, and the toxic and withdrawal symptoms of the
drugs are indistinguishable. There is a difference in the half-lives of the drugs’
effects. Cocaine’s effects tend to be brief, lasting a matter of minutes, whereas
amphetamine effects last for hours (Griffith, Cavanaugh, Held, & Oates, 1972;
Inaba & Cohen, 2014; Wesson & Smith, 1977).
Source: Comstock/Thinkstock.

The user of a psychoactive stimulant such as cocaine or methamphetamine at first

feels increased physical strength, mental capacity, and euphoria. The person feels
a decreased need for sleep or food. A sensation of “flash” or “rush” immediately
follows intravenous administration. It is described as an intensely pleasurable
experience. With time, tolerance develops, and more of the drug is necessary to
produce the same effects. With continued use, toxic symptoms appear. These
include gritting the teeth, undue suspiciousness, and a feeling of being watched.
The user becomes fascinated with his or her thinking and the deeper meaning of
things. Stereotypical repetitious behavior is common. The individual may become
preoccupied with taking things apart and then putting them back together. The
mixture of another CNS depressant drug, such as an opioid (speedball) or alcohol,
can be used to decrease irritable side effects. The client often becomes addicted
to both drugs (Wesson & Smith, 1977).

Pattern of Use
Stimulants may be injected or taken intranasally every few minutes to every few
hours around the clock for several days. Such a “speed run” usually lasts until the
individual has exhausted the drug supply or is too paranoid or disorganized to
continue. Stopping administration is followed within a few hours by deep sleep.
On arising, the individual feels hungry and lethargic. Sometimes the individual is
depressed. Cocaine is inhaled, smoked, or injected intravenously. Cocaine users
who try to maintain the euphoric state will ingest the drug every 30 to 40 minutes
(Inaba & Cohen, 2014; Wesson & Smith, 1977). Animals given free access to
stimulants develop weight loss, self-mutilation, and death within 2 weeks (Jaffe,
1980). Given a choice between food and cocaine, monkeys consistently choose
cocaine (Aigner & Balster, 1978).

A toxic psychosis may develop after weeks or months of continued stimulant use.
A fully developed toxic syndrome is characterized by vivid visual, auditory, and
tactile hallucinations and paranoid delusions indistinguishable from paranoid
schizophrenia (Griffith et al., 1972; Inaba & Cohen, 2014). Unless the individual
continues to use, the drug abuse-induced hallucinations resolve in the first 10
days, 80% in 30 days, with 15% lasting longer, sometimes forever. The
hallucinations are the first symptom to disappear (Jaffe, 1980). Craving for the
drug, prolonged sleep, general fatigue, lassitude, and depression commonly
follow abrupt cessation of chronic use (Inaba & Cohen, 2014; Post, Kotin, &
Goodwin, 1974).

Adolescent cocaine or methamphetamine abuse leads to more rapid and severe

consequences than adult stimulant abuse. Cocaine’s price has decreased to the
point where it costs as little as $5 to get high. During the mid-1980s, the
distribution of the ready-to-smoke freebase cocaine known as “crack” spread
nationwide (Courtwright, 2001; Featherly & Hill, 1989). With the potent freebase
form, there is an almost instantaneous euphoric high that is extremely desirable
(Frances & Franklin, 1988). Cocaine’s half-life is less than 90 minutes, but the
euphoric effect lasts for only 15 to 30 minutes (Jaffe, 1980).

The Stimulant Abstinent Syndrome

The stimulant abstinent syndrome has three phases. The first phase is the crash,
where the individual reports depression, anhedonia, insomnia, anxiety, irritability,
and intense craving. These symptoms can last for 7 to 14 days. In the second
phase, low-level stimulant craving continues along with irritability, anxiety, and
decreased capacity to experience pleasure. Over several days, the negative
consequences of stimulant use fade, the person feels more normal, and the craving
for stimulants increases, especially in the context of environmental cues. The third
phase consists of several weeks of milder episodic craving triggered by
environmental stimuli. Many clients will appear to have a major depression
shortly after cessation of stimulant use. These clients may become suicidal. Most
of these symptoms will clear, but some symptoms, such as sadness and lethargy,
can last for months (Gawin & Kleber, 1986a; Inaba & Cohen, 2014; Schuckit,
1984).

The treatments for stimulant rehabilitation are similar to the treatment for
alcoholism. The euphoria that stimulants offer needs to be replaced by more
adaptive coping skills. Stimulant intoxication can be managed with the
benzodiazepines, propranolol, or clonidine. Stimulant psychosis might have to be
treated with antipsychotic medication. Clients who are psychotic need to be kept
in a quiet place, supported, and reassured. Antidepressants such as desipramine
may ease the withdrawal syndrome (Gawin & Kleber, 1986b).
Phencyclidine
Phencyclidine (PCP) is an anesthetic initially manufactured for animal surgery.
For a short time, it was used as a general anesthetic for humans. Street use of PCP
became widespread during the 1970s, when it was introduced as a drug to be
smoked or snorted (Jaffe, 1980). It is still epidemic in certain eastern U.S. cities
(Caracci, Megone, & Dornbush, 1983; Inaba & Cohen, 2014).

In humans, small doses of PCP produce a subjective sense of intoxication with

staggering gait, slurred speech, and numbness of the extremities. The user may
experience changes in body image and disorganized thought, drowsiness, and
apathy. There may be hostile or bizarre behavior. Amnesia for the episode may
occur. With increasing doses, stupor or coma may occur, although the eyes may
remain open (Domino, 1978). Animals will self-administer PCP for its reinforcing
properties (Balster & Chait, 1978). Psychoactive effects of PCP generally begin
within 5 minutes and plateau in 30 minutes. In contrast to the use of hallucinogens,
the use of PCP may lead to long-term neurological damage (Davis, 1982; Inaba &
Cohen, 2014).

Few drugs are able to produce a more wide range of subjective effects than can
PCP. Among the effects that users like are increased sensitivity to external stimuli,
stimulation, mood elevation, and a sense of intoxication (Carroll & Comer, 1994).
Other effects, seen as unwanted, are perceptual disturbances, restlessness,
disorientation, and anxiety. Smoking marijuana cigarettes laced with PCP is the
most common form of administration (Frances & Franklin, 1988). PCP produces
several organic mental disorders including intoxication, delirium, delusional
mood, and flashback disorders (Spitzer, 1987). Acute adverse reactions to this
drug generally require medication to control symptoms. Benzodiazepines usually
are the drug of choice, but antipsychotics might become necessary.
Dissociative Anesthetics (Phencyclidine, Ketamine,
Dextromethorphan, and FLAKKA)
PCP and ketamine are dissociative anesthetics, and ketamine is still legally
marketed. In recent years, ketamine has developed greater popularity as a club
drug. Dextromethorphan (DXM) is widely available as an over-the-counter cough
and cold medication. Dissociative anesthetics produce a range of intoxicated
states that are grouped into three stages. Clients, particularly adolescents, use
large doses of DXM to get a “high” that they describe as feeling numb with visual
hallucinations.

Stage I: Conscious with mild psychological effects

Stage II: Stuporous or light coma, yet responsive to pain
Stage III: Coma, unresponsive to pain

Clients may emerge from one state to the other, and many of them become agitated
and delirious. Treatment is largely supportive by getting the client in a quiet room
and reassuring him or her that the intoxicated state will improve over time.
Sedatives and antipsychotic medications may be necessary to calm psychotic and
agitated states (Wilkins, Danovitch, & Gorelick, 2009).

FLAKKA is a new hallucinogen that causes disassociation, hallucinations, and

violent behavior. It has caused deaths in Florida, and users have been
disassociated for days after use. FLAKKA now is being passed around in Chicago
as a white powder and used by adolescents to get high.
Hallucinogens
There is no clear line that divides the psychedelics from other psychoactive drugs
that cause hallucinations. Anticholinergics, bromides, antimalarials, opioid
antagonists, cocaine, amphetamines, and corticosteroids can produce illusions and
hallucinations, delusions, paranoid ideation, and other alterations in mood and
thought similar to psychosis. What seems to distinguish the psychedelic drugs from
the others is the unique characteristic to produce states of altered perception that
cannot be experienced except in dreams (Carroll & Comer, 1994; Inaba & Cohen,
2014; Jaffe, 1980).

The psychedelic most available in the United States is LSD. The psychedelic
psilocybin has long been used in religious ceremonies by Southwest American
Indians. Fortunately, the use of this drug is on the decline.

Hallucinogens are not reinforcing to animals, only to humans. Using more than 20
times is considered chronic abuse. Hallucinogens produce a variety of organic
brain syndromes including hallucinogen hallucinosis, delusional disorder, mood
disorder, and flashback disorder (Spitzer, 1987). Flashbacks may occur in as
many as 25% of users (Naditch & Fenwick, 1977). Chronic delusional and
psychotic reactions, and rarely schizophreniform states, have been reported in
some psychedelic users (Vardy & Kay, 1983).
The Psychedelic State
During the psychedelic state, there is an increased awareness of sensory input
often accompanied by a sense of clarity. There is a diminished ability to control
what is experienced. The user experiences unusual and vivid sensory sensations.
Hallucinations are primarily visual. Colors may be heard, or sounds may be seen.
Frank auditory hallucinations are rare. Time seems to be altered. The user
frequently feels like a casual observer of the self. The environment may be
experienced as novel, often beautiful, and harmonious. The attention of the user is
turned inward. The slightest sensation may take on profound meaning. There
commonly is a diminished ability to differentiate the boundaries of objects and the
self. There may be a sense of union with the universe. The state begins to clear
after about 12 hours (Freedman, 1968; Inaba & Cohen, 2014). The intoxicated
client generally can be talked down without sedation. This client needs to be
placed in a quiet environment free of excess stimulation. A sedative occasionally
may be necessary to calm the client.
Cannabis
Cannabis is an India hemp plant that has been used for medicinal purposes for
centuries. Marijuana is a varying mixture of the plant’s leaves, seeds, stems, and
flowering tops. The psychoactive ingredient in cannabis is delta-9-
tetrahydrocannabinol (THC). Hashish consists of the plant’s dried resin, and it
contains a higher percentage of THC (Turner, 1980).

Source: Comstock/Thinkstock.

Marijuana remains the most commonly used illegal drug in the United States and
now is legal in many states. Surveys reveal that 31% of teenagers, 40% of young
adults, and 10% of older adults have tried marijuana. It is generally
acknowledged that marijuana use among adolescents peaked during the 1970s.
Daily users of marijuana dropped from 10.2% in 1978 to 5.0% in 1984 (Frances
& Franklin, 1988).

Cannabis produces effects on mood, memory, motor coordination, cognitive

ability, sensorium, time sense, and self-perception. Peak intoxication with
smoking generally occurs within 10 to 30 minutes. Most commonly, there is an
increased sense of well-being or euphoria, accompanied by feelings of relaxation
and sleepiness. Where individuals can interact, there is less sleepiness, and there
often is spontaneous laughter (Hollister, 1974; Inaba & Cohen, 2014; Jones,
1971). Physical signs of use include red eyes, strong odor, dilated pupils, and
increased pulse rate. With higher doses, short-term memory is impaired, and there
develops a difficulty in carrying out actions that require multiple mental tasks.
This leads to a tendency to confuse past, present, and future. Depersonalization
develops with a strange sense of unreality about the self (Melges, Tinklenberg,
Hollister, & Gillespie, 1970). Balance and stability of stance are affected even at
low doses (Evans et al., 1973). Performance of simple motor skills and reaction
times are relatively unimpaired until high doses are reached (Hollister, 1974;
Jones, 1971).

Marijuana smokers frequently report an increase in hunger, dry mouth and throat,
an increase in vivid visual imagery, and a keener sense of hearing. Subtle visual
and auditory stimuli may take on new meanings (Cloptin, Janowsky, Cloptin, Judd,
& Huey, 1979; Inaba & Cohen, 2014). Higher doses can produce frank
hallucinations, delusions, and paranoid feelings. Thinking becomes confused and
disorganized, and depersonalization and altered time sense increase. Anxiety to
the point of panic may replace euphoria. With high enough doses, the client has a
toxic psychosis with hallucinations, depersonalization, and loss of insight. This
syndrome can occur acutely or after months of use (Chopra & Smith, 1974; Nahas,
1973; Thacore & Shukla, 1976).

Chronic smoking of marijuana and hashish has long been associated with
bronchitis and asthma. Smoking affects pulmonary functioning—even in young
people. The tar produced by marijuana is more carcinogenic than that produced by
tobacco (Secretary of Health, Education, and Welfare, 1977). Individuals using
marijuana chronically exhibit apathy, dullness, impairment of judgment,
concentration, and memory problems. They lose interest in personal appearance,
hygiene, and diet. These effects have been observed in young users who regularly
smoke a few marijuana cigarettes a day. These chronic effects take months to clear
after cessation of use (Jaffe, 1980; Tennant & Grossbeck, 1972).

The pharmacological effects of marijuana begin within minutes after smoking.

Effects may persist for 3 to 5 hours. THC and its metabolites can be found in the
urine for several days or weeks after a single administration. THC is a highly
lipid soluble, and its metabolites tend to accumulate in the fat cells. They have a
half-life of approximately 50 hours (Hollister, 1974; Secretary of Health,
Education, and Welfare, 1977). Tolerance to and dependence on marijuana
develop, and abrupt cessation after chronic use is followed by headaches, mild
irritability, restlessness, nervousness, decreased appetite, weight loss, and
insomnia. Tremor and increased body temperature may occur (Gold, 1994a;
Jones, Bennowitz, & Bachman, 1976; Wikler, 1976). Because the withdrawal
symptoms tend to be mild, detoxification usually is not necessary (Frances &
Franklin, 1988).
Synthetic Designer Drugs
Some newer designer drugs are now marketed on the Internet and in service
stations. They are manufactured at home or in China and labeled as not for human
consummation, so they are not subject to any regulation or oversight, despite the
fact that many of them are stronger than their illegal counterparts. The three major
synthetic cannabinoids, synthetic stimulants, are often marked as bath salts but
mimic cocaine, amphetamines, Ecstasy, synthetic hallucinogens, and LSD. These
products have adolescent-attracting comic book covers that look harmless, but
users should know the truth about them. These products are called Salvia, Spice,
and K2 and are marketed as safe, natural products and are not detected in standard
drug tests. Frequently these drugs can cause permanent brain damage. Many other
names for these products are Demon Passion Smoke, Blaze, Blueberry, Bath Salts,
Khat, or MDMA (Ecstasy or Molly). A new product that has already caused 30
deaths is 25i. This is a synthetic LSD that can cause hallucinations, disorientation,
and violent behavior. Rophies or rohypnol, is Flunitrazepam, a benzodiazepine 10
times more powerful than Valium when used with alcohol-producing disinhibition
and amnesia. This along with GHB is used as a date rape drug. The drug is legal
in many countries, including Mexico and South America, and is diverted into the
United States. Ketamine is an animal tranquilizer and is still used in humans in
surgery. A K land dose of 200 mg causes a mild, dreamlike intoxication,
sensations of mind-body separation dizziness, slurred speech, and impaired
muscular coordination. E-cigarettes are battery-powered devices that simulate
tobacco smoking. This drug is marketed as a way to quit smoking. Among high
school students e-cigarettes have more than doubled in use from 2011 to 2012.
Some teenagers and young adults are soaking them in embalming fluid, a mixture
of formaldehyde, methanol, and ethanol. The World Health Organization
recommends against using e-cigarettes until research shows they are safe
(Perkinson, 2015).
Inhalants
Inhalants include substances with diverse chemical structures used to produce a
state of intoxication—gasoline, airplane glue, aerosol (spray paints), lighter fluid,
fingernail polish, typewriter correction fluid, a variety of cleaning solvents, amyl
and butyl nitrate, and nitrous oxide. Hydrocarbons are the most active ingredients
in these substances (Frances & Franklin, 1988; Inaba & Cohen, 2014).

Several methods are used to inhale the intoxicating vapors. Most commonly, a rag
soaked with the substance is applied to the mouth and nose, and the vapors are
breathed. The individual may place the substance in a paper or plastic bag and
inhale the gases. The substance also may be inhaled directly from containers or
sprayed into the mouth or nose (Spitzer, 1987).

Dependent individuals may use inhalants several times per week, often on
weekends and after school. Inhalants sometimes are used by children as young as
9 to 13 years of age. These children usually use with a group of friends who are
likely to use alcohol and marijuana as well as the inhalant. Older adolescents and
young adults who have inhalant dependence are likely to have used a wide variety
of substances (Spitzer, 1987).

Whereas high doses of these agents produce CNS depression, low doses produce
an increase in CNS activity and a brief period of intoxication. Intoxication can last
from a few minutes to 2 hours. Impaired judgment, poor insight, violence, and
psychosis may occur during the intoxicated period. Inhalants are easily acquired,
and they are cheap. This makes them attractive to children who cannot drink
legally. Animals will self-administer inhalants for reinforcement. There is a strong
cross-tolerance with inhalants and the CNS depressants. Studies of inhalers have
found indications of long-lasting brain damage (Cohen, 1979; Sharp & Brehm,
1977; Sharp & Carroll, 1978). Long-term damage to the bone marrow, kidneys,
liver, and brain also has been reported (Frances & Franklin, 1988). There have
been a number of deaths among inhalant abusers attributable to respiratory
depression or cardiac arrhythmia. These deaths often appear to be accidental
(King, Smialick, & Troutman, 1985).
Nicotine
Crew members who accompanied Columbus to the New World were the first
Europeans to observe the smoking of tobacco. They brought the leaves and the
practice of smoking back to Europe. Tobacco addiction is the number one
preventable health problem in the United States (Courtwright, 2001). Cigarettes
are responsible for more than 443,000 premature deaths each year in the United
States (CDC, 2010). About 4,000 different compounds are generated by the
burning of tobacco, but tobacco’s main psychoactive ingredient is nicotine.
Nicotine produces a euphoric effect and has reinforcing properties similar to
cocaine and the opioids (Henningfield, 1984). Tolerance to some of the effects of
nicotine quickly develops, but even the chronic smoker continues to exhibit an
increase in pulse and blood pressure after smoking as little as two cigarettes.
Nicotine has a distinct withdrawal syndrome characterized by craving for
tobacco, irritability, anxiety, difficulty in concentrating, restlessness, increased
appetite, and increased sleep disturbance (Hughes & Hatsukami, 1986; Inaba &
Cohen, 2014; U.S. Surgeon General, 1979).

Tobacco addiction has many properties similar to opioid addiction. The use of
tobacco usually is an addictive form of behavior (Frances & Franklin, 1988).
Tobacco produces a calming, euphoric effect, particularly on chronic users.
Nicotine in cigarette smoke is suspended on minute particles of tar, and it is
quickly absorbed from the lungs with the efficiency of intravenous administration.
The compound reaches the brain within 8 seconds after inhalation. The half-life
for elimination of nicotine is 30 to 60 minutes (U.S. Surgeon General, 1979).

Chronic use of tobacco is causally linked to a variety of serious diseases ranging

from coronary artery disease to lung cancer. The likelihood of developing one of
these diseases increases with the degree of exposure that is measured by the
number of cigarettes per day. Cigarette smoking men have a 70% higher death rate
than do nonsmoking men. Smoking in women is increasing along with smoking-
related diseases (Braunwald et al., 1987).

About 21 million Americans are still smoking, and most of them want to quit.
More than 90% of successful quitters do so on their own without participating in
an organized cessation program. Smokers who quit “cold turkey” are more likely
to remain abstinent than are those who decrease their daily consumption of
cigarettes gradually, switch to cigarettes with lower tar or nicotine, or use special
filters or holders. Quit attempts are nearly twice as likely to occur among smokers
who receive nonsmoking advice from a physician. Heavily addicted smokers who
smoke more than 25 cigarettes per day are more likely to participate in an
organized cessation program (Pierce, Fiore, Novotny, Hatziandreu, & Davis,
1989).

Counselors need to advise their clients against smoking and help them quit (see
the American Cancer Society Guide to Quitting Smoking, Appendix 60). Smokers
can and do quit. All smokers should consult with the staff physician for advice on
not smoking. Self-help material can be presented to the clients who request more
information. A pharmacological alternative, such as gum containing nicotine or a
nicotine patch, can be substituted to ease withdrawal. Formal smoking cessation
programs, such as the American Lung Association’s “Freedom From Smoking”
clinic, may be beneficial for heavier smokers (Glynn, 1990). The 12 steps can be
useful in giving smokers support in their attempts to quit. Some clients will want
to quit smoking while in treatment. This should be highly encouraged and
supported.
Club Drugs
Club drugs are typically used by teenagers and young adults at bars, clubs,
concerts, and parties. The most common club drugs include Ecstasy (3–4
methylenedioxymethamphetamine or MDMA), gamma hydroxybutyrate (GHB),
Rohypnol, ketamine, methamphetamine, and acid (LSD).
MDMA
MDMA is a synthetic drug with effects similar to methamphetamine and the
hallucinogen mescaline. MDMA can decrease the body’s ability to regulate
temperature resulting in dehydration, hyperthermia, and death. MDMA damages
serotonin neurons in as little as 4 days. Twenty minutes to 1 hour after ingestion,
MDMA causes stimulation and mild distortions of perception. The user also feels
a calming effect that heightens empathy for others and the desire to dance. Physical
dependence is generally not a problem, but tolerance can quickly develop with
any amphetamine-like substance. Starting in 1990 in Europe and then spreading to
the United States, there has been an increase in “rave” clubs. Flyers are handed
out during the week, and a few hundred to 1,000 teenagers get together at an empty
warehouse to dance.
GHB
Since about 1990, GHB has been abused in the United States. The drug causes the
user to feel euphoric and sedated. It also has anabolic (bodybuilding) effects and
is used to increase growth hormone production, build muscle mass, and decrease
water retention. It has been called liquid Ecstasy. GHB is usually dissolved in
water or alcohol by the capful or teaspoonful. The effects last 3 to 6 hours and can
cause amnesic effects; it can be used by sexual predators to lower the inhibitions
and defenses of women (Inaba & Cohen, 2014).
Ketamine
Ketamine is an anesthetic that was initially used to put animals to sleep for
surgery. About 90% of the ketamine used on the street is stolen from veterinary
supplies. Ketamine is also known on the street as “special K” or “vitamin K.”
Doses of ketamine can cause dreamlike states and hallucinations. In high doses, it
can cause delirium, amnesia, impaired motor function, high blood pressure,
depression, respiratory problems, and death.
Rohypnol
Rohypnol is a powerful benzodiazepine that is often mixed with alcohol to cause
decreased inhibitions and sedation. Rohypnol can incapacitate victims and
prevent them from resisting sexual assault. It can produce “anterograde amnesia,”
which means the user cannot remember the events they experienced while under
the effects of the drug (Inaba & Cohen, 2014).
Polysubstances
Few drug abusers use only one drug. There is a strong correlation between misuse
of heroin and alcohol problems, abusers of stimulants frequently use depressants
to cut irritable side effects, and alcoholics are at a higher risk for abusing other
depressants and stimulants (Schuckit, 1984).

In Western society, youths begin drug use with caffeine, nicotine, and alcohol. If
they go on to use other drugs, then the next drug of choice most likely will be
marijuana or prescription opioids followed by one of the hallucinogens,
depressants, or stimulants. These drugs first are taken on an experimental basis.
They are reinforcing and lead to few serious consequences. Marijuana is seen as a
step on the road to the use of other substances. Once the illegal barrier is crossed,
it becomes easier to take a second and a third drug (Gould & Keeber, 1974;
Kandel, 1978).

The effects of a drug may be either increased or decreased by adding an

additional drug. Depressants taken together may potentiate the effect of either drug
taken alone. Depressants and stimulants taken together may decrease the level of
side effects encountered when one of the drugs is used alone. Marijuana has been
shown to potentiate the effects of alcohol; it may increase the likelihood of a
flashback from hallucinogen use (Schuckit, 1984). More than half of the clients
who go to a polydrug clinic report the use of three or more substances (Cook,
Hostetter, & Ramsay, 1975).

The most common multiple drug withdrawal syndromes are those seen following
concomitant use of multiple depressants or depressants and stimulants.
Depressants produce the most severe and life-threatening withdrawal symptoms.
When depressants and stimulants are used together, the withdrawal syndrome
more closely follows the clinical picture of depressant withdrawal, but it
probably includes greater levels of sadness, paranoia, and lethargy (Schuckit,
1984).
Treatment Outcome
The Treatment Outcome Prospective Study (TOPS) is the largest and most
comprehensive study of substance use disorder treatment ever completed. It
collected data on more than 10,000 clients admitted for chemical dependency
treatment nationwide. The clients were in 37 different programs that varied from
methadone maintenance, to residential, to outpatient treatment. The major finding
was that treatment works. Substance abuse is significantly reduced after treatment,
and the amount of decrease is greater in clients who remain in treatment longer.
Clients needed to remain in treatment at least 6 months before a significant impact
on substance abuse was achieved. Associated problem behaviors decreased (e.g.,
criminal behavior, family problems, and suicidal thoughts). This study found that
drug addiction is a chronically relapsing condition usually requiring prolonged or
repeated treatment (Hubbard et al., 1989).

The overwhelming weight of evidence from a large number of outcome studies

and epidemiological studies indicates that treatment contributes significantly to
positive behavior change in chemically dependent clients (Anglin & Hser, 1990;
Gerstein & Harwood, 1990; Hoffmann, 1994; Hubbard, 1992).

The Institute of Medicine, Committee for the Study and Treatment and
Rehabilitation Services for Alcoholism and Alcohol Abuse (1990) and many
individual reviewers (e.g., Anglin & Hser, 1990; Hubbard & DesJarlais, 1991)
have concluded that chemical dependency treatment changes clients for the better.
Other studies confirm that the benefits of these changes considerably outweigh the
costs of treatment (e.g., Hubbard, 1992).

Follow-up studies of proprietary programs reviewed by the Institute of Medicine

(1989) found abstinence rates between 40 and 60% during the first year after
treatment. Similar results were found in studies of state and private programs
(Hoffman & Harrison, 1987; Hubbard & Anderson, 1988; Institute of Medicine,
1989).

Comprehensive Assessment and Treatment Outcome Research (CATOR) is the

largest independent evaluation service for the chemically dependent field in the
United States. Since 1980, CATOR has collected data on more than 50,000 adults
and 10,000 adolescents who have entered treatment programs. CATOR finds that
there are large differences in the clinical characteristics of clients admitted to
inpatient programs versus outpatient programs. Cocaine dependence is much
higher in the inpatient group; marijuana and stimulant dependence also is higher.
Half of the inpatients are dependent on illicit drugs, whereas only one third of the
outpatients are so addicted. Nearly 20% of inpatients admit to using at least two
drugs other than alcohol on a weekly basis, whereas only 8% of outpatients admit
to such heavy use. Recent ingestion is more common in the inpatient population,
with 44% using alcohol or drugs within the past 24 hours of admission, compared
to 23% of outpatients.

Detailed analysis of the CATOR research has encouraging words for chemical
dependency counselors. A client who completes treatment—either outpatient or
inpatient—has a 50% chance of staying clean and sober for the year following
treatment. If the client completes treatment and attends AA/NA once a week for
the next year, then he or she has a 70% chance of staying sober. If the client
completes treatment and attends one AA/NA meeting and one continuing care
session per week, then he or she has a 90% chance of remaining sober for the next
year. These are fantastic results: Fully 90% of clients can stay sober if they
complete treatment and attend AA/NA and continuing care on a regular basis
(Hoffmann, 1991, 1994).
8 Recovery Skills
Source: ©[Link]/jsteck.

Recovery skills are client homework. They educate a client about the tools of
recovery. The client completes each exercise and shares what he or she has
learned in recovery skills group. The group decides to accept or reject the
contract based on how well the client completes the exercise. If the homework
assignment is rejected, then the client has to do it over again. The skills group
meets daily. As the counselor, you decide which recovery skills to give based on
the problem list and the treatment plan.
Source: Created by Mervin Magus.

Recovery skills are used as specific objectives. They help a client to identify a
problem, understand the problem, and learn new skills to overcome the problem.
These tools of recovery are individualized for each client. The types of recovery
skills are infinite. You will want to develop some of them on your own. You will
use a few recovery skills more often. There are some, such as the Chemical Use
History (see Appendix 7), that you will use on every client. This chapter
discusses the recovery skills that you will use most often. You can order a wide
variety of other recovery skills from treatment facilities (e.g., Hazelden
Educational Materials, PO Box 176, Center City, MN 55012).
The Chemical Use History
The Chemical Use History (see Appendix 7) is designed to give clients and their
counselors a detailed account of the clients’ use of drugs and alcohol. This is an
excellent way of breaking through the clients’ denial. It is very beneficial for the
clients to see the whole thing written down at one time. There is nothing like
writing down the history of the clients’ chemical abuse and presenting it in front of
their treatment peers for breaking through the denial system.

Clients need to address each drug that they took and process through any problems
that the drug caused them in their lives. They need to identify specifically when
they started using and detail their patterns of use. Where do they use and with
whom? What happens when they use? What are the consequences? Each problem
caused or made worse by use is identified and discussed with the group.

Most clients will hedge, at least to some degree, in presenting their chemical use
history. Remember that these clients come into treatment in denial. They do not
know what the truth is. You and the group need to be ready to press a client when
group members feel that the client is not being completely honest. The group
members can give examples of how they answered certain questions when they
came into treatment. This solidifies that the client is not trying to lie. The client is
fooled by the denial process.

As you work through the chemical use history, you will be able to firm up clients’
diagnoses. Periods of intense intoxication; blackouts; withdrawal symptoms; using
to avoid symptoms of withdrawal; and all consequences in the home, work, and
school are covered. The feeling of shame and humiliation is identified, and the
group needs to support the clients when they have these feelings. The clients need
to feel like they are not alone. Now the clients are with their brothers and sisters
in this program.
Honesty
The Honesty exercise (see Appendix 8) helps clients to see how they have been
distorting reality. All clients use denial, in its many forms, to keep themselves
from experiencing the pain that the truth would bring. If they were to see the whole
picture about themselves, then they would realize that they were deathly ill and
needed treatment. This fact would create tremendous fear in the clients, and they
would have to do something about their problems.

Source: ©[Link]/clearstockconcepts.

Clients keep from feeling this fear by minimizing, rationalizing, denying, blaming,
distorting, projecting, intellectualizing, diverting, and engaging in countless other
ways of not seeing the truth. The other clients in recovery skills group will need
help with this exercise. Clients will be unable to uncover most denial self-
statements without help from the counselor or group. The Honesty exercise just
gets them started in this process. Treatment should be an endless search for the
truth.
It is an eye-opening experience for clients to realize just how much they have been
lying to themselves and to others. Clients usually feel guilty about lying to others,
but they do not realize that the persons to whom they have lied the most were
themselves.

Clients need to process how they feel about themselves when they lie and learn
the consequences of dishonesty. If clients lie, then they will be lonely and will not
be able to solve problems in the real world. They need to understand why
dishonesty leads to empty relationships. If you tell people lies about yourself, then
people cannot know the real you, and you will feel unloved, empty, and alone. If
clients lie to themselves about the real world, then they cannot use the facts to
solve problems. If problems are not solved, then they escalate until the clients go
crazy, get sick, and/or use drugs.
Love, Trust, and Commitment
The Love, Trust, and Commitment exercise (see Appendix 9) builds self-esteem.
Clients come into treatment not understanding what love is. They might have love
confused with sex. Clients need to develop a new, positive relationship with
themselves. They have been saying bad things to themselves for a long time: “I am
no good. I am bad. I am stupid. I am ugly. I am unlovable.” These thoughts
dominate the clients’ thinking and keep them feeling discouraged, depressed, and
anxious.

Using the Love, Trust, and Commitment exercise, clients build a positive
relationship with themselves and others. For this, they will need to understand the
essential ingredients in a healthy relationship. They need to understand where
their original feelings of inadequacy and rejection come from. They need to
explore their first relationships with their primary caregivers and how these relate
to their current relationships with themselves and others.

Clients need to learn what it means to trust themselves and to commit themselves
to their own individual growth. What do they need to see from themselves that
will show them that they are trustworthy? What do they need to see from
themselves that will show them that they are committed to their own recovery?

Clients need to learn how to be supportive and encouraging to themselves and to

others. They need to say positive things to themselves. They need to give
themselves a lot of praise whenever they try to do something well. These skills
will need to be practiced on a daily basis.

Many clients will have considerable difficulty in working through this exercise.
Some might even fight and say that there is nothing positive to say. They have a
hard time thinking up anything good to say. These clients need the help of the
group. Each group member might have to come up with something positive to say
about such a client. It might be a long time before the client believes these things,
but if he or she keeps trying, then the new ideas will begin to take hold.

Clients need to develop a personal plan that will help them to treat themselves
well. They need to act as if they are persons worthy of good things. They need to
learn how to praise themselves and others, and they need to practice this skill. A
compliments group often is helpful to get this process started. In this group, each
member comes up with positive things to say about each other.
Feelings
The Feelings exercise (see Appendix 10) is designed to help clients identify their
feelings and use them appropriately to solve problems. The clients are told that all
feelings are motivators. Feelings give energy and direction for movement. Each
feeling is connected to a specific motor activity. Fear gives the energy and
direction to run away from danger. If clients cannot use their fear, then they cannot
run, and they are handicapped. Similarly, if they cannot act appropriately on their
anger, then they are more vulnerable to the world. If clients cannot feel, then they
cannot adapt to their environment.

Chemically dependent people treat their feelings with drugs or alcohol. They do
not use their feelings to solve problems. The Feelings exercise takes the clients
through each feeling, connects them with the physical cues that accompany each
feeling, and teaches them how to problem solve.

The main point that clients need to get is this: Each feeling needs to be carefully
processed. Clients need to stop, think, and plan before they act. Each feeling is
directing the clients to take some sort of action. The clients must have the skill of
identifying each feeling and understand what each feeling is directing them to do.
Then the clients need to process through their options of action, decide which is
the best, and act.

Clients in treatment need a lot of practice in properly identifying their feelings.

They have old skills that will constantly get in the way. For example, when men
feel hurt or frightened, they often act angry. That is confusing. Once the clients are
able to identify the real feeling—the pain—they can address the problems more
accurately.

Women often cry when they are angry. This is confusing to them and to others, and
it muddies the waters of problem solving. Their husbands might react to the tears
when in fact the real problem is that the women are angry. You and the group help
the clients to get at the core feeling and then process through the feeling to resolve
the problem.

Bob might come to group acting angry and sullen. When it comes time for him to
talk, he might not talk about the anger at all. He might talk about his fear. Bob
might not even be aware that he is angry. Perhaps in his home of origin, he could
not get angry or else he would incur the wrath of his father. As a child, it was
dangerous for Bob to feel angry, so he did not feel it. He repressed it and felt
scared instead. The group might need to teach Bob how he is really feeling by
processing the situation with him. What happened to Bob that caused the feeling?
How would the rest of the group have felt in a similar situation? One group
member reflects Bob’s anger to him: “Bob, you say you feel scared, but you look
angry.”

Clients who have felt feelings for the first time in their lives can express their
feelings in group in a nonthreatening environment. They are not rejected for their
feelings. They are accepted and loved no matter how they feel.

Clients need to know that all of their feelings are friendly and are great and wise
counselors that need to be listened to and acted on. Acting too quickly on feelings
is a mistake. This causes impulse control problems, which make the clients
vulnerable to relapse. Feelings are processed carefully and acted on rationally.
That takes a lot of practice.
Relationship Skills
Most clients have poor interpersonal relationship skills. They manipulate, distort,
accuse, blame, shame, project, sulk, rage, and harbor deep-seated resentments.
They are trying to control the world and everyone in it, and they are furious when
not everything is going their way. The Relationship Skills exercise (see Appendix
11) is designed to teach and practice healthy interpersonal relationship skills.
Source: ©[Link]/1911.

Clients learn that love is not a feeling. It is an action in truth. You cannot love and
lie. Love is the interest in and active involvement in people’s individual growth.
Self-love is the interest in and active involvement in your own individual growth.
To love, you have to be there for yourself or for the other people when they need
you. Chemically dependent people cannot do this. Sometimes they are too
intoxicated or hungover. No drug addict is completely trustworthy.

Clients are taught that commitment means stability over time. Commitment is
developed by working a daily program of recovery. Clients must take the time
necessary to nourish themselves and others.

Clients need to be encouraging and reinforcing to themselves and others. They

practice the skill of giving praise. Some clients will need specific social skills
training. They need to learn how to do simple things such as making good eye
contact and standing at an acceptable interpersonal distance. As the clients
practice good interpersonal skills, it is important that they recognize how they feel
when they are using healthy skills compared to the old skills they have been using.

It is inevitable that clients will use their old methods of coping with conflict while
in treatment. When this happens, you and the group can help these clients to stop
and use their new skills. Nothing solidifies learning better than watching the
consequence of the old behavior compared to the new behavior. The clients will
see that the new skills work better and result in better problem solving. The old
skills tend to make the problem worse.

Clients will need a lot of practice in sharing how they feel and in asking for what
they want. Most of them are trying to tell people what they want to hear rather than
the truth. This results in the clients feeling unknown. They need to share their
feelings and watch the other members of the group respond appropriately.

Many clients are reluctant to share their feelings. They never have asked for what
they wanted. They have been taught that this is selfish or that other people simply
do not care. It is a new experience for these clients to see the power of the truth.

Compromise is necessary for healthy relationships. Clients have to practice

working through issues until every party is satisfied with the result. This is called
the “win-win scenario.” Each party in a conflict shares how he or she feels and
what he or she wants until the problem is resolved. New options have to be
constantly thrown out by the group for consideration. The primary principle is
this: Treat other people the same way in which you want to be treated.

Clients are taught that all people need to be respected equally regardless of race,
color, creed, education, or belief system. Healthy relationships demand caring for
how other people feel and caring for what they want.
Addictive Relationships
Many clients coming through treatment for chemical addiction are just as addicted
to some other person as they are to their drugs of choice. Addictive relationships
can be as destructive as alcohol or drugs. They leave the clients feeling empty,
abandoned, and unlovable. People can be so hooked on other people that they
cannot see the truth.

The Addictive Relationships exercise (see Appendix 12) is designed to teach

clients the difference between healthy and addictive relationships. It teaches them
what they need to do if they are in relationships that are addictive. These
unhealthy relationships are fueled by powerful sexual feelings that the clients
mistake for love. The clients become caught up in the excitement of emotionally
chaotic relationships.

Addictive relationships are characterized by the same loss of reality as is

involved in addiction. The clients are unaware that these relationships are bad for
them and are convinced that they are the best things that have ever happened in
their lives. Lies permeate these relationships, which are filled with feelings of
intense fear, anger, and pain.

An addictive relationship must use lies to keep going. The partners must feel that
they have to stay in the relationship to feel normal. They fear that without the
relationship, they will be lonely forever. “I will never have anything as good as
this. I cannot live without her.”

Addictive relationships are filled with verbal and physical abuse. They are
demoralizing and end in feelings of anger and abandonment. Clients who have
addictive relationships typically will have a pattern of these relationships rather
than just one.

Clients use these relationships in a similar way as they use drugs. The
relationships distract them from their real pain and fill their lives with something
to obsess about. The clients will need to make the decision either to get out of
these addictive relationships or to take the relationships into long-term treatment.
Communication Skills
The Communication Skills exercise (see Appendix 13) teaches healthy
communication skills. It is essential that these skills be practiced in group as well
as in individual sessions. The clients need to be constantly reminded to use these
skills.

Good communication necessitates being able to listen well and speak clearly.
Active listening pulls out more of a person’s communication until the entire
message is perceived.

Words are symbols for thoughts and feelings. They are accompanied by nonverbal
cues that often are more accurate than the words themselves. Clients who tell you
that they are doing well with flat, unemotional voices and downcast eyes are
telling you with their words that they are fine, but with their actions, they are
telling you another thing entirely.

To develop good listening skills, clients need to practice repeating what the other
person said. People often have different communication patterns, or family rules,
that other people do not understand. In certain cultures, for example, friends argue
vehemently about things. That is just how they communicate. In other cultures, this
behavior might be considered insulting. Clients who are used to using an angry
tone of voice to get their point across need to hear how it adversely affects other
people. They might not know how scary it is.

Many clients need to develop empathy skills. They have to practice understanding
and personally relating to how other people are feeling. This will take a lot of
trial-and-error practice. Clients must try to relate personally to what other people
are saying by directly relating it to their own personal experience.

As clients watch you validate the other members of the group, they will begin to
be more reinforcing to each other. Clients need to be encouraged to use “I feel”
statements when they speak. Many chemically dependent persons constantly blame
others for their problems. “You” is perceived as the problem rather than “I.”
Statements that begin with “you” usually are headed for trouble. In the great
scheme of things, we know much more about “I” than we do about “you.”

Clients need to be reminded to be positive in their interactions with each other. A

positive attitude needs to be soundly reinforced by all staff members. Clients who
are not positive need to see how their attitude clouds their whole day. They need
to practice saying positive things to themselves and others, even if they do not feel
positive.

Clients with poor communication skills need to go through the Communication

Skills exercise with at least five of their treatment peers. These skills have to be
practiced repeatedly until they are used automatically. The more the clients
practice, the better communicators they will become.
Self-Discipline
The Self-Discipline exercise (see Appendix 14) is for those individuals who have
a difficult time in delaying gratification and accepting responsibility for their own
actions. They constantly blame other people for their problems. They think that
they would be fine if other people would leave them alone. Clients with these
problems often have antisocial traits. They have had no experience with success.
They never have worked at a goal long enough to reach the goal.

These individuals need to see themselves achieve objectives in gradually

escalating steps. They can accomplish things if they settle down and try. Most of
these individuals have a low frustration tolerance, and they have serious problems
with impulse control. They act out too quickly on their feelings, particularly anger
and frustration.

Begin with a simple task, such as one of the recovery skills, and walk the clients
through it. Do not get frustrated with them when they procrastinate. That is all they
know how to do. Have them sit down for a few minutes at a time and work through
a page of the exercise. When they have accomplished something, reinforce them.
Tell them that they can do it if they try and that you have confidence in them. These
clients need to see themselves be successful. They need to feel like they can do
things that are difficult. Self-discipline is not an easy skill, and many times, it will
be frustrating. However, remember that if the clients are reinforced for doing
something, then the behavior will increase.

Clients need to see how poor self-discipline leads to failure. To accomplish this
objective, the clients need to process through several of their problems with you.
Take a problem that caused them quite a bit of pain, such as getting arrested or
failing at something they really wanted, and walk them through the problem.
Where did they go wrong? What else could they have done? Who was
responsible?

Let us take someone who was arrested for drunk driving. This person might be
blaming the police. “They have always been out to get me.” However, who was
drunk? Did the police make this person drive drunk? In what way is the client
responsible?

Clients must understand that if other people are responsible for everything bad that
happens to them, then other people are in control of their lives. They need to re-
achieve control by taking back the responsibility for their own behavior.

Clients with poor self-discipline do not understand the rules. They break the rules
of society to get their own way. They do not understand that the rules are there to
keep them safe. The spiritual part of the program can be a benefit here. The clients
need to understand that God did not make the rules to keep us from having a good
time. God made the rules so that we could be safe and happy. The same thing goes
for the laws of the state. The legislature makes the rules to protect its citizens.

These clients usually will break some rules in treatment and will blame others for
their rule breaking. You must walk them through these violations and help them to
see that it was their choice to break the rules. Breaking the rules resulted in their
getting caught and experiencing pain. If they could learn how to obey the rules,
then they would feel better all of the time.

Clients with self-discipline problems have poor problem-solving skills. They go

for the pleasure first, being unable to delay gratification long enough to achieve
long-term goals. They need to process several problems with you while in
treatment. If they want job training, how are they going to get that? What are they
going to have to do specifically? If they want to stay sober, how are they going to
get that? They must learn and practice working on a problem on a daily basis until
the problem is solved. These individuals usually have such low frustration
tolerance that they are unable to feel much pain without acting impulsively. People
who can tolerate little pain cannot work at anything for very long. They must see
themselves take off a small piece of a problem and work on it until the whole
problem is resolved.
Impulse Control
Clients who have impulse control problems act too quickly on their feelings. They
need only a little of a feeling to move into action. If they feel angry, then they act
angry immediately. This leaves them vulnerable to relapse. Craving is a feeling. If
they move too quickly when they crave, then they will relapse into using
substances. The Impulse Control exercise (see Appendix 15) helps the clients to
develop control over their feelings.

These clients need to stop, think, and plan before they act. This takes a great deal
of practice, particularly when the clients are feeling strong emotions.

Clients must be able to identify each feeling, understand why they are having the
feeling, consider the options of action, plan their response, and then act. When
they are having strong feelings, the clients need to stop and analyze their feelings
carefully. They cannot continue to act too quickly on their feelings. That leads to
disaster.

Clients need to understand the behavior chain and practice analyzing their
behavior carefully. They need to understand how their poor impulse control led to
excessive drinking or drug use. They have developed a habit of moving
immediately from craving to drug use. They will need to develop another plan and
practice that plan many times in treatment.

These individuals are particularly vulnerable when they are feeling angry and
frustrated. They have a low frustration tolerance, and they desire immediate
gratification. They need to understand how this has led them into trouble. Most of
them will have to work through the Self-Discipline exercise.

These individuals will need to learn assertiveness skills and will need to role-
play interpersonal conflict. When they act impulsively in treatment, they need to
process through the situation until they understand how they could have handled it
better.

As clients become more skilled at identifying their feelings, they can begin to
address the real feelings. What underlies most anger is pain. As the clients begin
to solve real problems in real time and with real people, they feel less frustrated
and more in control.
When angry, these clients must take a time-out and walk away from such
situations. They cannot stay in situations where they have lost control before.
Teach them and their significant others to use the time-out sign of a referee when
they are feeling too angry. They also can say “Time-out” as they make the sign.
Their partners then agree to say nothing except, “Okay, time-out.” The clients then
leave these situations to get their thinking accurate. They might have to call other
people to process the problem with a third party before they come back into the
original situations. The clients must promise to come back within a previously
specified length of time to continue to work on the problems. Both members of a
couple need to write this plan down and follow it every time they have a
significant conflict. Everyone who gets angry knows when he or she is beginning
to “lose it.” At the earliest possible opportunity, someone needs to make the time-
out sign and then follow the prearranged contract.

All anger, fueled by pain, is there to make the pain stop. To be angry, clients must
establish other people to blame. They must think that the other people purposely
did things wrong that hurt them. This rarely is accurate. Other people are just
trying to meet their needs. They rarely are trying to hurt others.

Clients with impulse control problems will need to come up with a written plan
that they carry with them at all times. When they are feeling strong emotions, they
need to carry out the plan. They can call their sponsors, go to meetings, read some
AA/NA material, turn the situation over, talk with friends, and so on.
Relapse Prevention
Relapse prevention is one of the most important aspects of addiction treatment.
Approximately two thirds of clients will use their drugs of choice within a year of
leaving treatment (Hunt et al., 1971; Marlatt & Donovan, 2008).

Most clients (60%) lapse within 3 months of leaving treatment. This is the period
of highest risk, and it needs the greatest attention. The clients must be willing to do
almost anything to prevent relapse during this period. They need to see themselves
as clinging to an ice-covered cliff with their recovery skills the only rope. The
most important thing that they can do is go to meetings. Clients who are working a
daily program of recovery will not relapse. They cannot work the program and
use at the same time. The two are incompatible.

Relapse is a process that begins before the first use. A client begins to feel under
stress. The client’s new tools of recovery are not used, so the problems continue
to escalate. The client reaches a point where he or she thinks that the only option
is to drink or use drugs.

The Relapse Prevention exercise (see Appendix 16) is designed to help the client
develop the skills necessary to prevent relapse. Relapse prevention takes working
a daily program of recovery. The client must take his or her personal inventory at
the end of every day. If any of the relapse symptoms become evident, then
immediate action must be taken.

The client checks every day for symptoms that he or she is having problems that
need intervention. The client will develop a written plan detailing the exact skills
that he or she will use when craving or considering relapse. The client carries an
emergency card full of telephone numbers of people he or she can call if problems
arise.

Other people need to be encouraged to check the client daily for relapse warning
signs. This is a good reason to go to daily meetings and to hang around other
recovering persons. Other people often can see what the client is unable to see for
himself or herself.

Clients need to identify high-risk situations that may trigger relapse and develop
coping skills to deal with each situation. The more clients can practice these
skills, the better off they will be. In groups, clients need to role-play high-risk
situations and help each other deal with relapse situations. High-risk situations
might include negative emotions, social pressure, outcome expectations, access to
substances, self-efficacy, lifestyle imbalance, and coping skills (Marlatt &
Donovan, 2008). Individuals who choose to indulge are vulnerable to the
abstinence volition effect, which are the guilt, hopelessness, and loss of self-
efficacy that occur when someone violates his or her own rules. Self-efficacy can
be measured using the Alcohol Abstinence Self-Efficacy Scale (see Appendix 63)
(Marlatt & Donovan, 2008; Marlatt & Gordon, 1985).

Using the Relapse Prevention exercise, clients develop the skills necessary to
deal with each of the high-risk situations and practice these skills in group. All
clients must role-play drug refusal situations until they can say no and feel
reasonably comfortable. They must examine and experience all of their triggers,
see through the first use, and learn about euphoric recall.

All clients must develop a written plan for a lapse. What are they going to do if
they use again? Whom are they going to contact? What are they going to say? This
must be role-played in group so that the clients can see that the people on the other
end of the phone are not going to be angry with them.

Clients must understand the behavior chain and develop skills for changing their
thoughts, feelings, and actions when they have craving. Using imagery and drug
paraphernalia, the clients need to experience craving and learn experientially that
craving will pass if they move away from their drugs of choice.

When you are discussing relapse with clients, you need to discuss the benefits of
medications that cut relapse rates. Naltrexone and acamprosate both reduce the
craving for alcohol and other drugs and decrease some of the reinforcing
properties of addiction. These medications consistently cut the relapse rates in
half. Naltrexone is an opioid antagonist that is helpful in many clients, particularly
those with chronic histories of relapse. Naltrexone blocks some of the reinforcing
properties of alcohol by blocking the action of endorphins (opium-like chemicals
that exist naturally in the brain to kill pain). Endorphins give addicts the euphoric
effects that trigger craving. Several studies have shown that alcoholics who take
naltrexone daily can decrease relapse rates by as much as 50%. The alcoholic
still may drink, but the intense craving is not triggered, so he or she can bring the
drinking under control more quickly (O’Malley et al., 1992; Volpicelli, Alterman,
Hayashida, & O’Brian, 1992). Naltrexone now comes in a depot injection
(Vivitrol) that lasts for 1 month. These medications can be lifesaving, so all
clients need to be educated and given a prescription.

Acamprosate works by affecting gamma-aminobutyric acid (GABA) and

excitatory amino acid (glutamate) neurotransmission rather than affecting the
endogenous opioid system. The medication cuts craving and increases the number
of days abstinent (Kranzler, Ciraulo, & Jaffe, 2009; Littleton, 1995, 1996). One of
these two medications should be encouraged to be used in everyone who can
afford it. Drug companies will often give price breaks to clients who are indigent.
These drugs must be used in addition to working a program of recovery.
Stress Management
The Stress Management exercise (see Appendix 29) helps clients cope with
stress. The inability to deal with stress effectively fuels addiction. The clients
have been using chemicals to deal with the uncomfortable feelings caused by
stress.

Source: ©[Link]/hidesy.

Stress is the physiological response of the organism to a stressor. A stressor is any

demand made on the body. This can include psychological or physiological loss,
absence of stimulation, excessive stimulation, frustration of an anticipated reward,
conflict, or the presence or anticipation of painful events (Zegans, 1982).

Selye (1956) found that if rats were presented with a problem to which there was
no solution, they got sick. There was a generalized stress response that affected
most organ systems. Initially, the body’s response to stress is adaptive, but chronic
stress is damaging. Severe stress has been linked with many diseases including
kidney impairment, malignant high blood pressure, atherosclerosis, ulcers,
anxiety, depression, increased infections, and cancer (Selye, 1956; Zegans, 1982).

To learn how to deal with stress more effectively, chemically dependent clients
need to do three things: (1) relax twice a day, (2) maintain regular exercise, and
(3) learn coping skills for dealing with stressors (Benson, 1975).

Many clients resist developing these programs, and some will be unable to do so,
but as many as possible need to be encouraged to practice these techniques. The
clients who have the most trouble will have problems with self-discipline. They
have not learned how to work toward a long-term goal. They will moan and
complain whenever you mention the exercise or relaxation program. What they are
really complaining about is they do not want to be told what to do. What is behind
that is the inability to stick to things that they want to do. They have just failed too
much and are unwilling to go to any length to stay clean and sober. Many of these
clients will have antisocial traits. You have to show them, repeatedly again, why it
is important to develop these programs.

If people relax twice a day for 10 to 20 minutes, they reap many benefits. They
learn how to control their feelings, decrease tension, and decrease psychosomatic
problems. In general, these people are happier and healthier. They learn that there
is something that they can do to make themselves feel normal (Benson, 1975).

Clients can go through one of the formal relaxation techniques listed in the Stress
Management exercise, or they can pray and meditate quietly twice a day. The
important thing is that they practice relaxing. The more they do this, the better they
will feel.

Once clients know what it feels like to relax, they can develop techniques to stay
more relaxed during the day. If something stresses them, then they can use one of
the techniques to recapture their serenity. The higher power can be used as an
adjunct to this process. The clients can turn things over and relax.

It is very difficult to get some chemically dependent individuals to maintain an

exercise program. This is like pulling teeth for some people, but you should
encourage them. Research has shown that exercise is important, not only for
cardiovascular fitness but also for a sense of psychosocial well-being (Folkins &
Sime, 1981; Greist et al., 1979; Ledwidge, 1980; Stern & Cleary, 1981).

It has been demonstrated that hospitalized alcoholics can increase fitness levels in
as little as 20 days. This increase enhances not only their physical fitness but also
their self-concepts (Gary & Guthrie, 1972). A strong exercise program is
important for developing a new sense of self-efficacy. Many chemically dependent
people come into treatment thinking that they cannot do anything. When they see
their strengths develop, they feel a new sense of power and control. They feel like
they can do it. This is key, particularly to adolescent clients who are concerned
about their body images.

Rigorous exercise produces natural opioids in the body that will give clients a
natural high (Appenzeller, Standefer, Appenzeller, & Atkinson, 1980). They feel
better all day after working out. The clients must be encouraged to develop a
stretching, strength, and cardiovascular fitness program. The exercise or
recreational therapist will help them to individualize the program.

In learning new coping skills, clients need to learn assertiveness skills, social
skills, and how to increase their involvement in pleasurable activities. The clients
need to be shown what they are doing that makes their lives difficult. If they are
frowning at everybody all of the time, they are not getting positive responses from
the world. They need to learn how to be pleasant and how to ask for what they
want. They need to practice sharing how they feel.

The Stress Management exercise helps clients to develop pleasurable activities.

They need to learn how to have fun clean and sober. They must be encouraged to
reach out and try different things. If they sit at home and wait for the wonders of
sobriety to overtake them, then they are going to be disappointed. They must reach
out to others and become actively involved in their AA/NA groups and
communities.

Many of these clients do not know how to have fun without chemicals. Chemicals
have been their whole lives, and they are all that they know. The clients need to be
shown that sobriety can be fun. This will be very difficult for many clients when
they are grieving the loss of their drugs of choice. The pleasure of the drugs must
be replaced by pleasure from the environment. This requires doing something
new. The best way to get clients motivated is to show them that drugs and alcohol
are no fun for them anymore. Once addiction clicks in, the drugs lose their ability
to make the clients feel better. The clients feel miserable when intoxicated and
when clean. A new lifestyle must be developed to help the clients enjoy their
sobriety. New hobbies and interests have to be tried until the clients develop a
leisure program that fits.
9 Steps

Source: ©Can Stock Photo Inc./Bialasiewicz.

The 12 steps are the core of treatment for most addiction treatment programs.
More individuals have recovered using the principles of the 12 steps than using
any other treatment. Alcoholics Anonymous (AA) currently has some 1.5 million
active members worldwide, including more than 700,000 members in the United
States. AA works, and it is free. The only requirement for membership is the
desire to stop drinking. Narcotics Anonymous (NA) and all of the other 12-step
groups developed their programs directly from the 12 steps of AA. The programs
are almost identical. “The program,” as it is called by 12-step groups, has been
broadened to cover many types of problems including not only NA but also
Gamblers Anonymous (GA), Overeaters Anonymous, Drugs Anonymous, Cocaine
Anonymous, and Pills Anonymous (Emrick, 1987).
Source: Created by Mervin Magus.

Treatment programs differ as to which steps they address in treatment. Some

programs address only Step One, some address Steps One to Three, and others
address Steps One to Five. This must be individualized. Some clients will be able
to embrace only the First Step, and that is fine if they do a good Step One. For
most clients, it is beneficial to complete at least Steps One to Three while in
treatment. The more steps the clients can complete, the better off they are in
recovery and the further along they are in the program. Working through the Fifth
Step takes a great burden of guilt and shame off clients. If they complete the Fifth
Step, then they will not have to carry the heavy burden of guilt into early sobriety.
If your center works only on the First Step, then that will give you more time to
work on powerlessness and unmanageability. This chapter teaches you how to
take the client through Steps One to Five, assuming that some inpatient programs
will go this far. Rare is the program that goes further than Step Five, but some
longer-term programs work all 12.

As you take clients through the steps, you must make sure that they are
internalizing the material. The clients must be able to identify each problem,
understand the problem, and learn coping skills for dealing with the problem.
They must be able to verbalize to you a solid understanding of each step and how
they are going to apply the step in their lives.

You will be able to tell when clients are complying and when they are
understanding and internalizing the material. The level of commitment to sobriety
will be evident in their behavior, in what they do, and in what they say. If you
watch how they act with you and with their treatment peers, then you will have a
good idea as to whether they are internalizing the information or not. If you are
hearing one thing in individual sessions and a client’s peers are hearing another
thing, then one of you is not getting the truth. The client has to be confronted in
group with the inconsistency of his or her behavior.
The Committee
Clients are constantly torn between the side of themselves that wants to use
alcohol and drugs and the side that wants to get clean and sober. There often is a
constant, and often turbulent, internal war going on inside of a client’s head. Each
side tries to take control over the client’s behavior. Each side has its good and bad
arguments. Sometimes it is hard for the client to know who he or she is or what he
or she wants. It feels as though there is more than one person talking to the client
inside of his or her head.

It is useful to label the three voices. Freud called them the id, the ego, and the
superego. In treatment, we call these voices the disease, the higher power, and the
client. One train of thinking is the disease process. This side only wants clients to
use drugs or alcohol, and it does not care how it gets the clients to do it. If the
clients feel miserable, this is all the better. Another voice is the voice of the
higher power. The higher power only wants the clients to love themselves and
others and to reach for their full potential in life. This voice is incredibly
supportive. The third voice is the clients’ own thinking. Here the clients are trying
to figure out things for themselves.

As you move clients through the steps, you must be careful not to continue to the
next step until they have a solid foundation in the prior steps. If the clients have
not embraced a good Step One, then there is no use in moving on to Step Two. If
you have to work on Step One the whole time the clients are in treatment, that is
fine, but do not try to move up in the steps until the clients have a firm foundation
of the prior steps. The steps must be built one on top of the other. The first
building block is Step One.
Step One
“We admitted we were powerless over alcohol—that our lives had become
unmanageable” (AA, 2001, p. 59). Assign the client to complete the Step One
exercise in The Alcoholism and Drug Abuse Client Workbook (Perkinson, 2017).
Copy Appendix 17, which is the same thing. The workbooks were made to be
cheaper than copying the exercises at the end of the book. The book is attractive,
so the clients like it and often take it home and read it again, reinforcing learning.
If you give the client copies, most of them will throw them away. Order the books
from Sage Publications (800-818-7243; [Link]), and give them the
following priority code: A030504. This will give you 40% off and save you hours
at the copy machine.

It is vital that all clients complete a solid Step One in treatment. Step One is the
most important step. Without it, recovery is impossible. Step One necessitates a
total surrender. Clients must accept as true that they are addicted and that their
lives are unmanageable so long as they use mood-altering chemicals. Until this
conscious and unconscious surrender occurs, the clients cannot grow. So long as
they believe that they can somehow bring their lives under control and learn to use
addictive behavior normally, they have not accepted their disease, they are stuck
in the illness, and they cannot break free.

Step work is mainly group work. Clients complete the Step One exercise and
present the exercise in group. The group members help the clients with the step,
ask questions, and help you decide whether the step is completed successfully.
You usually should not make this decision without the support of the group.
Particularly in an inpatient setting, things go on in treatment that you, as the
counselor, do not know about. The clients may be complying with treatment and
may be pretending that they are working when, in fact, they really are not
internalizing anything. The treatment peers are more likely to see these lies. They
see the clients in casual interaction and notice the inconsistencies.

In Step One, clients must learn to accept as fact that they are addicted, that they are
powerless, and that their lives are unmanageable. They must understand that they
cannot live normally so long as they use mood-altering substances.

The best way of convincing clients to surrender are to show them repeatedly that
they get into trouble when they drink, use drugs, or engage in addictive behaviors.
They do not get into trouble every time—just sometimes—but they never can
predict when the trouble is going to occur. They might drink a couple of beers and
go home, or they might drink more and get arrested for drunk driving. The clients
must process through many of their problems in detail until they realize that they
never have been able to predict when they were going to have addiction problems.
This is one of the primary reasons for processing through Step One.

How do clients feel about having blackouts? It is very scary for clients to know
that they were awake doing things and that they cannot remember what they did.
Did the clients do embarrassing things while intoxicated or gambling? What were
they, and how do the clients feel about what they did? How do they feel about not
doing things with their families, at school, or at work because they were too
intoxicated or hung over? You must get at the real stories—exactly what happened
—and examine how the clients feel. Talk about the shame, humiliation,
depression, and anxiety caused by the addiction. How depressing is it to know that
the clients’ families are falling apart? How did it feel to be unable to keep
promises?

Sometimes clients used chemicals more, or for a longer period, than they
originally had intended. Once they began using, the addiction took control. Even
when they promised themselves that they were going to stop or cut down, they kept
on using. The clients must understand that once they start using, they never know
what they are going to do.

Most addicts want to hold on to the delusion that they still are in control. Clients
do not want to admit that they are powerless and that their lives are unmanageable.
They were having problems sometimes, they think, but only occasionally. The fact
is that when the clients had problems, the problems usually were directly related
to the addiction. The clients got into trouble obtaining the substances, using the
substances, gambling, or recovering from substance use. Addicts do things when
they are intoxicated that they never would do when sober. They need to look at
each of these things and see the painful consequences of their addictions. They
need to take a careful look at their addiction histories—at the lies, the crimes, the
inconsistencies, and the people they have hurt. They need to understand that so
long as they use drugs or alcohol, they will hurt.
Step Two
“[We] came to believe that a power greater than ourselves could restore us to
sanity” (AA, 2001, p. 59). Read the Step Two exercise (see Appendix 18) before
continuing with this chapter.

The beginning of clients’ spiritual program is Step One. This is the surrender step,
and it is essential to accept powerlessness and unmanageability before the clients
reach toward a higher power. The essential ingredient of Step Two is willingness.
Without willingness to seek a power greater than themselves, the clients will fail.
“There is one thing more than anything else that will defeat us in our recovery; this
is an attitude of indifference or intolerance toward spiritual principles” (NA,
1988, p. 18). The clients have admitted that they are powerless and that their lives
are unmanageable. They must now see the insanity of their disease and search for
an answer to their problem.

The word sanity in AA means soundness of mind. To have a sound mind, a person
must be able to see and adapt to reality. The person must be able to see what is
real. No person who is an addict sees reality accurately. The person is living in a
deluded world of his or her own creation. The mind of an addict is irrational. The
person cannot see what is real, so he or she cannot adapt to reality.

In Step Two, clients look at their insane behavior. They see how crazy they were
acting and reach for an answer. They must conclude that they cannot hold onto
their old ways of thinking. If they do, then they will relapse into old behavior.
How to Help Clients Accept a Higher Power
Many clients rebel at the very idea of a higher power. They must be gently
encouraged to open the door just a little and to seek. They must be encouraged to
be honest, open-minded, and willing. They need power. They are powerless. They
need someone else to manage. Their lives are unmanageable.

At first, you encourage clients to see that some sort of a higher power can exist.
The clients must look at their interpersonal group and see that the group has more
power than they do. You can say something like this to a client: “If you wanted to
leave this room, and the group wanted to keep you in, do you think you could
leave?” The matter becomes obvious. The group could force the client to stay
inside of the room. It might take some wrestling, but the group has more physical
power than the client does. The client could then be asked if he or she is willing to
place his or her trust in the higher power of the group.

Trust is a difficult issue for most addicts, and they will need to process their lack
of trust with the group. This is a good issue for group work. If clients cannot trust
the group as a whole, can they trust anyone in the group? If they cannot trust
anyone, can they trust themselves? Are they willing to try to trust—to be open to
the possibility? If they are unable to trust themselves and are unable to trust
anyone else, then they are lost. They will have to start somewhere. This reality
will have to be driven home. The clients cannot really trust themselves. That
should be obvious. There were times when they were out of control, they were
powerless, and their lives were unmanageable.

The best way of having clients learn to trust the group is to develop a caring
group. The members are actively interested and involved in each other’s growth in
this group. They gently help each other to search for the truth. The group members
are kind, encouraging, and supportive. The group members never are hostile and
aggressive. They do not put each other down; that is counterproductive. If you
have an aggressive and highly confrontive group, then you destroy trust. People
must learn to confront each other in an atmosphere of love and unconditional
positive regard. It is your job to teach the group this process.

Once clients trust the group, they can begin to transfer this trust to the 12-step
group. The clients should attend as many meetings as possible while in treatment.
Gradually, the clients will feel safe and will begin to share. This builds trust. In
the group, members are interested in a client, and as they show love to the client,
the client’s confidence in the group grows. This probably is the first time in the
client’s life when he or she has told someone the absolute truth. When the group
does not abandon the client, it is a tremendous relief. This will show on the
client’s face and will be etched into his or her heart.

Clients see people further along in the program doing better. These people look
better and sound better. The clients cannot miss the power of the group process. It
changes people right in front of their eyes. They will see new members come in
frightened or hostile, and they will watch them turn around. They will watch the
power of group support. Soon they will be offering new clients encouragement.
They will learn how helpful it is to share their experiences, strengths, and hope.

Once clients see how insane they were acting and accept that the group has the
power to restore them to sanity, they have come a long way toward embracing
Step Two. By trusting the group, the clients open the door to a higher power. This
basic building block of trust is vital to good treatment. Clients can miss seeing a
higher power in others. These clients, on discharge, might feel that a higher power
is the only answer they need. They might think that they do not have to go to
meetings so long as they have a good spiritual program. These clients will not
work a program of recovery, and they ultimately will relapse. All clients must be
encouraged to trust the group process. They need other people to flag for them
what they do not see in themselves.
Step Three
“[We] made a decision to turn our will and our lives over to the care of God as
we understood Him” (AA, 2001, p. 59). Read the Step Three exercise (see
Appendix 19) before continuing with this chapter.

Most clients will have some difficulty with Step Three. They need to be reminded
to turn problems over to their higher power. Addicts are self-centered, and they
need to learn how to be God-centered. Clients can be so self-centered that they
constantly set themselves up for unnecessary pain. They think that the whole
world, and everyone in it, should revolve around them. When people do not
cooperate with their self-aggrandizing plans, they are furious. They think that their
spouses, children, and friends always should obey their every whim. Previous
relationships in which their partners have been involved are seen as humiliating
and self-degrading. They believe that everything should go exactly the way in
which they want it to go. They believe that they are deserving of special honor and
privileges. They care very deeply about what they want and how they feel, but
their ability to empathize with others is seriously impaired (B. Carr, personal
communication, 1992).

A client might get furious when someone does something simple such as turn up
the heat or fail to fix the car. When the world does not cooperate by doing exactly
what the client wants, he or she goes into a rage. A more serious form of this
character defect is called narcissistic personality disorder.

Clients correct this defect by learning empathy for others and turning their will
and their lives over to the care of a higher power. Our program is a set of spiritual
principles through which we are recovering from a seemingly hopeless state of
mind and body (NA, 1988, p. xvi).

The worst thing that you can do is push clients faster than they are ready to go. The
decision to turn things over is the clients’ decision. All you can do is encourage
them.

You have one big thing going for you in Step Three. When the clients finally do
turn things over, they feel immediate relief. They feel this relief emotionally, and
this is the most powerful way of learning. They will feel that the stress of trying to
figure out the problem is reduced. The pressure will be off, and they will feel
better. Nothing works better than to show the clients how this tool of recovery
works. If you give a chemically dependent person a good feeling, then he or she
will want to re-create the feeling. That is what the person was doing with
chemicals—seeking immediate relief from pain. The Third Step is the new answer
that clients have been waiting for. They must experience it to believe it.

Many clients will stubbornly resist Step Three. Even people who have been in the
program for years have difficulty with Step Three. Meetings are full of people
talking about turning over the controls and then taking them back. Step Three is a
decision that must be made every day.

There is a great hope here for clients in Step Three, and they will feel it. If there is
a God, and if God loves them and will help them, that is great.

This newfound hope must not be shattered by religion. Religion can make people
feel excluded. Religious doctrine must be kept out of the program as much as
possible. If clients want to use a religious structure, that is encouraged so long as
it does not immerse them in guilt and remorse. The higher power is presented to
the clients in an atmosphere of forgiveness.
How to Help Clients Embrace Step Three
The key to Step Three is willingness. Once clients are willing to seek a higher
power of their understanding, they have come a long way toward completing Step
Three. The clients will find relief in talking about a God that loves them and
forgives them.

When you hear clients say that they are willing to turn it over, you can tell them
that they are well on their way to recovery. The problems might not be solved
immediately, but the clients are moving in the right direction.

Clients need to trust and turn things over to the group. The group has more
collective wisdom than the client, and the group members can be helpful in
solving problems. As the clients use the power and support of their group, they are
learning about how to turn things over to their higher power.

Some clients have serious problems with the word God, and that is fine. They do
not have to use the word if they do not want to. Many clients have had the word
God crammed down their throats for so long—since they were children—that they
are sick of it. If you try to do the same thing, then they will revolt. Remember that
even God gives total freedom of thought and action.
Step Four
“[We] made a searching and fearless moral inventory of ourselves” (AA, 2001, p.
59). Read the Step Four exercise (see Appendix 20) before continuing with this
chapter. Much of this exercise was developed by Lynn Carroll during his years at
Hazelden and at Keystone Treatment Center.

Step Four is where clients make a thorough housecleaning. They rid themselves of
the guilt of the past and look forward to a new future. Detail is important here.
You must encourage the clients to be specific. They must put down exactly what
they did. The clients will share their Step Four with someone of their choice in
Step Five. They will go over the assets part of the Fourth Step in group. The
assets part of the Fourth Step allows the clients to share the good things about
themselves with their treatment peers. This keeps them from decompensating into
a negative attitude. Step Four can be very painful for many clients, and they must
be encouraged to look at the good parts of themselves.

Step Four was developed directly from spiritual principles. To get rid of guilt, if
someone admits his or her wrongs and asks God for forgiveness, then God wipes
the slate clean. You should discuss the grace of God with your clients. They need
to know that there is no way of earning God’s forgiveness. God offers it freely.
God wants to set us free and give us an opportunity to start over again.

To do this, clients must be honest. They must share their wrongs with God, with
themselves, and with one other person. The other person is necessary because
clients need to see a non-shaming face respond to their wrongs. Remember that the
illness has been telling them that if they tell anyone the whole truth about
themselves, then they will be rejected. The only way of proving this to be wrong
is to do it. The clients no longer will be excessively burdened with guilt if they do
their Steps Four and Five properly. They might have a difficult time forgiving
themselves, but God will forgive them. Faith can do for them what they cannot do
for themselves.

There will be a tendency for clients to leave things they consider bad out of the
Fifth Step. The “Big Book” (AA, 2002a) says that this is not a good idea. “Time
after time, newcomers have tried to keep to themselves certain facts about their
lives. Trying to avoid the humbling experience, they have turned to easier
methods. Almost invariably, they got drunk” (AA, 2002a, pp. 72–73).
Clients are encouraged to share everything that they think is important no matter
how trivial it might seem to be. If it causes them any degree of guilt or shame, then
it needs to be examined. The clients need to come face-to-face with themselves.
All of the garbage of the past must be cleaned out. Nothing can be left to fester and
rot. The clients who leave things out will feel unforgiven.

The Fourth Step is where clients identify their character defects. Once identified,
the clients can work toward resolution. Clients often will come upon material
suppressed for years. As memory tracks are stimulated, deeper unconscious
material will surface.

Clients need to concentrate on the exact nature of their wrongs rather than accuse
or blame other people. This is a time to take full responsibility. They do not make
excuses. They ask for forgiveness. Yes, there likely were mitigating
circumstances, but this is not a time to find out who was right and who was wrong.
It is the time to dump the guilt and the shame.

The illness of addiction projects on the screen of a client’s consciousness his or

her wrongs. This makes the client feel bad. By drowning in his or her guilt and
shame, the client cannot pull free. The client wallows in self-pity.

Clients who get too depressed doing their Fourth Step need to stop and
concentrate on their good qualities. They are not all bad. They need to be shown
that they are valuable persons who deserve to be accepted and loved. They have
done many good things in their lives, and they need to focus on these attributes.
Some clients might have to wait quite a while before doing their Fifth Step.
Absolute honesty is a requirement of their readiness.

Some clients are so used to being negative about themselves that they cannot come
up with their assets. These clients need to have the group help them to see the
positive things about themselves.

Step Four must be detailed and specific. The clients must cover the exact nature of
their behavior. This is the only way for them to see the full impact of their disease.
They should not color their stories to make themselves seem less guilty or
responsible.

Most of all, Step Four, like all of the steps, is a time of great joy. The clients
finally face the whole truth about themselves. The truth is that they are wonderful
creations of God. As they rid themselves of the pain of the past, they are ready to
move forward to new lives filled with hope and recovery.
Step Five
“We admitted to God, to ourselves, and to another human being the exact nature of
our wrongs” (AA, 1976, p. 57). Read the Step Five exercise (see Appendix 21)
before continuing with this chapter.

Your job in Step Five is to help a client match up with the right person with whom
to share the Step Four inventory. Who this person is and what he or she is like is
vitally important. This person stands as a symbol of God and all of the people on
Earth. This step directly attacks the core of the disease of addiction. If it is done
properly, then the client will feel free of the past. The person chosen should be in
the clergy, if possible, because a minister better symbolizes a higher power.
Someone else in the program will do if he or she is chosen carefully and has a
good spiritual program. The person chosen needs some experience in hearing Fifth
Steps and must have an attitude of acceptance and unconditional positive regard.
The person must be nonjudgmental and strictly confidential. It is helpful if this
person is working a 12-step program. The person should not look uncomfortable
when the client is sharing sensitive material. If this person looks uncomfortable,
then the client may take this negatively. The client needs to see a non-shaming
face.

The purpose of the Fifth Step is to make things right with the self, with others, and
with God. Clients should see themselves accurately—all of their positive and
negative points—all at the same time. At the core of the illness of addiction is this
firmly held belief: “If I tell anyone the truth about me, they will not like me.” This
is not accurate, but the clients have been living as if it were true. They have not
been honest with themselves and others for a long time—perhaps since childhood.
They have pretended to be someone else to get the good stuff in life. The only way
of proving to people that this held belief is wrong is to show them. This is the
purpose of having another person hear the Fifth Step. If this person does not reject
the client, then the belief is proved wrong. A new accurate thought replaces the
old one: “I have told someone the truth, and that person still likes me.” This is a
tremendous relief to the client, who has been living his or her life convinced that
he or she was very unacceptable to others. This is a deeply held conviction, and it
causes great pain. The client must come to realize that unless he or she tells the
truth, the client never will feel loved.
In the Fifth Step, clients must come to realize that they are good people. They have
made mistakes and have done bad things. However, they are not bad; they are
good. God will forgive them, and they can forgive themselves. They can start
over, clean and new. Clients have varying degrees of spirituality and religious
beliefs. You and the clergy must help the clients see that forgiveness has taken
place. All religious systems provide for the forgiveness of sin.

Many clients will be tempted to hold something back in their Fifth Step. They do
not want to share some part of their past. They do not think anyone can understand.
The clients must be warned against this tendency. If they hold anything back, then
the illness is still winning. All the illness needs to stay in operation is something
important kept secret. All major wrongs must be disclosed. The whole truth must
come out. The clients must stop living double lives.

After the Fifth Step, most clients experience a feeling of relief. The truth sets them
free. In time, the clients will need to process the feelings with you. Some clients
feel no immediate relief, but if they are honest, then they feel the relief later.
Sometimes this takes a little while to sink in. The Fourth and Fifth Steps are a
profoundly humbling experience, but once they are over, there is a feeling of
relief. The person giving the Fifth Step should be encouraged to end the step with
a prayer asking for forgiveness. The person listening to the step also should end
the session in prayer. The person who has heard the step should tell the client that
he or she understands what the client has said, that God forgives the client, and
that he or she believes in the client’s basic goodness.
Step Six
“Were entirely ready to have God remove all these defects of character” (AA,
2002b, p. 63).

What has happened so far is nothing short of amazing. The clients have admitted
powerlessness, come to believe that a power greater than themselves could
remove the addiction, made a decision to turn their will and lives over to the care
of God as they understood him, made a searching and fearless inventory, and
admitted to God and another human being the exact nature of their wrongs. Now
it’s time to be entirely ready to have God remove the defects of character. We
have to believe that we cannot make this journey forward alone. God and only
God can remove these defects of character. He will begin to correct our
minimization, rationalization, and denial. He can correct our tendencies to slip
back into old behaviors and attitudes. They may have to use the steps, particularly
Step One, over and over again, many times a day. We have to turn our will and our
lives over to the care of the God of our understanding. It takes nothing short of
total surrender to allow God to remove these defects of character. This is a
lifelong battle to walk in the darkness or walk in the light. Darkness means no
love, no light, no beauty, and no truth. With Steps One through Five under their
belts, they realize that only God can remove these defects of character; they are
too much a part of our lives. It seems like we cannot live without them.

Truly they could not stop the addiction on their own. They had to give this
problem and all of its defects of character to God and let him do what they could
not do on their own. God could and would remove these defect of character.
These defects are tenacious. It’s like in baptism; the old man goes under water and
comes up a new man, but the old man is a good swimmer. These defects of
character fight for life; they have a life of their own. They are deeply rooted in
thoughts and behavior. When the clients look at their struggle to remove these
defects of character, we try to make progress not perfection. To ask to never
minimize, rationalize, or deny again is to put an unrealistic expectation on
themselves. This guarantees failure. When the clients look at themselves
objectively, they can see if they are winning or losing the battle. When they take an
inventory at the end of every day, they can see how they made progress.

In 12-step groups all over the world, you will hear people say they have been
released from the compulsion of their addiction. The craving has been removed,
and a new peace has taken its place. Most people will say it was relieved by the
direct intervention of their higher power. When they let go and let God in, insanity
was replaced by serenity. Here we try to imitate God himself. The clients try to
treat others the way they want to be treated.
Step Seven
“Humbly asked Him to remove our shortcomings” (AA, 2014).

The attainment of a humble heart is the foundation of each of the 12 steps. Each
step in turn leaves the clients more humble and dependent on their Creator.
Without humility it is difficult to attain and maintain a clean and sober lifestyle.
The delusion that the clients can still use the addictive substance or behavior
safely leads to more addiction and can lead to an early death. Without humility it
is difficult to be happy because the client is always trying to run the show. Clients
who are addicted need to get out of the great golden idol of me, my, and I and get
into a program of we. The first word in the 12 steps is we, not me, my, or I. We get
better by helping each other. This gets rid of “self will run riot.” Addiction needs
a preoccupation with self. Clients follow this self to the point of delusion and
death. This is called narcissism. I know what I need. I know what I want. I know
the direction I must take, and when I trust myself, I can always find a way out of
a bad situation. When clients think like this, there no need for a higher power.
Step One takes the wind out of this delusion and brings us back to the truth.

When the clients come face-to-face with addiction, they learn that nothing short of
a miracle will relieve the craving to become involved in the addictive behavior
again. Clients find comfort in fellow 12-step members who are working a
program of recovery, and the best of these recovering people seem to have peace
and humility written on their faces. Clients find out they don’t have to be beaten
down by the addiction; they can make the decision to walk toward the peace that
the program offers.

Most 12-step programs recommend that this step be taken on the knees. Indeed
clients will often hear in meetings that people put their shoes under the bed, so
they are forced to get down on their knees, and once on the knees, it’s a good time
to say a prayer asking God to help them stay clean and sober for another day. The
chief problem is self-centered fear, and the way around that hurdle is humility—
not something we were beaten into but something we asked for and lived. Once
we embrace humility we can walk a road not covered by obsession but freedom of
spirit.
Step Eight
“Made a list of all the persons we had harmed and became willing to make
amends to them all” (AA, 2014).

Steps Eight and Nine have to do with personal relationships and how the clients
can begin to improve them. The client begins by going back and reviewing Step
Four and making a list of the persons they harmed. Then, asking their higher power
for help, they become willing to make amends to them all. At first this seems like
the most difficult of the steps, but nothing can bring more peace than setting the
record straight, correcting the wrongs, and asking for forgiveness. Like many steps
this is one that is never complete. The clients will need forgiveness many times
along the road of recovery.

In Step Eight the clients fight the desire to keep the harms hidden, but like an
iceberg most of what we did to harm people show only a little on the surface;
most traveled below the surface, waiting to shame the recovering person into
keeping quiet about the harms they have done. An iceberg will sink the greatest
person in recovery. The clients have to face the truth. The job in recovery is to
humbly face the truth. If the clients continue to lie, they will certainly relapse. It is
easy to avoid Steps Eight and Nine as if we didn’t really hurt anyone but this is
not the truth. Everyone around the addicted person is adversely affected,
particularly those who were trying to love her or him. Fear and false pride are
enemies here, but the client needs to be fearless and thorough; anything else leaves
him or her in fear and self-loathing.

The wonder about these steps is that everyone breaks the rules and suffers the
consequences for bad behavior. A walk through Step Four sets the stage for us to
learn how to forgive ourselves and others. As clients go over the behavior chain,
they can see how bad behavior led them into shame and more of the addiction to
deal with these feelings. The best part of these two steps is when we come to
realize how much God loves us and how completely he forgives us. We don’t
deserve this forgiveness, but God’s grace and love shines through seemingly
unresolvable problems. As the clients work through Steps Eight and Nine, they
become aware of their own capacity to forgive. The clients are taught how to let
go and let God in, saying to themselves, There but for the grace of God go I.
Step Nine
“Made direct amends to such people wherever possible, except when to do so
would injure them or others” (AA, 2014).

The client has made a list of persons harmed in Step Eight; now it’s time to share
the client’s journey through recovery and ask for forgiveness. The client may have
to correct financial and relationship problems. They need to explain what
happened and why this hurt innocent people. Most people who hear the story of
addiction will forgive us if they understand the lies we told ourselves and others.
The lies were there to protect the client from the pain of the truth. These lies were
unconscious and automatic. Correcting the past takes good judgment and the time
necessary to clear away the wreckage. The clients have to reflect carefully the
exact nature of their wrongs and listen carefully to the pain of others. Money
borrowed needs to be paid back, and we need to ask for forgiveness. When
assessing the past the client needs to be careful not to injure people. Some of our
old behavior needs to be shared with God alone. This is no time for excuses or
further lies to cover up the shame. This is a time of embracing the truth, and in this
process we gain freedom of the slavery to the lie.
Step Ten
“Continued to take personal inventory and when we were wrong promptly
admitted it” (AA, 2014).

At the end of every day, the client needs to take a personal inventory of how he or
she succeeded or fell short of working his or her program. Did old problems,
behaviors, and attitudes begin to creep in, making recovery unstable? This keeps
the client on track and helps to measure how well the program was worked during
the last 24 hours. The beginning of the day starts with a prayer asking the higher
power to help the person stay clean and sober. At the end of the day, the client
needs to thank the higher power for helping him or her stay clean.

The client is working a self-directed program of recovery that needs maintenance.

This step keeps the way clear and helps to keep the client on track. The client
often goes back a step to see how dishonesty may have started to creep in. How
did our old ways begin to take over again, leaving us to feel misunderstood, lost,
and alone? Have them create a plan to correct the mistakes. Here the client needs
to take stock of the problems that occurred during the day. This gives the client a
commitment to stay on track every day.

When disturbed it is an old habit to think the other person is to blame, but Step
Ten suggests that when we are feeling disturbed, something is wrong with us. The
client has to take the responsibility for all of our comfortable and uncomfortable
feelings. This takes away from the frustrating idea that other people have to
change and leaves us with a change that needs to be spiritual and internal. The
client needs to take responsibility for all of his or her feelings. The client needs to
take the responsibility to see that when I’m feeling bad something is wrong with
me.
Step Eleven
“Sought through prayer and meditation to improve conscious contact with God as
we understood him, praying only for the knowledge of his will for us and the
power to carry that out” (AA, 2014).

Prayer and meditation are how clients make conscious contact with God. Prayer is
where the client talks to God, and meditation is where the client listens for God to
talk back. This ongoing conversation is the primary means by which the client
stays on the road to recovery. Problems are solved when the client lets go and lets
God direct the recovery journey. Daily conscious contact begins with a morning
prayer asking God to help the client stay clean and sober and ends with thanks for
a clean and sober day. Conversations with God should go on all day as if God is
right there as a close friend. There will always be difficult decisions to make, but
they can be made much better with the input of a higher power.

Meditation begins by closing the eyes and paying attention to breathing. Then with
each exhalation the client repeats a word or phrase of his or her choice, words
like love, one, peace, or let go. The body and the mind can then become still and
relaxed. The client can repeat a scripture verse or say the serenity prayer inside of
his or her mind.

One way for the client to start this dialogue is to get up every morning and ask
God three questions: God, what is the next step in my relationship with you, what
is the next step in my relationship with my family, and what is the next step in my
recovery? The client then writes down whatever words or images that come to
mind and begins the day with new directions.

It is a good idea when communicating with God that the clients discuss all
communication and prayer with their sponsors. Using this person in this way, the
client can prevent making mistakes in the spiritual journey. It is also helpful to
keep a daily record of all communications. This will provide hope and peace.
Step Twelve
“Having had a spiritual awakening as the result of these steps, we tried to carry
this message to alcoholics, and to practice these principles in all our affairs” (AA,
2014).

From the first 12-step meeting to the first reading of recovery material to the first
meeting, clients learn they have stumbled onto something different and terrific.
You just don’t hear honesty like you do in 12-step recovery. It seems that every bit
of material is aimed at freedom from the lies that so permeate addiction. It’s like a
fresh wind from a new spirit is blowing. Immediately the clients begin to feel like
they fit in; even if at first they don’t want to, the truth sucks them in, and soon they
are hooked on something better than drugs. Soon it becomes obvious that this
honesty is contagious, and it brings a new freedom and hope. Sooner than they had
dreamed possible, a new spiritual connection with God is formed, and this spirit
is so loving that it is overwhelming. It loves the unlovable until even the
unlovable feels accepted. With this spiritual awakening, the client wants to share
this with as many others as possible, and the best place to share is with those who
are still suffering. The desire to carry the message to others is overpowering, like
sharing a new vacation destination, only this destination is even better—it is
sharing life itself.
10 Lectures

©[Link]/Christopher Futcher.

Once or twice a day, clients go to lecture. The lectures last 30 minutes to 1 hour.
All professional staff members will take their turns in educating the clients about
the various aspects of the program. The physician will lecture on medical aspects,
the psychologist on psychological aspects, the dietitian on diet aspects, and so on.
As the counselor, you will be responsible for lecture topics relevant to addiction.
You can use any of the exercises in this book to come up with a lecture. If the
clients hear the material more than once, that is better; at first they have a difficult
time remembering material and it should be repeated. Each of the 12 steps should
be presented in lecture. Other topics might include the disease concept,
spirituality, relapse prevention, feelings, relationship skills, communication skills,
impulse control, anger management, stress management, and defense mechanisms,
to name a few.
Source: Created by Mervin Magus.

Many of these topics have been discussed already, and it would be redundant to
present them again. You can use any of this information in developing your lecture
program.

The lecture schedule should be flexible enough to allow for something that the
current client population needs. You should read the “Big Book” and Twelve Steps
and Twelve Traditions (AA, 1976, 1981, 2002a) to round out your lectures. It is
not difficult to talk to the client population, and you soon will learn to breeze
through the lectures. Those of you who are frightened of public speaking will need
to make an outline of each talk and follow it carefully. The structure will give you
the confidence you need, and soon you will be speaking like a trained presenter.
PowerPoint presentations or using a blackboard is also very helpful. People learn
best when using all parts of the brain: visual, auditory, tactile, movement, verbal,
interpersonal, intrapersonal, musical, nature, feeling, reading, and writing. The
more parts of the brain you can use, the more people will acquire the information.
Some people learn best through movement, some visual, and some auditory. Make
your presentations full of different kinds of stimulations, and clients will learn
better. If you can make people laugh, cry, and learn, they will remember.

Examples of several lectures are presented in what follows, but it is important to

develop your own personal style. You must use your creativity. Only the important
points of each lecture are given. Your job is to fill in the lecture with examples
and stories of your own. You can use some of your own stories or stories that you
have learned from clients. The clients do not need to hear a lot of confusing
research or references in these lectures. They will be less confused if you put
forth the facts in a simple and straightforward manner.
The Disease Concept
This morning we are going to talk about the disease concept of addiction. It is
important for you to know that you have an illness. Dorland’s Illustrated Medical
Dictionary (1965) defines disease as “a definite morbid process having a
characteristic train of symptoms; it may affect the whole body or any of its parts,
and its etiology, pathology, and prognosis may be known or unknown” (p. 428).
During the late 1940s, E. M. Jellinek began to study alcoholism in more than
2,000 members of AA. He found that alcoholism had a characteristic set of signs
and symptoms and that it had a definite progressive course. In 1956, the American
Medical Association formally recognized alcoholism as a disease. Up until that
time, medical science, and society in general, thought that someone who was
chemically dependent was a person with a moral problem or someone with a
weak will. The American Psychiatric Association has also classified substance
abuse and dependence as a disease.

This illness has a certain set of signs and symptoms. It has a particular treatment
and course. Not one of you asked to be chemically dependent. It is not your fault.
You should not feel guilty. That would be unduly hard on you. You would not
blame someone for having cancer or heart disease, even though some of their
behaviors may have contributed to their disease. If you eat a certain way or smoke
cigarettes, then you increase your chances of coronary artery disease. If you drink
or use drugs, then you increase your chances of becoming chemically dependent.
Addiction Is Not a Moral Problem
Many years ago Americans thought of drinking, substance abuse, and gambling
problems as a weakness of moral character or a weakness of will. The addict was
considered too weak or inadequate to say no to the addictive behavior. Today,
animal experiments and experiments with humans have shown that an addict’s
brain is a changed brain. Scientists found out that animals will press a lever and
ignore all other survival behaviors to stimulate with an electric current or a drug
that stimulates the ventral tegmental area (VTA) and the nucleus accumbens in
the midbrain, which exists to help the organism survive. This area takes
precedence over all other higher levels of the brain, such as thought or choice.
This center produces dopamine, which tells the organism that engaging in a
survival behavior, eating, sex, drinking, avoiding predation, and even killing is
pleasurable. This area is so powerful that an animal will press a lever to get an
electrical stimulation or drug stimulation, avoiding all other survival behaviors, to
the point of death. In other words, the animal chooses a drug over food to the point
of starvation. Over time, the drug takes the highest level of survival behaviors.
The organism chooses the drug first and sees the drug as the most important for
survival. For an addict the drug equals survival. Drug dopamine spikes in the
midbrain are far higher than normal pleasure spikes such as eating or sex, so in
time the addict only feels pleasure when using drugs. All other survival behaviors
feel pleasureless. Chronic addiction leads to long-lasting changes in brain tissue
to the point that voluntary control is undermined. Recent imaging studies have
revealed that brain activity important for normal motivation, reward, and
inhibitory control are changed in addicted individuals. This provides the basis for
the idea that addiction is a disease of the brain and addicted behavior is the result
of dysfunction of brain tissue. Dopamine extends to the frontal cortex, telling the
brain that the drug is the most important behavior—so important that the prefrontal
cortex uses glutamate to make a hyper-memory of drug use. The drug and
everything surrounding the drug and drug use are laid down as a superhighway in
the brain. In time, the conscious part of the prefrontal cortex that inhibits drug use
goes offline (hypofrontality), and all inhibitory control is lost. The addict cannot
say no to drugs because to do so signals death (McCauley, 2009; Volkow & Li,
2009). Addicts can still choose not to use for short periods of time under intense
threat or incarceration, but they can’t choose not to crave, and craving is
miserable, suffering, and automatic. It always leads the addict back to the only
thing that will help him or her survive. Every counselor and patient needs to watch
the video Pleasure Unwoven by Kevin McCauley (2009). This is a wonderful
DVD that beautifully shows why addiction is not a choice but a disease.
Addiction Is Not Due to a Weak Will
Please do not think that a weak will had anything to do with your addiction. We
find that addicts are incredibly strong and resourceful people. More than 90% of
chemically dependent persons are able to keep functioning even when they are
deathly ill. You know how it goes. You come to work, and you have this
incredible hangover; your head is throbbing, and you feel like you are going to
throw up. Your coworker comes in and asks how you are doing. “Fine,” you say
cheerfully. You are there, you feel terrible, but you made it to work. That takes a
strong will.
Addiction Has Genetic Components
There are no medical diseases other than microbes that do not have powerful
genetic links. We all are genetically predisposed to certain physical and mental
illnesses. We are more likely to acquire the same diseases that the members of our
families have had. Cancer, hypertension, asthma, diabetes, and coronary artery
disease run in families; depression and anxiety run in families; and addiction runs
in families. For example, cells are programmed at birth to do certain things when
alcohol is in the body. Many sons of alcoholics need to drink more before they
feel intoxicated. They have a programmed need to drink more before they get the
same effect. You may have noticed in your drinking or drug use that you could use
more than other people could. This is because some people who are predisposed
to chemical dependency metabolize drugs differently. It seems that many people
who are chemically dependent were predisposed to the illness before they were
born (Anthenelli & Schuckit, 1994; Volkow & Li, 2009; Woodward, 1994).
Addiction Is a Social Problem
To be chemically dependent, you need to use chemicals. This is a psychosocial
issue. In some societies, drinking and drug use are not tolerated. For example,
Muslims and Mormons have a strong religious belief against the use of drugs.
They consider use to be a sin. There is less chemical dependency in these groups.
In France, drinking is a regular part of life. It is not uncommon for a French person
to have wine with breakfast, lunch, and dinner. Understandably, France has a
higher incidence of alcoholism.
Addiction Is a Psychological Problem
Certain psychological factors also have to come into play. There is no specific
addictive personality, but people do have to drink to become alcoholic. Drinking,
using drugs, and gambling are highly reinforcing to some people, and to other
people they are not. Not everyone who drinks or even uses drink a lot becomes an
alcoholic. You have to like drinking to drink. All behavior, including addictive
behavior, increases if it is reinforced. If the reinforcement is taken away, the
addiction slows down and eventually stops. Addictive behavior makes a person
feel good, so finding out other ways to feel good decreases addiction.

Addiction is a biopsychosocial disease. It has biological components,

psychological components, and social components. Two or more of these elements
appear to be necessary for addiction to exist.

Someone has a drug problem if he or she continues to use a drug despite persistent
physical, psychological, or social problems associated with that drug. Anyone
who continues to use despite persistent negative consequences is an abuser.
Obviously, if you get into trouble when you use chemicals, then you should not use
chemicals.
Addiction Is a Physiological Problem
Addiction is characterized by tolerance and withdrawal symptoms. As you use
cocaine, the cocaine tells your brain to wake up. The cells of your body gradually
catch on to this abnormal wake-up signal, and they produce chemicals that tell the
brain to go to sleep. The cells counteract the drug. Ultimately, it will take more of
the drug to produce the same effect. As you take in more of the drug, the cells
counteract even further. This is a vicious cycle called tolerance. You will find that
you are using more of the drug now than when you started.

People who are addicted know it—at least on some level—and they try to cut
down. They might change from beer to wine or from hard liquor to beer. They
might decide to use only after 5 o’clock or only on weekends. They might even
move or change jobs.
The Obsession
People who are having problems with addiction will find that more and more of
their time is taken up using the substance. People first use cocaine once in a while.
They occasionally use at parties. As their illness progresses, however, they find
themselves using more often, during the week, even when they are alone. More
and more of their time is spent in getting cocaine, using cocaine, and withdrawing
from cocaine. The more they use, the more they need. The more they need, the
more they use.

People who are chemically dependent find themselves intoxicated or hungover

when they need to do something else. The homemaker might be high when she is
supposed to be taking care of the children. She might be drunk at work. She might
have to call in sick because she is too hungover to work. More and more, the
disease takes over, usually over a long period. The drug becomes the center of the
universe. Dinnertime revolves around those first drinks. There begins a morning
hungover ritual and an evening get-high ritual. Eventually, the person gives up
normal activities. The person does not go fishing or camping. The person quits
school or is fired. Sexual activity decreases. Recreational activity decreases.
With more time needed for the addiction, time with family and friends decrease.
Any activity can go, but the addiction stays and grows more and more important.
The Problems
Eventually, problems begin to develop. There are social consequences caused by
the addiction: problems with the spouse, problems with the law, problems at
school, problems with friends, and problems with parents. The problems begin to
mount, but the addict keeps dealing with the problems in the same way. The
person gets relief the only way he or she knows how: with the addiction of choice.
The addiction becomes the addict’s best friend. It is the only thing the person
relies on for help. It always helps to ease the pain. It works, and it works every
time.

By this time, people around the addict are complaining. They are warning that
something is wrong. Someone might even have the unmitigated gall to talk to the
person about the problem. When someone does this, the chemically dependent
person hammers that person to the floor. “It is not my problem,” the addict shouts.
“It is your problem.” The lies escalate, and the addict begins to be caught in a web
of lies. People challenge the addict with the truth. All of this leads to more
addictive behavior, and the cycle goes on.

Finally, some crisis breaks through the lies the addict has been telling himself or
herself. Some glimmer of the truth seeps in, and the person comes into treatment.
The person is still in denial. This person is still lying to himself or herself. The
person still cannot see the full impact of the disease. But here this person is in
treatment.

Most people who are addicts die because they never seek treatment. Very few
make it into treatment. Of those who do make it into their first treatment, most will
achieve a stable program of recovery. They might have to come through treatment
several times, but you will abstain from the addiction, or you will die.

You will find treatment centers dedicated to the truth. We must tell the truth to get
clean and sober. We must give up all that control we have been working on and
turn our will and our lives over to the care of others. If you work this program,
then you will find relief. If you hang on to your old ways, then you will live in
pain. The choice is yours.
Defense Mechanisms
Today we are going to talk about where all the lies come from. How did we end
up being such liars? In addition, we tell incredible lies. We lie when we think we
have to, and we lie when we do not have to. We lie to get out of trouble, and our
lies get us into more trouble. We lie to increase our pleasure, and we lie to
wallow in our self-pity.

This illness must lie, and it must continue to lie, or it cannot exist. The illness
cannot live in the light of the truth. You cannot tell the truth to yourself and
continue to be an addict. With the truth, you would realize your problem and get
some help for it.

All of the lies exist to protect us from a painful truth. The truth is that we are out of
control, and if we keep up the addictive behavior, then we are doomed. The truth
causes us great anxiety, so we defend ourselves from the truth. We distort the truth
just enough to feel like nothing is wrong.
Minimization
The first lie we tell ourselves is called minimization. This is where we take
reality and make it smaller. We think the problem is not that bad. If an alcoholic
takes an 8-ounce glass, fills it up with ice, takes a shot glass full of whiskey and
pours it over the ice, and holds the glass up to the light, the alcoholic will be
disappointed. A shot glass full to the brim with whiskey makes a disgustingly
small splash in an 8-ounce glass.
Source: ©[Link]/YazolinoGirl.

If you are an alcoholic, you are not going to use a shot glass. If you have a shot
glass at home, it is gathering dust. You are going to pour your whiskey until you
see some color in that glass. Now, if we were to take this drink and measure how
many shots are in it, we are going to find about four shots in the glass. Here is how
we minimize. We think, and believe, that we are having one drink. However, it is
not one drink; it is four drinks.

We can do the same thing with beer cans. If you are a beer drinker, you probably
have a considerable collection of empty beer cans at the end of the week. When
you take out the garbage, you have maybe two big plastic trash bags full of cans.
As you are taking out the garbage, you may think, “Boy, I hope the garbage person
does not think I am drinking all this beer.” At that time, you may put one of the
bags on your garbage pile, and the other one on your neighbor’s pile.

Those who are into cocaine, remember when you have just picked up your stash.
You have this nice big pile of cocaine on your kitchen table. You feel self-
satisfied. You have more than enough. Your treasure chest is full. You are content.
You feel a great peace. This is going to last a long time. However, the next
morning, you are wondering who got into your stash. Where did it all go? You
used it all; that is where it went.

We can minimize about our mounting problems. Everyone gets a couple of DWIs,
right? Almost everybody gets a divorce. It is not so bad to spend a couple of
nights in jail. We are good persons. We are not bad. We were just unlucky; the
cops were after us. We take what is real and make it look smaller. We lie to
ourselves, and we believe the lie.
Rationalization
The next lie we tell is called rationalization. This is where we have a good
excuse. Probably the most commonly used excuse for drinking is “I had a hard
day.” It follows, then, that if I had such a hard day, I deserve to get blasted.
Anyone who had the hard day that I had would need to relax. Let us have a few
beers or a couple of joints. In rationalizing, we might blame our problems on
someone else. “If you would just lighten up,” we might say, “I could straighten
things out.” We might think remorsefully of all that we could have been if we had
been born wealthy or been given the right breaks. We look at all of those
successful people, and we hate them. We never had such a chance, we tell
ourselves. There is no God. If there was a God, then where was God when we
needed him?
Denial
The last type of lie that we tell ourselves—and this one is the most characteristic
of addiction—is denial. Denial is a stubborn and angry refusal to see the truth.
Here we refuse to see what is right before our eyes. We block out what is real
until we really do not see it at all. The best way of showing you how this works is
to give you an example. You are walking down the street on a very hot day. It is 95
degrees in the shade. Sweat is pouring down your face. As you walk up the road,
watching the heat waves rise up off the asphalt, people are standing along the side
of the road with pails full of ice water. As you pass each of them, they throw their
buckets full of ice water in your face. In addition, when they dunk you, they yell
the following words: “Your wife’s divorcing you! That is your third DWI! The
boss will not put up with you anymore! You are in trouble with your parents
again!” You see the pails of water, you see the people throw them in your face,
and you hear the words that are shouted at you, but you do not experience the full
reality of what is happening. You do not get the full emotional impact of the
problems. With your whole life falling apart, you are walking up the street as if
nothing was happening at all. The people around you are amazed. Why don’t you
see? Why don’t you understand? Why can’t you see what is happening to you? It is
because you are denying reality. The mind has a way of cutting off the painful truth
and living in a numb zone.
How to Begin to Live in the Truth
You cannot see what is happening to you because you are lying to yourself. You
cannot see the truth because you believe the lies. You are completely fooled. In
treatment, the full reality of what has been happening to you will be before you. It
will be painful, but the truth will set you free. Treatment is an endless search for
the truth, and you must be willing to listen to what others say. You must try to be
open to what people tell you about yourself. We will reflect to each other what we
see. We will try to find the truth together. What we cannot do alone, we can do
together.
The Great Lie
It is important for you to know how the psychology of addiction gets going. During
childhood, we come to believe in the great lie. This lie is at the core of addiction.
We do not hear this lie from our parents or from our friends. We do not hear it
from our teachers or from television. It is more powerful than that. We hear this lie
inside of our own thinking, inside of that most personal part of ourselves. The lie
is this: “If I tell people the whole truth about me, they will not like me.”

Once we hear this lie and believe this lie, we know that we never will be loved
for who we are. Therefore, to get any of the good stuff out of life at all, we have to
pretend to be someone we are not. We try to be someone else. We watch those
people who are popular, and we copy them. We are very careful about what kind
of clothes we wear. We copy people’s mannerisms and their fine little gestures.
We find ourselves cocking our heads in a certain way when we laugh or smile. We
are hoping to fool the people. We hope that they cannot see our real selves. We
want them to see our pretend selves.
How the Great Lie Works
As this coping behavior occurs, it works. Some people do like us for the new
selves we are trying to be. We become pleased to know that we are not going to
be alone. The people we are fooling will love us. We begin to wear specific
costumes and to play certain roles. We might wear the nice girl costume or the
cowhand costume. We might wear the hippie costume or the yuppie costume. We
know that it is a costume—we know it is not us—but the people are fooled, and
the lie goes on.
We Never Feel Accepted
You must look carefully at what is happening. We have fooled people into liking
us, but they do not really like us. They do not know us. We are keeping who we
are secret. As we keep doing this—making this effort to be loved—our emptiness
grows, and our pain increases. We try hard. We copy everyone who looks cool.
We put on the best false front that we can, but in time we realize that it isn’t going
to work. We feel more and more lonely and isolated. We have known all along that
we were not going to be loved, not for the real us. No one was going to love us.
The Promise of the Disease
When we are lonely enough in this process, when we are isolated enough, and
when we are hurting enough, the illness comes along and offers us a smorgasbord
of answers to our pain. Sex, money, power, influence, drugs, gambling, and
alcohol all are there—and more—and we begin to feed from this cafeteria of
behavior. For a while, things get better. All of these things relieve the pain for a
little while. We find ourselves irresistibly drawn to this table of wrongs. We
spend more time doing it. We eat, drink, stuff, cram, push, and shove. We find that
more and more of our lives center on the use of these things. We get up on the table
and stuff ourselves. We begin to lose our morals and values. We eat, consume,
vomit, and stuff ourselves even more. In time, there never is enough. There is not
enough sex. There is not enough money. There is not enough power. There is not
enough booze. AA says that one drink is too much and that a thousand is never is
enough.
Truth
Finally, you begin to get sick from this cafeteria of wrongs. You realize an awful
fact: The answer is not in these things. It is a terrible point of grief when you
finally realize that the answer is not in your drug of choice. This is not a happy
time, but by now, you are addicted. You cannot stop. You might be addicted to sex,
and you want to stop what you are doing, but you cannot stop. You might be
addicted to money, and you want to stop chasing money, but you cannot stop. You
want to stop drinking. You promise yourself that you will stop, but you cannot
stop. You are addicted.

Somehow, by the grace of God, you finally come to treatment. Maybe you are
ready to surrender. I hope so, because if you are not, then you are in for a lot more
misery. If you are ready to surrender, and if you are ready to try something new,
then this program is for you.
A Program of Rigorous Honesty
One of the things that you must be willing to do is tell the truth all of the time.
Nothing else will stop the great lie. The truth will set you free. You are enslaved
to your addiction, but the truth will set you free of your chains.

In treatment, probably for the first time in your life, you will have the opportunity
to get honest. If you do not, and if you hold anything back, then you will return to
chemicals. You do not have to tell everyone the truth, but there is a psychological
law at work. The law is this: The more you can share, the closer you can get; the
closer you can get, the more you can share. As intimacy grows, you tell more of
the truth. In your Fifth Step, you will tell someone the whole truth at one time. You
will tell that person exactly what happened. Time after time, we have had
newcomers decide to hold something back in their Fifth Step. They did not want to
tell that one thing. Invariably, these people get drunk because they do not prove to
themselves that people will like them if they tell the whole truth. They keep the
emptiness, loneliness, and isolation. The pain grows, and eventually they relapse.

It is vitally important that you find out the truth about yourself. God created you in
perfection. You are God’s masterpiece. You were created in the image of God.
God loves you and wants you to be happy. For some of you, this will be difficult
to hear and difficult to believe. How could God love you? Where was God when
you needed God? If there is a God, then where is God? These are the questions
that you will seek the answers to in this program.
Normal Development
Today we are going to talk about normal development and how things go wrong
for addicts. As infants, we cannot see very well. Our eyes are developing, and
everything looks hazy. An infant knows only when it feels comfortable and
uncomfortable. When it feels uncomfortable enough, it cries. It cries out in the
only way it knows how. This cry is at such a pitch and timbre that parents cannot
ignore it. Those of you who have heard the cry of an infant have experienced the
pain. The infant cries out into the haze, “Help me! Help me!” It is the only thing
the infant can do to show he or she needs help. Without someone coming to help,
the infant will die.
The Primary Caregiver
But out of the haze, someone comes, and that someone meets our needs, and we
feel comfortable again. In healthy homes, this someone always comes, at all hours
of the day and night, and as we grow older, this someone has a particular sight,
sound, taste, and smell. Later still, it has a name—mother.

A great trust develops between mother and child. We learn that whenever we cry
out, mother will come. It happens repeatedly. It happens every time, and we learn
to trust in mother. She is always there.
The Struggle for Independence
As we grow older, we begin to struggle for independence. We begin to do things
for ourselves. We reach out and grasp things. We learn language, and we ask for
things. During the second year, we learn the power of the word no. Mother can be
all ready to go home, she can have her hands full of packages, she can be walking
out the door, and we can say no. Oh, the power of that word. The whole world
seems to stop and revolve around us. “No!” People get very upset with that word.
It is very powerful.
The Fear of Abandonment
Somewhere between 3 and 5 years of age—and this depends on the maturity of the
child—we learn a terrifying fact: Other people can say no, too. This fact strikes
terror in a child’s heart. We know that we need other people for survival. What
will happen if we cry out in the night and someone does not come? We develop a
new fear—the fear of abandonment. We never get over this fear. We carry it with
us for the rest of our lives. It is the fear of life and death itself. When something
goes wrong in our lives, this fear can come back very intensely. Lovers and
spouses panic when one partner attempts to leave the other. They fear that if that
person leaves, then they will die. You hear them say things such as “I cannot live
without her” and “I cannot live without him.”
Learning the Rules
As a frightened child, we go to our parents and search out an answer. “Mom, Dad,
how can I be sure that when I cry out, you will always come?”

“These are the rules,” the parents say. “These are the rules about how to be a good
boy and a good girl. If you obey the rules, and you cry out, we will come. But if
you are a bad boy or girl, and if you break the rules, we might not come.” As a
child, we nod our head reverently. We want to live!
The Development of Insecurity
Now the parents hit us with a crippling blow, and from this blow, we will get
another new feeling—insecurity. They do not tell us all the rules. The rules are too
complicated, and the rules keep changing. Sometimes things are against the rules,
and sometimes they are not. Sometimes we are punished for things, and sometimes
we are not punished for the same things. We spend the rest of our lives trying to
learn the rules. In every situation, the rules are a little different. It is very
complicated, and it causes a great deal of anxiety.
The Peer Group
As we move out of the home and into the peer group, things are very different. The
peer group does not love us just because we are a part of the family. The peer
group loves us because we have a function. We are a good leader or a good
follower, we are funny, we laugh, we are strong, or we are loyal. If we do not
have a function in the group, then we are rejected.

Little boys and little girls are very different by this age. Boys struggle for power,
and girls struggle for connection. Boys work to control, and girls work to
cooperate. Boys work at being the ones who can solve the problem, and girls
work toward who is the closest to whom. It is not that either of these personality
styles is better or worse. They are just different. Both are necessary for healthy
family roles.

If we have been told how wonderful we are every day of our lives, then we might
be ready for school by 6 years of age. In the best of circumstances, school is a
struggle. It is a very new situation with a new set of rules. We are not rewarded
for our individuality or our creativity. We are rewarded for our ability to
cooperate. We are supposed to be quiet and stay still. It goes against everything
that a child is, but we try to cooperate, we try to be quiet, and we try to stay still.
We remember that we do not want to be abandoned.
Adolescence
Adolescence is a time of great change. There is a huge hormone dam. It leaks,
cracks, and finally breaks, releasing a flood of chemicals into our bodies. These
hormones say one thing—mate. They say this loud and clear. We begin to mate in
our dreams, in class, and in every waking moment. The opposite sex becomes
exciting, irresistible, and new. We try even harder than ever to fit in because, with
all these changes going on, it is even more critical to be accepted. We struggle to
fit in much more than we struggle for our individuality.

Society tells us to prepare to leave our parents, who have been at the very core of
our survival. We begin to question the morals and values of our parents. We begin
to make decisions on our own. We prepare ourselves for the commitment of
adulthood. We must know who and what we are. We try out many different things
in an attempt to find ourselves.

For most chemically dependent persons, it is here, during early adolescence, that
chemical use gets going. Here we first try chemicals, and they make us feel good.
Soon we begin to use chemicals to deal with our problems. Here is where our
emotional development stops. If we treat our feelings with chemicals, then we do
not learn to use our feelings to solve problems. If we continue to use mind-altering
chemicals, then we do not have our real feelings anymore. Most chemically
dependent persons are emotionally stuck in adolescence. They still do not know
how to use their feelings appropriately to solve problems.
Adulthood
The dividing line between adulthood and adolescence is the ability to make long-
term commitments. Adults are emotionally stable and mature. They can commit to
career, family, and home. They can build a nest and rear healthy young. Adulthood
should really be a long, smooth ride. It is a gradual building of knowledge and
skill. Financial problems fall to the wayside as we reach our full economic
potential.

Somewhere during our 60s, the decision comes: Should we retire? If we like our
work and if it gives us joy, then of course we should keep working. If we do not
like our work, then we should retire and do something that we do enjoy. We
deserve it.

During later life, there inevitably will come a time of terminal illness. We will
acquire a disease from which we will not recover. This usually is coronary artery
disease or cancer, but it can be many others. If we are close to God, then this is
not such a scary time. We will have the hope of eternal life. If we do not know
God, then this time may be more difficult. However, in normal life, everyone dies.

We have discussed the normal life cycle, and we have seen where it usually goes
wrong in addiction. The illness can occur at any stage in life, but it usually gets
started in adolescence. The moment we begin to use chemicals to excess, we
cannot live a normal life. It is impossible. We cannot use our feelings in real time,
and with real people, to solve life’s real problems. In treatment, you will learn the
skills necessary for living a normal life. These are the tools of recovery. If you
learn these skills, then your life will stabilize, and you ultimately will live a
normal life again.
Physical Addiction and Recovery
This morning we are going to talk about the physical changes that occur in
addiction. The cell is the basic building block of the body. It has a cell wall that
protects the cell from harm, a nucleus that is the brain of the cell, and a variety of
other specialized parts with specialized functions called organelles. The nucleus
is made up of deoxyribonucleic acid, or DNA, and it decides how the cell is made
and how the cell works. It is the manager of the cell in the same way as the brain
manages your body. The cell wall is an actively selective membrane that chooses
what comes into and out of the cell.
Source: From “Long-Lasting Effects of Recreational Drugs of Abuse on the
Central Nervous System,” by U. D. McCann, K. A. Lowe, & G. A. Ricaurte, 1997,
The Neuroscientist, 3, 399–411.
How Drugs Affect the Cell
Drugs pass through the cell wall in a variety of ways and influence how the cell
operates. This is a very involved process, and we do not know exactly what each
drug does. What we do know, however, is important, and you must understand
some of this in your recovery program. Alcohol is a drug. One of its effects is that
it dehydrates protoplasm. It sucks water out of the cell. This prevents the cell wall
from operating properly. This happens in every cell in the body, but it has its most
noticeable effect on the central nervous system (CNS). It suppresses higher
cortical centers in the brain. This reduces people’s normal ability to perceive the
environment. It tells the brain to go to sleep. This inability to perceive accurately
makes us feel less inhibited. We lose the normal constraints that the world puts on
us. We miss the subtle cues. It makes us feel free.

The brain of the cell picks this up as a problem and changes things in the cell to
correct the problem. Alcohol tells the brain to go to sleep. The cell tells the brain
to wake up. At first, these changes are transient chemical changes or subtle
changes in metabolism that will quickly return to normal after alcohol leaves the
body. However, if the alcohol keeps coming, then the cell produces permanent
changes in the cell wall. One way in which it does this is by making tunnels, or
chloride channels, through the cell wall. This provides for easier transport of
atoms across the cell wall. The more that alcohol stays around, the more of these
chloride tunnels are needed.
How Drugs Affect Behavior
Now let us see what is happening to you behaviorally. You start drinking, and one
beer gets you that feeling you are after. One beer is all that you need, but
eventually, the cell produces those changes, and you need two beers to get that
same feeling. In a few weeks, or months, or years, you are going to need three
beers, and then four, and five, and six, and so on. The more beer you drink, the
more the cell corrects with those chloride channels. This is called tolerance. You
need more and more of the drug to get the same effect. All chemically addicting
drugs create this physiological pattern.
Tolerance
It is important for you to know that these changes in the cell may take years to
develop, but once tolerance is there, it is there permanently. The cell never
changes back completely the way it was before. It never forgets. That is why you
never can use drugs normally again. You have developed permanent changes in the
cells in your body. If you were drinking a fifth a day, staying sober for 20 years,
and then start drinking again, you will be drinking a fifth a day within 30 days. It
took you years to develop tolerance, but this time it is there already. This never
will change. You can recover completely from some of the psychological and
social effects of this disease, but you never can recover from the physical changes
that have taken place in your cells. Your cells never forget.
Cross-Tolerance
This is why cross-tolerance is such a problem. Alcohol, pot, sedatives, and
sleeping pills all tell the brain to go to sleep, and the cells counteract that drug in
some of the same ways. If you develop tolerance for one of these drugs, then you
will develop tolerance for all of them. You cannot leave treatment and say to
yourself, “Well, I am sure glad I got that alcohol problem licked, but I never had
any problem with pot. I can have a little pot now and then.” This would spell
disaster for you. Taking a little pot is like taking a little alcohol because of the
cross-tolerance.

What we find in addiction treatment is that once you are addicted to one mood-
altering chemical, you are addicted to all of them. You have learned things
physically, psychologically, and socially that will cross over to any other mood-
altering chemical. If your drug of choice is whiskey, and if you go out of here and
smoke a little dope, then you will be back to the whiskey very soon.
Withdrawal
The cells produce all of these short- and long-term changes to counteract what the
drug is doing, so you can guess what happens when the drug is removed. All of
these cellular changes are still there, and the drug is gone. The cells are producing
wake-up signals to the brain to counteract the go-to-sleep signals that the alcohol
is producing, and all of a sudden, there is no alcohol. What happens is called
acute alcohol withdrawal. The cells are screaming for you to wake up, and no
alcohol is telling you to go to sleep. Acute withdrawal has been driving
alcoholics to the liquor store every day. They go to sleep under the effects of
alcohol, and in a few hours, they wake up feeling nervous and restless. They
cannot sleep. Their stomachs feel upset. They have headaches. Their hands shake.
All of these are withdrawal symptoms.

Some of you learned that what you needed was a drink or a Valium to get you back
to sleep, but if you have that drink or that pill, then the cycle starts all over again.
Acute withdrawal is not fun. It produces the opposite effect of the drug that you
are using. If you were using a sedative drug, then withdrawal will tell you to wake
up. If you were using a stimulant drug, then the withdrawal symptoms will tell you
to go to sleep.

The length of acute withdrawal differs depending on the drug you were taking.
With alcohol, withdrawal usually is over within a few days. With cannabis or
certain other benzodiazepines, it can be weeks or even months. Once acute
withdrawal is over, protracted withdrawal extends the problems for about 2
years. Protracted withdrawal is characterized by random mood swings, sleep
problems, and generalized feelings of stress. These symptoms will wax and wane
over the next few months. Do not think that you are crazy or think that anything is
wrong. Just recognize the symptoms for what they are (Geller, 1994).

The first 3 months out of treatment will be the hardest for you because of the
extended withdrawal syndrome. This is where people tend to relapse, so do
everything in your power to work a daily program of recovery in early sobriety.
The daily program will put hurdles in the way of the first use.
How We Learn
Drug use is a habit. We get into the habit of drinking or using in certain situations
or when having certain feelings. A habit is some movement or thought that is so
practiced that it has developed a nice, smooth pathway in the brain. Whenever we
even randomly approach that area in the brain, we are very likely to take that
pathway because it is so well traveled and easy to follow.

You have developed certain habits in your drinking or drug use. You might use
when you celebrate, or when you feel angry, or when you are frightened or sad.
You might always drink after work or always drink a certain kind of beer. These
pathways in your brain are well developed. What treatment is all about is teaching
you to get what you want by doing something else other than using your old
behavior. It is a process of learning new behaviors. For example, if you want to
feel less angry, then you will need to talk to someone about how you feel and try to
work through the problem. The second you realize that you are on one of your old
pathways, you need to stop and change direction. Drinking or drug use no longer is
an option for you. You need to find other methods for dealing with your problems.
Alcoholics Anonymous
The idea behind AA got started in 1935. Bill Wilson, one of its founders, had
gotten drunk again. He was at the end of his rope. He was afraid to go home. He
was afraid he was going to kill himself. He hated himself. His spouse was still
sticking by him, but he could not trust himself anymore. He had tried to quit
drinking countless times, in countless ways, and he had always ended up drunk.
Here he was in the hospital again. He did not know whether he wanted to live or
die, but he knew that he did not want to live this way anymore. Medical science
had given up on him as hopeless. He had nowhere to go. He was trapped.
A Spiritual Awakening
In his room alone, feeling very powerless, Bill looked up toward heaven, and he
cried out, “If there is a God, show me. Give me some sign.” At that moment, Bill’s
room filled with a great white light. He felt incredibly filled with new hope and
joy. “It was like standing on a mountaintop with a strong, clear wind blowing
through me. However, it was not a wind of the air. It was a wind of the spirit.”
Bill felt like he had stepped into another world full of goodness and grace. There
was a wonderful feeling of presence that he had been seeking all of his life. He
never felt so complete, so satisfied, and so loved. Bill had finally surrendered,
and when he surrendered, God came into his life. Notice that God came into his
life with such power and force that Bill never denied God again.

Bill never took another drink, but his spiritual awakening did not fully resolve his
problem. He still had a craving for alcohol. One day, he passed a bar and felt
himself being pulled into it. He thought that if he could just talk to another drunk,
he might be able to pull himself back together. He got on the phone and after
making a few calls, he finally found one: Dr. Bob Smith. Dr. Bob was a hopeless
alcoholic. He had destroyed his medical practice, and he was waiting to die. He
reluctantly agreed to see Bill, but he had no hope that Bill could help him. Dr. Bob
would have no nonsense. He had talked about his alcohol problem with the best,
and now here was some other guy—a drunk—who was coming over to try to help
him. He was in no mood for help.
Two Alcoholics Talking to Each Other
When Bill got there, Dr. Bob was surprised to learn that Bill was not there to keep
him sober. “No,” Bill said, “I am not here to keep you sober. I am here to keep me
sober.” Well, this was the new concept—one alcoholic talking to another to keep
himself (or herself) sober. Dr. Bob was going to give Bill only a few minutes, but
they talked easily, and Bill stayed for hours. Dr. Bob began to open up and speak
as frankly as Bill was doing. Having common experiences, they could speak to
each other without shame. They talked about the helplessness and hopelessness
that they had been feeling—the feeling of total powerlessness. They talked about
all of the problems that alcohol had caused them. Bill told Dr. Bob about the
spiritual experience that he felt had saved him.

These two persons became great friends, and AA was born. They began to meet
with other alcoholics. They began to carry the program to others. Dr. Bob got
drunk one more time—when he was away at a convention—but when he returned
he was more determined than ever to stay sober.

A bunch of alcoholics began getting together to help each other stay sober. To
everyone’s amazement, it worked. Hopeless cases began to recover. Of course,
the group members had their setbacks, but the way to recovery had been found.
The group would not have the name AA for 4 more years.
The “Big Book”
Bill dictated most of the first chapters to his secretary. He had considerable
resistance when he came up with the 12 steps. Some of the group members were
adamantly opposed to including so much God talk in the program. They did not
want to scare drunks away with all of the spiritual talk. Bill listened quietly, but
he knew that he was right. The only concession he made was to add the phrase
“God, as we understood him.” That made some members of the group feel more
comfortable.

As the program developed and people began to stay sober, Bill was offered a job
as the first alcohol counselor. A hospital wanted to incorporate the program and
use it to help alcoholics. The group was opposed. Group members were afraid
that it would make the program commercial and that this would destroy an
essential element of the group. This time Bill agreed, and AA remained a free,
self-supporting program.

Another problem was money. The group needed money to pay for expenses and to
reach out to alcoholics who were still suffering. They went to John D.
Rockefeller, and he gave the group $5,000. They had asked for $50,000, but
Rockefeller felt that financial backing would weaken the program.

With the individual stories written by the new groups, Bill completed the “Big
Book” in 1939. The groups ordered 5,000 copies to be printed. They did not sell
many until an article written by Jack Anderson appeared in the Saturday Evening
Post (Anderson, 1941). This gave AA national exposure, and the mail began to
pour in. AA now has more than 1 million members and has meetings all over the
world.
The 12 Steps
The program is made up of 12 steps. You will hear these steps read at every
meeting:

1. We admitted we were powerless over alcohol—that our lives had become

unmanageable.
2. [We] came to believe that a power greater than ourselves could restore us to
sanity.
3. [We] made a decision to turn our will and our lives over to the care of God
as we understood Him.
4. [We] made a searching and fearless moral inventory of ourselves.
5. [We] admitted to God, to ourselves, and [to] another human being the exact
nature of our wrongs.
6. [We] were entirely ready to have God remove all these defects of character.
7. [We] humbly asked Him [God] to remove our shortcomings.
8. [We] made a list of all persons we had harmed and became willing to make
amends to them all.
9. [We] made direct amends to such people whenever possible except when to
do so would injure them or others.
10. [We] continued to take personal inventory, and when we were wrong,
promptly, [we] admitted it.
11. [We] sought through prayer and meditation to improve our conscious contact
with God as we understood Him, praying only for His will for us and the
power to carry that out.
12. Having had a spiritual awakening as a result of these steps, we tried to carry
this message to alcoholics and to practice these principles in all our affairs.
(AA, 2001, pp. 59–60)

There are many slogans in AA that will help you to reorganize your life and your
thinking—slogans such as “one day at a time,” “easy does it,” “keep it simple,”
“live and let live,” and “let go and let God.” These slogans have great meaning,
and they will help keep your program on track.
Meetings
It is hoped that, after treatment, you will attend many AA or Narcotics Anonymous
(NA) meetings. The more meetings you attend, the greater your chances of
achieving a stable recovery. You need to ask someone further along in the program
to be your sponsor. That person will guide you through the steps and will be there
for you in times of need.

You will find this program to be a healthy family. The regular meeting that you
attend will be called your home group. There is a stable set of rules. People will
care about you. They will respond to how you feel. They will care for what you
want. They will be there for you when you need them.

The choice is yours. We strongly recommend that you throw yourself into this
program with all the enthusiasm and courage you can muster. Tell your group the
truth. Do not hold back. AA says, “Rarely have we seen a person fail who has
thoroughly followed our path.”
Feelings
Most chemically dependent people have difficulty with their feelings. They do not
know how to identify their feelings and do not know how to use their feelings
effectively. All feelings give us motivation. They give us specific energy and
direction for movement. If you cannot use your feelings effectively, then you
cannot adapt to the changes in your environment.

The reason why we, as chemically dependent persons, do not use feelings
appropriately is we learned not to trust our feelings. We learned that there was
something wrong with our feelings. We learned this from watching people respond
to us when we were having feelings. When we were children, and we were
feeling afraid, we heard, “There’s nothing to be afraid of.” When we were angry,
we learned that we were bad. “There’s nothing to be angry about,” our parents
said.

Look at what this does to us as children. We begin to think, “I am having feelings

that I shouldn’t be having. I am afraid when there is nothing to cause me to feel
afraid. I am angry when there is nothing to be angry about.” We believe our
parents. We can reach only one conclusion: Something is wrong with us. We are
not feeling right, or we are having the wrong feelings at the wrong time.

We might be further confused when we get to school and are teased when we have
feelings. The other kids tease us when we cry. They do not take us seriously when
we are in love. We all know that feelings are one of the most basic things about us.
It is one of the things that make us who we are as people. If there is something
wrong with our feelings, then there is something wrong with us. “Something is
wrong with me,” we think. “I cannot trust myself.”

Once we cannot trust who we are, we have to become someone else. We begin to
search for that person who we want to be. We copy other people who we respect.
We imitate various roles to see whether the roles fit us. Whatever we do, we do
not share our feelings. We have been taught not to do that. We keep our feelings
more and more to ourselves until sometimes we do not know how we feel
anymore. Boys are not supposed to cry, so they get angry instead. Girls are not
supposed to get angry, so they cry when they are angry. More and more, we
separate from ourselves. We become more isolated.
All Feelings Are Adaptive
Each feeling has a specific action attached to it. Fear gives us the energy to run
away. Anger gives us the energy to fight. Acceptance gives us the energy to move
closer. You may have more than one feeling at the same time, and this can be
confusing. However, if you break the feelings down into their basic units, then you
always can figure out what the feelings are telling you.

There are eight primary feelings: (1) anger, (2) acceptance, (3) anticipation, (4)
joy, (5) disgust, (6) sadness, (7) surprise, and (8) fear. More complicated
emotions are combinations of the basic eight. For example, jealousy is when you
feel sad, angry, and fearful all at the same time. When you feel jealous, you have
to break the feelings down into their smaller units. Each feeling has to be
identified and dealt with. What exactly are you frightened of, and what can you do
to relieve your fear? What exactly are you angry at, and what can you do with your
anger to make the situation tolerable? What makes you so sad, and what action can
you take to help you feel more comfortable? As each of the feelings is addressed,
you will have a more complete picture of the problem.

Remember that all feelings have movement attached. Fear moves you away from
an offending stimulus; so does disgust. Sadness gives you the direction to recover
the lost object. Anger gives you the direction to fight. Anticipation and surprise
are orienting responses that prepare your body for action. Joy and acceptance give
you the direction to move closer and stay with the object that gives you those
feelings.

You must learn how to identify your feelings and use them to help you take action.
It is a mistake to keep your feelings quiet. Sharing your feelings is an essential
skill in interpersonal relationships. You cannot be close to someone if you do not
know how that person feels and vice versa. You do not have to act on all of your
feelings—that would not be wise—but you do have to process or deal with each
feeling that is important to you.
Assertive Skills
In treatment, we are going to learn the assertive formula. This is an excellent way
of dealing with your feelings appropriately. This is what we are going to say when
we have an uncomfortable feeling:

I feel ______________________________________________.
When you _________________________________________.
I would prefer it if __________________________________.

Start by describing your feelings. That will be one or more of the eight feelings
that we discussed. Then describe the behavior of the other person that triggered
that feeling. Exactly what did he or she do or say that made you feel
uncomfortable? Then tell that person what you would prefer him or her to do.

Let us say that your husband is an alcoholic and that he is 2 hours late from work.
You are scared and angry. He could be drunk again. He could have been involved
in an accident. He could be having an affair. Just as your worry reaches its peak,
and you begin to call the police, he comes home. Using the assertive formula, you
would say, “I feel scared and angry when you come home late. I would prefer it if
you would call me and let me know where you are.” Now this statement gives him
knowledge about how you are feeling, what he did to give you that feeling, and
what he can do to improve things. This is good communication.

What if you feel as though someone in your group is in denial and lying to himself
or herself? You might say something like this: “I feel sad when I hear you say you
do not have a drinking problem. I would prefer it if you would try to see the truth
about what you are doing to yourself.”

In group, you will have people reflect your feelings to you. They are not trying to
hurt you. They are trying to get you to see the truth. They might tell you that they
experience you as mad or sad when you do not really know how you feel. It is
important to listen to your group members and try to see what they see. Maybe
they can see a side of you that you cannot see.

It is vitally important for you not to feel ashamed of your feelings. You can have
your feelings whether or not you have a good reason for having them. They do not
have to be logical and make sense to be important. You will learn how to trust
your feelings in treatment. You will learn that all of your feelings are great and
wise counselors.
11 Special Problems

Source: ©[Link]/KatarzynaBialasiewicz.

There is a high comorbidity rate among psychiatric diagnoses and addiction.

These addictions have another set of specific problems that complicate treatment
(Frances & Franklin, 1988; Mueser, Drake, Turner, & McGovern, 2006). If these
clients are treated for their dual diagnoses, then their chances of recovery
improve. If they are not treated for their secondary problems, then their chances of
recovery are significantly reduced (Mueser et al., 2006; Ries & Miller, 2009;
Woody et al., 1984). These clients need different treatment. For example, most
clients are depressed when they enter treatment. For some of these clients, the
depression is serious. Without treating the depression, these clients will be at
greater risk for relapse.
Source: Created by Mervin Magus.

One way of evaluating these clinical phenomena is to make a distinction between

the primary and secondary diagnoses. The disorder that occurred first is called
primary, and the problem that appeared second is called secondary. When the
disorder appearing first is abuse of substances, it is highly likely (but not always
true) that the secondary problems will improve rapidly (within days or weeks)
once abstinence is achieved (Schuckit, 1994).
The Psychiatric/Psychological Assessment
All clients need to be carefully screened for comorbid problems during the initial
assessment process. This screening must be done by a mental health professional
with the special skills necessary for this examination. The assessment must
include the following:

1. A systematic mental status examination with special emphasis on immediate

recall and recent and remote memory
2. A determination of current and past psychiatric/psychological abnormality
3. A determination of the dangerousness to self or others
4. A neurological assessment (if indicated by the psychiatric/psychological
assessment)
5. An evaluation of cognitive functioning including any learning impairment that
might influence treatment

This assessment will signal to the staff problems that need further treatment. The
mental health professional will flag for you serious psychopathology, but you still
need to keep him or her informed if you believe that something else is going on
other than addiction. You see the client on a daily basis, and you are the most
likely to know when things are not going well. Sometimes more of the client’s
abnormal behavior will become evident as he or she moves through the treatment
program.
How to Develop the Treatment Plan
Once the client is diagnosed with a secondary problem, the treatment team will
develop a treatment plan. Sometimes you will not be formally involved in the
treatment (the mental health professional may do it), but you will deal with the
problem on some level, so you need special skills. If you ever feel that you are in
over your head with a client, then you must inform the staff. You might need to
refer the client for further consultation or treatment. Do not strike out on your own
with these clients. Use the treatment team to guide you.

It would be beyond the scope of this book to cover all of the psychopathology that
you will experience as a counselor, but we discuss what you will see most often.
You should familiarize yourself with the latest edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM–5) (American Psychiatric
Association, 2013). Keep this manual close to you for reference. It is not your job
to diagnose these clients, but you should be alert for the major problems you will
see and become familiar with methodologies to treat the problems.

All of the major psychiatric diseases, like addiction, have a biological

component, a psychological component, and a social component. You must
consider all three parts of the problem in developing a treatment plan.

Some psychiatric diseases require psychotherapeutic medications (see all in

Appendix 55). There is an old idea in 12-step programs that all medications are
bad. This no longer is appropriate. Many clients need their medication to survive.
For example, a certain type of depression is treated very well with antidepressant
medication. If you deprive these clients of the treatment they need, then some of
them will die. Fully 15% of people who have serious depression eventually kill
themselves (Hirschfeld & Goodwin, 1988). Many psychiatric clients need their
medication for normal functioning. Let the physician make this decision. Once the
decision is made to treat the client with medication, it is vital that you support this
decision.
The Depressed Client
By far, the most common secondary diagnosis related to addiction is depression.
Depression is a whole body illness that involves a client’s body, mood, and
thinking. It affects the ways in which clients eat and sleep, feel about themselves,
and think about things. There is a consistently high rate of depression in substance
abusers (Dorus, Kennedy, Gibbons, & Raci, 1987; Hesselbrock, Meyer, &
Kenner, 1985; Nunes & Weiss, 2009). Most chemically dependent individuals
will come into treatment with some degree of measurable depression.
Source: Andrea Morini/Thinkstock.

Excessive use of alcohol and other chemicals results in depressed mood. This
depression can be organic, psychological, or interpersonal. You will first pick up
depression in the mental status examination or in the psychological testing. Client
depressed mood can range from mild to severe. The best way of measuring the
severity is to use a psychological instrument such as the Hamilton Depression
Rating Scale (HAM-D) (Hamilton, 1960) (see Appendix 30). The primary
symptom of depression is the inability to experience pleasure. This is called
anhedonia. Depression clouds the clients’ whole lives. The anhedonia is
persistent and pervasive. The clients feel numb as though life is dead. The joy is
gone. They feel sad or down most of the day almost every day. They sleep poorly:
They either under-sleep or oversleep. Their appetites are off. They have a
diminished ability to concentrate. They might feel helpless, hopeless, worthless,
or excessively guilty. When people feel this bad, they might think that they would
be better off dead. They may be suicidal.
How to Assess Depression
To assess depression, you will have the Hamilton score, the mental status
examination, the history of the present problem, and the past history. The client is
asked, “Have you ever felt sad or down most of the day, almost every day, for
more than 2 weeks?” If the answer to this question is yes, then the client needs to
see someone on the staff experienced in depression. As the counselor, do not try to
evaluate the extent of the depression yourself. It gets complicated and takes quite a
bit of diagnostic skill. You should be familiar with the types of depression listed
in the DSM–5 (2013). Some depressions are chronic and mild, and some can be
acute and life threatening.
How to Treat Depression
Depression can be treated by you if you work with the clinical team. Depression
is treated in three ways: (1) with antidepressant medication, (2) with
psychotherapy, cognitive therapy, or behavioral therapy, and (3) with
interpersonal therapy. If the clients are placed on medication, then you need to be
supportive of these decisions and encourage the clients to comply. In behavior
therapy, you will encourage the clients to change their actions. For example, you
will help the clients to develop leisure time activities that will increase their
opportunity to experience joy. What the clients do will change how they feel. In
cognitive therapy, you will help the clients to correct their inaccurate thinking. In
interpersonal therapy, you will help the clients to resolve interpersonal conflicts.
Psychopharmacology
The biology of depression is centered on a chemical problem in the brain. Certain
neurotransmitter systems (e.g., norepinephrine, dopamine, and serotonin) become
deregulated or out of balance. This chemical problem can be corrected chemically
with medication. (For a complete list of all psychotherapeutic medication
protocols, see Appendix 55.) There are four groups of antidepressant medications
commonly used in treating depression: selective serotonin reuptake inhibitors
(SSRIs), tricyclics, monoamine oxidase inhibitors (MAOIs), and lithium. Lithium,
carbamazepine, atypical anti-psychotics, and valproic acid are the current
treatments for bipolar affective disorder. The doctor might have to try a variety of
antidepressant medications or a combination of medications before finding the
right one. Depression has strong genetic links, and certain genes predispose some
people to manic or depressive episodes. Affective disorders can be caused by
physical, psychological, or interpersonal problems, or they can occur without
environmental precipitant. There is not always a psychological or social cause of
the disease, but it always has psychological and social effects that need treatment.

If the physician decides to put the client on antidepressant medication, there

usually will be a 3- to 6-week delay before the client begins to feel better. You
must encourage the client during this period. Keep telling the client that the
depression is going to get better. This encouragement will instill hope in the
treatment and will increase client compliance. There are side effects of
antidepressants that the client needs to discuss with the physician. Mostly, this
will be mild sedation and an overall drying effect experienced as dry mouth,
urinary retention, and constipation. Some of the newer antidepressants can cause
an increase in anxiety, weight gain, loss of appetite, and sexual dysfunction. Be
sure to chart any symptoms that the client reports and discuss them with the
clinical team.

Because it takes these drugs 3 to 6 weeks to work, you might not see the
antidepressants take effect in every client. The client might respond only after he
or she has left treatment. Once you see this change take place, however, you will
be totally convinced. The dramatic effect that these drugs produce will win you
over. They contribute in a major way to the treatment of depression.

Medication never should be the only treatment for depression. Studies have
consistently shown that clients who undergo medication plus psychotherapy have a
better prognosis (Beitman, Carlin, & Chiles, 1984; Conte, Plutchik, Wild, &
Karasu, 1986; Ries & Miller, 2009).

The two major psychological treatments for depression are behavior therapy and
cognitive therapy. In the biopsychosocial assessment realm, you will try to
uncover any psychosocial stressors that may have precipitated the depression.
Certain depressions are caused by specific environmental events such as a death
in the family or a divorce. If you can determine what caused or made the
depression worse, then you will have come a long way toward knowing where to
concentrate treatment.
Behavior Therapy
Behavior therapy for depression centers around teaching the client new skills and
increasing positive reinforcers in the client’s environment. This increase in
pleasure-oriented activity elevates mood. Studies have shown that depressed
people do not do fun things. They tend to sit and feel helpless, hopeless, and
depressed. Your behavioral intervention will increase the clients’ activities. You
will have them begin an exercise program; increase social interaction with
treatment peers; and become more involved in games, sports, and hobbies. You
must be specific in what you are recommending, and you must make sure that the
clients are following through with your recommendations.

Monitor depression with a weekly HAM-D. You can give this test daily if it is
necessary. As the client gets better, the HAM-D score will drop.

A word about psychological testing is appropriate here. Testing will give you a
general indication of what is going on. A test is not able to be certain about
anything. The scores need to be considered in light of the total clinical picture.
You need to trust your clinical judgment more than you trust a psychological test. If
the tests show that the client is not depressed and you believe that he or she is
depressed, you could be right. This issue needs to be discussed with the clinical
team. You will make more accurate judgments together.

An increase in goal-oriented behavior is essential to behavioral treatment of

depression. Depressed persons have a difficult time in doing anything, and they
will need encouragement to set goals. If they need to increase their level of social
interaction, then you can get them to go through a communication exercise with one
or two peers each day. You can get them to play pool or cards with someone once
a day. The recovery skills are very helpful here, and most of these clients will
need to work through the recovery skills with you or with a treatment peer.
Relaxation skills and stress reduction skills will be important to some of these
clients. Depressed clients might need to learn assertiveness, communication, and
social skills. You can work through these issues with your clients and come up
with specific behaviors for the clients to learn.

In groups, depressed clients will need to be encouraged to talk in both individual

and group sessions. They need to talk about how they feel, and they need to detail
what they are going to do to feel better. You cannot let these clients ruminate about
how bad they feel. They need to be encouraged to do something different. Have
them go for a bike ride, take a walk, play basketball, play pool, swim, talk to
someone, call a friend, become involved in a hobby, listen to music, read pleasant
material, breathe the clean air, pray, meditate, eat something good, listen to the
sounds of nature, give a gift, help someone in the program, do a job until it is well
done, take a hot bath, or kick the leaves. You can have fun coming up with new
ideas for them to try.

As the clients try these new, fun behaviors, they will naturally begin to feel better.
When they do, you need to reinforce them and show them that it is what they are
doing that is influencing how they feel. You must chart the new behaviors and the
responses of the clients. Place some quotations in their charts regarding what the
clients say about their new behaviors.
Cognitive Therapy
Cognitive therapy concentrates on how a client thinks. This therapy was
developed by Albert Ellis during the early 1960s (Ellis, 1962). It was further
refined for depressed clients by Aaron Beck and colleagues (Beck et al., 1979).
These researchers found that many depressed feelings come from negative self-
talk. This tends to be inaccurate thinking, and it needs to be corrected. All clients
who are depressed should read Coping With Depression (Beck & Greenberg,
1974). This monograph will explain cognitive therapy and will get the clients
started.

Using the technique developed by Beck et al. (1979), the clients keep a daily
record of their dysfunctional thinking. This is accomplished by having the clients
write down each situation that makes them feel uncomfortable during the day. The
clients need to be specific about this situation, stating exactly what happened that
triggered the uncomfortable feelings. Then the clients make a list of each
uncomfortable feeling that they had following the situation. Did the clients feel
fear, sadness, disgust, or anger? Then the clients rate the intensity of each feeling
on a scale from 1 (as little of that feeling as possible) to 100 (as much of that
feeling as possible). These numbers are called subjective units of distress. Only
the negative feelings are of interest to you. The clients add up the scores—the total
of the subjective units of distress that they felt during the situation.

Now you help the clients to determine what they were thinking between the
situation and the negative feelings. Ask the clients what they were thinking, and
then be willing to make suggestions. The clients will not be able to come up with
all of these thoughts by themselves because the thinking is out of their awareness.
The thoughts that you are after are negative, and they lead directly to
uncomfortable feelings. Pull for as many of these negative thoughts as you can, and
write all of them down. This is uncovering the automatic thinking that occurred
between the situation and the uncomfortable feelings. It must be emphasized that
the clients do not try to think these thoughts. They are automatic and come without
conscious effort.

Once you have a list of the negative thoughts and feelings, have the clients go back
and develop accurate thoughts. Go over what happened again, and help the clients
to decide what they should have been thinking. What would have been an accurate
judgment of that situation? Once you have a list of the accurate thoughts, re-rate
each of the feelings based on an accurate evaluation of the situation. You will
come up with new subjective units of distress based on accurate thoughts rather
than inaccurate thoughts.

The clients will be amazed at how their inaccurate thinking directly causes their
uncomfortable feelings. The clients need to keep actively involved in cognitive
therapy the whole time that they are in treatment. Each time the clients go through
an uncomfortable situation, they need to keep a record of the thinking. In time, the
clients will be able to catch themselves in inaccurate thinking, stop this thinking,
and get their thinking accurate. Once the clients are accurate, they will feel much
better.

An Example of Cognitive Therapy

Let us go through an actual cognitive therapy session. In this session, the counselor
uses the first time that the client hears about interpersonal group as the situation
that caused uncomfortable feelings. The first time that any client hears about this
group creates quite a bit of anxiety. The client is Kim, a 17-year-old female who
is rather shy and avoidant. Her Beck depression score is 24, which puts her in the
severely depressed range.

The counselor introduces the cognitive therapy session.

Counselor: Kim, I want you to begin to get accurate in your thinking. When you
do this, you will feel more comfortable. What we are going to do now is go
through an actual situation and see if we can uncover some of your inaccurate
thoughts. The first time you heard about interpersonal group, how did you feel?

Kim: Scared.

Counselor: How scared did you feel on a scale of 1 (as little scared as
possible) to 100 (as scared as possible)?

Kim: I do not know.

Counselor: We’re just going to guess. How scared do you think you were
feeling on a scale of 1 to 100?
Kim: (Pauses.) About 85, I guess.

Counselor: Great, 85. How else were you feeling?

Kim: Oh, I do not know.

Counselor: Were you feeling angry?

Kim: No, I was not feeling angry.

Counselor: Were you feeling sad?

Kim: Yeah, I guess I was.

Counselor: How sad were you feeling on a scale of 1 (as little sad as possible)
to 100 (as sad as possible)?

Kim: About 60.

Counselor: Good. How else were you feeling?

Kim: (No response.)

Counselor: Were you feeling surprised?

Kim: No.

Counselor: Were you feeling any anticipation?

Kim: No . . . I was feeling discouraged.

Counselor: How discouraged?

Kim: About 75.

Counselor: Good. Now if we add up all those negative feelings, we get 230
subjective units of distress. When you hear about interpersonal group, you feel
230 units of uncomfortable feelings. Now, what were you thinking between
hearing about interpersonal group and the feelings you felt? What thoughts ran
through your mind?
Kim: I will not fit in.

Counselor: Great. What else were you thinking?

Kim: I would be treated like an outcast.

Counselor: What else?

Kim: They will think I am a psycho.

Counselor: Okay, what else?

Kim: They will get the idea that I am not serious about treatment.

Counselor: What else were you thinking?

Kim: That is about it.

Counselor: Were you thinking, “They’re not going to like me”?

Kim: Yeah, I was.

Counselor: Okay, let us put that down. Were you thinking, “I would have to
talk”?

Kim: Yes.

Counselor: Were you thinking, “They will make me talk about things I do not
want to talk about”?

Kim: Definitely.

Counselor: Any other thoughts?

Kim: They will not understand me.

Counselor: Good. Now I have written down all of your automatic thoughts. It is
important to recognize that these thoughts came to you automatically. You did not
try to think these thoughts. They came on their own. You will find that before you
have negative feelings, you will always have rapid thoughts before the feelings.
This is where you make assumptions or judgments about the situation. It is where
you internally evaluate the situation and how it directly applies to you. Do you
understand?

Kim: Yeah.

Counselor: Good. Now we need to get accurate. Go back to the situation and
think about it. You hear about interpersonal group. What is accurate thinking about
that situation?

Kim: They might be able to help me in group.

Counselor: That is right. That is what they are there for. What else is accurate?

Kim: I will not have to talk if I do not want to.

Counselor: Good. What else is accurate?

Kim: I would try to fit in. We all have problems in common.

Counselor: That is right. What else?

Kim: They will try to make me feel like a part of the group.

Counselor: Yes. What else?

Kim: They have some of the same problems as I do.

Counselor: That is very true. What else?

Kim: That is all I can think of.

Counselor: How about, “They will try to be supportive of me”?

Kim: Yeah, that is true.

Counselor: How about, “If I want to get help, I should try and share as much as I
can”?

Kim: That is right.

Counselor: Okay, now let us go back and rate each of the negative feelings we
rated before. You hear about interpersonal group, but this time you think
accurately. You think, “They will try to make me feel like a part of the group. They
might be able to help me. They will try to support me. They will try and
understand me. I will not have to talk, but if I want help here, I should try and
share as much of myself as I feel comfortable sharing.” How much fear do you
feel when you are thinking accurately?

Kim: About 20.

Counselor: How sad do you feel?

Kim: I do not feel any sadness.

Counselor: How discouraged?

Kim: About 5.

Counselor: Great. Now let’s see. When you are thinking automatically and
inaccurately, you score 230 units of distress. But when you stop and get accurate,
you feel only 25 units of uncomfortable feelings. How do you feel about that?

Kim: That is amazing.

Counselor: Yes, it is. Many of these inaccurate thoughts come out of childhood.
We judge situations automatically as if our inaccurate thoughts are accurate. No
wonder you were feeling bad about interpersonal group. You were thinking, “I
will not fit in. I would be treated like an outcast. They will think I am a psycho.”
What we are going to do over the next few weeks, Kim, is to keep account of each
situation that makes you feel uncomfortable. Then we are going to uncover the
inaccurate thinking that leads to your uncomfortable feelings. Then we are going to
challenge these thoughts and get accurate. You need to live in the real world. You
can no longer live in the painful world of your inaccurate thinking. You need to
commit yourself to reality.

In cognitive therapy, you can decrease your clients’ negative feelings substantially
if you get the clients accurate. You must make this therapy formal. The clients will
be unable to do this therapy on their own. They will not be able to uncover their
inaccurate thoughts or get accurate without your help. You will need to make
suggestions. As the clients understand that they have been getting their depressed
feelings from inaccurate thoughts, they will feel better, and their depression will
begin to lift.

As the clients bring in their dysfunctional thoughts, you will begin to see patterns
in their thinking. Some of the same thoughts will come up repeatedly. These
thoughts give the clients false information from which they make false
assumptions. They collect the inaccurate thoughts and reach conclusions based on
false information. These conclusions must be challenged with accurate
information. It is not uncommon for clients to reach conclusions such as “I am
stupid,” “I am ugly,” “I am unworthy,” “No one will ever love me,” “I am
inadequate,” and “Everyone is better than I am.” They live their lives as if these
false conclusions were true.

You will have some interesting therapy sessions with these clients. Many of their
false assumptions are held onto quite rigidly. You might have to get the support of
the group to help convince the clients that they are wrong. It is not uncommon for a
strikingly beautiful person to think that he or she is ugly. Many clients will fight to
hold on to their inaccurate opinions of themselves.

Trust in you and in the group is important here. The clients will need to trust
others to make accurate judgments. This is difficult. The old ideas die hard; they
seem to have lives of their own. With work, the clients will get more accurate.
You should see the clients in cognitive therapy at least once a week. The more the
clients keep up on their thinking, the more rapidly they will improve.
Interpersonal Therapy
Interpersonal therapy of depression has been outlined by Klerman, Weissman,
Rounsaville, and Chevron (1984). This therapy seeks to heal interpersonal
problems that leave the clients feeling depressed. For example, many clients will
come into treatment with abnormal grief reactions. They have had a loss of a love
object or self-esteem that they have not dealt with. Some clients are involved in
interpersonal disputes. These unresolved conflicts leave the clients feeling lost
and depressed. Some clients are in a role transition that they cannot deal with.
Some clients are impoverished. They have no socially reinforcing situation from
which they can gain pleasure.

Clients in interpersonal disputes will have to work toward resolving the

interpersonal problems. In addiction treatment, you often will see spouses who
are being rejected by their significant others. The drinking and drugging have
taken their toll, and the spouses have left their relationships. The clients may come
into treatment in a frantic attempt to save their relationships. These clients may
feel hopeless and solely responsible for the problems.

Treatment begins with helping the clients to identify the problems. The clients
need to plan what they are going to do. What are all of the possible actions that the
clients can take regarding the problems? The clients will need to improve
communication skills. They should work through the Relationship Skills exercise
(see Appendix 11) and the Communication Skills exercise (see Appendix 13).
They will need to practice these skills with their peers before they bring these
skills into play in their current conflicts. If possible, you need to meet with the
clients and the significant others to work toward resolution.

At times, the client will need only to renegotiate a dispute with a significant other.
This is the easiest type of conflict to resolve. First, you need a commitment from
each party to work on the problem. At times, there is an impasse, where one
member of the couple is not willing to cooperate. You cannot do much here except
to encourage the client to hope that in recovery this other person will change.
Often a spouse needs to see recovery to know that it is real. Many marriages
reconnect after a few months or years of sobriety. The client must understand that
the other person has been devastated by the disease. It is the disease that is the
problem. The best thing that the client can do now is to get into a stable program
of recovery and turn the situation over to a higher power: “God, grant me the
serenity to accept the things I cannot change, the courage to change the things I can,
and the wisdom to know the difference.”
Grief
Clients in an abnormal grief reaction need to work through the grief process.
Normal grief is much like depression, but it lifts without treatment within 2 to 4
months. The persons gradually deal with the loss and move on with their lives.
Sometimes the persons suffering a loss do not grieve until much later. This is a
delayed grief reaction. They postpone the grief because they cannot deal with it at
the time of its occurrence. Persons with a delayed grief reaction will feel numb at
the actual loss. It is only later that they begin to experience the pain.

Some clients will drink or use drugs that prevent them from feeling the pain. Grief
can be unresolved for years. When clients come into treatment with a significant
loss of a close family member or friend, you must consider how they handled the
grief process. Did they work the death through, or do they still need grief work? Is
the issue resolved, or are the clients still stuck in the grief process? Many persons
who have had abortions have unresolved grief.

Normal grief runs through a range of highly charged feeling states. The loss of a
loved one leads to at least 1 year of disturbance, and 3 years of disturbance is not
uncommon. Normal bereavement reactions include states of shame, guilt, personal
fear of dying, and sadness. In normal grief, anger at the person who died, at the
self, and at persons who are exempted from the tragedy is common. In
pathological grief, the client becomes frozen in one or more of these stages for
weeks, months, or years (Karasu, 1989).

People in the unresolved grief process need to talk about their grief. To accept the
reality of their loss, they need to experience their pain. They need to talk about it
in individual sessions and in group. They need to share the good and bad
memories. They need to discuss the events prior to, during, and after the loss.
They need to adjust to a new environment. This may include coming to terms with
living alone, managing finances, learning to do the chores, facing an empty house,
and changing social relationships. They need to begin to withdraw emotionally
from the lost person, reinvest in new relationships, and acquire new interests to
substitute for the loss. They need to be reassured that they have a program full of
people, which makes it impossible that they ever will be lonely again. They need
to see what they lost accurately, with all of the good and bad qualities. People
who see only the good things will not work through the grief.
These clients need to develop new relationships in the program. They need to be
encouraged to increase their social interaction with treatment peers. Do not let
them huddle up in your office bemoaning their fate. Get people further along in the
program to stick with them and keep them out with the client population.
Suicide
Most clients who are depressed consider suicide to relieve their pain. There is a
15% mean suicide rate in alcoholics (Talbott, Hales, & Yudofsky, 1988). Suicidal
ideation begins with clients thinking that everyone would be better off if they were
dead. Remember that the primary symptom of depression is the absence of
pleasure. When all of life’s pain remains and all of the pleasure leaves, it is
logical for the clients to consider death. The incidence of suicide is about 20
times higher in substance abusers (Blumenthal, 1990). Clients who are a suicide
threat will move through three phases of increasing lethality.

1. They will have increasing suicidal thoughts.

2. They will plan their suicide.
3. They will carry out their plan.

Your job is to recognize the process and reestablish hope. No clients commit
suicide if they can see that they can live lives that have meaning and worth. All
clients who are depressed need to hear that depression is an illness from which
people recover. Depression is treatable and curable. The depression is not their
fault. A sickness happened to them. It is not a punishment.

On the HAM-D, Question 2 assesses hopelessness, and Question 8 assesses

suicidal ideation. Both of these questions, when answered positively, should be
taken seriously. The higher the score, the greater the risk.

In the mental status examination, all clients are formally assessed for suicidal risk,
but you also can ask the suicidal questions anytime during treatment when you
believe that they may be important. The questions are as follows:

1. Have you ever wanted to go to sleep and not wake up? (If the answer is yes,
then ask the client about that. What was going on?)
2. Have you ever thought about hurting yourself? (If the answer is yes, then ask
the client what was happening.)
3. If you were to hurt yourself, how would you do it? (If the client has a suicidal
plan, then write it down.)
4. If the above answer is yes, have you carried any of that plan out? (Carefully
assess any actions the client has taken to arrange for or to commit suicide.)
These four questions accurately assess suicidal risk in escalating order of
severity. Clients who have suicidal ideation, have an active plan, and have carried
out any part of the plan should be transported to a psychiatric unit. These clients
are in danger of hurting themselves and need more structure. A psychiatric facility
has rooms and wards that are specifically designed to reduce the possibility of
suicide. Clients who are suicidal usually are afraid of themselves or are resigned
to their death. Each of these signs is an ominous indicator of serious intent.

Most clients who come in for addiction treatment have thought about suicide but
do not have an active plan. If they do have a plan, then they developed one outside
of the treatment center. Clients who have been actively considering suicide and
who have been considering a plan in treatment need to be transported. Do not
leave these clients alone, not even for a second. Wait until you turn them over to
the care of professionals.

Do not make decisions about suicidal clients by yourself. This is outside of your
level of expertise. All of these clients need to be examined as soon as possible by
a mental health professional. This covers you and your staff, and it will give you
confidence in the decisions reached.

Clients who are experiencing suicidal ideation with no plan can stay in treatment.
They will need extra support, and they will need to be watched more carefully
than will other clients. You do not want these clients isolating themselves. You
want them to be with people who are supporting and encouraging them. These
clients need to feel that they are in a safe environment, and they need to be certain
that the staff is going to respond to their needs. Once these clients begin to feel
hope, their suicidal ideation will subside.
The Angry Client

Source: ©[Link]/JodiJacobson.

Anger and resentments are poison for chemically dependent persons. “Resentment
is the ‘number one’ offender. It destroys more alcoholics than anything else” (AA,
2001, p. 64). It is not very far from that burning angry feeling to the chemicals.
Anger has a lot of energy behind it. This angry energy is going to have to go
somewhere, and it is important that it be directed positively into the recovery
program. Anger at the illness can be constructive.

Anger necessitates blame. Clients must believe that someone purposely did
something wrong that ended up hurting them, or else the anger cannot continue.
Each of these beliefs must be checked out for accuracy. The clients must stop and
think before they act.
How to Handle a Violent Client
Clients who are acting violent do not belong in a treatment center. Like the
actively suicidal client, these clients belong in a more secure psychiatric facility.
Psychiatric hospitals have the equipment and the staff to deal with violent clients.
Most addiction centers do not have this expertise. If your client makes overt
attempts, acts, or threats of substantial bodily harm to himself or herself or other
persons, then the client should be transferred to a more structured facility. Keep as
many staff members with this client as necessary to transport him or her safely. Do
not hesitate to call the police. Apprise the officers carefully of your situation, and
tell them to bring enough backup to manage the situation. Get an immediate
consultation from your psychiatrist or psychologist, and follow his or her orders
carefully. The doctor can order a sedative if this is necessary.
How to Handle an Angry Client
Clients who are feeling angry, or are verbally acting angry, usually can be
managed in your facility. It is rare for a client to go through treatment without
expressing anger. Most of your clients have unresolved anger issues. Chemically
dependent persons tend to harbor deep anger and resentments. They boil and fume
for years over some real or imagined slights. This all comes from the desire to be
in control. “Each person is like an actor who wants to run the whole show; [the
actor] is forever trying to arrange the lights, the ballet, the scenery, and the rest of
the players in his [or her] own way” (AA, 2001, pp. 60–61). When people do not
do what chemically dependent people want them to do, the latter become furious.

The treatment for angry clients revolves around having them complete the Anger
Management exercise (see Appendix 32), where the clients learn about their anger
problem and learn specific skills to deal with angry feelings. Most people feel sad
and fearful along with the anger. All of the feelings need to be expressed. The
clients need to verbalize how they see the whole situation while you support them.
Do not argue with angry clients. Stay out of their reach, and use a calm voice. Do
not stand in the way of an exit. Let them rant and rave if they want to do so. The
clients need to feel that they are important. If you listen to them, even when they
are angry, it validates them as people.

Angry clients are feeling afraid and will need a lot of reassurance. The clients
often feel that their anger is so repulsive that they will be rejected for expressing
it. You need to show them that their anger is friendly so long as it is used
appropriately. Anger exists to help us establish and maintain boundaries around
ourselves. It keeps us from being violated. Anger is adaptive. People who cannot
get angry will have their boundaries violated.

Help your clients see that all anger comes from hurt. Anger is there to make the
pain stop. First, something violates the clients physically or emotionally, and then
they get angry. If the clients learn to hold people accountable by expressing all of
their feelings, then they might not even get angry.
Assertiveness Skills
Clients do not have to act aggressively to show that they are angry. They need to
be taught assertiveness skills. They need to see that assertiveness skills work and
bring people closer together. Aggressive skills, on the other hand, drive people
away. The book Your Perfect Right: A Guide to Assertive Living (Alberti &
Emmons, 1995) is an excellent resource for you and your clients. If your clients
need assertiveness training, then they can read assigned parts of this book as
homework. Assertiveness skills need to be practiced repeatedly in individual
sessions, in role-playing, and in group.
The Importance of Forgiveness
Clients with an anger problem must learn how to forgive. They can use a higher
power for this if they cannot forgive themselves. They want to be forgiven, and
God will forgive them as they learn to forgive others.

Forgiveness is difficult. Clients never will forget what happened, but they can
understand the persons who hurt them by understanding their own disease.

We realized that the people who wronged us were perhaps spiritually sick.
Though we did not like their symptoms and the way they disturbed us, they,
like ourselves, were sick too. We asked God to help us show them the same
tolerance, pity, and patience that we would cheerfully grant a sick friend.
(AA, 2001, p. 67)

All clients who are angry and resentful need to read the following passage
from the “Big Book”:

And acceptance is the answer to all my problems today. When I am

disturbed, it is because I find some person, place, thing, or situation—some
fact of my life—unacceptable to me, and I can find no serenity until I accept
that person, place, thing, or situation as being exactly the way it is supposed
to be at this moment. Nothing, absolutely nothing happens in God’s world by
mistake. Until I could accept my alcoholism, I could not stay sober; unless I
accept life completely on life’s terms, I cannot be happy. I need to
concentrate not so much on what needs to be changed in the world as on what
needs to be changed in me and in my attitudes. (AA, 2001, p. 417)

Have clients who are angry keep an anger diary. Take them through some
cognitive therapy. Every time they feel angry, they should write down the situation
and uncover their automatic thoughts. As these inaccurate thoughts are uncovered,
the clients will see why they have been so angry. They take the slightest look or
word as an attack. They need to work through the impulse control exercise and
begin to practice the assertive formula repeatedly.

I feel ____________________________________________.
When you ________________________________________.
I would prefer it if _________________________________.
How to Teach the Client to Recognize Anger
These clients need to learn the specific changes in their bodies when they are
getting angry. They need to learn how this feels. Do they feel tightness in their
chests? Do their faces feel flushed? As early in the anger process as possible, the
clients need to back out of the situation and use their new assertiveness skills. The
initial response needs to be delayed until they can stop, think, and plan. This
requires a lot of practice. Have the clients write down every time they use
assertiveness skills and every time they lapse back into aggressive behavior. You
will be able to show them the damage that they are doing to relationships with
their old behavior. You also will show them how assertiveness skills bring people
closer together.
Disengagement
It often will help angry clients to disengage from the current situation and detach
as if the situation is happening to someone else. It is here that the clients can step
back from themselves and see themselves as if they were their own counselors.

“I am feeling some anger.”

“This is interesting.”
“I need to check this out.”
“What is going on with me right now?”

By stepping out of themselves and checking out the anger, clients will be more
likely to get accurate and make better judgments. They can even laugh at
themselves. They can recognize their anger, smile at themselves, and realize that
getting angry is a silly thing to do to themselves. The clients can then take two
deep breaths, breathing in slowly through the nose and out slowly through the
mouth. As they exhale, they feel a warm wave of relaxation move down their
bodies. The clients should practice this technique in your individual and group
therapy sessions.
Time-Out
Clients who have a tendency to become verbally or physically violent must move
away from an escalating situation as soon as possible. They must move away from
the situation as far as necessary to recover their normal feelings. One useful
technique to use if the anger happens in a family is to develop a time-out contract.
This is a written contract between two or more people in which they agree that
either party can say “time-out” at any time. Once one person has said “time-out,”
the other party can only say, “Okay, time-out.” At this point, the couple separates
and agrees to return in an hour to further process through the problem. When they
are separated, it is important that they do not rehash the argument over again in
their minds. Otherwise, they might come back even more furious than when they
left. When separated, it is important that they both tell themselves certain things to
get their thinking more accurate (McKay, Rogers, & McKay, 1989).

1. No one is completely right or wrong.

2. It is okay to disagree.
3. The other person is not trying to hurt me. The other person is trying to meet
his or her needs.
4. Do I need to call someone and talk about this? If I do, then I need to do that
right now.
5. I will turn this situation over to my higher power.

The clients need to keep with them a list of these statements along with several
numbers of people to call at all times.
How to Keep Your Cool as a Counselor
It is not easy dealing with people who are angry. They may verbally abuse you,
and you need to keep calm. The worst thing that you can do is to lose your temper.
Anger from the counselor can do a lot of damage. Concentrate on feeling yourself
relax. Feel your arms and legs become heavy and warm. Focus on your breathing,
and breathe slowly. If you are getting angry, then excuse yourself and take a few
minutes outside of the room. Let someone else take over for a while. The best
thing that you can do for angry clients is to remain calm and take good care of
yourself.
The Homicidal Client
Clients who are experiencing homicidal ideation need to ventilate their feelings
and then process through their options. They are not thinking clearly. They need
help in processing through their options to a logical conclusion. It is not unusual
for some clients to feel like killing someone, even someone they love. You will
find homicidal thoughts to be a common element in dealing with angry clients.
Most clients are just blowing off steam, thinking about homicide, wanting the
ultimate revenge.
The Duty to Warn
If staff members determine that a client presents a serious danger of violence to
another person, then they have the obligation to protect the intended victim
(Tarasoff v. Regents of the University of California, 1976). This is an unusual
event, but it does happen, and it should be carefully discussed with the clinical
staff. There is a delicate balance between duty to warn and confidentiality.
Whenever you have a client seriously threatening another person, it is necessary to
staff the problem and document the staff decision in the client record. This client
might have to be transferred to a more secure facility, or the threatened person
might have to be warned.

Persons who have homicidal ideation usually can be reasoned with if they can be
guided to see the truth. What is going to really happen if they kill someone? They
need to process through the whole idea from beginning to end. Is killing someone
taking good care of themselves, or will it put themselves in harm’s way? What
good is going to come of homicide? Is murder going to do the world any good? Is
it going to do the clients any good? What does God want from them? These
persons will need to be encouraged to turn the situation over to the perfect judge
—God.

Homicidal intent is assessed in escalating order of severity:

1. Have you ever thought about hurting anyone or anything like that? (If yes, ask
the client who. Ask what happened.)
2. If you were to hurt that person, how would you do it? (If the client has a plan,
then write it down.)
3. Have you carried out any of that plan? (Get the details of the client’s
behavior.)

Clients with homicidal ideation who have a plan and have carried out any part of
that plan are considered seriously homicidal. They must be watched. They must
not be discharged or allowed to leave without being processed by the clinical
staff. If the clients are imminently harmful to others by overt attempts, acts, or
threats within the past few hours, then they might have to be detained against their
will and transported to another facility. A psychiatrist, psychologist, physician,
and/or police officer are necessary for these decisions. Your job is to keep the
appropriate personnel informed of the clients’ conditions. Let them take over the
responsibility for these clients when they can.
Personality
Personality is composed of two basic parts: (1) temperament and (2) character.
Temperament is the general psychological tone of the client. Some people are
more sensitive to incoming stimulation. Some people seem dull and unresponsive.
Character is what we learn about what to do and how to behave. It is shaped by
the family and the social environment. Temperament and character are the primary
elements in all personality disorders (Millon, 1981).
What Is Personality?
Personality is the enduring way in which a person thinks, feels, and acts.
Personality is stable, well learned, and resistive to change. Personality makes up
the total person. It is the pattern of behavior that a person evolves as the style of
his or her life or how the person adapts to the environment.

A state is a person’s current condition. This is transient, flexible, and easily

manipulated by environmental stimulation. A person may feel sad, or even
depressed, by the loss of his or her car keys. Once the keys are found, the person
immediately returns to his or her normal state of thinking, feeling, and acting.

A trait is a long-standing tendency to react in a particular way to a set of

circumstances. A trait is fixed and resistant to change. This is how a person has
acted for years. A person might feel frightened of social interaction. This person
fears doing something to embarrass or humiliate himself or herself in a group.
This tendency may be persistent.

Personality disorders are patterns of inflexible and maladaptive traits that cause
significant impairment. These patterns are not time limited. They are chronic.
Personality disorders become evident by late adolescence and often last a
lifetime. The symptoms of personality disorder can be relieved. The client can
learn how to function better and more comfortably.
The Antisocial Personality
You will see many antisocial personality disorders in your career. There is a
higher incidence of this disorder in substance abusers (Khantzian & Treece, 1985;
Weiss, Mirin, Griffin, & Michaels, 1988). This personality disorder has at its
biological base the tendency to act aggressively and impulsively. These clients
have a diminished capacity to delay or inhibit action, particularly aggressive
action (Siever & Davis, 1991; Siever, Llar, & Coccaro, 1985). These clients act
too quickly on their feelings. They have a tendency to act before they think. They
do not feel the same arousal levels that normal people feel, so they can push the
limits further (Eysenck & Eysenck, 1976). These biological tendencies leave these
individuals vulnerable to a variety of problems. When most people break the
rules, they are afraid of being caught. Antisocial persons do not feel this fear as
much. They have difficulty in anticipating the effects of their behavior and learning
from the consequences of their past.
Source: BananaStock/Thinkstock.
A Disorder of Empathy
Antisocial clients do not feel normal empathy. They can break the rules of society
to get their own way. They can openly defy authority and break the law without
suffering much guilt or remorse. They do not feel at fault, and they have a tendency
to blame others for their faults. They lack insight and fail to learn from experience.
This is easy to understand. If they do not feel responsible for their actions, why
should they change?

Antisocial clients begin to get into trouble with society by their early teens. They
are in trouble at home, at school, and often with the police. As they grow older,
they are unable to sustain work, and they fail to conform to the social norms with
respect to lawful behavior. This is one of the most difficult disorders to treat.
These clients can spend more time trying to outwit the staff than trying to work the
program.
How to Treat the Antisocial Personality
Treatment for these clients revolves around teaching them the consequences of
their behavior and learning how to think in a new way. They need to stop blaming
others and accept responsibility for their own actions. They must see how their
choices lead directly to painful consequences. At every opportunity, you need to
show them how their decisions and actions got them into trouble. (An excellent
resource for corrective thinking is the Truthought Corrective Thinking Process
listed in Appendix 54 [Barriers in Thinking]. The manual can be obtained from
Truthought, PO Box 222, Roscoe, IL 61073; 815-389-0127.) They will love to
argue the point so that they can place the blame on someone else, but you are not
going to allow them to do this. You are going to constantly direct them to see the
truth.

You may hear these kinds of statements from a client with an antisocial
personality:

“I did not know that was a rule.”

“She did not explain it properly to me.”
“He did it. I did not do it.”
“I was just standing there. What are you looking at me for?”

These clients are used to lying their way out of everything. They need to keep a
daily log of their honesty and work hard at learning from their behavior. Each time
they do something wrong, take them aside, and take them through the behavior
chain. Cover the trigger, thoughts, feelings, actions, and consequences carefully.
They need to see their patterns repeatedly.

Working with the antisocial personality can be a frustrating experience, but these
clients can do well in recovery. They will need a lot of structure in early sobriety.
A halfway house or some other facility can be helpful during those first few
months out of treatment.

These clients have little self-discipline and have poor impulse control (see
Appendixes 14 and 15). They will need to work through each of these problems in
treatment. They need to stop, think, and plan before they act. This will be learned
only with practice. The clients need to learn to stick to a task until it is completed.
The recovery skills in treatment give them an opportunity to learn this new skill.
They are notorious for procrastinating at their work or for doing barely enough to
get by. The group will have to reject these poorly done recovery skills and put up
with these clients’ anger to show the clients what is required. Sobriety
necessitates a long-standing commitment.
How to Deal With a Rule Violation
You need to be familiar with the rules of your facility. These clients will push the
limits and will argue that they are right. If they can find a way around a rule, then
they will break the rule. Rather than being very negative, this provides the staff
with an opportunity to intervene and teach these clients. The clients need to see
what is causing their pain. The rules do not exist to keep them from having a good
time. The rules exist to keep them safe. They need to practice turning things over
rather than trying to manipulate everything.

If an antisocial client is caught breaking a rule, have him or her write a report on
the incident and present it to the group. This is not intended to shame the client. It
is intended to help the client see the consequences of this behavior. The group
encourages the client and supports him or her in trying to bring the antisocial
behavior under control. The group and the counselor should constantly reinforce
prosocial behavior.

Learning empathy and appropriate guilt is a difficult skill. An antisocial client

will do most of this work in group. When someone in the group is having a strong
feeling, the antisocial client can be asked to relate to the feeling. Have the clients
ever felt in a similar way? The client tries to match his or her experience with the
feeling of the other person. If the feelings can be matched, then empathy will begin
to develop.

When an antisocial client takes advantage of someone in treatment (this is

inevitable), he or she needs to see the other person’s pain. Take the client through
the behavior chain that revolved around the incident.
Moral Development
Moral development occurs in stages.

1. It is right so long as I can get away with it (no rules).

2. It is right if it is within the law (rules outside of self).
3. It is right because I believe it is right (rules internalized).

Antisocial clients are stuck in the first stage of moral development. A spiritual
program can do wonders for these clients. If they can see that a higher power is
there and watching, then they can begin to develop some external control.

Cognitive therapy is helpful with these clients, but they must learn to be honest.
Sometimes they will deny or hide what they are thinking to prevent reprisals. It is
very important for these clients to know that you understand them and do not
blame them for their antisocial thinking. The clients need to feel like they can
share their antisocial thoughts and acts with you. Clients must never be shamed for
their thinking. They are held accountable only for their actions.

It is very easy to get into a “bad guy” role with antisocial clients. They might feel
like you are pushing them around or being unnecessarily controlling. They want
you to be the problem. That is why the rules, and the consequences of breaking the
rules, need to be very clear from the outset. Then when the client breaks a rule, all
you have to say is, “It is not me doing this to you. It is you doing this to yourself.
You knew the rule, and you broke it. There is a consequence for that. I hope that
next time you will think before you act.”
How to Deal With the Family of an Antisocial Client
The family of an antisocial client usually is in chronic distress. The family
members need to be educated in how the client manipulates them. Communication
patterns need to be improved. The family must hold the client accountable for his
or her actions. This means allowing the client to suffer the consequences. This
means no more enabling.

Antisocial clients are not used to being loved, and they often are suspicious of
anyone who tries to get close to them. They wonder what you really are after.
They look for the hidden motive. Once they see you consistently act on their behalf
—even when they are being difficult—they will begin to come around. The worst
thing that you can do with these clients is get angry with them. This is playing their
game, and they know it better than you do. They are used to dealing with people’s
anger. They know just how to manipulate this situation. They will just blame you.

If you establish a good therapeutic alliance, there will come a time when
antisocial clients will want to please you. This gives you great power as a
reinforcer. By carefully selecting when to give positive reinforcement, you can
effectively shape the clients’ behavior. A day without a violation of the rules
should be soundly reinforced, perhaps by congratulating the clients in front of the
staff or the client population. A day without a lie is cause for celebration. The
more positive attention you can give these clients for prosocial behavior, the
further along they will be in their treatment program.
The Borderline Client
The biological component of borderline personality disorder is a tendency to act
impulsively plus emotional instability. The affective instability is characterized by
rapidly changing moods that are overly reactive to environmental emotional
stimulation (Linehan, 1993; Siever & Davis, 1991; Siever et al., 1985). These
clients overreact when they encounter emotional events such as relationship
problems, separation, criticism, and frustration. They need long-term
psychotherapy and many times psychopharmacology to stabilize their psychiatric
symptoms. Dialectical therapy is very helpful for borderlines (Linehan, 1993).
They feel too much too long, and this raises havoc with self and interpersonal
relationships. Borderlines do not have a sense of self, and they tend to feel
alienated and abandoned easily. When having extreme feelings, it is very difficult
to think normally. The emotional shift can be quick and extreme, rarely lasting
more than a few hours. It is common for borderline clients to attempt to control
these affective shifts with self-damaging behavior such as suicide attempts, self-
mutilation, eating disorders, sexual acting out, and overusing mood-altering
chemicals (Widiger & Frances, 1989). These clients grow up immature and
unstable. They experience their feelings as being outside of their own control,
controlled by environmental events. The environment becomes a major regulator
of self-esteem and well-being. The boundaries between the clients and their
environment become blurred (Siever et al., 1985). These clients do not feel safe
and do not trust others because, whenever they have trusted in the past, bad things
inevitably occurred. Many of these clients have a history of childhood physical or
sexual abuse. Dialectical behavior therapy has been designed to help borderline
clients develop the skills necessary to cope with borderline feelings and
situations. Clients are taught how to tolerate stress, regulate emotions, develop
stable interpersonal relationships, and use a state of mindfulness to stay in the
moment and nonjudgmental.
Interpersonal Relationships
When borderline clients sense supportive relationships with other persons,
counselors, staff members, or loved ones, they feel uncomfortable. At first, they
adopt an engaging, clinging, overly dependent style of relating. You are the
greatest counselor in the world, and you can do no wrong. You are the only person
who can help them. When the relationship is threatened through normal treatment,
whether real or imagined, the clients shift to angry manipulation. Then you become
the worst person in the world, and you cannot help anyone. The clients may
become self-destructive to regain control. The clinging dependency is rapidly
replaced by devaluation of the goodness and worth of the other person (Gunderson
& Zanarine, 1987).

Borderline clients tend to throw temper tantrums and will often use one staff
member against another. They seem to flourish in an atmosphere of conflict,
splitting people into having all good or all bad characteristics. This split often
occurs with the same person hour by hour. At times, the other person is the best,
and at times, the other person is the worst. This can be very difficult for you to
deal with, but remember that these clients need to feel safe. Staff members need to
work together to prevent the clients from manipulating. Constantly ask the clients,
“What do you need to feel safe right now?” Then try to support the clients. After
they calm down, try to help them to see the emotionally charged situation more
accurately.
Emotional Regulation
Borderline clients have extreme feeling shifts and act impulsively on their
feelings. They repeatedly become involved in self-destructive behavior. They
often cut themselves to feel some relief. This can also work by holding an ice
cube, which causes pain but not self-damage. Borderlines have chronic
abandonment fears. They have a difficult time distinguishing who they are at any
point in time. They often have attempted to hurt themselves, and they tend to
become involved in dangerous activities such as shoplifting, sex, substance abuse,
and reckless driving. They lack a life plan. They chronically feel empty and
bored.
How to Treat the Borderline Client
Borderline clients bring all of this psychopathology into the treatment program.
They can act out of control, and they can be very disruptive. You must provide a
stable framework from which they can grow. They are emotionally immature and
unstable. They will try your patience and push the limits of their relationship with
you. Use the Skills Training Manual for Treating Borderline Personality
Disorder (Linehan, 1993). You will find this very helpful in teaching borderlines
skills to use when they feel uncomfortable.

You must remain alert and active in their treatment. They need a lot of direction
and input. They need to be confronted about their maladaptive behavior. Use the
group if the clients are not under control. Meet with the clients and the whole staff
if necessary. The clients need to identify the feelings and motivations behind their
acting out. Often this comes as a shock to them. Self-destructive behavior will
become unwanted if you draw the client’s attention to the consequences. They
need to get real about what they are doing and what happens when they do it. They
are often in a mess, and they rarely believe that the problem is their fault. They
need to see how their behavior affects what happens.
Setting Limits
Treatment centers on setting limits, learning impulse control, and developing skills
for dealing with feelings. The staff will have to keep up on these clients to make
sure that they do not pit one staff member against another. Often a borderline client
will believe that one staff member is the enemy and someone else is a trusted
friend. Without staffing this client, two staff members might end up in
confrontation with each other. In such a situation, the staff needs to bring the client
in during staffing. Here everyone can get the same story at the same time.
Dealing With Transference
Transference and countertransference can be a real problem with these clients.
They seem to have a way of creating strong feelings and relationships among staff
members. You might end up feeling angry, guilty, or frustrated. You might feel
helplessness or rage. At first, the clients might see you as their savior, and then
they might see you as their persecutor. It feels like an emotional roller-coaster
ride. It is common for some to see these clients as “poor little things” who just
need nurturing and for other staff members to see these clients as angry
manipulators who need limits. Consultation with other staff members is essential.
This will keep you in balance. This is the clients’ problem, not yours. Borderline
clients can form overly intense relationships with their counselors. You need to
maintain your boundaries. Do not become overly involved. Do not do anything for
borderline clients that you would not normally do for someone else.
Stress Tolerance
When borderline clients are feeling uncomfortable, they need to do something.
They need a specific plan of action when they have strong feelings. They can
exercise, talk to someone, turn it over to a higher power, become involved in
something else, go to a meeting, read recovery material, and so on. They should
not always talk to you when they are upset; this fosters dependency. It is notorious
for borderline clients to say that they have to talk to you right now. You need to
teach them that they cannot always come to you. You cannot always be there for
them. They need to develop other coping skills.

Cognitive therapy is important. Clients need to be able to see a person’s good and
bad qualities at the same time. When the clients are extremely angry with
someone, help them to see the person’s positive characteristics. Borderline clients
would rather be joined in attacking someone, but you should encourage them to
look for the good. The clients need to see themselves and others more
realistically. Cognitive therapy will help them to uncover their unconscious
thoughts and motivations. They need to see why they feel and act the way they do.
What are they after? How can they get what they want more appropriately?
Dealing With the Family
Two family issues may be important with the borderline client. The family may be
overinvolved and need to let go, or the family may have a history of abuse or
neglect. Both of these issues need further counseling than you can provide in an
inpatient program. They will need long-term psychotherapy. You can just help the
family to get started. The family members must be referred to make sure that they
address the problems in continuing care. The borderline client often has clinging
dependency needs or extreme anger at his or her family members.

Everyone in a borderline client’s family needs to be educated about the client’s

diagnosis and become actively involved in treatment. They will be relieved to
know that there is an illness called borderline personality disorder, and they need
to understand the signs and symptoms. Most family members will be amazed that
other people have this disease and that treatment is very effective.

Behaviorally, clients need to work through the Impulse Control exercise (see
Appendix 15), the Relationship Skills exercise (see Appendix 11), and the
Communication Skills exercise (see Appendix 13). They need to practice these
skills with their treatment peers. They need to rehearse and role-play problem
situations in interpersonal group.

Borderline clients are a challenge for you and the staff. They take a lot of energy.
It is important to remember that these clients have an illness. They did not ask for
their disease, nor did they create it themselves. They are frantic for love and
affection with no idea about how to get it. They should work through the Love,
Trust, and Commitment exercise (see Appendix 9) to help them understand exactly
what love is. They need to practice establishing relationships without unrealistic
expectations.

These clients will need to be referred to outpatient psychotherapy in continuing

care. They might need the structure of a halfway house or some other long-term
facility. Long-term involvement with a 12-step group is very beneficial to these
clients. They can learn to function well over the years.
The Narcissistic Client
Narcissistic clients can be difficult to deal with emotionally. They have a
grandiose sense of their own self-importance and capabilities. They feel as if they
are so special that everyone should treat them as if they were unique and
amazingly talented. They think that they have special skills, beauty, power, or
abilities. If you do not treat them in a special way, they get mad and reject you,
destroying the therapeutic alliance. It is very difficult for them to hear the truth
about themselves because they cannot tolerate criticism. They are excessively
sensitive to having any flaws. When they are confronted with a problem that they
have, they tend to dissolve into shame and worthlessness. When they become
extremely angry and resentful, it is called narcissistic rage. Narcissistic clients do
not think they need to learn anything from you. They know everything already.
They tell everyone else what to do.

These clients spend a lot of time with big plans and schemes for unlimited success
or power. They want to rule over others rather than be one of the common people.
They believe that they deserve to be treated specially due to their outstanding
achievements, brilliance, beauty, or ability. They believe that only the special
people of the world, those of a similar high caliber, can understand them. They
think that they should interact only with the beautiful people.

It is very easy to counter transfer with these clients and get angry, but if you do,
then you will destroy your therapeutic alliance, and they will think of you as
inadequate. The best way of treating these clients is as if they really were the
ruler. If you treat them as if they are the ruler, and you are the servant, then you
will go a long way toward getting them to listen. They often need to see that you
are special too, with special powers and abilities. After all, only the greatest
professional could help them. Once they see that you are wonderful, you can then
show them that you have faults and that you have made some mistakes. If you and
these clients can agree that both of you are wonderful but that both of you have
made some mistakes, the clients are beginning to get accurate in their thinking.

Give these clients the Narcissism exercise (see Appendix 33), which allows them
to learn about their narcissistic traits. The most important thing for narcissistic
clients to do is get honest with themselves and others. After they do that, they need
to turn their wills and their lives over to a higher power. This is very difficult for
them to do because they have been playing God for a long time.

Narcissistic clients grew up as the kings or queens of their households, and they
need long-term psychotherapy to improve. At home, they were in total control of
the household. Their every whim was met. One of their primary caregivers often
doted on their every word and told them that they were wonderful. The adults in
their homes used these children to build their own inadequate self-esteem. If their
children were wonderful, then they were wonderful.

Narcissistic clients are interpersonally exploitative because they are interested

only in their own needs. They are not capable of understanding that other people
have feelings, wants, and needs. Their relationships start in a blaze of glory but
end in despair. A high relapse trigger for them is sex, and they often fall in love in
treatment. They can become convinced that any new relationship, no matter how
bad it might seem to others, is going to be ideal and wonderful. It is as if they are
blind to the truth, making the same mistakes repeatedly. They need love and
attention so much that when they get it, they tend to idealize the other persons, and
this sets these relationships up to fail.

Narcissistic clients need to spend time developing empathy for others. In group,
when someone is having a feeling, have the narcissistic client try to connect with
the other client’s feeling.

Most of the time, you inevitably will end up disappointing narcissistic clients. You
will not be empathic in the right way, in the right amount, or at the right time, and
they ultimately will decide that you are not enough for them. Every relationship
ends up this way. That is why the higher power concept works. God is the one that
can be enough. God always is available. God has all the power. God is smart
enough. When you feel these clients’ disappointment, carefully explain the ABCs
of AA: (1) that we were alcoholic and could not manage our own lives, (2) that
probably no human power could have relieved our alcoholism, and (3) that God
could and would if God were sought. When narcissistic clients see that no one can
meet their needs except God, things can change. It is to be hoped that the clients
will begin a genuine search for their higher power. God is the only one that seems
good enough for them anyway.
The Anxious Client
Anxiety is a vague generalized fear. Some children are born with a nervous system
that is more sensitive (Kagan, 1989; Kagan, Reznick, & Gibbons, 1989; Kagan,
Reznick, & Snidman, 1987). This increased physiological responsivity can
heighten the sensation of unpleasant experience. These children have a low
threshold for subjective fear and a high arousal in anticipation of adverse
consequences (Siever & Davis, 1991). Children with such a heightened response
to the environment can become shy and inhibited. It takes less of an adverse
experience to upset them (Rosenbaum, Biederman, Hirshfeld, Bolduc, & Chaloff,
1991).

Source: © Can Stock Photo Inc./gina sanders.

Anxious clients are afraid, but they are not sure why. These individuals are
hypervigilant and tense. They look for the impending disaster. They believe that
the ax is falling. They feel a sense of dread and impending doom. Most of these
clients are avoidant. They avoid social situations. They feel uncomfortable in
groups and fear doing something that will humiliate them.

There are a high percentage of anxiety disorders in clients who end up abusing
depressants (Dorus et al., 1987; Hesselbrock et al., 1985). Clients attempt to
reduce their anxious feelings with drugs that suppress central activity.
How to Measure Anxiety
Anxiety can be tested with a variety of psychological tests including the Hamilton
Anxiety Rating Scale (HAM-A) (see Appendix 64). The test scores will help you
to determine the effectiveness of your treatment. The Self-Rating Anxiety Scale
(Zung, 1971) and the State-Trait Anxiety Inventory (Spelberger, 1983) can be used
to measure anxiety. The tests are simple and can be given as often as necessary.

Multiple somatic complaints accompany anxiety. Clients may feel sweaty palms, a
pounding heart, trembling, light-headed, dizzy, or numb. They may feel as though
their lives are threatened. They may think that they are having a heart attack. The
anxiety may go on for a few minutes, or it may last most of the day.

There are nonaddictive medications that can suppress or block certain forms of
anxiety. Panic disorder is improved or eliminated with certain antidepressant
medications such as SSRIs.

Mood stabilizers or other psychiatric medications can also be helpful. Feel

relieved when doctors order medication for your clients. Physicians can be trusted
to treat these clients with medication appropriately.

Outside of the chemical dependency field, anxiety often is treated with

benzodiazepines. These central nervous system (CNS) depressants are
contraindicated in chemically dependent persons because they can be highly
addictive. Clients who come into chemical dependency treatment taking these
drugs will have to be withdrawn.
The Psychological Component of Anxiety
The psychological part of anxiety disorders centers around an inaccurate
perception of threat. This threat can be real or imagined, but it is exaggerated to
the point where it interferes with normal functioning. To these clients, all of the
fears are real. The intensity of the fear is preparing them to escape a dangerous
situation. Clients can be immobilized by fear. They can freeze and be unable to
move. This is no joke, and you will get nowhere pretending that these clients have
no worries. You must try to relate to, and understand, the intense fear that these
clients are feeling. Clients can be intensely afraid of spiders even if there are no
spiders. They can be terrified of a group even if there is no logical reason to be
afraid. These clients need gentle support and encouragement. They need to feel as
though someone understands them.

There are many forms of anxiety disorders, and the feared objects are incredibly
variable, but you can approach all anxiety in the same general way. You need to
know the following things about an anxious client:

1. What is the client afraid of?

2. Where did the fear seem to come from?
3. Is the fear accurate or inaccurate?
4. What can the client do to reduce the fear?

Anxiety disorders are not character disorders. In character disorders, the clients
blame everyone else for everything. In anxiety disorders, the clients blame
themselves for everything.
How to Use Relaxation Techniques
Anxious clients need to learn how to relax. They cannot be anxious and relaxed at
the same time. The two physiological states are incompatible. The clients will
have to be taught how to relax using relaxation techniques. There are many
relaxation tapes on the market. You can use relaxing music, sounds of nature, or
imagery. Get a few, and have the clients listen to a relaxation exercise twice a day.
You can take clients through a relaxation exercise yourself by doing the following
exercise.

Make sure that you will not be interrupted. Have the clients sit or lie down in a
quiet, comfortable place. Read these words in a slow, quiet voice:

“Close your eyes, and pay attention to your breathing. Feel the cool air coming in
and the warm air going out. As you focus your attention on your breathing, feel
yourself beginning to relax. There is no right way or wrong way to do this
exercise. There is just your way. Feel yourself becoming calm. Your arms and legs
are feeling heavy and warm. Inside of your mind, as completely as you can, in
your own way, see ocean waves. Do not worry about how you are seeing these
waves. Just see them as completely as you can. Match the waves with your
breathing. As the wave builds, you inhale, and as the wave washes on shore, you
exhale. See yourself standing on an island, on a white, sandy beach, looking at the
waves. You are feeling at peace. With each breath and each wave, you feel more
relaxed. It is warm, and you can feel the sunshine on your cheeks and on your
arms. You are on an island. This is your island inside of your own mind. You are
safe here. There is no one else on the island except you. There are palm trees and
lush green vegetation on the island. There is a trail on the island, and you turn and
see yourself take that trail. You are not in a hurry. You have plenty of time. You are
walking slowly. There are flowers along the trail of every imaginable color and
hue. You begin to walk up a hill, and as you walk up the hill, you become tired.
Your arms and legs feel heavy. You come to a ridge that overlooks a lush, green
valley filled with waterfalls. You wander for as long as you like in this valley,
feeling at peace.”

You can add any other relaxing scene to modify this exercise. When the clients
have been relaxing for 10 to 20 minutes, you need to bring them out of the state of
relaxation. Say something like this:
“You walk out of the valley and down the trail. You walk back on the beach and
watch the waves. They build and wash on the shore. You feel yourself becoming
more awake and aware of yourself. You wiggle your toes and fingers. You feel
yourself in this room and in your chair. Your eyelids begin to flicker. When you
feel comfortable, open your eyes, and become fully awake.”

While the clients are relaxed, you can give them some positive affirmations. The
clients are good persons. They have talents. They have a higher power. They have
people who support them. How the clients feel is important. They are going to
take care of themselves. The clients are going to commit themselves to being
honest. They should help you to develop these positive self-statements. Use this
exercise to build a more positive self-image.
The Daily Log
These clients will need to score the level of relaxation after each exercise from 1
(as little as possible) to 100 (as much as possible). They also need to keep a log
of their daily anxiety using the same scale. The clients score their general anxiety
level at the end of each day. The clients should log any situation that caused or
made their anxiety worse. This plus the psychological testing will give you a good
idea of where the clients are in working their program.
Cognitive Therapy
Anxious clients need to see you in individual sessions at least twice a week. You
will take the anxious situations and go through the same cognitive therapy
suggested for depression. The clients can complete Mastering Your Fears and
Phobias: Workbook (Craske, Antony, & Barlow, 2006), Coping With Anxiety and
Panic: SCT Method (Beck & Emery, 1979), or Panic Attacks: How to Cope,
How to Recover (Greenberg & Beck, 1987) to introduce them to the cognitive
techniques. (Some of these pamphlets can be ordered from the Foundation for
Cognitive Therapy, 133 South 36th Street, Room 602, Philadelphia, PA 19104.)

Anxious clients often exaggerate the level of threat by inaccurately perceiving and
judging the situation. They can do this in many ways. They may make any of the
following cognitive distortions:

1. Catastrophizing
“I am going to pass out.”
“I am going crazy.”
“I am losing control.”

2. Exaggerating
“This is the worst thing that could happen.”
“I fail at everything.”
“I would make a fool of myself.”

3. Ignoring the positive

“They hate me.”
“Nobody likes me.”

Each of these clients’ inaccurate thoughts needs to be challenged for accuracy. The
clients will need to keep track of their automatic thinking while in treatment. You
cannot just do this for a few days. Cognitive therapy takes weeks of concentrated
effort.

If it is medically possible, these clients need to exercise for 20 minutes a day at a

training heart rate (220 minus age times 0.75). The clients might have to build up
to this level of fitness. The exercise will burn off excess stress hormones that the
clients are producing. They will be more relaxed for 24 hours following the
exercise.

Anxious clients need to understand what triggers their anxiety and prepare for
anxious moments with accurate thinking and relaxation techniques. These clients
must learn that they can cope with anxiety using the tools of recovery. They are not
going to die or go crazy from anxiety. They need to slow the anxiety cycle by
stopping and thinking when they feel anxious. What are they thinking? Is it
accurate? Then they replace negative thinking with positive thinking. At any time,
they can use a relaxation technique to block the anxious symptoms.
Post-Traumatic Stress Disorder
The essential feature of post-traumatic stress disorder (PTSD) is the development
of troubling symptoms following exposure to an extreme direct personal
experience that involves actual or threatened death or serious injury, or a threat to
one’s personal well-being, or witnessing another person going through a similar
trauma. The person’s response must involve intense fear, helplessness, or horror.
The person persistently avoids any stimuli that are associated with the trauma and
has a general feeling of numbness. These symptoms have to cause significant
distress and impairment in psychological, social, or emotional functioning. To test
for PTSD, use the PTSD Checklist Civilian Version (PCL) (see Appendix 61) or
the PTSD Checklist Military Version (PCL) (see Appendix 62).

The counselors will need to reassure the client and educate them about PTSD.
They need to understand how the past trauma clouds their whole life and
undermines a feeling of well-being. The client can then be referred to a
professional who specializes in PTSD treatment. Cognitive behavioral therapy
seems to work best with these clients, helping them to identify and overcome the
impact of the traumatic event, the meaning of the event, and how to identify stuck
points that interfere with the acceptance of the trauma. This is done by helping the
client to remember the details of the trauma and its meaning. The client writes and
reads an account of the trauma both with the counselor, therapy group, or a
concerned other. The client is asked to rewrite and reread the account throughout
treatment. This is done when the client has practiced relaxation exercises and can
reexperience the trauma with his or her emotions under control. These clients tend
to overgeneralize and establish inaccurate beliefs about the world. For example,
they might think everyone is going to hurt them. These inaccurate beliefs have to
be challenged and replaced with accurate information. It is essential that these
clients feel safe during treatment—by the counselor remaining relaxed and
supportive during the therapy sessions. Most of the time the trauma has led these
clients not to trust themselves, or they feel like they have to control everything, so
they will feel safe. The counselor needs to discuss how these fears and controlling
mechanisms interfere with normal relationships and a feeling of intimacy. It often
helps to have the client write down the event or events that caused the trauma in
detail. Then the client reads this over to himself or herself and listens to the
reading to begin to deal with the trauma. You will find that the client has
generalized the traumatic feelings to people, places, and things that should not be
traumatic. The client needs to think of events outside of the traumatic event to see
things accurately. Have the client write down these events repeatedly until the
client uncovers more and more of the memory. If it is safe, the client can share the
traumatic events with his or her counselor or group. Once the clients have put the
trauma into perspective and learned how to cope with stress, they are ready to
terminate PTSD treatment. They will still need to work a daily program of
recovery to stay clean and sober.
Panic Attacks
If these clients come to you when they are having a panic attack, you need to be
calm and reassuring. Have them look at you and slow their breathing—slow, deep
breaths, inhaling and exhaling slowly as if breathing through a straw. Then begin
one of your relaxation techniques to distract the clients from their feelings. Tell
them the anxiety will pass. You might want to take them on a walk and have them
look at the scenery—at the blue sky and the clouds. You might have them contact
their higher power and have the higher power begin to fill them with peace. Have
the clients float in their anxiety and go with it. Reassure them that nothing bad is
going to happen and that you are going to stay with them until they feel
comfortable.

These clients will need to practice distracting themselves when feeling anxious.
They can notice some fine details in the room or in the environment. They can look
for styles of clothing or shoes. They can read something or estimate the cost of
things. They need to develop a simple coping imagery, such as a trip to the beach,
to replace the fearful thoughts. The coping fantasy can be any relaxing situation in
which the clients feel comfortable and in control.

Anxious clients usually are easy to work with. They are frightened, but they are
responsible individuals. They are willing to do almost anything to get better.
These clients need a lot of love. It will be hard for them to accept your rewards.
They often do not feel worth it, but you should give reinforcers lavishly. When
they feel praised by their treatment peers for their work in group, it is a triumph.
Clients with a history of panic disorder should complete the Mastery of Your
Anxiety and Panic: Workbook (Barlow & Craske, 2006).
The Psychotic Client
Psychotic clients persistently mistakenly evaluate reality. They have disturbances
in cognitive and perceptual organization. They are unable to perceive important
incoming stimuli, process this information in relation to experience, and select
appropriate responses (Siever & Davis, 1991). This mistaken evaluation of
experience results in tenacious false beliefs (Klein, Gittelman, Quitkin, & Rifkin,
1980). If you walked into a restaurant and a person turned around and looked at
you, you would not think much about it. However, a psychotic client might
mistakenly evaluate this situation and think, “That person is after me.” This
mistaken evaluation has the force of reality, and it results in distorted conclusions.
“The mob sent that person to kill me.”
Hallucinations and Delusions
The hallmarks of psychosis are hallucinations and delusions. Hallucinations are
false perceptions. They can seem to come from any sense organ. Clients may hear
voices, see visions, have a strange taste or smell, or feel something unusual on or
under their skin. To psychotic clients, these false perceptions are as real as reality
itself.

Delusions are false beliefs that are intractable to logic. The clients may believe
that they are being watched by someone, that they have strange or unusual powers,
or that one of their body organs is not operating properly. No rational argument
will deter them from this irrational belief. Some clients have social or cultural
beliefs that might seem odd, but if they occur in a normal social context, they are
not considered psychotic. For example, someone could believe that he or she has
the power to read minds, but that person has been trained culturally in this belief.
Psychosis is a persistent, mistaken perception of reality that is not accounted for
by social indoctrination or normal life experiences.

All psychotic states are due to an abnormal condition of the brain. Chronic
disorders, such as schizophrenia and schizoid personality disorder, seem to result
from a core vulnerability expressed in a relative detachment from the
environment, often with defects in reality testing. This seems to be due to inherited
neurointegrative dysfunction. These individuals do not develop normal
interpersonal relationships. They lack empathy and a sense of connectedness.
Their relationships are shallow and not satisfying (Siever et al., 1985).

Acute organic brain syndromes, including intoxication and withdrawal, can

produce psychotic symptoms. Many other psychiatric conditions, such as
schizophrenia and major depression, can create psychosis. Acute organic brain
syndrome must be ruled out first because it can be life threatening. Psychosis can
be transient, as in some forms of acute alcohol withdrawal, or it can be chronic,
as in some forms of schizophrenia.
How to Treat the Psychotic Client
In psychotic clients, there is a mix of psychotic and real perception being
evaluated. Your job is to respond to, and reinforce, the healthy side of these
clients. Rarely will you respond to a psychotic statement other than to reassure the
clients and point out reality to them. Even in the most florid psychotic states,
clients have some hold on reality and do remember what happened. The
environment of a client having active hallucinations needs to be reduced to its
lowest level of stimulation. A quiet room, without a radio or television, is best.
Keep calm yourself. There is no reason for you to be afraid. A conversation with a
psychotic client might go something like this:

The client, Mary, is lying in her bed, covers drawn up to her chest. She is looking
at the walls with a frightened look on her face. The counselor walks over and sits
in a chair beside the bed.

Counselor: How are you doing, Mary?

Mary: Okay, I guess. . . . I keep seeing colors. The walls seem to be moving, as
if they are breathing.

Counselor: That is withdrawal, Mary. We are treating you for that. It will pass.
Just hang in there.

Mary: And I see spiders on the wall.

Counselor: I know that seems real to you, but the bugs are not real. They are
coming from the withdrawal. There are no spiders on the wall.

Mary: But I see them.

Counselor: It seems real, doesn’t it? Shows you how tricky the mind can be.
You are going to be feeling a lot better soon. I am proud of you coming into
treatment. That took a lot of courage.

Mary: Thanks.

Counselor: Can you tell me a little bit about your drinking?

The counselor did not try to prove to the client that there were no spiders. The
counselor just told the client the truth and reassured her. Then the counselor began
to get some history of the client’s problems.

There may be clients who will have psychotic symptoms throughout treatment.
These clients might need to be treated with antipsychotic medications that are the
mainstay of the treatment for psychosis. The psychotic symptoms probably will
gradually decrease in intensity over time. The hallucinations will go first, with the
delusions gradually decreasing over the next several months. Some of the
delusional material may be persistent, lasting for years or even the client’s entire
life. Once these beliefs are set, they are very tenacious to change.

Do not allow psychotic symptoms to trouble the other clients. Psychotic clients
rarely are dangerous. For the most part, you can ignore the symptoms in group. If
they do come up, a frank explanation might be necessary. The other clients will
understand so long as they know they do not have to feel frightened. The group can
be helpful in assisting the client to test reality and to gain social skills.

Diseases such as schizophrenia and mania can be difficult to manage, and they
need psychopharmacological intervention (see Psychotherapeutic Medications in
Appendix 55). Clients who are not in good control will need to be transferred to a
more structured psychiatric facility. The psychotic clients that you work with will
be having perceptual and thought disturbances. It is useless to argue with clients
about their delusional material. These beliefs are well defended and intractable.
For the most part, you will reassure, support, and try to take them through your
program.

Many psychotic clients will have an unusual affect. The range of feelings may be
flat; they say few words, are not goal directed, and have attention problems. The
clients usually have a strange feel to them. Their behavior might not fit the
circumstances. They may have little or no motivation. With the flat affect, you can
help the clients to identify and use their feelings. Motivation can be improved by
having the clients do many small tasks that can be separately reinforced. Do not
set the clients up to fail by asking them to do things that are too difficult for them.

These clients usually need social skills training. They might have to be taught how
to sit, walk, talk, smile, and use interpersonal space and eye contact appropriately.
They might have to learn what appropriate conversation is and what it is not. They
might need to practice communication skills and interpersonal relationship skills.
Clients who are chronically mentally ill will need help in becoming acquainted
with community resources. They need to be referred to the appropriate agencies
for follow-up. Social, vocational, and housing needs all will have to be
appropriately addressed.

Insight-oriented therapy, or therapy that is highly confrontive, is contraindicated

with these clients. If painful material is uncovered, then the psychotic symptoms
may worsen. With these clients, it is best to stay with the here and now.

The clients will need to learn problem-solving skills in treatment and will need to
practice these skills. They need to identify the problem, consider the options, plan
their actions, and carry out the plan. The clients should check the problem later to
see whether their plan has been successful.
The Family of the Psychotic Client
The client’s family will have to meet with the staff to be educated about the
disease. The psychologist or psychiatrist should do this because he or she knows
more about the psychopathology. If you do not have anyone on staff who has this
expertise, then you might need to refer the client to an outside agency. The family
is important in preventing a relapse with the client. An emotionally unstable
family will increase the client’s chance of relapse (Brown, Monck, Carstairs, &
Wing, 1962). A family needs to be educated to keep criticism and over
involvement to a minimum.

The great healer in any good treatment program is love. You can actively care for
and respond to these clients, even though they make you feel a little
uncomfortable. They are just people who have a difficult disorder. They need all
of the love and encouragement that you can give them. It is incredibly rewarding to
see these people improve.
Acquired Immune Deficiency Syndrome
Some clients in need of treatment for addiction will have acquired immune
deficiency syndrome (AIDS), will have AIDS-related complex (ARC), or will
test positive for HTLV-III antibodies. Needle sharing among intravenous drug
users places them at high risk for contracting this disease. AIDS can affect the
CNS, and it can affect thinking, feeling, and behavior, even in the absence of other
symptoms (Gabel, Barnard, Norko, & O’Connell, 1986; Perry & Jacobsen, 1986;
Stulis, 2009). Clients with AIDS can develop a psychosis characterized by
delusions, hallucinations, bizarre behavior, affective disturbances, and mild
memory or cognitive impairment. The cause of this psychosis is yet to be
established (Harris, Jeste, Gleghorn, & Sewell, 1991).

Approximately 30% of all AIDS cases are intravenous drug users. They are the
second leading risk group for infection for transmission of the disease to the adult
heterosexual population (CDC, 1990).

More than one third of AIDS clients develop symptoms of AIDS dementia
complex. This organic brain disease may complicate the diagnosis and treatment
of chemically dependent individuals because of the complicated cognitive,
emotional, and behavioral changes that can occur. The course of AIDS-related
dementia is variable. Early signs and symptoms may be subtle. AIDS dementia
complex generally progresses to severe global impairment within months.
Depression and psychosis are frequent complications (Perry & Jacobsen, 1986).
The High-Risk Client
All high-risk clients, homosexuals, intravenous drug users, and sexual partners of
high-risk individuals should be routinely screened and educated about HIV
infection and risk, particularly if they present with signs of organic or psychotic
impairment, fever, or weight loss. Informed consent should be obtained before
testing. Clients who are seropositive without active symptoms of AIDS can be
safely taken through the program.

AIDS clients will have special issues revolving around their disease. Uncertainty
of diagnosis, guilt about the previous lifestyle, fear of death, exposure of lifestyle,
changes in self-esteem, and alienation from family and friends all can be important
elements in treatment. The catastrophic nature of this illness will have to be dealt
with on an individual basis. If possible, the clients need to be referred to a facility
that specifically deals with AIDS for continuing care.

The AIDS and Chemical Dependency Committee (1988) of the American Medical
Society on Alcoholism and Other Drug Dependencies recommend that treatment
be provided for these clients. The clients need to be assessed on a case-by-case
basis and referred for follow-up by a physician familiar with AIDS. Clients with
AIDS do not require isolation techniques any differently from clients with active
hepatitis B. Hepatitis B precautions should be followed carefully. Caps, gloves,
masks, and other kinds of protective wear are not necessary in routine contact.
Nevertheless, use gloves when dealing with bodily fluids. The principle of
confidentiality is particularly important in protecting these clients (AIDS and
Chemical Dependency Committee, 1988).
The Client With Low Intellectual Functioning
Clients with low intellectual functioning have defects in learning and in adaptive
skills. Most of these clients will have low average to borderline intelligence many
times due to fetal alcohol spectrum disorders. You occasionally will see someone
in the mildly mentally retarded range. Intelligence below this is not amenable to
the normal treatment program.
How to Treat the Client With Low Intelligence
Some of these clients will need a specialized treatment plan. These clients have
difficulty with abstract reasoning. Their program will have to be tangible and
concrete. Many of them will have deficiencies in social skills that will need
remediation. Social skills training can be very helpful here as the group teaches
them how to communicate and solve problems effectively. Most of these clients
will need an advocate or a group home in their community to assist them in
developing and maintaining life skills.

Abstract thought is more complicated than concrete thought. To have normal

abstract thought, clients must easily shift from one aspect of a situation to another,
keeping in mind simultaneous aspects of the situation. They must be able to grasp
how the parts fit into a whole. They must be able to separate the parts and put
them back together again mentally. Clients with good abstract thought can plan,
organize, and think in complex symbols.

Concrete thought is immediate and tangible. It is set in the current situation without
the ability to generalize to other situations. Use of complex symbols or the ability
to see all of the parts is not present. The ability to effectively plan and understand
complicated issues is impaired if the client can think only concretely. Most of
these clients only think concretely, so they have difficulty planning, organizing,
resisting primitive impulses, and learning from experiences. Many of them have to
be reminded of the rules repeatedly because they forget or cannot generalize rules
from one situation to another.
The Client Who Cannot Read
Some of these clients cannot read nor do the written exercises. Most of the reading
material in the 12-step program is written at a sixth-grade level. Clients with
reading levels two or more grades below this are going to have difficulty. The
psychologist can help you determine the extent of these problems and can give you
advice on how to present the program. If the clients can read a little, then they
should be encouraged to do so. The encouragement and praise that they receive
will more than offset minor problems.

If the clients cannot read, then the program will have to be presented to them in
oral form. They can watch videos and hear 12-step material on tape. Every
treatment center has audiovisual material around for just such a purpose. The
clients will need more individual attention and additional support in group. Some
of the group sessions will be over their heads, and that is okay so long as they are
getting the basic program. The program can be made simple enough for most
anyone to follow.

You will have to do a lot of repeating with these clients, and you need to keep
asking them to repeat what you said. This is the only way of being sure that they
understand. Many of these clients learn to be great head-nodders when they do not
understand. If they can repeat the program to you, then they are learning it. Give
them a few key phrases to learn by heart. Check on them from time to time to see
whether they are learning the phrases and understanding what they mean. “Do not
drink. Go to meetings. Turn it over to your higher power.”

These clients may need occupational rehabilitation in continuing care. They may
qualify for locally supported programs such as Supplemental Security Income
(SSI) of Social Security. They may need a halfway house or other structured
facility in continuing care. The Division of Vocational Rehabilitation is an
excellent program for many of these clients.
The Family of the Client With Low Intelligence
The family of a person with low intelligence might not know of their loved one’s
disability. The family will need to be informed about the client’s liabilities. These
clients can be some of the best AA/NA members. They can be fiercely loyal and
consistent. They often are willing to do jobs that other members find distasteful. It
is very reinforcing to watch them bond with the group and find a place for
themselves.
The Elderly Client
Most counselors do not realize how prevalent addiction is among the elderly. A
recent study revealed that substance abuse was the third-ranked mental disorder in
a large geriatric mental health population (Reifler, Raskind, & Kethley, 1982).
The elderly are vulnerable to becoming addicted to a variety of over-the-counter
or prescription medications, and they tend to take a variety of medications without
proper medical supervision. Any medication or illicit drug tends to have more
effect on the elderly than on younger persons. Drugs usually have one third more
power in older individuals for a variety of physiological factors. There appears to
be no age-related change in liver detoxification, but there is a decline in brain
cells that results in higher concentration of alcohol and other substances. With
normal aging, there is a decline in extracellular and intracellular fluid and an
increase in body fat that result in a greater effect of many drugs on the CNS
(Gambert, 1992).

Source: ©[Link]/azndc.
Elderly clients often have outlived their psychosocial support system. Their
spouses may have died or been incapacitated, and their children may be unable to
care for them. Loss of family and friends, coupled with retirement and loss of job
and self-esteem, may lead elderly clients into a depressive state where substances
are used to ease the pain. A study at the Mayo Clinic’s inpatient alcohol unit found
that 44% of elderly clients were compromised organically from chronic alcohol
or drug use but that they went through treatment with no appreciable difference in
treatment outcome (Morse, 1994). Only 10% of elderly clients have a dementia
that is serious enough to hamper them in retaining a recovery program. Many
clients suffer from mild cognitive defects including impairment of orientation,
concentration, short-term memory recall, and abstract thinking.

Atkinson and Kofed (1984) found a number of risk factors that contributed to the
vulnerability of the elderly to substance abuse. Biological sensitivity to
chemicals, loneliness, pain, insomnia, depression, and grief all were predisposing
factors.

Symptoms of substance abuse often are overlooked in the elderly in medical

settings because they suffer from multiple pathological conditions. Changes in
cognition or behavior may be blamed on an illness or old age rather than on
substance abuse.

For a variety of reasons, the elderly may start drinking heavily after they retire.
They have more time on their hands, and drinking or drug use can easily become a
habit using relatively small amounts of substances. It is most common for these
clients to drink or use alone. Like any addict, there is a strong desire for the
clients to hide their use. This may be easy to do when they live alone and have no
one to check on them periodically.

The good thing about recovery is that it gives clients a new family. They do not
have to live alone anymore. The clients can use their support group to reestablish
social connections and develop new leisure activities. They develop a sense of
belonging by helping other addicts, and this improves their self-worth. This gives
elderly clients, who often are ready to die, a reason to live. The clients have to
know that their recovery group needs them. God trained them in addiction, they
have grown wise over the years, and now they need to heal. They can do this by
going to meetings and sharing their experience, strength, and hope. It might take a
while before elderly persons realize this truth. The best way of having them learn
it is to have them help someone in treatment. They can help someone go through
detox or someone earlier in recovery. Once they see that their lives have meaning
and worth for others, they are on the road to recovery.
The Client With Early Childhood Trauma
Many chemically dependent clients were raised in severely dysfunctional
families, and some of them were abused as children. Some of these clients will
meet the criteria for PTSD from the abuse, but all of them will be adversely
affected. Some clients are so preoccupied with the abuse that it has to be
addressed in early treatment. The best way to determine this is the extent of the
client’s preoccupation with the traumatic material. If they are obsessed with
thoughts, intrusive memories, and dreams, it seems best to let the clients vent some
of their story to provide them some relief. Eye movement desensitization and
reprocessing (EMDR) can be helpful with some of these clients.

If clients disclose abuse in individual sessions or in group, they need to be

supported. They need to hear that it was not their fault. Little children are not
responsible for what adults do. If a client who discloses abuse is an adolescent,
then the situation will have to be reported to the proper authorities. This is to
protect the child from further harm. Do not do this without consulting with the
clinical staff and carefully documenting it in the client record.
How to Deal With Sexual Abuse
If a client is stuck in treatment because of this pain, then it will have to be
addressed to relieve the pressure. This is a clinical decision. If the client is too
vulnerable for this issue, then he or she will feel anxious, and you will feel uneasy
yourself. If you can, transfer this issue to the psychiatrist or psychologist. You
might have to refer the client to an outside mental health professional. Clients with
PTSD from childhood trauma will need to reexperience the trauma in a safe
environment. They will need to tell their stories many times. Details are
important. The stories need to include the events before, during, and after the
trauma. Therapy begins with a safe relationship with the therapist.

Clients may decompensate when this material comes out. If staff members are
supportive, this should not last long. The clients may experience feelings of
derealization or depersonalization. This can be frightening to an unskilled
counselor. If at any time you feel that you are in over your head, stop and get the
help of someone more experienced.

Sexual abuse is a topic for men’s and women’s groups. The material can be
disturbing and explosive. These matters need to be addressed in individual
sessions. Events such as rape and insults to self-esteem and security are
particularly likely to cause long-term problems. The more extreme and long-
lasting the trauma, the more likely the events are to cause psychological damage.

These clients ultimately need to see the past events in a new context and attempt to
forgive themselves and the offenders. The clients no longer are children, and these
things are unlikely to happen again. The clients now have power and control that
they did not have before. They will need to see themselves as competent and
capable of handling stressful situations now. You can role-play situations for them
and help them to develop skills for getting themselves out of trouble. “If that
happened to you now, at your present age, what would you do?” The clients can
learn that they can take care of themselves.

People who were involved in traumatic events often become anxious when they
have to deal with similar situations in their current life situations. A spouse who
was sexually abused as a child may feel frightened or numb when called on to
perform sexually in his or her marriage. This client may need some of the
techniques you used with the anxious client.
Cognitive Therapy
Cognitive techniques are necessary to correct the negative self-talk of these
clients. They often call themselves bad or evil in their own thinking. They think
that no one will like them because they have been bad. This negative self-talk will
have to be exchanged for positive affirmation.

These clients will need to develop trust. The Love, Trust, and Commitment
exercise (see Appendix 9) is a good one for them to start with. First, they need to
reestablish a trusting relationship with themselves and then hopefully with you.
This trust ultimately can be transferred to the group. The clients need to be
encouraged to see their new support group as the healthy home that they never had.
The home group will be there for them when they need it. The group has a stable
set of rules that do not change.

These clients need to learn interpersonal relationship skills and to practice these
skills with their treatment peers. They need to work on honesty. The cocoon of
individual therapy is important here, and the clients must know that they can trust
you. You need to be consistent and nonjudgmental. You need to be honest about
how you feel about the abusive issues.
How to Learn Forgiveness
As these clients develop a good spiritual program, they need to try to forgive the
perpetrators. By seeing the abusers as spiritually sick, the clients are relieved of
some of the anger and the feeling of responsibility. When the clients are ready,
they can be encouraged to pray for the perpetrators. They can turn the judgment
over to the perfect judge. God will judge all humankind. The judgment will be
perfect because God sees into everyone’s heart.

Small steps in trust will be beneficial with these clients. You may find the clients
sharing their abuse with other clients who have had similar experiences. The Fifth
Step is tremendously beneficial for these clients. If the step is done properly, they
will feel relieved of the guilt and rage.
Love in the Treatment Center
“I found out from another client that he liked me. After that, it preoccupied my
mind. I jumped ahead and thought of marriage with this guy, and I did not even
know him. It was hard to concentrate on the lectures or the steps because I could
not wait for us to have a break, so I could be with him. He told me how violent he
was, but that did not faze me. I thought he was changing. The staff talked to me
about it, and I started to think and realize it was wrong, but I needed to have a man
in my life.”

These thoughts and feelings are all too familiar. Two clients, during those fragile
first few weeks of sobriety, have become romantically involved. These clients can
lose the focus of treatment. They do not respond well to the interventions of the
staff who are trying to get them to see the mistake they are making. They are in
love, and to them it is real. It is difficult for these clients to realize that what they
are feeling is not love at all and that the intense feelings they are experiencing are
sexual. In their passion for each other, they are confused. It feels like love, it feels
like the real thing, it is heaven, and it is the answer to what they have been looking
for. They came into treatment feeling worthless and unimportant, and this other
person has restored their sense of value. They have been made whole again. These
clients do not realize that they are particularly vulnerable to such feelings in early
sobriety. Feelings, which were deadened by chemicals before treatment, are just
beginning to blossom new and untested. Their whole treatment program is at stake.

One client described the consequences of love in the treatment center like this:
“After treatment, we had sex right away, and it all went downhill from there fast.
He got too jealous. I was totally bending over backward for him, buying him
cigarettes and pop. Even when I told him I only wanted to be friends, he wanted
me back. He got drunk and threatened to kill me, so I went back with him for a
while. I finally got the courage to tell him the truth. When he finally left, I felt so
guilty.”
The Importance of the Unit Rules
It is prudent for treatment programs to develop a set of unit rules that discourage
these relationships from developing. The rule that only three or more clients may
pair off together at any one time is a valuable one. Then if staff members see two
clients pairing off, they can intervene.
How to Deal With Clients in Love
The first intervention attempted should be individual counseling with each client.
These sessions should focus on educating the clients about what love is and what
it is not. The clients can explore the Addictive Relationships exercise (see
Appendix 12) with you and use this opportunity to learn and grow in treatment.
They must be helped to see the reality of the situation. With assistance, they can
begin to see the situation accurately. Is this really the best time for romance? Is
this the person they want to spend their life with? What is their history? The
clients and counselor must carefully collect all the evidence possible. They must
get accurate and explore all of the options available. What is going on? Why?
What do the clients hope to gain? What does it mean to the clients? Can they get
their needs met in another way? Do they see the danger? What is love? What are
romance and sexual attraction? How do they differ? How are they alike? The
complexities of the feelings and motivations must be thoroughly explored. The
dangers of this relationship at this time must be emphasized and addressed.

Disciplinary action might become necessary to prevent further problems.

Considerable clinical skill is necessary here. Transference and
countertransference issues may arise. The clients may resist your attempt to end
the relationship that they see as beneficial. The staff must be sensitive to how in
love these clients feel. Disapproving looks and derogatory comments will tend to
intensify the feelings and draw the clients closer together.

The next intervention that you might need is conjoint counseling. Here the
relationship can be addressed with both parties at the same time. If the clients
have separate counselors, then both counselors should be involved in this session.
The clients should be warned that they are placing each other’s treatment at risk. It
is not right to risk someone else’s sobriety. If the problem persists, then it
becomes an issue for the group. Now everyone’s treatment is threatened, and the
client population needs to respond. If the group cannot stop it, then the transfer of
one client to another facility, or dismissal from treatment, becomes a viable
option.

Love in the treatment center is a crisis from which all clients can grow. They can
learn more about themselves. They can learn more about how to develop healthy
relationships and the challenges that will confront them in sobriety. They must be
encouraged to focus on their own recovery. The clients need to concentrate on
supporting and encouraging themselves.
The Pathological Gambler
“Gamblers Anonymous (GA) has been, and is, the single most effective treatment
modality for the pathological gambler” (Custer, 1984a). This point continues to be
true today. The American Psychiatric Association’s Treatments of Psychiatric
Disorders states, “In general, an approach which utilizes several treatment
modalities, including participation in Gamblers Anonymous, appears warranted at
this time” (Karasu, 1989, p. 2466).

GA is a 12-step program modeled after the 12 steps of AA. The program provides
hope to recovering individuals. Many clients recover by going to GA alone, but
some clients, particularly those with concomitant psychiatric disorders, need the
structure of inpatient or outpatient treatment (Custer, 1984b; Karasu, 1989).

All clients with gambling issues need to be thoroughly assessed for their gambling
problem and take the South Oaks Gambling Screen (see Appendix 53). Gamblers
tend to leave things out of their gambling history (see Appendix 68), so you must
be careful to collect all of the problems caused by gambling. It helps to use the
financial forms (see Appendix 51) to assess the amount of debt and develop a pay
budget to pay back debtors.

Clients who have entered gambling treatment need to do a minimum of three things
to begin recovery: (1) get honest with themselves, (2) embrace the first few steps
of GA, and (3) develop a good relapse prevention program. These steps provide
the foundation for recovery. The recovery skills presented in this book are client
work. They educate about the disease of pathological gambling, teach the tools of
recovery, and have clients apply the tools in their daily lives. Each client
completes each exercise and shares his or her answers with the recovery skills
group. The group decides by majority vote to accept or reject the contract based
on how well the client completes the exercise. If the contract is rejected, then the
client has to do it over again.

Recovery skills help a client to identify the problem, understand the problem, and
learn coping skills for dealing with the problem. The types of recovery skills are
infinite. You will want to develop some on your own, but there are a few
exercises that you will use with nearly every client. The following recovery skills
are the ones that you will use most often. If there is no pressure relief group in
your local GA chapter, then you will have to help the client make a payback plan
using the pressure relief group and financial forms in Appendix 51.
Honesty
The Honesty for Gamblers exercise (see Appendix 34) helps clients to see how
they have been distorting reality. All clients use denial, in its many forms, to keep
from experiencing the pain of the truth. If they see the whole picture about
themselves, they hurt. They realize that they are sick and need help. This creates
tremendous fear. Clients keep from feeling this fear by minimizing, rationalizing,
denying, blaming, distorting, projecting, intellectualizing, diverting, and utilizing
dozens of other ways of not experiencing the truth.

Clients cannot uncover denial without getting help from others because denial
tends to be unconscious. The Honesty for Gamblers exercise gets them started in
this search for the truth. It is the job of the counselor and treatment center to set up
an atmosphere of love and trust and then to give clients the opportunity to search
for and share the truth with each other. The truth sets people free. Treatment is an
endless search for truth.

Working through the Honesty for Gamblers exercise is an eye-opening experience

for clients. They come to realize how much they have been lying to themselves and
to others. They feel guilty about lying to others. However, clients usually do not
realize that they have lied to themselves more than to anyone else. This comes as a
startling revelation.

Clients need to process how they feel about themselves when they lie, and they
need to learn the negative consequences of dishonesty. First, if they lie, then they
will hurt. If they do not tell people the truth, then they will not be known or feel
loved. Second, without truth, clients cannot solve problems accurately. To solve
problems, you need the facts.

The 12 steps should be the core of treatment for pathological gambling. More
individuals have recovered using the principles of GA than using any other
treatment. GA works, and it is free. The only requirement for GA membership is
the desire to stop gambling.

Treatment programs differ in terms of the steps that they address. Some programs
address Step One, some address Steps One to Three, and others address Steps
One to Five. This must be individualized. Some clients will be able to work only
through Step One, and that is fine if they do a good Step One. For most clients, it
is a benefit to complete at least Steps One to Three while in treatment. The more
clients can do, the better off they will be in recovery. Working through the Fifth
Step takes a great burden off the clients. If they complete the Fifth Step, then they
will not have to carry as much guilt and shame into abstinence from gambling.

If your program works only on the First Step, that will give you more time to work
on powerlessness and unmanageability.

As you take clients through the step exercises, make sure that they are internalizing
the material. They must be able to identify the problem, understand the problem,
and learn coping skills for dealing with the problem. They must be able to
verbalize a solid understanding of each step and how they are going to apply the
step in their lives.

You will be able to tell when clients are just complying and when they are
actually understanding and internalizing the material by their level of commitment
to remain free of gambling. This will be evident in their behavior. If you watch
how clients act with you and with their treatment peers, you will have a good idea
of whether they are internalizing the information or not. If you are hearing one
thing in individual sessions and a client’s peers are hearing another thing around
the treatment center, then someone is not getting the truth. This client needs to be
confronted with the inconsistency of his or her behavior.

Clients often feel torn among various parts of themselves. There seems to be a
side that wants to gamble and a side that wants to stop. There seems to be a side
that wants to love and a side that wants to hate. There is a constant, and often
turbulent, internal war going on inside the clients’ thinking. Each side tries to take
control of the clients’ behavior. Sometimes it is hard for a client to know who he
or she really is. It feels as though there is more than one person talking inside the
client’s own head.

Freud (2000) called these internal voices the id, ego, and superego. Berne (1964)
called them the child, adult, and parent. In recovery, we call the voices the illness,
self, and higher power. One train of thinking is the thought process of the disease.
This side only wants the clients to gamble, and it does not care how it gets them to
do it. If the clients feel miserable, that is all the better. Another voice is that of the
higher power. The higher power wants the clients to love themselves, others, and
the higher power. This voice is supportive. The third voice is the clients’ own
thinking.
As you move these clients through the steps, do not move a client to the next step
until he or she has a solid foundation of successfully completing the previous step.
If the client has not embraced a good Step One, then there is no use in moving to
Step Two. If you have to work on Step One the whole time that the client is in
treatment, that is fine. Some clients do that. However, do not try to move up in the
steps too quickly. The steps must build on top of each other. The first building
block is Step One.
Gambling Step One
“We admitted we were powerless over gambling—that our lives had become
unmanageable” (GA, 1989b, p. 38).

It is vital that all clients complete a solid Step One for Gamblers (see Appendix
35) in treatment. Step One is the most important step because without it, recovery
is impossible. Step One necessitates a total surrender. The clients must accept as
true that they are pathological gamblers and that their lives are unmanageable.
Until this conscious and unconscious surrender occurs, these clients cannot grow.
So long as clients think that they can bring the gambling under control, they will
not accept their disease. “The idea that somehow, some day, we will control our
gambling is the great obsession of every compulsive gambler. The persistence of
this illusion is astonishing. Many pursue it into the gates of prison, insanity, or
death” (GA, 1989a, p. 2).

Step work is mainly group work. The clients complete the step exercise and
present the exercise in group. The group helps the clients with the step by asking
questions, giving constructive comments, and deciding whether the step is
successfully completed. As the counselor, you usually should not make the
decision to clear the step without the support of the group. The clients may be only
complying with treatment, pretending that they are working, when in reality they
are not internalizing the information. The treatment peers sometimes are more
likely to see this manipulation. The peers see the clients in casual interaction, and
they may notice the inconsistencies.

In Step One, the clients must learn to accept that they are pathological gamblers
and that they are powerless over gambling. Their lives are unmanageable. They
also must understand that they cannot live normally so long as they gamble.

The best way of convincing clients to surrender is to show them that they get into
trouble when they gamble. They do not get into trouble every time, but they cannot
predict when the trouble is going to occur. They may place a few bets and go
home, or they may gamble away the farm. The key point is inconsistency once they
place the first bet.

Clients need to process through many of their problems until they realize that they
cannot predict their behavior. Have clients share exactly what happened when
their gambling got out of control. Talk about the fear, shame, humiliation, and
depression caused by gambling. How depressing was it to know that their families
were falling apart? How did it feel to be unable to keep promises?

Sometimes the clients gambled more, or for a longer period, than they originally
had intended. Once they began gambling, the addiction took control. Even when
they promised themselves that they were going to stop or cut down, they kept on
gambling. Clients must understand that once they place the first bet, they do not
know what they are going to do.

Most gamblers want to hold on to the delusion that they are still in control. They
do not want to admit that they are powerless and that their lives are unmanageable.
Sure, they were having problems sometimes, but they think that they were having
problems only occasionally. The fact is that when clients had serious problems,
they usually were related to gambling. Gamblers do things when they are gambling
that they never would do otherwise. They need to look at each of these behaviors
and see the painful consequences of their addiction. They need to take a careful
look at their gambling histories—at the lies, the crimes, the inconsistencies, and
the people they have hurt. They need to understand that so long as they gamble,
they will be in pain.
Gambling Step Two
“[We] came to believe that a power greater than ourselves could restore us to a
normal way of thinking and living” (GA, 1989b, p. 39).

The beginning of the clients’ spiritual program is Step One, or the surrender step.
It is essential to accept powerlessness and unmanageability before the clients
reach to a higher power. The essential ingredient of Step Two for Gamblers (see
Appendix 36) is willingness. Without being willing to seek a power greater than
themselves, the clients will fail. They have admitted that they are powerless over
gambling and that their lives are unmanageable. Now the clients need to see the
insanity of their disease and search for an answer.

In Step Two, the clients look at their insane behavior. They see how crazy they
were acting and reach for an answer. They must conclude that they cannot hold
onto their old ways of thinking and behaving. If they do, then they will relapse.

Many clients rebel at the very idea of a higher power. They are encouraged to
open the door, just a little, and seek a higher power of their own understanding.
They are encouraged to be honest, open-minded, and willing. They need power;
they are powerless. They need someone else to manage; their lives are
unmanageable.

At first, you encourage the clients to see that a higher power can exist. The clients
are encouraged to look at their interpersonal group and see that the group has more
power than they do. You can say something like this to a client: “If you wanted to
leave this room, but the group wanted to keep you in, do you think you could
leave?” It soon becomes obvious to this client that the group members could force
the client to stay inside the room if they so desired. The client is then asked to try
to place his or her trust in the higher power of the group.

Trust is a difficult issue for most gamblers, and they need to process their lack of
trust with the group. This is good group work. If clients cannot trust the group as a
whole, can they trust anyone in the group? If they cannot trust anyone, can they
trust themselves? Are they willing to try? If they are unable to trust others, then
they are lost. Clients who obviously cannot trust themselves are out of control.

The best way of helping clients learn to trust the group is to create a supportive
group. The members are actively interested in each other in this group. They are
involved in each other’s recovery. They gently help each other to search for the
truth. The group members are kind, encouraging, and supportive. They are
confidential. The group members never are hostile or aggressive. They do not put
each other down. This is counterproductive. If you have an aggressive, highly
confrontational group, you will destroy trust. People must learn to confront each
other in an atmosphere of unconditional positive regard. It is the counselor’s job
to teach the group this process.

Once the clients trust the group, they can be encouraged to transfer this trust to the
GA group. The clients in treatment should attend as many regular meetings as
possible. Gradually, they will feel safe enough to share. This builds trust.

As the group becomes involved in the clients’ growth, confidence in the group
process grows. This probably is the first time in these clients’ lives when they
have told someone the whole truth. When the group does not reject these clients,
the clients feel a tremendous relief. This will show on their faces.

The clients also see people further along in the program doing better. These
people look better and sound better. The clients cannot miss the power of the
group process. It changes people. Clients see new members come in frightened or
hostile and watch them turn around. Clients watch the power of group support.
Soon the group will be offering the new clients encouragement. Clients learn how
helpful it is to share their experiences, strengths, and hopes. Once these clients see
how insane they are acting and accept that the group has the power to restore them
to a healthy way of thinking and living, they have embraced Step Two. By trusting
the group, the clients open the door to a higher power. This basic building block
of trust is vital to good treatment. Clients who move too quickly to the concept of
God miss the power of the group. They miss seeing the higher power in others.
These clients sometimes believe that God is the only answer they need. They
might think that they do not have to go to meetings so long as they have a good
spiritual program. These clients might not work a program of recovery, and they
probably will relapse. All clients are encouraged to trust the group process.
Gambling Step Three
“[We] made a decision to turn our will and our lives over to the care of this
power of our own understanding” (GA, 1989b, p. 40).

Most clients have difficulty with Step Three for Gamblers (see Appendix 37).
They need to be reminded to turn problems over to their higher power. Clients can
be so self-centered that they set themselves up for pain. They think that the whole
world should revolve around them. When people do not cooperate with their
plans, they are furious. They think that their spouses, children, and friends should
obey them. They believe that everything should go exactly the way in which they
want events to go. They believe that they are deserving of special honors and
privileges. They care very deeply about what they want and how they feel, but
their ability to empathize with others is seriously impaired. Clients correct this
defect in treatment by learning empathy for others and turning their will and their
lives over to the care of a power greater than themselves.

The worst thing that a counselor can do in the Third Step is to push clients faster
than they are ready to go. The decision to turn things over is the clients’ decision.
As the counselor, all you can do is encourage, educate, and support. However, you
have one big thing going for you in Step Three. When clients turn something over,
they feel immediate relief. They feel this relief emotionally, and this is a powerful
way of learning. Nothing works better than showing clients how this tool of
recovery works. If you give gamblers a good feeling, they will want to re-create
that feeling. That is why they were gambling. The Third Step is the answer that
these clients have been waiting for. They must experience it to believe it.

Many clients resist Step Three. Even people who have been in GA for years have
difficulty with it. Meetings are full of people talking about turning things over and
then taking them back. Step Three is a decision that is made every day.

There is great hope for clients in Step Three, and they usually feel it. This
newfound hope must not be confused with religion. Religion is an organized
system of faith and worship. Spirituality is the innermost relationship that you
have with yourself and all else. If the clients want to use a religious structure, that
is encouraged so long as it sets the clients free and does not immerse them in guilt
or remorse.
The key to Step Three is willingness. Once clients are willing to seek a higher
power of their own understanding, they have come a long way toward completing
Step Three. As soon as you hear clients say that they are willing to turn it over,
they are well on their way to recovery. Clients need to trust and turn things over to
the group. The group has more collective wisdom than does the individual client,
and the group can be helpful in solving problems. As clients use the power and
support of their group, they learn how to turn things over.

Some clients have serious problems with the word God. They feel better if they
use the words good orderly direction (for each letter in God). Clients do not have
to use the word God if they do not want to. Many clients have had God and
religion crammed down their throats for so long that they are sick of it.
Gambling Step Four
“[We] made a searching and fearless moral and financial inventory of ourselves”
(GA, 1989b, p. 42). Much of this exercise was developed by Lynn Carroll during
his years at Hazelden and at Keystone Treatment Center. The material has been
expanded and adapted for use with gamblers.

Step Four for Gamblers (see Appendix 38) is where clients make a thorough
housecleaning. They rid themselves of the guilt of the past and look forward to a
new future. Detail is important here. You must encourage clients to be specific.
They must put down exactly what they did. The clients will share their Fourth Step
inventory with someone in the Fifth Step. Another part of Fourth Step group work
involves each client’s assets. This work allows clients to share good things about
themselves with their peers.

To do a good Step Four, clients must be honest. They will relieve themselves of
the guilt if they do their Steps Four and Five properly. They might have a difficult
time in forgiving themselves, but they can feel that their higher power has forgiven
them. Faith can do for them what they cannot do for themselves.

There is a tendency for some clients to leave something bad out of the Fifth Step.
This is not a good idea. Clients are encouraged to share everything that they think
is important, no matter how bad it might seem. If it causes them guilt or shame,
then it needs to be shared. Clients need to come face-to-face with their problems.
All the garbage of the past must be cleaned out. Nothing can be left to fester and
rot.

The Fourth Step is where clients identify their character defects. Once these
defects are identified, the clients can work toward resolution. Often clients will
come upon material suppressed for years. As memory tracks are stimulated,
deeper, unconscious material may surface.

Clients need to concentrate on the exact nature of their wrongs. Do not let them
accuse or blame someone else. This is a time to take responsibility. They should
not make excuses. They should just ask for forgiveness. Yes, there were mitigating
circumstances. This is not a time to find out who was right and who was wrong. It
is time to dump the shame.
Clients who get depressed doing their Fourth Step need to concentrate on their
good qualities. These clients are not all bad. They need to be shown that they are
valuable persons who deserve to be loved. Some clients might have to wait quite
a while before doing their Fourth Step. Absolute honesty is a requirement.

Some clients are so used to being negative about themselves that they cannot come
up with their assets. These clients need to have the group help them to see the
positive things about themselves.

Step Four must be detailed and specific. Clients must cover the exact nature of
their behavior. This is the only way for them to see the full impact of their disease.
They should not color their stories to make them seem less guilty or responsible.

Most of all, Step Four (like all of the steps) is a time of great joy. Clients finally
face the whole truth about themselves. The truth is that they are wonderful. As they
rid themselves of the pain of the past, they are ready to move forward to new lives
filled with hope and recovery.
Gambling Step Five
“[We] admitted to ourselves and to another human being the exact nature of our
wrongs” (GA, 1989b, p. 44).

As the counselor, your job in Step Five for Gamblers (see Appendix 39) is to help
the client to match up with the right person to share with. Who this person is and
what each is like is vitally important. This person stands as a symbol of the higher
power and all people on earth. This step directly attacks the core of the disease. If
it is done properly, the client will be free from the past. The person chosen should
be someone who understands the program and who has experience in hearing Fifth
Steps. This person needs an attitude of acceptance and unconditional positive
regard. The individual must be nonjudgmental and strictly confidential. It is
helpful if this person is working a 12-step program himself or herself. The person
should not look uncomfortable when a client is sharing painful material. The client
needs to see a non-shaming face.

The purpose of the Fifth Step is to make things right with self, others, and the
higher power. The clients should see themselves accurately—the positive and
negative points, all at the same time. At the core of the illness is this firmly held
belief that if the clients tell anyone the truth about themselves, then that person
will not like them. This is not accurate, but the clients have been living as if this
were the truth. The clients have not been honest with themselves and others for a
long time, perhaps since childhood. The clients have pretended to be somebody
else to get the good stuff in life. The only way of proving to these clients that their
held belief is wrong is to show them. This is the purpose of having another human
being hear the Fifth Step. If this person does not reject the clients, then the
inaccurate thinking is proved wrong. A new accurate thought replaces the old one:
The clients can tell the truth, and people will still like them. This is a tremendous
relief to clients. They have been living their lives convinced that they were
unacceptable to others. This is a deeply held conviction, and it causes great pain.
Clients must come to realize that unless they tell the truth, they never will feel
loved.

In the Fifth Step, clients need to come to realize that they are good persons. They
have made mistakes. They have done bad things. They are not bad; they are good.
They need to forgive themselves and start over, clean and new. Clients have
varying degrees of spirituality and religious beliefs. You must help each client see
that forgiveness has taken place.

Many clients will be tempted to hold something back in the Fifth Step. They do not
want to share some part of their past. They do not think that anyone can
understand. Clients must be warned against this tendency. If they hold anything
back, then the illness will win. All major wrongs must be disclosed.

After the Fifth Step, most clients experience a feeling of relief. The truth sets them
free. In time, clients will need to process these feelings with you. Some clients
feel no immediate relief. If they were honest in the step, they will feel the relief
later. Sometimes it takes a while to sink in. Steps Four and Five are profoundly
humbling experiences. Once these steps are over, there is a profound feeling of
relief.
Gambling Step Six
“Were entirely ready to have God remove all these defects of character (AA,
2014, p. 63).”

What has happened so far is nothing short of amazing. The clients have admitted
powerlessness, come to believe that a power greater than themselves could
remove the addiction, made a decision to turn their will and lives over to the care
of God as they understood him, made a searching and fearless inventory, and
admitted to God and another human being the exact nature of their wrongs. Now
it’s time to be entirely ready to have God remove the defects of character. We
have to believe that we cannot make this journey forward alone. God and only
God can remove these defects of character. He will begin to correct our
minimization, rationalization, and denial. He can correct our tendencies to slip
back into old behaviors and attitudes. They may have to use the steps, particularly
Step One, over and over again, many times a day. We have to turn our will and our
lives over to the care of the God of our understanding. It takes nothing short of
total surrender to allow God to remove these defects of character. This is a
lifelong battle to walk in the darkness or walk in the light. Darkness means no
love, no light, no beauty, and no truth. With Steps One through Five under the belt,
they realize that only God can remove these defects of character; they are too
much a part of our lives. It seems like we cannot live without them.

Truly they could not stop the addiction on their own. They had to give this
problem and all of its defects of character to God and let him do what they could
not do on their own. God could and would remove these defects of character.
These defects are tenacious. It’s like in baptism, the old man goes under water and
comes up a new man, but the old man is a good swimmer. These defects of
character fight for life; they have a life of their own. They are deeply rooted in
thoughts and behavior. When the clients look at their struggle to remove these
defects of character, we try to make progress, not perfection. To ask to never
minimize, rationalize, or deny again is to put an unrealistic expectation on
themselves. This guarantees failure. When the clients look at themselves
objectively, they can see if they are winning or losing the battle. When they take an
inventory at the end of every day, they can see how they made progress.

In 12-step groups all over the world, you will hear people say they have been
released from the compulsion of their addiction. The craving has been removed
and a new peace has taken its place. Most people will say it was relieved by the
direct intervention of their higher power. When they let go and let God in, insanity
was replaced by serenity. Here we try to imitate God himself. The clients try to
treat others the way they want to be treated.
Gambling Step Seven
“Humbly asked Him to remove our shortcomings” (AA, 2014).

The attainment of a humble heart is the foundation of each of the 12 steps. Each
step in turn leaves the clients more humble and dependent on their Creator.
Without humility it is difficult to attain and maintain a clean and sober lifestyle.
The delusion that the clients can still use the addictive substance or behavior
safely leads to more addiction and can lead to an early death. Without humility it
is difficult to be happy because the client is always trying to run the show. Clients
who are addicted need to get out of the great golden idol of me, my, and I and get
into a program of the we. The first word in the 12 steps is we not me, my, or I. We
get better by helping each other. This gets rid of “self will run riot.” Addiction
needs a preoccupation with self. Clients follow this self to the point of delusion
and death. This is called narcissism. I know what I need. I know what I want. I
know the direction I must take, and when I trust myself, I can always find a way
out of a bad situation. When clients think like this, there no need for a higher
power. Step One takes the wind out of this delusion and lands us back to the truth.

When the clients come face-to-face with addiction, they learn that nothing short of
a miracle will relieve the craving to become involved in the addictive behavior
again. Clients find comfort in fellow 12-step members who are working a
program of recovery, and the best of these recovering people seem to have peace
and humility written on their faces. Clients find out they don’t have to be beaten
down by the addiction; they can make the decision to walk toward the peace that
the program offers.

Most 12-step programs recommend that this step be taken on the knees. Indeed
clients will often hear in meetings that people put their shoes under the bed, so
they are forced to get down on their knees, and once on the knees, it’s a good time
to say a prayer asking God to help them stay clean and sober for another day. The
chief problem was self-centered fear and the way around that hurdle is humility—
not something we were beaten into but something we asked for and lived. Once
we embrace humility we can walk a road not covered by obsession but freedom of
spirit.
Gambling Step Eight
“Made a list of all the persons we had harmed and became willing to make
amends to them all” (AA, 2014.)

Steps Eight and Nine have to do with personal relationships and how the clients
can begin to improve them. The client begins by going back and reviewing Step
Four and making a list of the persons they had harmed. Then asking their higher
power for help, they became willing to make amends to them all. At first this
seems like the most difficult of the steps, but nothing can bring more peace than
setting the record straight, correcting the wrongs, and asking for forgiveness. Like
many steps this is one that is never done. The clients will need forgiveness many
times along the road of recovery.

In Step Eight the clients fight the desire to keep the harms hidden, but like an
iceberg most of what we did to harm people shows only a little in the surface;
most of the harms travel below the surface, waiting to shame the recovering
person into keeping quiet about the harms they had done. An iceberg will sink the
greatest person in recovery. The clients have to face the truth. The job in recovery
is to humbly face the truth. If the clients continue to lie, they will certainly relapse.
It is easy to avoid Steps Eight and Nine as if we didn’t really hurt anyone, but this
is not the truth. Everyone around the addicted person is adversely affected,
particularly those who were trying to love her or him. Fear and false pride are
enemies here, but the client needs to be fearless and thorough; anything else leaves
them in fear and self-loathing.

The wonder about these steps is everyone breaks the rules and suffers the
consequences for bad behavior. A walk through Step Four sets the stage for us to
learn how to forgive ourselves and others. As the client goes over the behavior
chain, they can see how bad behavior led them into shame and more of the
addiction to deal with these feelings. The best part of these two steps is when we
come to realize how much God loves us and how completely he forgives us. We
don’t deserve this forgiveness, but God’s grace and love shines through seemingly
unresolvable problems. As the clients work through Steps Eight and Nine, they
become aware of their own capacity to forgive. The clients are taught how to let
go and let God in, saying to themselves, “There but for the grace of God go I.”
Gambling Step Nine
“Made direct amends to such people wherever possible, except when to do so
would injure them or others” (AA, 2014).

The client has made a list of persons harmed in Step Eight; now it’s time to share
the client’s journey through recovery and ask for forgiveness. The client may have
to correct financial and relationship problems. They need to explain what
happened and why this hurt innocent people. Most people who hear the story of
addiction will forgive us if they understand the lies we told ourselves and others.
The lies were there to protect the client from the pain of the truth. These lies were
unconscious and automatic. Correcting the past takes good judgment and the timing
necessary to clear away the wreckage. The clients have to reflect carefully the
exact nature of their wrongs and listen carefully to the pain of others. Money
borrowed needs to be paid back, and we need to ask for forgiveness. When
assessing the past the client needs to be careful not to injure people. Some of our
old behavior needs to be shared with God alone. This is no time for excuses or
further lies to cover up the shame. This is a time of embracing the truth, and in this
process we gain freedom from the slavery to the lie.
Gambling Step Ten
“Continued to take personal inventory and when we were wrong promptly
admitted it” (AA, 2014).

At the end of every day, the client needs to take a personal inventory of how he or
she succeeded or fell short of working his or her program. Did old problems,
behaviors, and attitudes begin to creep in, making recovery unstable? This keeps
the client on track and helps to measure how well the program was worked during
the last 24 hours. The beginning of the day starts with a prayer asking the higher
power to help the person stay clean and sober. At the end of the day, the client
needs to thank the higher power for helping him or her stay clean.

The client is working a self-directed program of recovery that needs maintenance.

This step keeps the way clear and helps to keep the client on track. The client
often goes back a step to see how dishonesty may have started to creep in. How
did our old ways begin to take over again, leaving us to feel misunderstood, lost,
and alone and have them create a plan to correct the mistakes? Here the client
needs to take stock of the problems that occurred during the day. This gives the
client a commitment to stay on track every day.

When disturbed it is an old habit to think the other person is to blame, but Step
Ten suggests that when we are feeling disturbed, something is wrong with us. The
clients have to take the responsibility for all the comfortable and uncomfortable
feelings. This takes away from the frustrating idea that other people have to
change and leaves us with the fact that the change needs to be spiritual and
internal. The client needs to take responsibility for all of his or her feelings. The
client needs to take the responsibility to see when feeling bad, something is wrong
with him or her.
Gambling Step Eleven
“Sought through prayer and meditation to improve conscious contact with God as
we understood him, praying only for the knowledge of his will for us and the
power to carry that out” (AA, 2014).

Prayer and meditation are how the clients make conscious contact with God.
Prayer is where the client talks to God, and meditation is where the client listens
for God to talk back. This ongoing conversation is the primary means by which the
client stays on the road to recovery. Problems are solved when the client lets go
and lets God direct the recovery journey. Daily conscious contact begins with a
morning prayer asking God to help the client stay clean and sober and ends with
thanks for a clean and sober day. Conversations with God should go on all day as
if God is right there as a close friend. There will always be difficult decisions to
make, but they can be made much better with the input of a higher power.

Meditation begins by closing the eyes and paying attention to breathing. Then with
each exhalation the client repeats a word of phrase of his or her choice, words
like love, one, peace, or let go. The body and the mind can then become still and
relaxed. The client can repeat a scripture verse or say the serenity prayer over
inside of his or her mind.

One way for the client to start this dialogue is to get up every morning and ask
God three questions: God, what is the next step in my relationship with you, what
is the next step in my relationship with my family, and what is the next step in my
recovery? The client then writes down whatever words or images that come to
mind and begins the day with new directions.

It is a good idea when communicating with God that the clients discuss all prayer
with their sponsor. Using this person in this way the client can prevent making
mistakes in the spiritual journey. It is also helpful to keep a daily record of all
communications. This will provide hope and peace.
Gambling Step Twelve
“Having had a spiritual awakening as the result of these steps, we tried to carry
this message to alcoholics, and to practice these principles in all our affairs” (AA,
2014).

From the first 12-step meeting to the first reading of recovery material to the first
meeting, clients learn they have stumbled onto something different and terrific.
You just don’t hear honesty like you do in 12-step recovery. It seems that every bit
of material is aimed at freedom from the lies that so permeate addiction. It’s like a
fresh wind from a new spirit is blowing. Immediately the clients begin to feel like
they fit in, even if at first they don’t want to; the truth sucks them in, and soon they
are hooked on something better than drugs. Soon it becomes obvious that this
honesty is contagious, and it brings a new freedom and hope. Sooner than they had
dreamed possible, a new spiritual connection with God is formed, and this spirit
is so loving that it is overwhelming. It loves the unlovable until even the
unlovable feels accepted. With this spiritual awakening, the client wants to share
this with as many others as possible, and the best place to share is with those who
are still suffering. The desire to carry the message to others is overpowering, like
sharing a new vacation destination, only this destination is even better; it is
sharing life itself.
Gambling Relapse Prevention
Relapse prevention is one of the most important aspects of treatment. In studies of
many different addictions, approximately two thirds of clients seem to relapse
within the first year of leaving treatment (Hunt et al., 1971; Marlatt & Gordon,
1985; Shaffer & LaPlante, 2008).

Most clients relapse within 3 months of leaving treatment. This is the period of
highest risk. Clients must be willing to do almost anything to prevent relapse.
They need to see themselves as clinging to an ice-covered cliff with their
recovery support group holding the only rope. The most important thing that they
can do is go to meetings. Clients who are working a daily program of recovery
will not relapse. You cannot work the program and gamble at the same time. These
behaviors are incompatible.

Relapse is a process that begins long before making the first bet. If the new tools
of recovery are not used and problems begin to escalate, then clients reach a point
where they think that their only option is to gamble.

The Relapse Prevention for Gamblers exercise (see Appendix 40) assists
gamblers in developing a relapse prevention plan. Some of this work was done
with alcohol or other addictions, but it is applicable for gambling problems
(Shaffer & LaPlante, 2008).

Relapse prevention requires that clients work a daily program of recovery. The
clients must take their personal inventory at the end of every day. If any of the
relapse symptoms become evident, then immediate action must be taken.

Other concerned individuals need to check clients daily for relapse warning signs.
This can be done by family members, sponsors, or coworkers. This is a good
reason for clients to go to daily meetings and hang around other recovering
persons. Often other people can see what clients are unable to see for themselves.

The clients need to identify high-risk situations that might trigger relapse and to
develop coping skills to deal with each situation. The more clients can practice
these skills, the better off they will be in recovery. In group, clients need to role-
play high-risk situations and help each other develop relapse prevention plans.
Each client will be different. Marlatt and Gordon (1985) found that most relapses
occur when clients are experiencing the following high-risk situations:

1. Negative emotions: These include particularly anger and frustration. They

also can be negative emotions such as boredom, jealousy, depression, and
anxiety.
2. Social pressure: This is being in a social situation where people are
gambling or being directly encouraged to gamble by someone.
3. Interpersonal conflict: This can be a conflict with a parent, spouse, child,
boss, friend, and so on.
4. Positive emotions: Something positive happens and the client wants to
celebrate. This can be a promotion, wedding, birth of a child, graduation, and
so on.
5. Testing personal control: The client gambles to find out whether he or she
can control the gambling.

Using the Relapse Prevention for Gamblers exercise, clients develop the skills
necessary to deal with each of the high-risk situations and then practice the new
skills until they become good at them. All clients must role-play gambling refusal
situations until they can say no and feel relatively comfortable. They must examine
and experience all of their triggers, see through the first use, and learn how to deal
with euphoric recall.

Clients must develop a plan for a lapse. What are they going to do if they gamble
again? Whom are they going to contact? What are they going to say? This must be
role-played in group to give the clients practice.

The clients must understand the behavior chain. They also must develop skills for
changing their thoughts, feelings, and actions when they have problems. Using
imagery, the clients need to experience craving and learn experientially that
craving will pass if they move away from the situation and use their new tools of
recovery. No gambler should carry money in early recovery. It is a relapse trigger.
Someone else, such as a spouse, has to manage the client’s money and give him or
her only enough to buy the essentials, such as lunch, that he or she needs each day.
This is a humbling experience for most gamblers but is necessary to prevent
relapse.
12 Adolescent Treatment

Source: ©[Link]/Wavebreakmedia.

Adolescent treatment must be different. You cannot use the same program for
adolescents that you use for adults. Teenagers have not developed the skills that
adults have. The client’s biopsychosocial level of development must be assessed
and used to develop an appropriate age-level treatment plan. Adolescents are not
socially and emotionally mature. Adults have a stable identity. Adolescents are
developing an identity. Only at the age of 15 does an adolescent have an idea of
who he or she is. Adolescence is the age at which tremendous physiological
changes occur in the body, mind, and spirit. The clients’ emotional and physical
structure is in transition from childhood to adulthood.
The Normal Adolescent
Studies have shown that most adolescents are well adjusted. They get along well
with their peers, teachers, and families. Despite greater demands, most youth are
rising to the challenge and developing higher levels of skill and maturity than
were common in prior generations (Block, 1971; Csikszentmihalyi & Larson,
1984; Douvan & Adelson, 1966; Larson, Brown, & Mortimer, 2003; Offer &
Offer, 1975; Offer, Ostrov, & Howard, 1981; Santrock, 2010; Vaillant, 1977;
Westley & Epstein, 1969). Adolescence should be understood as a transitional
stage that allows individuals to adjust to growth, development, and change. Each
cycle of life brings new challenges and opportunities, but all of the changes will
be incorporated into the basic personality structure. At the end of high school, the
majority of American adolescents enter a new phase of life called young
adulthood.

Source: Jupiterimages/Thinkstock.

Normal adolescents do not feel inferior to others. They do not believe that other
people treat them badly. They feel relaxed. They believe that they can control
themselves, and they have confidence that they can handle novel situations. They
feel proud of their body image and physical development. They feel strong and
healthy. They have embraced a work ethic. They feel good when they do a good
job. They are not afraid of their sexuality, and they like the recent changes in their
bodies. They do not perceive any major problems between themselves and their
parents. They are hopeful about the future, and they believe that they will be
successful. They do not believe that they have major problems (Larson et al.,
2003; Santrock, 2010).

Most adolescents have strong egos and are able to cope well with internal and
external stimuli. They have mastered previous developmental stages without
serious problems. They accept social norms and feel comfortable in society.
These adolescents are free of adolescent turmoil, and they comprise 80% of the
adolescent population (Offer, 1986; Santrock, 2010).
Puberty
Puberty is a period of rapid physiological development involving massive
hormonal and bodily changes that take place primarily in early adolescence.
Puberty is accompanied by changes in the endocrine system, body fat, muscle size,
new brain connections, height, weight, bone density, and secondary sexual
characteristics. Heredity is an important factor, but it does not totally determine
these events. Puberty takes place between the ages of 9 and 16 for most
individuals. Environmental factors can influence its onset and duration
(Blakemore, Berenbaum, & Liben, 2009; van den Berg & Boomsma, 2007).

From the first whiskers of boys and the budding of the breasts of girls is a giant
hormone flood. Hormones are like a light switch; they might look small, but once
switched on the whole room lights up. Androgens are the main male sex
hormones, and estrogens are the main class of female hormones. Both sexes
secrete each of these hormones but in different quantities. Testosterone is an
androgen that plays an important role in male development including development
of external genitals, increase in height, voice changes, and increased sexual
desire. Estrogens play an important role in female pubertal development including
breast development, uterine development, and skeletal changes (Cameron, 2004).

The hypothalamus, pituitary gland, thyroid gland, and the gonads all play roles in
growth and skeletal maturation. The hallmark of puberty is the reactivation of the
hypothalamic-pituitary-gonadal axis. In the United States, puberty begins at
approximately 9 to 10 years of age in girls and 10 to 11 years of age in boys. For
girls, the mean beginning of the growth spurt is 9 years of age and for boys 11
years of age. During their growth spurt, girls increase in height about 3.5 inches
per year and for boys about 4 inches per year. Because of these dramatic changes,
during puberty adolescents understandably become preoccupied with their bodies.
Throughout puberty, girls are less happy with their bodies, probably because their
body fat increases, and boys become more satisfied—probably because of an
increase in muscle mass (Santrock, 2010).

Some adolescents mature early, and some mature late. This is often called early
and late bloomers. Recent research shows that it is an advantage to be an early-
maturing boy and a disadvantage to be an early-maturing girl. Early-maturing boys
felt good about their early increase in height, muscle mass, and secondary sexual
characteristics. Early-maturing girls have more problems in school, were more
independent, and more popular with boys than late bloomers. In the 6th grade,
early-maturing girls were more satisfied with their body image, but by the 10th
grade, late maturing girls were more satisfied with their body image. By late
adolescence, early-maturing girls are shorter and stockier, while late maturing
girls are taller and thinner. The late maturing girls have body images that more
closely match the American ideal of beauty—tall and thin (Simmons & Blyth,
1987).

Early maturing increases vulnerability to a number of problems. Early-maturing

girls are more likely to smoke, drink, be depressed, have an eating disorder,
request independence from their parents, and have older friends. Their bodies are
more likely to elicit responses from males that lead to earlier dating and earlier
sexual experiences. Because of their cognitive and social immaturity, combined
with early physical development, early-maturing girls are easily lured into
problem behaviors. They look older and appear to be more capable of taking on
more mature responsibilities when they are not ready. Early-maturing adolescents
of both sexes take more risks, especially sexual risks (Santrock, 2010). It is
important for parents, mentors, and other responsible adults to monitor adolescent
behavior. When adolescents are in tempting and dangerous risk-taking situations
with minimal adult supervision, they become more vulnerable to negative
outcomes. Parents play the most important role and are the best at protecting their
children from the negative consequences of risky behavior (Arria et al., 2008).

Adolescents reach a level of health, strength, and energy that they will never again
have in their lives. They develop a sense of uniqueness and invulnerability that
convinces them that they will never suffer from poor health. Risk taking increases
from ages 10 through 15 and then declines and remains stable through the
remainder of adolescence and early adulthood. Even 18-year-olds are more
impulsive, less future-oriented, and more susceptible to peer pressure than adults
in their mid- to late 20s. This leads adolescents to seek experiences that create
intense feelings, such as loud music, horror movies, amusement rides, sex, and use
of alcohol and drugs (Dahl, 2004).
Ages 13 to 16
The period of ages 13 to 16 brings an enormous change in physical and
psychological development. Throughout adolescence, girls remain about 2 years
ahead of boys in their level of maturity. Some adolescents bloom early, and some
bloom late, each having a different psychological challenge. Early bloomers may
be expected to perform with individuals of their size, whereas late bloomers
suffer from the problems of self-esteem that result from looking more immature
than their peers look.

Adolescents of this age group experience a great deal of ambivalence and conflict,
and they often blame the outside world for their discomfort. As they struggle to
develop their own identities, dependence on parents gives way to a new
dependence on peers. These adolescents struggle to avoid dependence and may
disparage parents, devaluing past attachments. These early teens often find new
ego ideals that lead to idealization of sports figures or entertainers. Adolescents at
this stage are particularly vulnerable to people who they would love to emulate. It
is sometimes useless to try to get these adolescents to connect past, present, and
future behavior. Because they think concretely, they have difficulty connecting
current behavior with future negative consequences or connecting current negative
consequences with their past choices. These adolescents spend most of their time
in the present, but they can learn in treatment to do positive things to get positive
results. Nothing works better with adolescents than being reinforcing. When they
succeed, tell them that you are proud of them. Punishment and control does not
work as well as being reinforcing. You should be reinforcing the clients about
90% of the time and giving negative consequences about 10% of the time. Many
counselors think this loses them control, but in reality, this gains control. If your
clients care about you and respect you, they will do anything for you. Nothing is
more powerful than love, and these adolescents are starved for it.

The development of a self-concept is crucial at this stage. These adolescents must

explore their own morals and values, questioning the accepted way of society and
family to gain a sense of self. In treatment, they need to spend a lot of time
processing the positive and negative consequences of their behavior. Because
these clients have difficulty with connecting past, present, and future behavior, it
helps to show them how this works on paper or a blackboard.
Counselor: It says here that you got arrested for breaking into a gas station.

Client: I did not do anything.

Counselor: Then how did you get arrested?

Client: One of my friends told the cops I broke into the store.

Counselor: I am getting confused. Let’s write down on the blackboard exactly

what happened.

Client: Sure.

Counselor: Okay, you were riding around with your friends, right?

Client: Right.

Counselor: Had you been drinking?

Client: Yeah, we were drinking beer.

Counselor: So you decided to get in a car with people who were drinking beer?

Client: Yeah.

Counselor: But you could have said no, and you knew you were on probation,
and you knew that one of the requirements of your probation was not to drink
alcohol. Let us write that on the blackboard.

Client: Yeah, but I was not going to drink.

Counselor: Did you drink?

Client: I had a few beers.

Counselor: So you made a decision to drink beer when you knew it was against
the law and you knew it was against a court order. Let’s write that on the
blackboard.
Now, what happened with the gas station?

Client: We ran out of beer.

Counselor: So what happened then?

Client: Well, I knew of this gas station that was down a gravel road that had
beer.

Counselor: Was the gas station open?

Client: No, it was 3 o’clock in the morning.

Counselor: But you decided to drive down to the gas station anyway? Were you
hoping it would be open?

Client: No, I knew it was closed.

Counselor: How did you know that?

Client: We steal beer from there all the time. The owner leaves the back door
open.

Counselor: Let us put all these decisions on the blackboard. (The counselor
writes them all down.) Then what happened?

Client: The cops stopped us and found beer in the car.

Counselor: How much beer did they find?

Client: Five cases.

Counselor: What happened then?

Client: I got arrested for being in possession of alcohol.

Counselor: But you said you were not guilty of anything? Let us look at all the
choices you made that resulted in your arrest. (The counselor points the decisions
out one by one.) At any time, you could have made a decision that would have had
a different result. That is what we are trying to learn in treatment—to make better
decisions. To tell yourself that you didn’t make any bad decisions is lying to
yourself. We have a list of many decisions you made that resulted in a negative
consequence. In treatment, we are going to practice thinking through your
decisions, so you can end up with different results. Now, looking at all the
decisions you made, do you think you did anything that resulted in you getting
arrested?

Client: Yeah, I shouldn’t have gotten in the car.

Counselor: And?

Client: I drank when I knew it was wrong.

Counselor: And?

Client: I shouldn’t have told my friends about the gas station.

Counselor: And?

Client: And, I shouldn’t have had my friends steal the beer.

Counselor: That is right. Now copy all these decisions down, and carry them in
your pocket. Take them out each day for a week, and read them through. Your
decisions are important. They make you the person you want to be.

As the counselor, you cannot create the client you want. You can only show the
clients how to develop positive social, emotional, nutritional, and recreational
skills. Adolescents make up their own minds about who they are and what they
believe in. They must reassess the facts that were accepted during childhood and
must accept, reject, or modify these societal norms as their own. The here and
now thinking of earlier childhood gives way to a new capacity for more abstract
thought. These adolescents may spend long periods contemplating the “meaning of
life.”
Ages 16 to 19
In our culture, we expect a gradual development of independence and self-identity
by 19 years of age. The physical manifestations of approaching adulthood require
numerous psychological adjustments—in particular the development of how one
views the self in relation to others. The vast majority of adolescents attain their
adult size and physical characteristics by 18 years of age, and the earlier
differences between early and late bloomers no longer are evident. The process of
abstract thinking changes along with physical development, becoming more
complex and refined. Late adolescents are less bound by concrete thinking. A
sense of time emerges where these individuals can recognize the differences
between the past, present, and future. They can adopt a future orientation that leads
to the capacity to delay gratification. These individuals develop a sense of
equality with adults.

In the brain, adolescents are developing the prefrontal cortex, which controls
executive functioning such as focusing attention, prioritizing, planning, organizing,
and resisting primitive impulses. In childhood and early adolescence, the
amygdala, the site of many primitive emotions, takes priority; later in adolescence
the prefrontal cortex thinks through behavioral options and can inhibit maladaptive
risky behavior. It is here where a person learns how to resist primitive impulses.
This is the first area of the brain to go off-line in addiction. Drug addicts cannot
plan, organize, or resist primitive impulses because the prefrontal cortex is not
working. The prefrontal cortex comes completely online at about age 20 (Lerner
& Steinberg, 2009).

Self-certainty and an internal structure develop, while teens experiment with

different roles. By 19 years of age, most adolescents are considering occupational
choices and have begun to develop intimate relationships (Weedman, 1992).
Source: From PNAS USA, 2004, May 25; 101(21):8174–9. Epub 2004 May 17.
Copyright © 2004 National Academy of Sciences, U.S.A.
Interesting Adolescent Facts
In general, throughout puberty girls are less happy and have more negative
body images than boys (Bearman, Presnall, Martinez, & Stice, 2006).
Adolescents have a sense of uniqueness and invulnerability that convinces
them that they will never suffer from poor health (Santrock, 2010).
The three leading causes of death in adolescents are (1) accidents, (2)
homicide, and (3) suicide (National Vital Statistics Reports, 2008).
When given the opportunity, adolescents will sleep an average of 9 hours and
25 minutes a night (Tarokh & Carskadon, 2008).
Forty-five percent of adolescents get less than 8 hours of sleep on school
nights (National Sleep Foundation, 2006).
Adolescent girls engage in more self-disclosure in close relationships and
are better at active listening than boys (Leaper & Friedman, 2007).
In a recent national survey, 63% of high school seniors (64% of boys and
62% of girls) report they have experienced sexual intercourse (MMWR,
2006).
The overwhelming majority of adolescents growing up in a gay family have a
heterosexual orientation (Tasker & Golombok, 1997).
Children and adolescents who experience a heavy media diet of violence are
more likely to perceive the world as a dangerous place and to view
aggression as more acceptable (Wilson, 2008).
The Chemically Dependent Adolescent
Troubled adolescents comprise about 20% of the adolescent population. These
adolescents come from family backgrounds that are not stable. There often are
histories of mental illness in these families, the parents often have marital
conflicts, and the families often have economic difficulties. The moods of these
adolescents are not stable, and they are more prone to depression. They have
significantly more psychiatric disturbances, and they do well only with the aid of
intense psychotherapy. They do not grow out of it (Larson et al., 2003; Masterson
& Costello, 1980; Offer, 1986; Santrock, 2010). It is in this troubled group that
addiction often develops.

In this country, the average first use of mood-altering chemicals for boys is 11.9
years and for girls is 12.7 years (U.S. Department of Justice, 1983). Adolescents
usually use alcohol or drugs for the first time under peer pressure. They want to be
accepted and part of the group. Children are likely to model after the chemical use
of their parents. Children with alcoholic parents are at greater risk for becoming
chemically dependent. More and more adolescents are using prescription drugs
found in the medicine cabinets of their parents. Individuals who begin drinking
before the age of 14 are more likely to become alcohol dependent (Hingson,
Heeren, & Winter, 2006; Spalt, 1979; U.S. Department of Health and Human
Services, 2009).

Adolescents who continue to use will increase drinking to a regular pattern

(usually weekends). They may experiment with other drugs, particularly
prescription medication taken from their parents or friends. The use of opioids is
becoming more often the second drug of abuse. Hydrocodone is now one of the
most prescribed medications in the country, so opioids are widely available.
Adolescents begin to use drugs to communicate, to relate, and to belong. With
regular drinking, tolerance develops. The adolescents need more of the drug to get
intoxicated. Emotional changes may first be noticed here by their families. The
adolescents may become irritable and more noncommunicative. They may begin to
spend more time alone in their rooms. They may begin not caring for themselves
or for others. Polarization of parents and children begins to occur (Morrison &
Smith, 1990; U.S. Department of Health and Human Services, 2009).

As addiction further develops, adolescents no longer can trust themselves when

using chemicals. The choice to use these drugs no longer is available to them; they
have to use to feel normal. The continued use of chemicals eliminates the ability to
think logically and rationally. Rationalization, minimization, and denial cut the
adolescents off from reality (Soujanen, 1983).

Chemically dependent adolescents gradually change their peer group to include

drinking and drug-using friends. They begin to use chemicals to block out the pain.
They no longer use for the euphoric effect. They drink to escape pain. Anger,
blackouts, and drinking alone are strong indicators of addiction in the adolescent
population. With the progression of the disease, family conflicts increase. The
adolescents may run away, withdraw, or act out at home and at school. They
withdraw from family and community activities. Problems with the police and
school officials increase and become serious. The adolescents may become
verbally abusive to parents and more rebellious to authority figures. Life begins to
center around the drug or addicted behavior of choice. Daily use begins, and these
addicted individuals begin to use to maintain rather than to escape. The
adolescents attempt to cut back or quit, but they are unable to stay clean and sober.
Physical deterioration begins. Hiding and lying about drugs becomes more
common. The adolescents feel more intensely isolated and alone. Concern is now
openly expressed by parents, teachers, and even peers. Gradually, the adolescents
lose all self-esteem, and depression begins. Persistent chemical use leads to
incarceration, institutionalization, or death (Chatlos & Jaffe, 1994; Morrison &
Smith, 1990).

Addiction stops emotional development and the addicted adolescent stays

immature. Their prefrontal cortex goes off-line, so they become unable to focus
attention, plan, organize, inhibit primitive impulses, and learn. To develop
normally, adolescents must learn to use their feelings to give them energy and
direction for problem solving. When feelings are consistently altered by alcohol
or drugs, this no longer is possible. The major coping skill of addicts is their
addiction.

Adolescent addiction can occur extremely quickly—within weeks—because

adolescent emotional development is immature. Adolescents do not have the
internal structure to bring themselves and their lives under control. They cannot
delay the onset of addiction for years, as can adults.
The Adolescent Chemical Dependency Counselor
Working with adolescents can be among the most rewarding work in the field. By
making an early intervention in an adolescent’s life, you can save him or her years
of misery and certain death. Adolescents can be frustrating, but to see them
blossom from hurting children into children who can laugh, play, and learn is a
wonderful thing to watch. Just being a part of their recovery will make you feel
good about yourself.
Source: ©[Link]/monkeybusinessimages.

Becoming an adolescent counselor is not for everybody. These clients have a lot
of energy, and the counselor has to have a high frustration level to deal with a
certain amount of disorder without feeling too uncomfortable. As the counselor,
you must be able to withstand people challenging you face-to-face and toe-to-toe.
You must have good impulse control. If you have a weak spot, these clients will
find out what it is and use it against you. They are expert manipulators. It is
normal for them to want to manipulate you and the system.

Adolescents almost never decide to come into treatment on their own. They are
forced into treatment by other people, their parents, or the courts. Most of their
homes are dysfunctional, and many have chemically dependent parents. These
clients come into treatment angry and resistive. Where most adults are ready to
surrender, most adolescents are ready to fight. The staff must be willing to endure
this initial resistance. These clients gradually will change their attitudes about
chemicals as they settle down and process more of the facts.
Unlike adults, adolescents are not frightened by the physical consequences of
addiction. It does little good to threaten them with talk about addiction being a
deadly disease. The adolescents need more time before they will pay attention to
this information. They think that they are invincible when it comes to physical
problems. Adolescents are resistive to the initial part of the program, and they
need more structure in treatment. This allows them to learn self-discipline and
social responsibility. A good way of adding structure is to develop a level system
(see Appendix 22) in which the clients move up in rank as they progress through
the program. At each level change, the clients earn increased freedom and
responsibility. A point system (see Appendix 22) is used in conjunction with the
level system to increase the structure. In the point system, the clients earn points
for working the program and lose points for resisting. Points can be given for a
clean room, a neat appearance, level of commitment, participation in group,
completion of exercises, positive interaction with treatment peers, and so on.
More resistive adolescents will need more structure (Davidson & Seidman, 1974;
Kazdin & Weisz, 2003; Phillips, 1968).
The Point System
Most adolescent programs these days will need a point system (see Appendix 41).
Points give you more advantage, and rewards are instantaneous, providing for
faster behavior modification. With a point system, clients earn privileges as they
accumulate points. They can earn telephone calls, soft drinks, free time, visits
from guests, television or radio time, snacks, and so on. They lose points for
breaking the rules. Each treatment center needs to develop its own point or level
system geared to its specific client population. Each center will be different, and
the systems will have to be constantly revised or updated. Various point systems,
sometimes called token economies, have been developed for these purposes
(Cohen & Filipczak, 1971; Phillips, 1968).

In the point system, the clients earn points for each goal that they complete during
the day. Points can be given or taken away as the staff desires. For example,
clients will be required to keep their rooms clean. They will be given points for
completing this goal or will lose points for failing to complete the goal. They can
earn or lose a certain number of points per day for keeping their rooms clean.
They can be scored on participation in group or on commitment to treatment.

The staff must make sure that reinforcers are positive. The clients turn in points
for positive reinforcers, candy, television time, or trips to the recreation room.
The clients can earn greater privileges by saving points. For example, a “fun”
video might cost 100 points. A telephone call to a family member might cost 200
points. This teaches the clients self-discipline and how to delay gratification.
Clients with serious conduct disorders need this kind of structure (Graziano &
Mooney, 1984; Herbert, 1982; Kazdin & Weisz, 2003; Ollendick & Cerny, 1981).

A point system adds structure because it gives the staff more control. This tends to
shape behavior more quickly. Token reinforcement programs for adolescent
clients have existed for a long time and have a proven record of accomplishment
(Kazdin & Weisz, 2003).
The Primary Elements in Adolescent Treatment
The most important thing that occurs in adolescent treatment is the change in
perceptions, attitudes, and behaviors that revolve around addictive chemicals. The
clients must come to realize that they have a problem, come to understand the
problem, and develop recovery skills. Adolescents must be habilitated rather than
rehabilitated. They have never developed the skills necessary to lead a normal,
sober lifestyle. They need to learn these skills for the first time. They must stop
using chemicals so that they can grow and mature normally. Healthy role models
are essential to this process. The staff on any adolescent unit must show the clients
how to deal with problems. Clients further along in the program also will model
coping skills. Clients must be shown how to treat each other with respect at all
times. New adolescents room with someone further along in treatment to show him
or her the ropes and be a good role model.
The Rules
Adolescents will constantly test the rules and each staff member. The staff must
rigidly adhere to the rules of the treatment center. It is a manipulation for an
adolescent to try to get special privileges from you. If they can get you to bend a
rule even a little, then they have you right where they want you. Your rules do not
mean anything because they can be manipulated.
Communication Skills
Adolescents need to focus on developing communication skills (see Appendix
13). They need to practice identifying their feelings and sharing their feelings with
their treatment peers. They must practice telling each other the truth. In the skills
groups learned from Treating Alcohol Dependence: A Coping Skills Training
Guide (Monti et al., 2002), the clients role-play nonverbal communication,
assertiveness, drink and drug refusal skills, and how to develop a supportive
support network at home. As the clients develop new skills, they can transfer this
behavior to their families during family visits (Monti et al., 2002).

As open communication begins, the clients build trust. They usually transfer trust
from the treatment peers to you (the counselor) and to the parents in that order.
Mutual respect is necessary, and the clients must hear you be positive about
treatment. A positive attitude will take you a long way with these clients.

It is important for you to know that adolescents are not trying to hurt you. They are
not mad at you. They are just mad at their lives. Most of their anger is transferred
from the family and environment from which they came. If they act out, then you
must provide the structure of consequences. Do not hesitate to give these
consequences. They are learning tools. Explain to the adolescents that it is not you
who is doing this to them. They knew the rule, and they broke it. They knew the
consequence, and now they must accept it.

It is normal for adolescents to push the limits and break the rules. They will try to
manipulate their environment just as they did at home and at school. This is all that
they know how to do. You cannot blame them for using the old skills that have
worked for them. Treatment will teach them what is wrong with the old skills, and
it will teach them new skills to get what they want more appropriately.
Honesty
Lying is a good example of an old behavior. Adolescents have learned how to lie
to get their way. They lie to get out of trouble. They lie to get what they want. This
works for them, at least to some degree, and the lying increases. As the lying
grows, they feel more lonely and isolated. What they do not understand is that
lying and loneliness are directly connected. If they lie, they will be lonely. Most
adolescents do not understand this, but they will learn it with education. Once they
learn why they are telling the truth, they will be motivated to be honest. All
adolescents complete the Honesty exercise (see Appendix 8).

Adolescents need to practice honesty. Just because they understand the principle
does not mean that the behavior changes. They must practice it repeatedly. They
need to experience the natural rewards that come when they use a new skill. As
the clients set up natural reinforcers, the behavior ultimately will become
automatic.
Exercise
Adolescents need a challenging exercise program. They need to exercise at a
training heart rate at least once a day. This needs to be about 1 hour of fun activity
that can turn a bad day into a better one. Sometimes adolescents do not like each
other, but if they play games with each other, the interpersonal dynamics change.
They need to be actively involved in sports and other athletic events. Weight
training, playing sports, and jogging are excellent accompaniments to any
program. These are exercises where the adolescents can see their gains and feel
good about themselves. Adolescents care about how they look, and exercise can
show them they are gaining in strength, flexibility, and endurance. Boys get to feel
like a pro athlete if they play a game well. This helps them to identify with
positive role models who are clean and sober. The girls get to learn activities that
can control their weight and shape their bodies to be more attractive. It is
particularly important that the adolescents do activities that they know they cannot
do. This improves self-efficacy and proves they can stay clean and sober. Hiking,
walking, rock climbing, backpacking, and camping make kids work together to
accomplish goals. They have to help each other, or the activity will fail. In rock
climbing, for example, you have to trust your belayer to save your life if you fall.
This brings trust and pride in the accomplishment. Not every program has a ropes
course, but these are excellent activities to show adolescents that they can do what
they know they cannot do. This means they can stay sober even if they have always
thought they could never live without drugs or alcohol. Many of these kids have
never done any healthy activity, such as a hike or picnic, so it is a new world for
them where they can succeed and work together to accomplish goals. When
adolescents are acting out by destroying property or not complying with treatment,
there is nothing like fun exercise to turn the group around.
Fun in Sobriety
Adolescents need to learn how to have fun in sobriety. One of the things that they
are worried about is that they will not be fun if they stop using drugs and alcohol.
They do not want to be boring to their friends. They need to see that they can feel
good without chemicals. The only way of doing this is to take the clients out on
recreational activities and have them experience firsthand that they can still enjoy
themselves. Trips to the zoo, an amusement park, a pizza parlor, an ice cream
stand, or a video arcade all can be used to show the adolescents that they can still
have fun in sobriety.
The Reinforcers
Adolescents are very concerned about how they look and how they get along with
their friends. If you are searching for a reinforcer, you always can hook into one of
these. Adolescents desperately want to be loved, no matter what they say. These
children are starving for genuine love, compassion, help, attention,
encouragement, and praise. They need people to listen to them, and they need a
chance to prove what they can do. Most of these clients feel like failures in the
real world. They are mad at themselves, and they are mad at everyone else. They
have felt overwhelmed by their dysfunctional home situations. Many of these
children come from homes of severe abuse and neglect. They have been beaten
down by society, and many of them have given up. You will see these clients
flourish in an environment of love. You will see the real child be reborn. It is a
beautiful thing to watch.
Spirituality
Adolescents have more difficulty with spirituality than do adults. Most
adolescents still have their health, and they are not as ready to surrender. They
need to be shown a higher power is there for them. This takes a spiritual program
of action rather than of words. You need to seek a clergy person with particular
skills in working with adolescents. The clients should trust this person and not
feel intimidated by him or her. The clients need to explore spirituality in
spirituality group. The best way of hooking adolescents into a higher power is to
have them directly experience a higher power’s presence. This is done using the
meditation exercise discussed in Chapter 6.

Some of the adolescents will resist a higher power, but they cannot deny their own
experiences. Some of these clients have been involved in Satanism, and it takes a
great deal of skill to get them to a place where they can be open to a higher power.
The best therapist here often is another peer. Peers have a way of trusting each
other about this sensitive issue. Adolescents will explore spirituality if they do not
feel as though they will be shamed by their peers. A peer further along in the
program is an excellent model.
Group Therapy

Source: ©[Link]/clearstockconcepts.

Group therapy with adolescents is different. The level of sharing is shallower at

first. Adolescents are inexperienced with their deeper feelings. They do not have
the skills necessary to share openly. They feel just as deeply as adults do, but most
of them never have practiced communicating their feelings. Early attempts to share
feel clumsy and awkward, and the adolescents fear being humiliated in group.
Once older members of the group begin sharing, the way is paved for new
members. Role-playing works well for adolescents. They do not feel as
vulnerable when playing a role. They can role-play drug refusal situations or
parent–child conflicts.

Adolescents need to role-play the skill exercises in group. For example, you can
hold denial court for those clients who remain in denial. This is an active group.
The adolescents enjoy and benefit from the experience. In denial court, the clients
divide and play the roles of defense attorney, prosecuting attorney, judge, and jury.
The client who is in denial is called to the stand and is examined and cross-
examined by the attorneys. The client tries to prove to the court that he or she is
not an addict. The group holds the trial and reaches a verdict.

The clients can act out the thoughts that exist inside of someone’s head at certain
decision points. One client can pretend to be the illness, while another pretends to
be the healthy side. The two sides try to get the adolescent in question to behave in
certain ways. These three—(1) the illness, (2) the healthy side, and (3) the person
—can be placed in a variety of situations to see how all sides respond. Use your
creativity, and come up with group exercises. What you are after is active
participation by all of the group members. Once the group members start talking,
let them go, with only occasional guidance from time to time. The best treatment
will be between the clients further along in the program and those just coming into
the program. Once they get the hang of it, the adolescents will enjoy group. It
draws them closer together. They feel supported, listened to, and understood. They
lose that sense of separateness that has haunted them all of their lives.

Give each client a paper bag and many old magazines. On the outside of the bag,
have them glue on pictures that show how they want the world to view them. Then
on the inside of the bag glue on how they really feel inside. Then have the group
discuss the differences from the outside person they are pretending to be and the
real person inside.

If possible, have a ropes course where the clients can learn self-efficacy. Ropes
courses challenge the clients to work together to accomplish a goal. All of these
exercises can teach adolescents that they can do something they know they cannot
do. If they can do this, maybe they can stay clean and sober.
Peer Pressure
Peer pressure is vitally important to adolescents, and they can easily be swayed to
use drugs by their peer group. Peer pressure comes in two forms: (1) being in a
social situation where chemicals are available and (2) being actively encouraged
to use chemicals by friends. The adolescents need to spend a lot of time role-
playing drug refusal exercises. They need to practice exactly how they are going
to say no. Most of the adolescents will need to work through the Peer Pressure
exercise (see Appendix 23). Sometimes the adolescents will attempt to gang up on
the staff because of something that happens between a staff member and a client.
This is a good sign because the group members function to help each other. This
process should be encouraged, and the staff should carefully listen to the
complaint. Try to compromise and reach a decision that is agreed on by all. The
center rules must not be broken or manipulated in the process, but the situation can
be explored to determine exactly what happened and who is responsible. This can
be a difficult process, but once the whole truth comes out, it will be clear where
the client or staff member went wrong. Everyone makes mistakes, and Step Ten
says, “When we were wrong, we promptly admitted it” (AA, 2001, p. 59). This
goes for the staff as well as for the clients. It is a great learning experience for the
clients to see the staff struggle to be fair and impartial. It is not easy.
Continuing Education
Continuing education is necessary for adolescents—even those who have dropped
out of school. They should have a thorough educational assessment, including an
examination of school records and psychological testing. From these data, the
schoolteacher develops individual educational treatment plans. Some clients will
need intensive remedial work, and some can continue regular assigned
schoolwork. School is an excellent opportunity to develop self-discipline. The
clients need to determine what they want from further education, and they need to
help develop a plan for reaching their goals. Do not allow clients to slough off
school because they are dropouts. Quitting is old behavior. All adolescents need
continuing education.
Continuing Care
During the discussion of the treatment plan, it is a good idea to begin continuing
care planning. This will include a 5-year follow-up plan run by the continuing
care case manager. This is a formal contract negotiated with the client and
significant others. The plan includes an agreement that the client work all aspects
of the continuing care plan with detailed consequences if the client fails to meet
his or her obligations. The plan should include the following:

Client sends in a log of 12-step meetings by the 10th of every month. The
number of meetings each week is set by the case manager based upon client
needs.
Client will meet regularly with his or her 12-step sponsor, mentor, or coach.
Client will agree to attend all therapy recommended by the primary
counselor with a report from the primary care giver as deemed necessary.
Client will agree to up to one random drug screen a week for the first 6
months and up to one random drug screen a week for the next year and a half.
The client can easily use the PharmChek Drugs of Abuse Patch that lasts for 7
days or longer ([Link]) or use an alcohol ankle bracelet, the
Secure Continuous Remote Alcohol Monitor (SCRAM), that measures
alcohol from the sweat 24 hours a day, 7 days a week. Redwood Toxicology
Laboratory ([Link]) has also developed an ethyl
glucuronide (EtG) alcohol screen that will show any alcohol use for the last
80 hours. This test is often too sensitive as it picks up any alcohol use,
including shaving lotion and hand sanitizers.
Client will take all medications as ordered.
Client needs a school and community advocate, so she or he has many healthy
adults to contact if she or he needs encouragement or support. A school
teacher, counselor, coach, or youth pastor can often be elicited to pay special
attention to a new student and keep encouraging him or her to work toward
positive life skills.
If the client fails to meet any of his or her obligations, the client is first sent a
letter explaining the deficiency and asking that it be corrected.
If the client fails to answer the letter, an appointment will be set up with the
continuing care case manager.
If the client still fails to comply with the contract, the consequences agreed
upon will be implemented. This might include contacting the clients,
 professional board, employer, probation officer, drug court judge, family
members, and so on. The client has initially signed a release of information
to all such individuals and written each of them, cosigned by the continuing
care case manager. These letters are signed, sealed, stamped, and mailed if
necessary. The continuing care manager must be very careful to design a
consequence that leads the client back into treatment.

Continuing care is essential for adolescent clients, and many of them will need
long stays in a halfway house or group home. If you send them back to a sick home
and community, they will be using. Adolescents do not have the internal structure
necessary to stick to a recovery program on their own. Just going to meetings is
not enough. The continuing care program should continue to teach the tools of
recovery and show the clients that they can have fun in sobriety. The group
members need to go on outings and do fun things together. They can attend
concerts or go to the zoo, parks, games, dances, and so on. This establishes a new
peer group and solidifies recovery.
The Parents Support Group
As the adolescents are going through treatment, the parents attend at least two
groups per week. Again, this is individualized and based on the needs of their
families. All parents attend a parents support group and a weekly conjoint session
with the clients. The parents support group encourages the parents, supports them
emotionally, and teaches them the tools of recovery. This is a 12-step group. The
clients’ families concentrate on working the steps, developing healthy
communication skills, and learning a behavior program to follow in continuing
care. All parents need to read Parenting Your Out-of-Control Teenager: 7 Steps
to Reestablish Authority and Reclaim Love by Scott Sells (2001) and discuss
each chapter in this book with other parents. A parent support group that teaches
parenting skills is an essential component in any adolescent program.
The Behavioral Contract
The Behavioral Contract (see Appendix 24) is the primary method by which
clients and their families hold each other accountable for their actions. The
contract is necessary to show the clients and families that they can function
together in an atmosphere of mutual support. A point system will be necessary for
more seriously disturbed adolescents. All parents need to be taught behavioral
contracting and the point system.

Using the approach of Alexander and Parsons (1973), the parents negotiate a
behavior contract with the adolescent. The contract is jointly developed by the
client, the family, and the counselor. The family is taught how to negotiate future
recovery skills on its own. The benefit of behavioral contracting has been widely
confirmed by a variety of studies (Alexander, 1974; Sanders & Glynn, 1981;
Wells & Forehand, 1981, 1984).

If the adolescent has a more serious behavior problem, then the parents will need
to develop a point system. The parents will need intensive training and practice in
this procedure before the child comes home. The training is divided into three
phases. In the first phase, the parents are taught basic social learning concepts
(Patterson, 1977; Patterson & Gullion, 1976). In the second phase, they are taught
how to define, track, and record deviant and prosocial behaviors. In the third
phase, the parents learn how to develop a point system where the adolescent earns
or loses points contingent on positive and negative behaviors. Points are
exchanged daily for rewards previously selected by the child. The parents are
taught to use positive social reinforcers (e.g., smiles or pats on the back) for
appropriate behaviors and time-out procedures for inappropriate behaviors. As
the counselor, you must work closely with the parents, particularly shortly after
discharge. Daily phone calls from the case manager might be necessary to make
sure that the parents and other mentors are following the program. The parents and
the client need to attend continuing care for at least 1 year following treatment.
Some will attend for years depending on their specific needs.
Phases of Adolescent Treatment
Adolescent treatment seems to go in phases. When the adolescents come into
treatment, most of them are angry. This may be expressed overtly or covertly. They
may be overly aggressive toward the staff, or they may be quiet and sulk. This
defiant period is a good indication that the clients have been out of control. They
are attempting to use old skills to bring order to a new situation.

In 1 or 2 weeks, the adolescents will begin to comply with the staff, but they still
have not begun to internalize the program. They have learned how to get along in
treatment, but they do not think that they have a problem, and they are planning to
go back to their old behavior when they leave treatment.

As the adolescents begin to feel the genuine love of the staff and the group, they
begin to take a real look at themselves. They see the negative consequences of
their addiction. They realize that they do not want to go on living like that. This is
positive movement, and it depends primarily on trusting other people. Many of
these clients never have trusted anyone, but as they open up to the group and
continue to be accepted, they soften. When they behave at their worst and the staff
still sticks with them, a light comes on in their heads. The adolescents, who came
into treatment defiant and trusting no one, begin to reach out to others. They feel
loved and understood for the first time in their lives.

As trust develops, denial becomes more evident. The clients begin to see the truth.
The clients are encouraged to transfer this trust of the group to trust of their new
AA/NA group. Many adolescent clients hate group when they come into treatment,
but in time, they learn to like it. It is the only time in their lives when people have
dealt with real feelings. The clients are encouraged to see their new AA/NA group
as a healthy family. In this family, the clients can grow and develop normally. The
goal is to stay involved with a 12-step group and a higher power for life.
13 The Family Program

Source: ©[Link]/Deborah Cheramie.

The purpose of the family program is to begin to heal the many wounds caused by
addiction and to improve the client’s recovery environment. A family system that
has been altered by the disease may reinforce addiction. Frequently, a family
crisis brings the client into treatment. Including the family in the treatment program
increases the chances that the client will engage and stay in treatment.
You should carefully evaluate the client’s social system and move it toward being
supportive of recovery. If anyone in the family needs intervention for a mental
disorder or substance abuse, it is your job to refer that person to the appropriate
professionals.

If the family is not supportive, then you should intervene with education and
counseling to change the attitudes and behaviors that will make the client’s
recovery possible. It should be obvious that the client will do better in recovery
when supported by his or her family. This is motivational enhancement like you
used on the client to bring him or her out of denial and into the truth. At first, you
need to listen to each family perspective so carefully. From there, you can
understand their needs from their perspective. Once each family finally feels
heard, you can move into family meetings without the client and finally into
meetings with the family including the client. You will find that everyone has
unmet needs, and they have maladaptive ways of getting their needs met. You need
to help each family member learn and practice new coping skills to get their needs
met appropriately.

Each primary relationship needs to be examined carefully. You should send each
significant person the Family Questionnaire (see Appendix 25). This will give you
a good idea of how the family members are functioning and explore what they
think about the client and his or her addiction.

By the end of the family program, you should know how each person is functioning
and how the family is functioning as a unit. The family is like a mobile, or a group
of objects suspended by strings. They are all connected, so if you touch one part of
the mobile, the whole system moves. This is how a family works. If one person
changes, the whole family system changes. You need to gather enough data to show
you how the family members are coping with their environment. Many families
will need financial aid or therapy of some sort in continuing care.
The First Family Contact
The client’s family should be contacted within the first few hours of the client’s
admission. Once you have met the client, you need to speak with the family
members either in person or over the phone. You need to speak to them and light a
spark of hope about recovery. Explain that their loved one has a chronic, relapsing
brain disease that will need to be managed for life. In time, the family will commit
to an active recovery program for at least the next 5 years. The family members
will be relieved to have the client in treatment, but they will feel frightened that
treatment might not work. Do not give them unrealistic expectations, but reassure
them that the client is safe and has a new opportunity to recover. The family
members should be immediately encouraged to begin attending 12-step meetings
such as Al-Anon, Alateen, or Alatot. Give them a list of meetings in their area,
and stress that they need to get some support right now from people who
understand the disease. The best place to feel understood is with people who are
in recovery.
How to Handle the Early Against Medical Advice Risk
The family must be warned that the client may attempt to leave treatment early
against medical advice (AMA). It is not uncommon for clients to want to go home
after the first few hours in treatment. You want to reduce the possibility that the
client will call the family and have someone come and pick the client up. You
need to make it clear that this is very common and is to be expected in early
recovery. It is not a matter of concern so long as it is handled properly. Tell the
family to say a firm no along with some gentle encouragement. That usually is
enough to keep the client in treatment. If the client is a serious AMA risk, you
might have to plan an in-house intervention with the family. Some clients come
into treatment not yet ready to surrender to the disease. The family may need to tell
the client that if he or she leaves treatment early, they will file an involuntary
commitment. Most states allow this for substance abuse. Here the client is brought
into custody by the police and sent to a qualified mental health professional for a
formal evaluation. If the professional believes the client is chemically dependent
and because of this dependency is harmful to himself or herself or others, the court
can order a client into treatment. Your most important job early on with the family
is to instill hope. If the client works the program of recovery, there is over a 90%
chance that the client will stay clean and sober.

The family members may have a lot to tell you over the phone, but you want them
to save this information for the forms that you will be sending them. The first
contact with them is to reduce fear and to support their decision for treatment. The
forms take a history of the problem and give the family members an opportunity to
provide input into the treatment process.
Common Family Problems

Source: ©[Link]/Alina555.

No one can grow up in an addicted family, or live in one, without it changing him
or her. Clients who live in addicted homes live in a chaotic whirlwind. These
clients grasp at anything that will help them regain control. Their environment has
been totally out of control for a long time. They do not know what is going to
happen next. They cannot predict or trust anyone. They live in fear, anger,
confusion, and mistrust. They desire, more than anything else, to achieve stability
in their families.
Codependency
A codependent person is obsessed with controlling the person who is out of
control (Beattie, 1987; Weinhold & Weinhold, 1989). Addiction adversely affects
everyone in the home. Codependents, adult children of alcoholics, and children of
alcoholics are some of the names given to these suffering persons.

These people have been seriously damaged by addiction. They have learned to
live in an addicted world, and this takes using maladaptive skills. They learn to
stuff their feelings and to keep secrets. Their motto is do not trust, do not talk, and
do not feel. They focus their lives totally on the addicted person. They do not have
time for themselves and their own needs.

Codependents are as blinded and reality distorted as are addicted persons. They
do not think about their own problems because their own problems are too
painful. They would rather think about other people. Their whole lives revolve
around the sick persons. Codependents become so obsessed with helping and
controlling the other persons that they lose the ability to think. They cannot see
reality. Over the years, in an unbearable situation for most, they have developed
an incredible tolerance for neglect and abuse. They keep thinking that if they just
do enough—if they figure it out—then everything will work out.
Guilt
Family members often feel incredible guilt. They think that they are at fault. The
addicted person keeps denying responsibility, and someone must be held
accountable, so the family members often take the blame. The spouse might feel
that everything would be okay if he or she could just be the right kind of husband
or wife or could just do the right thing.

These people attempt to control their out-of-control environment in any way they
can. They whine, wheedle, threaten, cry, bemoan, seek counseling (for
themselves), manipulate, and lie. Each attempt at control works to some degree,
and it is kept tucked away in their behavioral repertoire to be used later.

The wife might start calling her husband to make sure that he got to work. She
feels responsible for her husband getting to work on time, and her anxiety builds
as the time approaches for him to be there. The little boy of the family might try to
do especially well in school in hopes that the drinking or drug use will stop. The
child is anxious because he feels a direct relationship between his grades and the
family problems. Family members will go to incredible lengths to control the
addiction. They pour out bottles. They threaten using friends. They scold, argue,
hide money, cry, get depressed, get anxious, go to church, talk to the boss, and
make excuses. They chase addicted friends away from the house. They talk to the
family physician or their clergyperson in trying to get support.
Loss of Control
As more and more energy is expended in trying to control someone else, the
family members lose contact with themselves. They become so involved in the
addicted person that they lose who they are. They do not know what they want.
They do not know how they feel. They cannot ask for what they want. They cannot
share how they feel. This leaves their interpersonal relationships empty, isolated,
and alone. They cannot use their real feelings to solve problems. Therefore, their
problems escalate out of control. They are on a treadmill, frantically trying to
keep the family together.
Shame
Codependency is deeply rooted in the feeling of shame. The family members feel
as though something is wrong with them. They believe that the reason why the
family is in such a mess is that they are not good enough. They are not working
hard enough or long enough. If they could just figure this whole thing out, then
things would be better. They are battered and beaten. They keep trying, but they
keep failing. They never can keep up with the increasing nightmare.
Caretaking
Family members of an addicted person learn to be caretakers. They are obsessed
with taking care of the addicted person. In their frantic attempt to take care of
someone else, they lose contact with their own needs. In group, they will be able
to tell you how the addicted person is feeling, but they will be unable to tell you
how they themselves are feeling. Their whole lives are caught up in taking care of
the other person. This happens to divert the family members from feeling the pain
in their lives. In group, you must redirect the family members to stop concentrating
on the other person and to explore their own pain. This will not come easily for
them because many of them have been feeling numb. You must listen with your
whole body to step into this other person’s life. You must remove yourself and
how you feel and tune into the family members’ perception and level of coping
skills.
Enabling
The family members will have a long history of making excuses for the addicted
person. They have been protecting the addicted individual from facing the severity
of the problem. They help the addicted individual get out of trouble. They will lie
because they are ashamed of the reality of their family life. Children will lie to
friends, the spouse will call the boss, the father or mother will make excuses, and
the siblings will pretend that nothing is wrong. Enabling is the major way in which
the family members protect themselves from the reality of the situation. They fear
that if they do not enable, then their world will collapse. The truth is that they are
living with an addictive individual and their lives are out of control, but they keep
the family from falling into disaster by shoring up the situation.

The family members must realize that they have kept the illness alive by protecting
the chemically dependent individual from the reality of his or her behavior. By
their constantly getting the addicted individual out of trouble, the addicted
individual could not learn the truth. To protect themselves, the family members
allowed the illness to go unchecked. They fed into the denial of the disease.
Inability to Know Feelings
People in addicted homes are so separated from reality that they do not know how
they feel. Their feelings have been suppressed for so long that all they feel is
numb. They have let go of the pain and live in lives full of false beliefs. They have
learned to keep their feelings hidden because they fear that if they expressed
themselves, the drug addict will get worse. Some family members who have been
subjected to incredible abuse think they feel fine.
Inability to Know Wants
The family members do not know what they want. Their lives are centered on the
addicted individual. They only know what the addict wants. That is the primary
focus of attention. Most family members are trying to hold on to their sanity and to
keep themselves, and the family, from going under. They have no time for the
superficial wishes and wants of normal people. They only have vague hopes that
everything can be better. They are so used to the broken promises that they do not
listen anymore.
Lack of Trust
The family members have learned to trust no one. The people who they trusted
ultimately abandoned them repeatedly. Therefore, they lie to everyone—parents,
friends, brothers, sisters, neighbors, and fellow employees. They tell no one their
secrets. They never trust that they will be safe and comfortable again. They have
had their dreams shattered so often that they are afraid to dream anymore.
People Pleasing
The family members of the addicted person learn to be people pleasers. They will
do anything to prevent someone from feeling bad. This comes from the attempt to
be responsible for other people’s pain. If someone is hurting, the family feels
anxious and numb. The pain is their fault, and they have to do something about it.
They feel that their wants and wishes always are secondary to the needs of
someone else. They get to the point where they feel guilty when they get anything;
someone else might be deprived.
Feelings of Worthlessness
The family members feel worthless. They feel as though no one cares for how they
feel or for what they want. They feel profoundly inadequate and unlovable. They
feel rejected by others. They do not feel as though they have a fair chance in life,
and somehow they feel as though this is fair—that it is their entire fault anyway.
This would not be happening to them if they were better persons. This is all they
deserve. This is the best they can get.
Dependency
Codependent persons do not trust their own decisions. They feel incapable of
dealing with life. Something always goes wrong with their plans. The very thought
of leaving the addicted individual terrifies them. They cling to that person. The
more they try to control things, the more things lapse out of control. They develop
a profound sense of inadequacy and indecisiveness that keeps them locked in to an
intolerable situation.
Poor Communication Skills
The family members have poor communication skills. They learned a long time
ago the credo of the addicted family: “Do not talk, do not trust, and do not feel.”
These individuals do not talk to their friends or other family members. They are
cut off from everyone. They feel afraid of open communication. If they talked
openly, then the truth might come out, and the family would be destroyed. They
constantly tell other people what they think these people want to hear rather than
how or what they really think or feel. Each of them may need to work through the
Communication Skills exercise (see Appendix 13).
How to Treat Family Members
Before reading this section, read the Codependency exercise (see Appendix 26).
The exercise will show you what the family members need to work on in
treatment. It must be emphasized that each family—and each family member—
must be treated individually. No one intervention works for everyone. All families
will need individually developed treatment plans. No two families are the same.

The first thing that the family members need is support. They need to feel listened
to and like you understood them. They need to be encouraged to share the reality
of their lives. They need to feel as though they are in a safe place where others
care for how they feel and will respond to what they want. These people are not
used to being cared for; they are used to caring for someone else. Some of them
will resist any attempt by you to help them. They will tell you that they are fine.
They want you to help their loved one, not them. They have identified that person
as the “sick” one. Addiction makes the whole family sick.

In treatment, the family members will need to realize that they have a problem.
Each member of the family will work through the Codependency exercise (see
Appendix 26). This should open their eyes to what they have been doing, which is
maladaptive. This exercise gives basic information about codependency and helps
each family member identify the problems that he or she is having.

These individuals have been living in an addicted world, and they are suffering
whether they realize it or not. They have learned survival skills that are
inappropriate for normal living. They will need to examine exactly what they are
doing wrong and learn how to do it in another way. They need to practice the tools
of recovery in the family groups and with the client. You must try to see the family
as often as they need to be seen both during treatment and in continuing care. You
might have to refer the family to a marriage and family therapist to continue their
growth. Many families, or family members, will have to be referred to outside
agencies. They have severe mental, emotional, spiritual, marital, and family
problems that need further treatment. It is your job to refer them to appropriate
therapists. Make sure you have a list of therapists in the family’s hometown who
can work with the family and family members for years.

The family members need to understand that they are powerless over the disease
and that their lives have been unmanageable. If they think that they can still control
things, then they might try to work the client’s program for him or her, and that is a
setup for relapse. The family members need to admit to the client that they have
problems, too. The family members need to identify exactly what the problems
are, understand the problems, and learn what they are going to do differently in
recovery.

Some family members come into the program ready to unload and blame the client
for everything. This is not going to do anybody any good. Addiction is a family
disease. Everyone is affected, and everyone needs to bear some responsibility.
Everyone needs to keep the focus on what he or she can do to make things better.
All of the eight core feelings need to be explored. Do not let the family get by with
sharing only the feelings with which they feel comfortable.

Do not think that you can handle all of the family problems in treatment. All that
you can do is start the family members off in the right direction and give them
some practice in the tools of recovery. You will see the family members in
conjoint sessions. In these sessions, try to get the family members to share the
whole truth with each other. If a family member withholds the truth or lies, then the
illness will have a foothold and, just like a cancer, will grow until it ends in
relapse.

Each family member needs to write a letter to the client stating how the person
feels and asking for what he or she wants. The client does the same thing for each
family member. The family will read each other these letters in the conjoint
sessions. It is from these letters, and from the questionnaires, that you will get a
good idea of what needs to be worked on in the conjoint sessions. Only with the
whole truth can you help the family to move closer to a healthy lifestyle.

The only truth that can be withheld is something that will injure someone. Use
your best judgment here. AA (2001) says, “[We] made direct amends to such
people wherever possible, except when to do so would injure them or others” (p.
59). Sometimes a truth is too painful or harmful to the client or to others to
disclose.

After the family members have been involved in the family program long enough
to break through initial resistance, they should be given the Codependency
exercise (see Appendix 26) to complete at home. Each family member will then
read his or her answers to the group. As the family members do this, they will
begin to bond together and understand how addiction has affected them.
The Family Program Schedule
The family program begins at admission and in most facilities lasts for 1 week,
but you should have weekly family sessions if possible. This gives the family
members enough time to get started in their own recovery. The family group meets
separately from the clients for the first few sessions. The family members are
oriented to the program and hear several lectures. They learn about the disease
concept of addiction and how it affects the family. The family members need to
see people talk about their problems rather than keep them secret.

The family program members need to share their experiences, strengths, and hopes
with each other. A family group, without the clients, should meet at least once a
day. Here each family member needs to tell his or her story in brief
autobiographical form. This helps to remove the intense shame and guilt that the
family members have been feeling. For the first time, family members do not feel
alone anymore when hearing each other’s stories. The counselor should continue
to educate them about addiction and codependency in the groups. The family
members need to see how the tools of recovery offer better solutions to their
problems.

Many times, family members are so beaten up by the disease that it is difficult for
them to share. If you wait and extend the silence, then they will begin talking. They
really want to talk. They have been closed up for a long time, and they long for
closeness, openness, and love. These people are people pleasers, and they will
want to please you. They feel uncomfortable and anxious in extended silence. Try
to create an atmosphere that is so tender and kind that people who are very afraid
can search for and share the truth. If you ask a question and remain quiet, then
someone will get the idea and start sharing. Once the ice is broken, it will become
easier for others.

The group needs to be introduced to the Al-Anon, Gam-Anon, or Narconon

program and should attend a 12-step group once a day throughout the family week.
It is essential that the family members bond with their 12-step group as quickly as
possible. This will happen only with regular attendance at meetings. They should
be encouraged to begin daily prayer and meditation.

As the family group members share, they will feel understood and supported by
the group. Most groups begin to bond after 1 or 2 days. Many tears will be shed as
they hear each other’s stories. Once the group of family members has bonded, the
clients can be brought into the group. This must not be done until the family
members are supporting each other. The clients have bonded in treatment, and they
are supporting each other. This prevents the addict from eventually coming into the
groups and attempting to take control. The family members need a solid support
system to prevent the illness from shaming and blaming others. The groups with
the family members and addicted clients in them will be able to address the
problems more fully.
How to Work With the Family in Group

Source: ©[Link]/Alina555.

You cannot solve each family problem in these groups. You need to concentrate on
the process. Help the family members gain support from each other and eliminate
dysfunctional communication skills. You should have each person share and work
toward group acceptance. This is the first time in years that these people have had
anyone listen to them.

You should not let one family member interrupt, manipulate, or speak for another.
You must explain how these techniques are used for control. With group support
and encouragement, the clients and their family members will have the opportunity
to express themselves fully. Quiet family members, who have been intimidated at
home, will find new strength from the group. This group work prepares the family
members for flowing smoothly into continuing care.

Family members are encouraged to keep a daily journal during the family
program. At the end of the day, they write down the important things that they
learned. They write down how they did that day, and they make plans for what
changes they need to make the next day. This is their daily inventory. What do they
need to do next? How can they be more actively involved in uncovering the truth?
This log can be shared periodically in group.

The family members will need to learn and practice healthy communication skills
(see Appendix 13) and healthy interpersonal relationship skills (see Appendix
11). They can work through each of the exercises, just as the client in treatment
did. You will develop a treatment plan for each family. What does this family
member need specifically? The family members need to identify that they have a
problem, understand the problem, and learn skills to deal with the problem. They
must see that they have a problem, or else they will not continue to go to
continuing care and support groups.
The Conjoint Session
Once the family has practiced the tools of recovery for a few days, you will begin
to see the family in conjoint sessions. This is where you meet with the family
members and the client and work out a family recovery plan. You may want to
meet with the spouse more regularly, but you need at least several sessions with
the whole family. All family members need to hear the plan of recovery and
understand their responsibility. They need to know exactly what they are expected
to do. This is a family disease, and everyone will have to do things differently to
make recovery work.

In the conjoint sessions, the family members will read the letters that they have
written to the client. Each family member will share how that person feels and
will ask for what he or she wants from other family members. All of them need to
understand that they are developing a program of recovery. Every family member
is responsible to act in a manner that is conducive to recovery. Not all of the
problems are going to be solved now. First, the family members must enter into a
personal recovery program. They need to take one day at a time. They are not
going to address all of the problems now.

You occasionally will get resistance from the family. Some family members are
not willing to cooperate. Some are chemically dependent or are not interested in
recovery. Some individuals have an investment in keeping the client sick. They
might fear that if the sick person gets well, their role in the family will be
threatened. Out of fear, they want things to stay the same. If you are sensitive and
listen hard enough, you will understand these needs and be able to respond to
them. The family needs to see the truth about this dynamic, and the problem needs
to be worked through. The family members who want the client to remain sick
cannot see that everyone will be better off in recovery. They are trying to meet
their own needs. Once they see the truth, you will see these family members turn
around.

At the end of the family program, there will be a short process whereby the family
members say good-bye to each other. For the first time in their lives, they have felt
unconditionally accepted, known, and loved. They do not want to leave this warm
supportive atmosphere. If you have encouraged them to seek this support in their
outside 12-step meetings, this will not be overly difficult, but some pain will be
involved. They need to transfer a good feeling to their new support group. All of
the family members will need continuing care, and some will need further
counseling or treatment. This must be arranged before the family goes home. At
the last session, make sure you have a big group hug. The family now should be
bonded and ready for the rigors of continuing care.

To see the family members come into the family program frightened and sad, and
then to see them go out with new hope, is a very rewarding experience. The family
members never will forget the major role that you played in restoring their lives.
You led them from the darkness into the light. They will be eternally grateful.
14 The Clinical Staff

Source: ©[Link]/LivingImages.

The staff of any treatment center is the lifeblood of treatment. A good staff can do
effective treatment anywhere. The clinical staff has a great deal of respect for
each individual member of the staff and listens carefully to each other. No one
staff member is more important than another is. All are equal and essential for
recovery. They work together like a symphony all playing the same masterpiece.

A good staff is fun. The staff members enjoy working together and supporting each
other in the war against addiction. A good staff laughs a lot. Sometimes you have
to laugh to keep the disease from getting you down.

Everyone has input into the clients’ treatment plans, but everyone has his or her
own area of specialization. Professional boundaries are important and should be
respected and guarded. To question another person’s skills or decisions when you
do not know their profession is silly. Let them do what they are trained to do and
trust that they have you and the client’s best interest at heart. If you stay within
your own boundaries—the boundaries of the chemical dependency counselor—
then you will be a lot better off, you will feel better, and you will give better
quality treatment. All staff members are experts in their chosen fields. They are
licensed or certified by their respective boards, and you have to believe that they
know what they are doing.
The Physician/Addictionologist
The medical doctor is in charge of all medical treatment. This physician has the
most training in the total disease process. A physician completes a premedical
bachelor’s degree, 3 or 4 years of advanced medical training, and at least 1 year
of interning. Many physicians go on to specialize in one or more areas of
medicine. Physicians can have a specialty in addiction called addictionology.

Source: Comstock Images/Thinkstock.

All clients must have a complete history and physical examination given by a
physician. If you have any questions about any type of physical disease or medical
treatment, then the physician is the person to rely on. It is important to establish a
professional working relationship with the physician. He or she is a wealth of
information. Do not be intimidated by professionals with advanced degrees. They
are just people like you—fallible and human. Discuss your client’s case with
them, and respect their judgment. Good physicians are easy to talk to and readily
admit that they do not know everything. They often need you to tell them how the
client is responding to treatment.

The physician will be in close contact with you, particularly if your client has a
medical condition that requires treatment. Close consultation with the physician
will prevent you from assuming that behavior is caused by an organic disease or
is a psychological problem.

The physician is in charge of any medication order. If you believe that your client
needs pharmacological treatment, then you need to tell the physician or nurse.
Once you have discussed this issue carefully with the medical staff, your job is
over. The physician will examine the client and make the determination based on
his or her own clinical judgment. Do not argue with the physician or the nurse
about what they are doing. They know more about it than you do. Trust them to do
their job. You must keep the medical staff advised about your client’s condition if
they are not doing well or might be having side effects to the medication. Let them
know your concerns, and leave it to them to treat the medical condition.
The Psychologist/Psychiatrist
All treatment centers should have a consulting psychologist or psychiatrist. The
psychologist or psychiatrist has advanced training in the diagnosis and treatment
of mental disorders. A psychiatrist is a medical doctor with 3 years of residency
in psychiatry. A psychologist has a 2-year master’s degree and a 4-year doctorate
degree with 1 year of internship during the doctoral training and 1 year
postdoctorate. These two professionals are the best-trained mental health
professionals. Only psychiatrists can order medications, and usually only
psychologists are heavily trained in psychotherapy, particularly evidence-based
cognitive behavioral therapy and psychological testing.

Two thirds of chemically dependent clients have a concomitant psychiatric

diagnosis. They have problems such as depression, anxiety, and/or personality
disorders in conjunction with their addiction. Clients will not do well in recovery
unless these disorders are treated effectively (Frances & Franklin, 1988; Ries &
Miller, 2009; Talbott et al., 1988; Woody et al., 1984). It is important to have a
professional in your center who can deal with these coexisting problems.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

and the Commission on Accreditation of Rehabilitation Facilities (CARF) require
that all clients in inpatient substance abuse treatment receive a psychiatric or
psychological evaluation. This examination includes a mental status examination,
a determination of current and past psychiatric or psychological abnormality, a
determination of the degree of danger to self or others, and a brief
neuropsychological assessment. It is from this examination that you will learn
about any secondary diagnosis and will develop a treatment plan. The psychiatrist
or psychologist will tell you what to do. Follow his or her directions as precisely
as you can. Use this professional as a valuable information source. This
professional understands the development of personality and the forces that
motivate behavior. If you are confused by a client, talk the situation over carefully
with the psychiatrist or psychologist.
The Social Worker/Mental Health Counselor
Social workers and mental health counselors are wonderful mental health
professionals. They usually have been through a 2- to 3-year graduate program
and are licensed by the state. These mental health professionals have many fine
qualities. They are excellent therapists and group leaders. They understand the
community of mental health professionals and are often charged with testing and
treating co-occurring disorders and arranging for continuing care placements,
including referrals to other professionals, halfway houses, and group homes.
These professionals are good at just about anything and can handle almost any
mental health task except ordering medication. They are a lot like mental health
professionals or professional counselors who have a master’s degree in
counseling and have many things to offer you and your clients.
The Nurse
There are two types of nurses: (1) registered nurses and (2) licensed practical
nurses. Registered nurses complete a registered nurse’s degree from an accredited
institution. Most go on for a bachelor’s degree. Licensed practical nurses
complete a 1-year vocational–technical program in nursing.

Nurses are frontline medical personnel. They take responsibility for the client in
the absence of the physician. In an inpatient setting, they usually are guiding the
ship and are available 24 hours a day. There is a tendency in some centers for
there to be some conflict between the nursing staff and the counseling staff. This is
a big mistake for all concerned. A good clinical staff has few of these turf battles.
Each staff member should feel comfortable with his or her unique function in the
treatment setting.

Nurses are second in command in medical treatment. Only the doctor has more
medical authority. The physician writes the orders, and the nurses carry them out.
In many facilities, there are standing orders that allow nurses to make medical
decisions. This is necessary to reduce response time and to prevent the physician
from being called every time a decision is made. If a nurse tells you to do
something, then you should carry out this order as if it came from the physician.

Nurses will listen to you and help you. You will find them to be supportive. They
tend to be caring people who are willing to go the extra mile to provide good
quality care. They are used to charting and usually are wonderfully self-
disciplined.
The Clinical Director
The clinical director has the primary responsibility for making sure that the
clinical team provides the best possible treatment. This individual develops and
implements the whole treatment program. He or she has advanced training and
experience in treating addiction and co-occurring disorders. The clinical director
makes sure that the team is working well together and is accomplishing its goals.
The clinical director decides who does what, when, how, and with whom. This
person leads the clinical team and the client population. The clinical director has
administrative experience. This individual usually sees the clients and the staff
who are having more severe problems. All program and policy changes go
through the clinical director.
The Clinical Supervisor
The clinical supervisor is an addiction counselor with several years of experience
in counseling and supervision. This individual’s primary responsibility is to
supervise the counseling staff. The clinical supervisor will be doing some hands-
on work with the clients and will be sitting in on some of your individual sessions
and groups. He or she makes up the work schedule. You should use this person
often. The clinical director and clinical supervisor are your mentors. This person
will set a good example for how to take a client through treatment effectively. If
you have any questions about treatment planning, charting, or therapy, then these
are the first people to ask. You should receive continuing education from the
supervisory personnel. If you feel as though you have any weak points in your
training, then ask them for in-service training sessions to build your expertise.

The clinical supervisor will be going over your charts to be sure that you are
treating the clients according to JCAHO or CARF. JCAHO and CARF require
specific standards of care to be met before it will allow a facility to receive
accreditation. (You can order a copy of the standards by contacting JCAHO, 875
North Michigan Avenue, Chicago, IL 60611 or CARF International, 4891 E. Grant
Road, Tucson, AZ 85712 USA, 520-325-1044 or 888-28106531 voice/TTY, 520-
318-1129 fax.)
The Chemical Dependency Counselor
Chemical dependency counselors must meet state standards set by a certification
board. They take specialized college courses and work for at least 1 year in a
treatment setting under a qualified supervisor. In most states, they have to pass a
national examination and are state certified or licensed. Counselors must show
competency in 12 core function areas: (1) screening, (2) intake, (3) orientation,
(4) assessment, (5) treatment planning, (6) counseling, (7) case management, (8)
crisis intervention, (9) client education, (10) referral, (11) reports and record
keeping, and (12) consultation. Many counselors are involved in their own
recovery programs, but many are not. It does not seem to matter. It is the on-the-
job training in addictions and personal experience that gives addictions
counselors their unique professional character. They are excellent, highly
qualified health care professionals.
The Rehabilitation Technician or Aide
Rehabilitation technicians, sometimes called aides, usually are individuals with
no formal training in addiction. Sometimes they are people who are getting their
degrees in addiction and need experience. These people do a variety of work
assigned by supervisory personnel. They work with the clients, sometimes
individually and sometimes in groups. They work under the direct supervision of
the counseling staff. It is your responsibility to help them to function effectively
around the client population. Many times, the tech or aid says just the right thing at
just the right time to turn a client toward recovery. Never forget that they are
smart, willing, and able to go the extra mile for you and your clients.

There often is some conflict about how far these people should go in treating
clients. For the most part, the care they offer should be highly structured and
supervised by someone on the clinical staff. You will find that much of the real
work in treatment is offered by these individuals. You must see to it that they offer
quality care. The only way of doing this is to listen to them, talk to them, and
educate them. They might be in recovery and know the 12-step program well, but
you can still improve their skills by extending yourself to support, educate, and
encourage them. They are working harder than you often think and are having more
effect than you can possibly imagine.
The Recreational Therapist
The recreational therapist is a certified coordinator in charge of getting the clients
involved in fun, constructive exercise, and leisure time activities. This individual
will be doing an activities assessment to see what the clients are doing for
entertainment, play, or fun. The activities coordinator will develop an exercise
program for each client. Most addiction clients have lost the capacity to have fun
in sobriety. They need to be encouraged to develop healthy recreational activities
and hobbies. They need to learn how to have fun clean and sober. It is important
that you encourage your clients to become active in pleasure-oriented activities in
recovery. The clients who enjoy sobriety will be more likely to stay sober. One of
the most important things that clients can do in their recovery program is to
establish regular exercise habits. All clients should be encouraged to exercise on
a daily basis. The recreational therapist needs to be a lot of fun to be with and
very encouraging. Most addicts have not exercised or enjoyed recreational
activities in a long time, so they need someone fun to encourage them to try new
activities.
Source: Paul Sutherland/Thinkstock.
Clinical Staffing
The clinical staff makes up the treatment team. The staff usually meets once a day,
usually at each shift change, to discuss the clients’ status. Once a week, the staff
meets for a more formal clinical staffing. Here the clients will be discussed in
more detail, and each problem on the problem list will be evaluated.

The staff must be constantly kept informed about how the clients are doing in
treatment. In these meetings, treatment plans will be updated. A multidisciplinary
staff can take clients through treatment much more effectively. More expertise
comes into play, and many heads are much better than one.

Clinical staffing is your opportunity to discuss a client with the whole team. You
can get advice and help from everyone at the same time. The client is reassessed
throughout treatment to determine current clinical problems, needs, and responses
to treatment. The assessment includes major changes in the client, family, or life
events that could complicate or alter treatment. A client could have just learned
that his wife is divorcing him or that he is being prosecuted for a crime. Someone
in the client’s immediate family could die or become ill. All changes in treatment
need to be documented in the client record.

The atmosphere of clinical staffing is a professional one. The principal matter of

concern is the clients. You must assume that all members of the professional staff
are willing and able to help. The staff members should be supportive of each
other. Treating addiction is emotionally draining, and everyone occasionally will
make mistakes. The atmosphere in clinical staffing should be one of mutual
respect. You should enjoy clinical staff meetings. They should be educational, and
they should help you to develop your professional skills.
How to Present a Client
You will present each of your clients to the clinical staff and will discuss how
treatment generally is going. If you have any questions, now is the time to ask
them. The first time that you present a client, you need to be thorough. As the client
remains in treatment, you need to cover just the pertinent issues. An outline for
case presentation is handy to use your first few times. The outline might look
something like this:

1. Identifying data
2. Present illness
3. Past history
4. Family history
5. Social history
6. Medical history
7. Mental status examination
8. Most likely diagnosis

9. Formulation
1. Predisposing factors
2. Psychosocial stressors
3. Stress that precipitated treatment
10. Further assessment you propose
11. Treatment plan
12. Prognosis

Your presentation should sound something like this:

Jason Roberts is a 43-year-old black male who just got his third DWI. He
has been drinking heavily for the past 20 years. He is divorced with two
children. He lives alone. He came to treatment after spending the night in jail.
He is working on his chemical use history and problem assessment form. He
is doing well around the unit so far. He is in good physical health except for
some mild withdrawal symptoms. His CWIA scores have averaged around 8
to 14. He seems to be getting along well with his treatment peers. In group,
he did admit to a drinking problem. He seems committed to treatment. He
says he does not want to go on living this way anymore. I talked to his oldest
 son this morning, and the family is supportive of treatment. He is in some
withdrawal, but he seems to be handling that okay. He needs to visit with the
psychologist to rule out other psychiatric disorders. He is depressed and
reports he is not sleeping well. His diagnosis is alcohol dependence—severe
—with a possible substance-induced depression or a major depression. He
will be working through the steps, and we will probably address his
depression depending on the psychologist’s report.

The case presentation globally advises the treatment team of the client’s condition
and describes how the client is doing in treatment. After you present the client,
each member of the treatment team can comment. The physician or the nursing staff
may have something to share about withdrawal or the medical condition for which
the client is being treated. The dietitian may make a report on the client’s diet. The
recreational therapist may have a comment on how the client has been using his or
her leisure time. The other counselors may have something to say about what they
see. As the primary counselor, you collate this material and enter the staff’s input
into the client record. These progress notes do not have to be very long, but they
do have to show that the treatment team is reassessing the client and changing the
treatment plan where necessary.
Team Building
A good staff is constantly building the team. These staff members are actively
encouraging each other and reinforcing each other’s work. When you see someone
do a good job, you say so: “You did a good job with Mark this morning. I was
impressed with how you handled yourself.” These comments are very reinforcing
to fellow staff members. The staff members often put so much energy into the
clients that they forget that they have needs, too. This is emotionally difficult
work, and everyone needs support. A good team knows this. Each member goes
out of his or her way to treat each other well.

New team members are welcomed and are assisted in adjusting to the flow of
treatment. Every treatment center is different, and new staff members need
orientation on both an intellectual and an emotional level. A good team’s members
constantly talk each other up to insiders as well as outsiders. They never talk
someone on the staff down. You can share the truth about someone without
damaging his or her reputation. The members of a good staff communicate well
together. They share openly how they feel and what they think. They work together
as a group. If a personal problem develops between staff members, then the
problem is handled by a supervisor.

A good staff’s members never gossip about each other. Gossip is one of the most
harmful things that can occur in any staff organization. Gossip will cause a team to
fail. Everyone’s life outside of the center should be private. Unless someone
decides to confide in you, keep out of the issue. Do not spread damaging rumors
about anyone. A good way of checking yourself is to refuse to repeat anything
unless you have the permission of the person in question.

Good staff members get support, not treatment, from their fellow staff members. It
is a mistake for someone in recovery to think they no longer need their 12-step
meetings because they have the support of the clinical team. The clinical staff does
not exist to treat you; it exists to treat the clients. If you want to see someone on the
staff for a brief consultation about a problem, that is fine, but keep it short. Do not
be afraid to seek outside help for your problems. Your mental and physical health
directly affects your job performance. If your problems are bogging you down,
then you cannot be effective. Becoming involved in a good program of recovery
will make you a better counselor and a better person. One of the best ways of
learning about good therapy is to go to a good therapist. Make sure that this
therapist is highly qualified in his or her field.

A good clinical staff does not “subgroup” against each other. This is where a
smaller group of staff members gets together and talks about the other members.
This is very common, and it is a disaster for the clinical team. If you are having
problems with a staff member, then go to that staff member first and try to work the
issue through. If you are unable to resolve the problem, then go to your supervisor
and get him or her to help you. If you and the supervisor cannot handle the
problem, then it needs to be addressed before the clinical staff as a whole. Do not
let problems fester. The only way of resolving problems is to get everyone
together and have each person share how he or she feels. Any problem can be
solved in an atmosphere of love and truth. The staff needs to practice what it
preaches to the clients.

The following guidelines are excellent for maintaining productive staff

interaction.
Commitment to Coworkers
As your coworker with a shared goal of providing excellent care to our clients, I
commit myself to the following:

1. I will accept responsibility for establishing and maintaining healthy

interpersonal relationships with you and every member of this staff. I will
talk to you promptly if I am having a problem with you. The only time I will
discuss it with another person is when I need advice or help in deciding how
to communicate to you appropriately.
2. I will establish and maintain a relationship of functional trust with you and
every member of this staff. My relationships with each of you will be equally
respectful, regardless of job titles or levels of educational preparation.
3. I will not engage in the “3 Bs” (bickering, back-stabbing, and bitching) and
will ask you not to do [so] as well.
4. I will not complain about another team member and ask you not to do [so] as
well. If I hear you doing so, I will ask you to talk to that person.
5. I will accept you as you are today, forgiving past problems, and ask you to do
the same with me.
6. I will be committed to finding solutions to problems, rather than complaining
about them, and ask you to do the same.
7. I will affirm your contribution to quality client care.
8. I will remember that neither of us is perfect and that human errors are
opportunities, not for shame or guilt but rather for forgiveness and growth.
(Manthey, 1991)

________________________________________

Signature and date

Boundaries
Everyone on the clinical team needs to know and respect each other’s
professional boundaries. You need to know what each person’s function is in
treatment. Once you know that a part of treatment is not in your area of expertise,
stay out of that area. Everyone on the staff wants to hear what you think—that is
helpful—but do not concern yourself with client care outside of your area of
specialization. You are an addiction counselor, not a physician or a nurse. You
should not concern yourself with who gets certain medications, but you should
express your concern about your client’s signs and symptoms. Many counselors
spend long hours worrying about whether or not their clients are being properly
treated by the medical staff. If you worry that your medical staff is inadequate,
then work somewhere else. Never accept a job in an institution that gives
substandard care. Once you decide to accept a position, act as if your staff is the
greatest. Be grateful for all of the good work the staff is doing.

Most staff problems are attitude problems, and attitudes can change. You need to
keep a positive attitude about you and your coworkers. This will go a long way
toward making your day more pleasant and enjoyable. If you see your attitude
slipping, then talk about this with your supervisor. Check your own life. How are
you doing? Many times, a negative attitude flags personal problems that need to be
addressed outside of the treatment center. Remember that if you do not take good
care of yourself, you are not going to be very helpful to others. If you are suffering,
your staff and clients will suffer. Do not hesitate to get help from your supervisor
or an outside counselor. Most treatment centers have an employment assistant
professional (EAP) who will see you a few times and, if you need it, will help
you get a referral to the right professional.
Staff–Client Problems
The staff and the clients will constantly have problems with each other. It is the
nature of transference and countertransference that there will be conflict. As the
clients’ maladaptive attitudes and behaviors come into play, the staff can teach
new methods of dealing with problems.

Never agree that a client has been treated unfairly by a staff member until you first
talk with the staff member. Clients will attempt to use you in a manipulative way
against someone else. Remember the staff comes first. You must not subgroup with
clients against staff. This decreases the effectiveness of the entire facility. You
must prevent clients from using their old manipulative skills. If a client is having a
problem with a staff member, then arrange for the staff member and the client to
meet to see whether they can resolve the issue together. You are teaching the client
how to resolve interpersonal problems. If the client has a problem with someone,
then he or she has to go to that person to resolve the issue.

Certain clients will try to pit the staff members against each other. This is common
for borderline and antisocial clients. This must be resolved by the staff as a
whole. A client usually attempts this by telling different staff members different
things. The only way of making this manipulation stop is to call everyone together
at the same time. This way, the client cannot continue to manipulate. Any other
means of trying to solve this problem will not work because the lies will continue
to operate. Once everyone gets together with the client at the same time, you will
have a more accurate picture of what the problem is and how to resolve it.
What to Do When a Client Does Not Like a Counselor
Sometimes a client will want to change counselors. This client needs to share how
he or she feels with the current counselor often with a supervisor present.
Something might be going wrong with the therapeutic alliance. This matter needs
to be discussed with the counselor and the client who are having the problem. It
should be rare for a client to change primary counselors while in treatment. Most
of these problems revolve around lack of trust, and this is a common problem for
chemically dependent persons.

Many staff–client problems result from miscommunication. It is common for two

people to misinterpret each other’s behavior. Only by bringing the parties together
and having them check out their interpretations will the problems be resolved.
Each person needs to ask for—and listen to—the other person’s thoughts and
feelings.

Sometimes clients will want the counselor to do too much. It is as though the
clients want the counselor to do all of the work for them. When the counselor
balks at this, the clients feel resentful. These clients need to accept the
responsibility for their own behavior. They cannot count on someone else to work
the program for them. They must work it for themselves.

A client who is having a problem with a staff member might need more time in
individual sessions. The client needs to get his or her thinking accurate. Trust
issues are of paramount importance in recovery. Trust is essential for the
development of a good therapeutic alliance. If a client is having trust problems
with the staff, you can bet that the client has this same problem outside of the
treatment setting. The client might need to track his or her lack of trust to earlier
situations, perhaps during childhood. Things that happened early can convince a
client to trust no one. Keep asking the client if he or she ever felt these feelings at
an earlier time. These situations will have to be explored in depth and worked
through. The client needs to see that the situation has changed. The client is not in
the original situation anymore. He or she is in a new situation that demands a new
level of trust. What about the new situation makes the client feel that he or she
cannot trust someone? What is the most rational decision for the client to make?
Trust issues must be resolved for the client to move forward in treatment. The
client will remain stuck until he or she can trust someone. Once the client trusts
one person, the client can transfer the trust to someone else, the group, and then the
higher power.

Source: ©[Link]/slobo.
What to Do When a Client Complains About a Rule
Many staff–client problems revolve around rule violations. Clients will say that
they did not break the rule, and they may have a very good story to tell about the
situation. You must support other staff members in the things they direct the clients
to do. Support their consequences. They were there, and you were not there. Talk
about how to do it next time if you need to, but do not change the consequence. If
you do this, your staff members will be unable to discipline the clients. If the
clients learn that the rules can be manipulated, then all of the rules become
meaningless. Bring all members involved in the situation together, and talk the
issue through. In very rare instances, the person who leveled the consequence may
remove the consequence or change it to something more appropriate. This should
be done only by the person who leveled the consequence.

No chemically dependent persons want to obey the rules, but the rules exist to
protect them from harm. Once they understand that the rules are for them rather
than against them, they will be more likely to obey the rules. Clients who are
breaking the rules need to see how this tendency feeds into their addiction. If they
learn how to follow the rules—particularly the rule of the 12-step program—then
this is recovery.
The Work Environment
A treatment center should be a fun place to work. People who come into recovery
at their worst are at their best in a few short weeks. This is an extremely
rewarding environment. It is a place full of great joy. Real love abounds in a good
treatment center. Clients and staff alike enjoy their days. If you do not genuinely
enjoy your work, then you are at the wrong place or you are in the wrong business.
Chemically dependent persons are a lot of fun to work with. They laugh and have
a good time. They have been the life of the party. The staff can learn how to have
fun at work. If the staff members work together and love each other, then they can
grow from each work day.

Good treatment must be done in an atmosphere of love and trust. Staff members
must support each other through the good times as well as the bad times. The old
saying applies: “When the going gets tough, the tough get going.” Even during
periods of stress, the well-functioning staff pulls together and works things out.
Humor often saves the day, and a genuine caring for each other smoothes the rough
spots for staff members. Remember that you are in this field not only for your
clients but also for yourself. You are actively involved in your own individual
growth.
15 Discharge and Continuing Care

Source: ©[Link]/Juanmonino.

This is where the rubber hits the road, and it’s where most addiction programs fall
far short. Most programs advise the client to continue to work his or her 12-step
program. The theory is if clients continue to work the 12 steps, they will stay
clean and sober. This is true, but most clients do not go to many 12-step meetings
after treatment; some only go to one or two, and then they drop out. This is why
two thirds of clients relapse in the first year of recovery. Work with physicians
and airline pilots shows that the case manager must follow the clients for 5 years
after treatment. At the 5-year point, the relapse rate falls to around zero (Earley,
2009; Vaillant, 2003).

What the client needs is a contract negotiated with the continuing care case
manager where they agree to all of the following:
 Submit to up to three random drug screens a week for the first 6 months and
up to one random drug screen per week for the next 5 years. The client makes
a phone call to the medical review officer, family member, or professional
each day to see if this is the day for a drug test. If the test is refused, it is
considered a positive sign of addiction. If this does not work, the client can
wear a mechanical device that tests for alcohol in the blood and gives the
GPS position of the client. Often a drug test failure means going directly to
jail or into treatment.
Send in a 12-step log sent to the case manager every month. This is a list of
all meetings attended signed at the end of each meeting by the group leader.
Get a sponsor, mentor, coach, school advocate, and community associate, and
make contact with him or her at least once a week. For the first 90 days, the
sponsor needs to be contacted with a daily telephone call.
Attend all therapy recommended by the initial treatment team. This would
include things such as anger management, marriage counseling, probation
officer visits, school counselor sessions, and so on. The more that people
help and the less the client isolates, the more likely that he or she is to stay in
recovery.
Take all medications as ordered.
Agree to several painful outlined consequences if the client does not follow
recommendations or becomes involved in their addiction again. Here you
must outline what will happen if the client fails to follow his or her
continuing care plan. These consequences have to be unwanted events such
as transferring the case to the judge, medical board, drug court, employer,
spouse, family, significant other, sponsor, school advocate, probation officer,
and so on. These consequences have to be people who are prepared as a
group to arrange for further assessment and inpatient or outpatient treatment if
necessary.

Discharge planning begins at admission. You need to be constantly aware of what

the client might need in continuing care. The discharge summary is the document
that tells the client’s story from the beginning to the end of treatment, and it details
what the client is going to do in continuing care. It includes the initial assessment,
diagnosis, course of treatment, final diagnosis, and continuing care plan. It
summarizes the significant findings at the time of admission including the primary
and secondary diagnoses. Significant findings that led to each diagnosis must be
included. What were the problems, how were the problems treated, and what was
the result of treatment?
Source: ©[Link]/tomeng.

The course of treatment includes detoxification and withdrawal, any medical

treatment, and all treatment provided by the clinical team. You will follow each
problem on the problem list, detailing what the problem is and how the problem
was treated. You will discuss how the treatment affected the problem. Make sure
that you concentrate on client behaviors, not your opinion. Include any changes in
the treatment plan and the reasons for those changes as well as the family’s
response to treatment.

The final assessment of the client’s current condition must include how the client
is functioning at discharge compared to how he or she was functioning before
treatment and during treatment. The changes in feelings, thoughts, and behaviors
should be detailed. The continuing care plan should be laid out, and the client
must agree to follow the continuing care plan. If the client needs to see someone
for further treatment in continuing care, then this person must be named along with
his or her address, e-mail address, and phone number in the discharge summary. If
the client is on any medication at discharge, then this medication should be listed
along with a follow-up plan for continuing or discontinuing this medication.
All clients must meet the discharge criteria developed by the American Society of
Addiction Medicine (ASAM) (Mee-Lee, 2001).
Outpatient Discharge Criteria
For adult and adolescent outpatient discharge, the client must meet one of the
following conditions:

1. The client is assessed, postadmission, as not having met the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5, 2013) criteria for a
substance use disorder (APA, 2013).

2. The client must meet at least one of the following criteria:

1. The client must meet all of the following:

1. The client is not intoxicated or in withdrawal.
2. The client does not manifest symptoms of protracted withdrawal
syndrome.
3. The client does not meet any of the Level I continued stay criteria.

2. The client must meet one of the following:

1. The client’s medical problems, if any, have diminished or
stabilized to the point where he or she can be managed through
outpatient appointments.
2. There is a biomedical condition that is interfering with treatment
and requires treatment at another setting.

3. The client must meet one of the following:

1. The client’s emotional behavioral problems have diminished or
stabilized to the point where he or she can be managed through
outpatient appointments.

4. The client must meet one of the following:

1. The client’s awareness and acceptance of an addiction problem

and commitment to recovery are sufficient to expect maintenance of
a self-directed recovery plan as evidenced by the following:
1. The client is able to recognize the severity of his or her
relationship with alcohol or drugs.
2. The client has an understanding of his or her self-defeating
relationship with alcohol or drugs.
 3. The client is applying the essential skills necessary to
maintain sobriety in a self-help fellowship and/or with further
post treatment care.
2. The client has consistently failed to achieve treatment goals, and
no further progress is likely to be made.

5. The client must meet one of the following:

1. The client’s therapeutic gains that address cravings and relapse
issues have been learned and internalized.
2. The client is experiencing an exacerbation in drug-seeking
behavior or craving that necessitates treatment in a more intense
treatment setting.

6. The client must meet one of the following:

1. The client’s social system and significant others are supportive of
recovery to the point where the client can be expected to adhere to
a self-directed treatment plan.
2. The client is functioning adequately in assessed deficiencies in life
areas of work, social functioning, or primary relationships.
3. The client’s social system remains non-supportive or has
deteriorated, and the client is at risk for relapse. The client needs
placement in a higher level of care to prevent relapse.
Inpatient Discharge Criteria
Adults and adolescents in inpatient treatment are ready for discharge if they do not
meet the DSM criteria for substance use disorder or when they meet the
specifications in one of the following six dimensions:

1. The client must meet one of the following:

1. The client is not intoxicated or in withdrawal, or the symptoms have
diminished to the point where the client can be managed in a less
intense level of care.
2. The client has protracted withdrawal symptoms that no longer require
24-hour monitoring.
3. The client meets criteria for a more intensive level of treatment.

2. The client must meet one of the following:

1. The client’s biomedical problems, if any, have diminished or stabilized
to the extent where daily availability of a 24-hour medical staff no
longer is necessary.
2. There is a biomedical condition that needs treatment in another setting.

3. The client must meet one of the following:

1. The client’s emotional or behavioral problems have diminished or
stabilized to the point where a 24-hour staff no longer is necessary.
2. An emotional or behavioral problem exists that needs treatment in
another setting.

4. The client must meet one of the following:

1. The client’s awareness and acceptance of an addiction problem and

commitment to treatment are sufficient to expect compliance in a less
intensive setting as evidenced by the following:
1. The client is able to recognize the severity of his or her addictive
problem.
2. The client understands his or her self-defeating relationship with
alcohol and other drugs and also understands the triggers that lead
to use.
3. The client accepts continued care and has participated in the
development of a continuing care plan.
 4. The client does not meet any of the Level III continuing care
dimensions.
2. The client has consistently failed to meet treatment goals even with
changes in the treatment plan, and no further progress is expected.

5. The client must meet one of the following:

1. The client is capable of following and completing a continuing care
plan, and the client is not at substantial risk for relapse.
2. The client is not committed to continuing care and has achieved the
maximum benefit from all attempts to have the client see that he or she
needs a continuing care plan.

6. The client must meet one of the following:

1. Problem aspects of the client’s social and interpersonal environment are
responding to treatment, and the environment is now supportive enough
to transfer the client to a less intense level of care.
2. The social and interpersonal environment has not changed or has
deteriorated, but the client has learned skills necessary to cope with the
situation or has secured an alternative environment.
3. The social environment has deteriorated, and the client has not learned
the skills necessary to cope. An extended care environment has been
secured, but the client is unwilling to be transferred.
How to Develop a Discharge Summary
The discharge summary must be entered into the client record within 15 days
following discharge. It must summarize the following things about the client’s
treatment:

1. The significant findings of the clinical staff, including the problem list and
the initial primary and secondary diagnoses
2. The course of treatment through each identified problem
3. The final assessment of the client’s current condition
4. The recommendations and arrangements for further treatment and continuing
care
5. The final primary and secondary diagnoses

The continuing care plan details how the client is going to continue treatment after
he or she leaves the treatment center. Each client will have a written continuing
care plan that will list the specific arrangements for continuing care.

Each client will need a 12-step contact person, mentor, or coach. It is this
person’s job to see to it that the client gets to the new 12-step group and is
introduced to members. The contact person stays close to the client until the client
chooses a sponsor. You will want to carefully build up your 12-step contact list
over the years and get the other counselors to help you. Try to match the client and
the contact person, mentor, or coach carefully. Some clients will need this person
to be hard and pushy, and some will need just the opposite. The contact person is
an important link from you to the new group. This contact will keep you informed
if anything goes wrong.

The continuing care plan is developed in accordance with the client’s identified
needs at the time of discharge. The plan is developed with the full participation of
the client. The client must agree and sign a contract that agrees to abide by the
continuing care plan. There is no use in developing a great continuing care plan if
the client does not intend to follow it.

Clients will need a variety of care following treatment, and you need to find the
least restrictive environment for the clients. Each of the following methods of
continuing treatment needs to be considered in developing a continuing care plan:
 1. Inpatient treatment. If clients’ recovery is still shaky and they have serious
medical or psychological problems, then the clients might need further
inpatient care.
2. Halfway house. Some clients will need the structure of a halfway house to
help them stay clean and sober. These clients will not function well on their
own. They might have poor social skills, or they might need someone else to
be in control of their environment. A good halfway house will structure the
clients’ days and usually will have 12-step meetings held at the house.
Everyone eats together and shares the responsibilities of cooking and
cleaning. This is a good alternative for many clients who are shaky in early
recovery. If you feel uncomfortable about a client’s ability to maintain a
recovery program, then this is something you should encourage.
3. Outpatient treatment. Some clients need further treatment, but they can
handle treatment in an outpatient setting. Outpatient programs usually offer 1
to 3 days of structured treatment per week. The clients come in and move
through an individualized outpatient program. This is much like inpatient
treatment, but it is not nearly as intensive or as structured. These clients must
be able to stay abstinent between appointments.
4. Continuing care. All clients who come through treatment will need an
extended care program to make sure that they are following through with their
recovery plan. Ideally, a program should offer continuing care so long as it is
necessary to stabilize recovery.

The Personal Recovery Plan (see Appendix 27) describes the client’s goals in
recovery. It is another treatment plan developed with the client’s input. If the client
still has problems that need to be addressed in continuing care, then each of these
problems will need a treatment plan. You cannot send a client out of treatment
with an unstable psychiatric or family problem without arranging for the client to
receive treatment for this problem.
The Discharge Summary
You have collected the data necessary, and you are ready to do your discharge
summary. You have the client’s record before you. Remember that this is a
summary. You do not have to put in everything, just the significant findings and the
course of treatment. You will keep the personal recovery plan in the chart and give
a copy to the client to take home. A sample discharge summary is given in
Appendix 28.

After you have completed the discharge summary, write a letter to each of the
people to whom you are referring the client. These letters are important to
maintain good communication between your facility and the other professionals in
the community. You will need to telephone all of these professionals and tell them
about the client. You might want to send each of them a copy of the discharge
summary.

The client’s employer may request an exit interview. You should call the employer
and let him or her know that the client is getting out of treatment and tell the
employer how the client is doing. Employers are an important referral source for
your facility, and they have an interest in the client’s recovery.
Saying Good-Bye
When your clients walk down that hallway for the last time, they are going to have
mixed feelings. Probably for the first time in their lives, the clients have had a
group of people consistently act on their behalf. The clients will not want to leave
a good program. They will be feeling some fear of what is going to happen on the
outside. For the first time in weeks, they are going to be on their own. It will be
easy to get back to the old, self-destructive behaviors, and the clients should know
this. Alcohol and drugs will be easily accessible. The clients do not know
whether they are going to make it. It is a long walk out that front door.
Source: John Foxx/Thinkstock.

You need to be smiling and offering your clients encouragement all the way. Tell
them that you are available if they have difficulty. Explain that you want to see
them at the alumni functions that your center will be sponsoring. Tell the clients
that they can make it and that you have faith in them. Tell them that no matter what
happens out there, you care for them. You will be there for them if they need you.
If they have trouble, they can call you or come back to the treatment center. Most
of all, you need to give these clients a hug. You have walked with them through
one of the most difficult and rewarding periods of their lives.
16 The Good Counselor

Source: ©[Link]/101dalmatians.

If you were to ask people in the field what makes a good substance abuse
counselor, you would get many answers. This is a complicated question.
Sometimes good counselors seem to be born rather than made. Clinical skills can
be learned, but some characteristics a counselor has to have naturally developed
from a variety of genetic and environmental factors.
Good Counselors Are Caring
Good counselors are, first of all, caring. They are interested and actively involved
in other people’s individual growth. They care for how people feel, and they care
for what people want. They feel this not only at work but in their social lives as
well. They instinctively believe that their clients have great worth. They help their
clients grow by gently guiding them. They do not hammer their clients; hurting
their clients would deeply hurt them. They do not constantly confront clients with
their faults; rather, they praise clients for their strengths. They build on clients’
strengths rather than concentrating on clients’ weaknesses. They focus their
attention on helping their clients grow in the way that they want to grow. They
never push their own values and moral beliefs on their clients. They constantly
encourage their clients to see the truth about themselves and others. They want
their clients to be fully themselves and to reach for their full potential.
Good Counselors Love Their Work
Counselors do not feel burdened by their work. They feel that their work is a great
privilege. It is an honor to have people share the intimate details of their lives
with them. By caring for others in this program, the counselors will have love
turned back on them. They will feel loved and important. Thomas Merton said,
“Happiness is unselfishly giving to others.” Caring counselors give freely of
themselves and expect nothing in return.
Source: ©[Link]/track5.
Good Counselors Do Not Become Overly Involved
Good counselors do not become overly involved with their clients because to do
so would not be helpful; it would be self-serving. To be caring, you have to be
healthy in your life. You have to be reasonably comfortable with who you are,
where you are, what you do, and whom you are with. If you have unmet needs,
these will be a roadblock to you in becoming a good counselor. It is not that you
have to be completely problem free—no one ever is—but you have to have a
strong support system within yourself and outside of the treatment center. You have
to be able to meet your own needs. If you ever think that clients can meet your
needs, then you are in for trouble. Counselors who are in the field to heal their
own problems will feel angry and frustrated. Clients are too sick to help you.
They need to concentrate on their own recovery.
Good Counselors Do Not Lie
Good counselors never lie. Love necessitates action in truth. Without truth, love
cannot occur. You can tell a client that you do not want to talk about an issue, but
you never should make up a story, even if you think it is for the client’s own good.
It never is good to lie to a client. Lies cut the client off from reality and destroy
their trust in you. Without trust, good treatment becomes impossible.
Good Counselors Are Gentle
Good counselors are gentle, tender, and kind. They are sensitive to their clients’
pain. To cause unnecessary pain is inexcusable. The truth also may cause clients
some pain, but without the truth, the clients never will recover. Good counselors
can give consequences because they know that it is for the clients’ own good.

Gentle means that you encourage the client to see the truth. Tender means you
never yell or call the client names. You may get angry—that is normal—but try to
use your anger appropriately. The client might have a very difficult time in dealing
with your anger. It can permanently damage the therapeutic relationship. When you
are angry, it is useful to be angry at the illness rather than at the client. If the client
understands this, then he or she can join you in feeling angry at the disease. It
might hurt the client some to give him or her a consequence, but it will feel good
in the long run. You are doing the right thing by helping the client learn from his or
her maladaptive behavior.
Good Counselors Like Themselves
Good counselors like themselves. They nourish themselves. They cultivate stable
relationships with family and friends. They spend quality time alone. If they are in
recovery, then they work a daily program of recovery. Good counselors do not
overwork, and they do not become overly involved. When they leave work, they
do not bring the problems home.
Good Counselors Are Supersensitive
Good counselors must be supersensitive to other people’s feelings. This seems to
be an inborn trait rather than something learned. Some people have this sensitivity
from birth or early environmental experiences, and other people do not. Some
sensitivity can be learned, but the sensitivity that counselors need cannot. You
need a hypersensitive autonomic nervous system for this. To be sensitive, you
need to feel other people’s pain almost as if it is your pain. When they hurt, you
hurt. When they feel joy, you feel joy. This is called empathy. With empathy, you
perceive, feel, and understand other people’s experiences. Empathy means you
concentrate on the other person so hard that every sense becomes involved. You
have to be so concentrated that your feelings, wishes, wants, and judgments are
placed in the background. The best way to tell if you understand the client is to
repeat or rephrase what they just said until they agree you understand.
Good Counselors Have a Sixth Sense
The more sensitive you are, the better counselor you are going to be. The
sensitivity will enable you to know where a client is emotionally. This gives you
accurate information about your clients’ motivation. The clients might not know
how they feel. They may be cut off from their feelings. In a sense, you need to be
ahead of the clients. You will feel the feelings as they are feeling them, but you
will feel the feelings before they have processed them. There will be those few
seconds when you know where they are going. You know because that sixth sense
of yours has picked it up. This is your clinical thermometer, and it can get hot or
cold, each temperature telling you something more about your client. Remember,
feelings give us energy and direction for movement. If you know how other people
feel, then you can predict what they are going to do.

You can learn sensitivity to some degree by trial and error. Constantly ask clients
how they are feeling to check yourself for accuracy. Most clients will correct you
if you are wrong. As you reflect or rephrase what the client says and they correct
you, you will develop more sensitivity. This skill will develop and become more
accurate over the years of your career. Practice this skill when you are away from
work. Talk to the checkout person until you trigger them to feel like you see them
as a person not a machine. Do this with every waiter, bell person, cab driver,
neighbor, or family member. As you learn what people want and how they feel,
you will be able to help them to move forward more quickly. You will make
mistakes, but you will learn many things about people. You will learn that no one
really wants to do a bad thing. People do bad things because they see the good in
them. If you understand this, then you will be able to understand your clients.
Child abuse can occur simply because the parent wanted the child to be quiet. The
parent did not want to hurt the child for the joy of seeing someone in pain.

Your supersensitivity will help you to know what motivates clients. Borderline or
schizophrenic clients are very difficult to understand unless you understand how
they are feeling and what they are thinking. These are clients whom you have to
explore until you understand their worldview.
Good Counselors Do Not Become Overly Emotional
Some counselors become overly emotional. This is countertransference. These
counselors weep openly with most clients and at family sessions. They encourage
their clients to call them at home, anytime. They call clients after they leave
treatment just to see how they are doing. They encourage clients to drop by their
homes, give them rides, and lend them money. These counselors have a great need
to be liked, and they are transferring their unmet needs to their clients. Some of
these counselors have unresolved psychological problems that are driving them.
Their desire to help, please, and take care of others is out of control. These
counselors get hurt, frustrated, and angry because they learn that the clients do not
want a friend; they want a counselor. Many of these counselors burn out and
eventually leave the profession. They never seek the professional help that they
need to get their work in perspective.

You cannot be too sensitive if you use your sensitivity correctly. This
supersensitivity will give you accurate direction. You will be able to say the right
thing at the right time. You will just know what to say. You will know what you
would want to hear. Best of all, this supersensitivity will give you great timing.
You will be able to say the right thing at the right time. This is almost a magical
experience. It will happen to you more and more as you grow in your counseling
career.
Good Counselors Are Active Listeners
Good counselors actively listen. They know when to be quiet and focus on what
their clients are saying. They are interested in how the clients perceive things.
They want to know what the clients are thinking and how they are feeling. They
desire to become a part of the clients’ world. Counselors who are good listeners
will have clients tell them that they are good. Good counselors are constantly
pulling for more information and not only the facts but how the client feels about
the facts. Good counselors make their clients feel understood.
Good Counselors Do Not Talk Too Much
A common mistake of new counselors is to talk too much. If they recorded
themselves in group or in individual sessions, then they would see that they do
most of the talking. They think that they have a lot to say, and the clients have a lot
to learn, so why not just teach them. Counseling with these individuals is more
like going to a lecture. Good counselors ask many questions, and they listen
carefully for the answers. They are attentive to the clients’ verbal and nonverbal
behavior. If they see the clients saying one thing with their words and another thing
with their behavior, they believe the behavior.

Active listeners will reflect how the clients are feeling and wait for feedback.
Even with supersensitivity, you never know exactly what other people are
experiencing. You have to ask and listen. Nothing helps clients feel more
understood than to be listened to attentively. As you focus your attention on the
clients, they feel important. They feel as though someone cares for them and
knows them. Active listening takes a lot of energy. It is not easy. You have to listen
with every fiber of your being. If you do not listen, then your clients never will
feel loved. Counselors with poor listening skills hear their clients say, “You do
not understand me.” Good counselors rarely hear these words. If clients do not
feel understood, then they will be frustrated, their treatment will suffer, the
therapeutic alliance will be shaky, and the clients will not trust. To trust you, the
clients must feel known.
Good Counselors Maintain Boundaries
Good counselors know their boundaries. They know who they are as people, and
they will not allow other people to violate them. You will have clients in
treatment who will try to threaten you or throw their weight around. You will use
the group with these clients to give you the support you need. Angry clients are
using the only skill that they know how to use. It is your job to teach them how to
get what they want in some other way.

You must know your professional boundaries and not cross them. You must use
only techniques that you have learned through professional training and
experience. You never should use a technique if you have only heard about it.
Watch a skilled person use the technique a few times, and then have that person
watch you. Use only the skills that you have been trained to use. You must be able
to demonstrate, through professional education and experience, that you know
what you are doing.

If you feel comfortable with yourself and your training, it allows the rest of the
staff members to do their own thing. You do not have to question their skills. The
professional staff organization will accept that responsibility. You can relax and
enjoy your role as the counselor. That is plenty of work. You do not have to do
everyone’s job, just your own.

Boundaries include keeping your relationships with your clients professional.

Good counselors never take advantage of their relationships with clients. They
never act on romantic feelings or become involved in business dealings with their
clients. If you do these things, it will be confusing to you and your clients. The
clients are in a vulnerable situation, and you are their confidant—their hero. If you
use these relationships for your own gain, then you are going to hurt your clients.
The relationships with your clients are special. Do not take advantage of them.
Good Counselors Are Client Centered
Good counselors are client centered, not counselor centered. They treat
chemically dependent people at their own pace. They know that different clients
come into treatment with different levels of readiness for treatment. Some clients
are ready to disclose the truth very fast—the first day—and some clients will be
reluctant to share the truth. It never helps to threaten or push clients to disclose
information. All you can do is to give the clients the opportunity to share in a
supportive environment. You teach the clients the consequences of not sharing. If
the clients understand and see unconditional positive regard, then they will share.
If they cannot share with you, then they can share in their Fifth Step. If they cannot
share the truth there, then encourage them to share later. You cannot make people
talk. If you try, you will be in trouble. People will view you as abusive and
harmful. Your job is to provide a safe atmosphere in which people want to talk.

You need to give the clients the chance to grow at their own pace. You must take
them through treatment at a pace that they can follow and understand. The clients
must recognize the severity of their illness, understand their self-defeating
relationship with substances, and apply the tools of recovery. They must see their
new behaviors work.

Some clients will not do written work well, or they will not get things if they read
them. Learning disabilities can handicap some clients. These clients have to be
treated differently. If you try to push them to do something that they cannot do, then
you will fail. Many people have physical, emotional, or social roadblocks to
learning. You must recognize when clients are struggling and intervene as soon as
possible. You must do something differently to make the program more
understandable.
Good Counselors Have Effective Relationship Skills
Good counselors have good interpersonal relationship skills. They are good
communicators. They tell people how they feel and what they think. They do not
keep their feelings to themselves. They use their feelings appropriately to help
them solve problems. They are trustworthy and reliable. If they tell the clients that
they are going to do something, then they do it. They are there for the clients when
they are needed. If a client asks for help, then good counselors stop what they are
doing and focus on the client. This might take only a few minutes. If the discussion
is going to take longer, then they can make an appointment to see the client later.

Good counselors never manipulate to get their way. They never say one thing and
mean another. They never plot or plan against a client or against a member of the
professional staff. Manipulation necessitates lies, and this is a program of
rigorous honesty. Good counselors will not become involved in dishonest
communication.

Good counselors are assertive, not aggressive. They do not use the power of their
positions or their personalities to make the clients do things. They share with the
clients how they feel and ask for what they want. If the clients have broken the
rules and consequences are required, then the consequences are leveled without
excessive guilt or remorse. Good counselors never attack, assault, abuse, yell,
scream, chastise, torment, scold, assail, batter, shame, berate, condemn, lie into,
insult, tongue-lash, intimidate, threaten, terrorize, force, violate, oppress, sneak,
defame, or belittle. They treat the clients the same way in which they would want
to be treated.

Good counselors suspect when clients are transferring energy from a previous
relationship to the therapeutic relationship. They help the clients understand and
work through the transference. Good counselors always keep clients informed
about what they are thinking and how they are feeling. The clients never feel left in
the dark.

Good counselors treat clients with honor and respect. They believe that it is a
privilege to work with all clients no matter who they are. If they have a client who
they cannot work with, then they refer the client to someone else. They care for
how clients feel and for what clients want. They want to help clients to feel
comfortable.
Good counselors are constantly reinforcing. They are fun to be around. They enjoy
life. They like giving people praise. They look for things to reinforce. These
counselors try to see the good in everything. They always are reaching for the
positive. They praise people for the little things. They notice when someone does
something right, and they point it out. Good counselors rarely are punitive; they do
not like to punish. When they are giving good things to others, they feel the best
about themselves.
Good Counselors Have a Sound Code of Ethics
Good counselors have a good code of ethics (See Appendix 67, National
Association of Alcohol and Drug Abuse Counselors [NAADAC] Code of Ethics).
This is what you need to do to maintain the highest in ethical principles:

1. You respect the dignity and worth of each client and strive to protect
individual human rights.
2. You are committed to clients understanding themselves and reaching their full
potential.
3. You protect the welfare of those who seek your services as a professional.
4. You do not permit clients’ skills to be misused.
5. You accept the responsibility for the consequences of your actions. When you
are wrong, you promptly admit it.
6. You make sure that your services are used appropriately.
7. You avoid relationships that may create a conflict of interest.
8. You try to prevent distortion or misuse of your findings.
9. You present material objectively, fully, and accurately.
10. You know that your work bears a heavy responsibility because your
recommendations and actions may alter the lives of others.
11. You accurately represent your competence, education, training, and
experience.
12. You recognize the need for continuing education and are open to new
procedures and changes.
13. You recognize the differences among people of different races, sexes,
cultures, creeds, ethnic backgrounds, and socioeconomic statuses. When
necessary, you are willing to obtain special training in how to deal
effectively with such persons.
14. If you use assessment tools, then you are responsible for knowing the
reliability and validity of such instruments.
15. You recognize that personal problems may interfere with your professional
effectiveness. You refrain from becoming engaged in an activity where your
personal problems may have an influence. If you have serious problems, then
you have a responsibility to seek appropriate professional assistance.
16. You obey the law.
17. You do not condone practices that you perceive as being inhumane or unjust.
18. When announcing professional services, you do not make claims that cannot
 be demonstrated by sound research.
19. You present yourself accurately, avoiding misrepresentation of you or your
findings.
20. You respect the confidentiality of all information obtained within the context
of your work.
21. You reveal such information only with the written permission of the client or
the client’s legal representative, except when the client is a clear danger to
self or others.
22. When appropriate, you inform the client of the legal limits of confidentiality.
23. You discuss information obtained in professional relationships only for
professional purposes and only with persons clearly concerned with the
case.
24. You ensure that appropriate provisions are made for maintaining
confidentiality in the storage and disposal of the client record.
25. You recognize your own needs and are cognizant of your potential to
influence clients and subordinates.
26. You make every effort to avoid relationships that could impair your
professional judgment or increase the risk of exploitation. This includes, but
is not limited to, treatment of employees, close friends, or relatives.
27. You understand that sexual intimacies with clients are unethical.
28. You arrange for payment of services that safeguard the best interest of the
client.
29. You terminate your services when it is reasonably clear that the client is not
benefiting.
30. You understand the areas of your competence and make full use of other
professionals who will serve the best interests of your client.
31. You cooperate fully with other professionals.
32. If a person is receiving a similar service from another professional, then you
carefully consider that relationship and proceed cautiously, protecting the
other professional and the client.
33. If you employ or supervise other professionals or professionals in training,
then you accept the obligation to facilitate the professional development of
these individuals. You provide appropriate working conditions, timely
evaluations, constructive consultation, and continuing education.
34. You do not exploit your professional relationships with clients, supervisees,
students, or employees sexually or otherwise. You do not condone or
participate in any form of sexual harassment.
35. When you know of an ethical violation by another counselor, if it seems
appropriate, you bring this violation to the attention of the counselor. If this
 behavior is not corrected, then you bring the information to the appropriate
local, state, or national board.

Are you a good counselor? I hope so. If you are, you have chosen a field that will
give you indescribable joy. You will see people at their worst and at their best.
You will see them crying, and you will see them laughing. You will help people to
change for the better. You will be there to help put broken families back together
again. You will see, in the eyes of your clients, the love and appreciation that they
will feel for you. You will experience a deep love for others. You will learn to
appreciate people for their uniqueness. You will savor the fact that no two people
are the same. You will travel with men and women who are addicted as they
struggle toward new hope and new lives. Their hope is in you because you are the
chemical dependency counselor.
Appendix 1: Cognitive Capacity Screening
Appendix 2: Short Michigan Alcoholism
Screening Test

1. Do you feel you are a normal drinker? (By normal, we mean you drink less
than or as much as most other people?) (No)
2. Does your wife, husband, a parent or other near relative ever worry or
complain about your drinking? (Yes)
3. Do you ever feel guilty about your drinking? (Yes)
4. Do friends or relatives think you are a normal drinker? (No)
5. Are you able to stop drinking when you want to? (No)
6. Have you ever attended a meeting of Alcoholics Anonymous? (Yes)
7. Has drinking ever created problems between you and your wife, husband, a
parent or other near relative? (Yes)
8. Have you ever gotten into trouble at work because of your drinking? (Yes)
9. Have you ever neglected your obligations, your family or your work for two
or more days in a row? Because you were drinking? (Yes)
10. Have you ever gone to anyone for help about your drinking? (Yes)
11. Have you ever been in a hospital because of drinking? (Yes)
12. Have you ever been arrested for drunken driving, driving while intoxicated,
or driving under the influence of alcoholic beverages? (Yes)
13. Have you ever been arrested, even for a few hours, because of other drunken
behavior? (Yes)

Answers related to alcoholism are given in parentheses after each question. Three
or more of these answers indicate probable alcoholism; two answers indicate the
possibility of alcoholism; less than two answers indicate that alcoholism is not
likely.

Source: Reprinted with permission from Short Michigan Alcoholism Screening

Test. (1975). Journal of Studies on Alcohol, 36, 117–126. Copyright by Journal
of Studies on Alcohol, Inc., Rutgers Center of Alcohol Studies, New Brunswick,
NJ 08903.
Appendix 3: DSM–5 Psychoactive Substance
Use Disorder
Appendix 4: Alcohol Withdrawal Scale

Client Date Time

Pulse or heart rate taken for 1 minute

Blood pressure /

Nausea and Vomiting

Ask, “Do you feel sick to your stomach? Have you vomited?”

Observation:
0 No nausea and no vomiting
1 Mild nausea with no vomiting
2
3
4 Intermittent nausea with dry heaves
5
6
7 Constant nausea, frequent dry heaves, and vomiting

Tremor

Arms extended and fingers spread apart

Observation:
0 No tremor
1 Not visible but can be felt fingertip to fingertip
2
3
4 Moderate, with arms extended
5
6
7 Severe, even with arms not extended

Proximal Sweats
 Observation:
0 No sweat visible
1 Barely perceptible sweating, palms moist
2
3
4 Beads of sweat obvious on forehead
5
6
7 Drenching sweats

Anxiety

Ask, “Do you feel nervous?”

Observation:
0 No anxiety, at ease
1 Mildly anxious
2
3
4 Moderately anxious or guarded, so anxiety is inferred
5
6
7 Equivalent to acute panic states, as seen in severe delirium or acute
schizophrenic reactions

Agitation

Observation:
0 Normal activity
1 Somewhat more than normal activity
2
3
4 Moderately fidgety and restless
5
6
7 Paces back and forth during most of the interview or constantly thrashes
about

Tactile Disturbances
Ask, “Have you had any itching, pins and needles sensations, burning, or
numbness? Do you feel bugs crawling on or under your skin?”

Observation:
0 None
1 Very mild itching, pins and needles, burning, or numbness
2 Mild itching, pins and needles, burning, or numbness
3 Moderate itching, pins and needles, burning, or numbness
4 Moderately severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations

Auditory Disturbances

Ask, “Are you more aware of sounds around you? Are they harsh? Do they
frighten you? Are you hearing anything that is disturbing to you? Are you hearing
things that you know are not there?”

Observation:
0 Not present
1 Very mild harshness or ability to frighten
2 Mild harshness or ability to frighten
3 Moderate harshness or ability to frighten
4 Moderately severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations

Visual Disturbances

Ask, “Does the light appear to be too bright? Is the color different? Does it hurt
your eyes? Are you seeing anything that is disturbing to you? Are you seeing things
that you know are not there?”

Observation:
0 Not present
1 Very mild sensitivity
2 Mild sensitivity
3 Moderate sensitivity
 4 Moderately severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations

Headache, Fullness in Head

Ask, “Does your head feel different? Does it feel like there is a band around your
head?” Do not rate dizziness or lightheadedness. Otherwise, rate severity.

Observation:
0 Not present
1 Very mild
2 Mild
3 Moderate
4 Moderately severe
5 Severe
6 Very severe
7 Extremely severe

Orientation and Clouding of Sensorium

Ask, “What day is this? Where are you? Who am I?”

Observation:
0 Oriented and can do serial additions
1 Cannot do serial additions or is uncertain about date
2 Disoriented about date by no more than 2 calendar days
3 Disoriented about date by more than 2 calendar days
4 Disoriented about place and/or person

Total Score

Rater’s Initials

Maximum Possible Score = 67

A score higher than 25 indicates severe withdrawal (impending delirium tremens).

If score is lower than 10 after two 8-hour reviews, then monitoring can stop. If
score is higher than 20, then the client should be assessed hourly until the
symptoms are under control.
Appendix 5: Narcotic Withdrawal Scale
Appendix 6: Sample Biopsychosocial
Interview

DATE: 2-2-17

CLIENT NAME: Jane Roberts

DEMOGRAPHIC DATA: This is a 28-year-old, single, white female. She is

childless. She lives in Sioux Falls, South Dakota, by herself. She has lived in
Sioux Falls for the past 5 years. She has a high school education. She is self-
employed as a beautician at The Cut Above.

CHIEF COMPLAINT: “I could not go on drinking the way I was.”

HISTORY OF THE PRESENT ILLNESS: This client’s father died when she
was very young. She was raised by an overly demanding, alcoholic mother. Her
mother had strict rules and made the client work hard to keep the house clean. The
client never made an emotional connection with her mother. “I grew up feeling left
out, abandoned, lost, and alone. I think I was loved, but I was not shown it.” In
school, she continued to feel isolated from her peers. She began drinking during
her early teens. In high school, the client did not date a lot, but when she did, she
fell immediately in love. She began a series of addictive relationships with men.
In these relationships, she was able to experience the affection she had always
longed for. The client was “devastated” when her boyfriends would go out with
someone else. She would frantically “keep grasping” to hold onto these
relationships. After high school, the client had an affair with a married man. This
man was demonstrative in his affection, and this fooled the client into thinking that
he “really loved me.” The client was unable to disengage from this relationship,
even though the man was married and emotionally and physically abusive. The
client’s drinking began to increase. Her tolerance to alcohol increased. She had
blackouts. The client began to use Valium for sleep. Her dose of Valium has more
than doubled. She currently is drinking at least a six-pack of beer and taking 30
milligrams of Valium every night. The client currently is suffering from acute
alcohol and anxiolytic withdrawal. Her withdrawal will probably be protracted
because she has been on Valium for 5 years. In withdrawal, she reports that she
feels restless and is sleeping poorly. The client has few assertive skills and can be
excessively dependent. She enjoys men who are powerful and controlling. The
client has few healthy relationship skills, and she is dishonest. The client is
accepting of treatment and has a strong desire to get help for her chemical
dependency.

PAST HISTORY: This client was born in Livingston, South Dakota, on June 28,
1983. She reports a normal birth and normal developmental milestones. She was
raised with her mother and two younger sisters. Her father died when she was too
young to know him. Her ethnic heritage is Irish. She describes her home of origin
as “I did not like it. I felt alone.” In grade school, “I was timid, not very
outgoing.” In high school, “I was scared to relate.” The client denies ever serving
in the military. Her occupational history includes a 5-year stint as a secretary. She
has held her current job as a beautician for 5 years. She is happily employed.
Sexually, the client is heterosexual. She has a complex history of addictive
relationships with men who have been abusive both verbally and physically. The
client currently is involved with a new boyfriend. She has been seeing him for the
past few months. She reports that this relationship is going well. Her friends and
family support her coming into treatment. Spiritually, the client believes in God.
She was raised in the Lutheran faith. She attends church regularly. She denies any
legal difficulties. For strengths, the client identifies that “I am caring. I get along
with people real well. I think that I am intelligent.” For weakness, the client states,
“I have a drinking problem.” For leisure activities, the client enjoys biking and
jogging. Her leisure activities have been only mildly affected by her chemical use.

MEDICAL HISTORY:

Illnesses: Measles, mumps, chicken pox

Hospitalizations: None
Allergies: None
Medications at present: 5 milligrams of Valium three times a day for
withdrawal

FAMILY HISTORY:

Father: Age of death, “in his 20s”; cause of death, unknown; client does not
remember her father
Mother: Age 53, in good health; history of alcoholism; described as “quiet,
demanding”
Other relatives with significant psychopathology: None
MENTAL STATUS: This is a tall, thin, 28-year-old white female. She has short,
curly, light-brown hair and blue eyes. She has a broad smile and a freckled face.
She was dressed in white jeans and a white sweatshirt. Her sensorium was clear.
She was oriented to person, place, and time. Her attitude toward the examiner was
cooperative, friendly, and pleasant. Her motor behavior was mildly restless. The
client fidgeted in her chair. She made good eye contact. Her speech was
spontaneous and without errors. Her affect was mildly anxious. Her range of
affect was within normal limits. Her mood was mildly anxious. Her thought
processes were productive and goal directed. Suicidal ideation was denied.
Homicidal ideation was denied. Disorders of perception were denied. Delusions
were denied. Obsessions and compulsions were denied. The client exhibited an
above-average level of intellectual functioning. She could concentrate well. Her
immediate, recent, and remote memories were intact. She exhibited fair impulse
control. Her judgment was fair. She is insightful about her alcohol problem and is
in minimal denial about her drinking. She is in more denial about her problem
with Valium.
Diagnostic Summary
DATE: 2-10-17

CLIENT NAME: Jane Roberts

This is a 28-year-old, single, white female. She is childless. She lives in Sioux
Falls, South Dakota, by herself. She has lived in Sioux Falls for the past 5 years.
She has a high school education. She currently is self-employed as a beautician.
She comes to treatment with a chief complaint of a drinking problem. The client’s
father died when she was very young. She was raised by an emotionally distant
alcoholic mother. Jane grew up feeling a profound sense of abandonment. All her
life, she has felt empty and lost. She could gain her mother’s approval only by
being a hard worker. In grade school, the client was timid and shy. In high school,
she began a series of addictive relationships with men. Jane gets love and sex
mixed up. She is starved for attention and affection. She is vulnerable to
manipulation. She had an affair with a married man. Her relationships with men
have been dysfunctional and abusive. The client has few assertive skills. She
cannot ask people for what she wants or share how she feels. She is dishonest.
She lies to get what she wants. Jane began drinking during her early teens. After
high school, her drinking began to increase. Her tolerance to alcohol increased.
She has had multiple blackouts and has suffered withdrawal symptoms. She is
drinking at least a six-pack of beer per day. Jane has been taking Valium for sleep
for the past 5 years. She has increased her tolerance to Valium, and she has more
than doubled her bedtime dose. The client currently is experiencing symptoms of
alcohol and Valium withdrawal. She has been anemic for the past several years.
She is being treated with vitamins. She has cold symptoms and is taking aspirin
and an antihistamine. She has a history of arthritis, but she exhibits no current
symptoms. She has a history of a heart murmur. The client is highly motivated for
treatment, and her relapse potential is low. She is psychologically minded and is
opening up well in group. She shows minimal resistance to treatment. Her current
recovery environment is poor. She has no social support system except for her
boyfriend of the past 2 months. The psychological testing shows that Jane is
emotionally unstable and manipulative. She will break the rules of society to get
her own way. She will openly defy authority. She is suffering from mild
depressive symptoms, and she is experiencing significant daily anxiety. These
symptoms seem to relate to the client’s chemical dependency.
DIAGNOSIS:

303.90 Alcohol Use Disorder, severe

304.10 Anxiolytic Use Disorder, moderate
291.80 Alcohol withdrawal
292.00 Anxiolytic withdrawal
Problem List and Recommendations:
Problem 1: Extended withdrawal from alcohol and Valium, as evidenced by
autonomic arousal and elevated vital signs

Problem 2: Inability to maintain sobriety outside a structured program of

recovery, as evidenced by client having tried to quit using chemicals many times
unsuccessfully

Problem 3: Anemia, as evidenced by a chronic history of low red cell counts

Problem 4: Upper respiratory infection, as evidenced by sore throat and rhinitis

Problem 5: Fear of rejection and abandonment, as evidenced by client feeling

abandoned by both her mother and her father and now clinging to relationships
even when abusive

Problem 6: Poor relationship skills, as evidenced by client not sharing the truth
about how she feels or asking for what she wants, leaving her unable to establish
and maintain intimate relationships

Problem 7: Dishonesty, as evidenced by client chronically lying about her

chemical use history

Problem 8: Poor assertiveness skills, as evidenced by client allowing other

people to make important decisions for her, inhibiting her from developing a self-
directed program of recovery
Treatment Plan
Problem 1: Inability to maintain sobriety outside a structured program of
recovery, as evidenced by repeated unsuccessful attempts to remain abstinent
as well as increased tolerance and withdrawal symptoms
Goal A: Acquire the skills necessary to achieve and maintain a sober
lifestyle.

Objective 1: Jane will discuss three times when she unsuccessfully

attempted to stop drug and alcohol use with her counselor by 2-15-17.
Intervention: Assign the client to list three times when she
unsuccessfully attempted to stop or cut down on her drug and alcohol
use, and have her discuss this in a one-to-one session.
*Responsible professional: Carla Smith, LAC

Objective 2: Jane will verbalize her powerlessness and unmanageability in

group by 2-15-17.
Intervention: Encourage the client to share her powerlessness and
unmanageability in group.
*Responsible professional: Carla Smith, LAC

Objective 3: Jane will verbalize her understanding of her chemical

dependency with her group by 2-15-17.
Intervention: Assign the client to complete her chemical use history, and
encourage her to share her story in group.
*Responsible professional: Robert Johnson, LAC

Objective 4: Jane will share her understanding of how to use Step Two in
recovery with her counselor by 2-20-17.
Intervention: Assign the client to meet with her clergy person to discuss
how to use a higher power in recovery.
*Responsible professional: Father Larry Jackson

Objective 5: Jane will log her meditation daily and will discuss how she
plans to use the Third Step in sobriety with her clergy person by 2-25-17.
Intervention: The staff will administer medications as ordered and
monitor for side effects.
*Responsible professional: Margaret Roth, RN
Objective 6: Jane will develop a written relapse prevention plan by 2-30-
17.
Intervention: Help the client to develop a written relapse prevention
plan.
*Responsible professional: Carla Smith, LAC

Objective 7: Jane will develop a continuing care plan with her counselor
by 3-5-17.
Intervention: Have the continuing care coordinator help the client to
develop a continuing care program.
*Responsible professional: Martha Riggs, LAC
Problem 2: Chronic fear of abandonment, as evidenced by fear of losing all
interpersonal relationships
Goal B: To alleviate the fear of abandonment by connecting the client to
her higher power and her Alcoholics Anonymous (AA)/Narcotics
Anonymous (NA) support group

Objective 1: In one-to-one counseling, Jane will share her feelings of

abandonment by her parents and how this relates to her chemical dependency
by 2-15-17.
Intervention: In a one-to-one session, encourage the client to share her
feelings of abandonment by her parents, and help her to connect this to
her chemical dependency.
*Responsible professional: Carla Smith, LAC

Objective 2: Jane will share her feelings of fear, loneliness, and isolation
with her group by 2-20-17.
Intervention: Assign the client to share her feelings of fear, loneliness,
and isolation in group.
*Responsible professional: Carla Smith, LAC

Objective 3: Jane will discuss her fear that the group will abandon her and
receive feedback from the group by 2-25-17.
Intervention: In group, encourage the client to share her fears that the
members of the group will abandon her.
*Responsible professional: Carla Smith, LAC

Objective 4: In one-to-one counseling, the client will discuss accepting her

AA/NA group as her new support system by 2-28-17.
 Intervention: Teach the client about how her recovery group can be her
new support system.
*Responsible professional: Carla Smith, LAC

Objective 5: Jane will write a letter to her father and mother telling them
how she felt as a child, and she will share this letter with her counselor and
in group by 2-20-17.
Intervention: Assign the client to write a letter to her father and mother
telling them about the abandonment she felt as a child, and have her read
this letter to her primary counselor and the group.
*Responsible professional: Carla Smith, LAC
Problem 3: Poor interpersonal relationship skills, as evidenced by inability
to share emotions, wishes, and wants with others
Goal C: To develop healthy interpersonal relationship skills

Objective 1: Jane will verbalize an identification of her problem with

relationships with her counselor by 2-15-17.
Intervention: Teach the client about interpersonal relationship skills and
how her addiction affected her ability to have healthy relationships.
*Responsible professional: Carla Smith, LAC

Objective 2: Jane will ask five treatment peers for something she wants
and share with them how she feels, keeping a log of each conversation and
sharing this with her counselor by 2-15-17.
Intervention: Assign the client to ask five treatment peers for something
she wants and share how she feels, and have her log each event and
share in a one-to-one session.
*Responsible professional: Carla Smith, LAC

Objective 3: Jane will complete the Addictive Relationships exercise (see

Appendix 12) and share her understanding of the differences in addictive and
healthy relationships with her counselor by 2-20-17.
Intervention: Assign the client to complete the Addictive Relationships
exercise, and teach her the difference between addictive and healthy
relationships.
*Responsible professional: Carla Smith, LAC

Objective 4: Jane will use and log 10 “I feel” statements a day until the end
of treatment, and she will share her daily feeling log with her counselor
weekly by 2-25-17.
Intervention: Assign the client to log 10 feeling statements a day and to
share in one-to-one sessions.
*Responsible professional: Carla Smith, LAC

Objective 5: Jane will discuss her normal and addictive relationships with
her group by 2-30-17.
Intervention: In group, encourage the client to share her understanding of
addictive relationships and the tools she can use to develop and
maintain healthy relationships in recovery.
*Responsible professional: Carla Smith, LAC
Problem 4: Dishonesty, as evidenced by chronic lying about chemical use
Goal D: To develop a program of recovery based on rigorous honesty

Objective 1: Jane will complete the Honesty exercise (see Appendix 8)

and verbalize in group 10 times when she was dishonest about her chemical
use by 2-15-17.
Intervention: Assign the client to complete the Honesty exercise, and in
group have her verbalize 10 times when she was dishonest about her
addiction.
*Responsible professional: Bill Thompson, MSW

Objective 2: Jane will discuss in group how her alcohol use contributed to
her dishonesty by 2-20-17.
Intervention: In group, have the client discuss the connection between
addiction and dishonesty.
*Responsible professional: Bill Thompson, MSW

Objective 3: Jane will keep a daily log of the times when she lies in
treatment and will share this log with her counselor weekly by 2-25-17.
Intervention: Help the client to keep a daily log of the lies she tells in
treatment, and discuss with her how it feels to lie and how it feels to tell
the truth.
*Responsible professional: Carla Smith, LAC

Objective 4: Jane will give a 20-minute speech to her group about why it is
important to be honest in recovery by 2-25-17.
Intervention: Assign the client to write a 20-minute speech about why it
is important for her to get honest, and then encourage her to read her
 paper in group.
*Responsible professional: Carla Smith, LAC

Objective 5: In a conjoint session with her mother, Jane will share her
chemical use history by 2-30-17.
Intervention: In a family session, have the client share her chemical use
history with her mother.
*Responsible professional: Ronda Vocal, L.M.F.T.

Objective 6: Jane will discuss how dishonesty separated her from her
higher power with the clergy by 2-20-17.
Intervention: Have clergy meet with the client and discuss how her lies
kept her away from her higher power.
*Responsible professional: Pastor Steve Schultz
Problem 5: Poor assertiveness skills, as evidenced by being too passive
and allowing other people to make important decisions
Goal E: To develop assertiveness skills

Objective 1: In group, Jane will verbalize an identification of her problem

of being passive and will directly relate her passivity to her chemical use by
2-20-17.
Intervention: The psychologist will help the client to understand passive
traits and how this relates to addiction.
*Responsible professional: Frank Rockman, PhD

Objective 2: Jane will verbalize an understanding of how her passive

behaviors lead directly to increased chemical use with her group by 2-15-17.
Intervention: Assign the client to discuss in group how her passive traits
lead to chemical use.
*Responsible professional: Carla Smith, LAC

Objective 3: Jane will practice the assertiveness formula with two

treatment peers per day, keeping a daily log of each interaction by 2-20-17.
Intervention: The psychologist will teach the client the assertiveness
formula and, using behavior rehearsal, will role-play several
assertiveness situations.
*Responsible professional: Frank Rockman, PhD

Objective 4: Jane will have weekly individual sessions with the

psychologist in which she will role-play assertiveness situations by 2-30-17.
Intervention: The psychologist will meet with the client weekly to role-
play assertiveness situations.
*Responsible professional: Frank Rockman, PhD
Appendix 7: Chemical Use History

Robert R. Perkinson, PhD

This exercise will help you to become more aware of how chemicals have
affected your life and the lives of those around you. Using alcohol, or any other
mood-altering substance, is considered to be chemical use. Answer the questions
as completely as you can. It is time to get completely honest with yourself. Write
down exactly what happened.

1. How old were you when you had your first drink? Describe what happened
and how you felt.
2. List all of the drugs you have ever used and the age at which you first used
each drug.
3. What are your drug-using habits? Where do you use? With whom? Under
what circumstances?
4. Was there ever a period in your life when you used too much or too often?
Give at least five examples.
5. Has using chemicals ever caused a problem for you? Describe the problem
or problems. Give at least five examples.
6. When you were using, did you find that you used more—or for a longer
period of time—than you had originally intended? Give at least five
examples.
7. Do you have to use more of the chemical now to get the same effect? How
much more than when you first started?
8. Did you ever try to cut down on your use? Why did you try to cut down, and
what happened to your attempt?
9. List at least five ways you tried to cut down. Did you change your beverage?
Limit the amount (“I would only have three tonight”)? Restrict your use to a
certain time of day (“I would only drink after five o’clock”)?
10. Did you ever stop completely? What happened? Why did you start again?
11. Did you spend a lot of time intoxicated or hungover?
12. Did you ever use while doing something dangerous such as driving a car?
Give at least five examples.
13. Were you ever so high or hungover that you missed work or school? Give at
least five examples.
14. Did you ever miss family events or recreation because you were high or
hungover? Give at least five examples.
15. Did your use ever cause family problems? Give at least five examples.
16. Did you ever feel annoyed when someone talked to you about your drinking
or use of drugs? Who was this person, and what did they say? Give at least
five examples.
17. Did you ever feel bad or guilty about your use? Give at least five examples.
18. Did using ever cause you any psychological problems such as being
depressed? Explain what happened.
19. Did using ever cause you any physical problems or make a physical problem
worse? Give a few examples.
20. Did you ever have a blackout? How old were you when you had your first
blackout? Give some examples of blackouts.
21. Did you ever get sick because you got too intoxicated? Give at least five
examples.
22. Did you ever have a real bad hangover? Give at least five examples about
how you felt.
23. Did you ever get the shakes or suffer withdrawal symptoms when you quit
using? Describe what happened physically, mentally, and spiritually to you
when you stopped using your drug of choice.
24. Did you ever use chemicals to avoid symptoms of withdrawal? Give at least
five examples of when you used a substance to control withdrawal
symptoms.
25. Have you ever sought help for your drug problem? When? Who did you see?
Did the treatment help you? How?
26. Why do you continue to use? Give 5 to 10 reasons.
27. Why do you want to stop using? Give at least 10 reasons.
28. Has alcohol or drug use ever affected your reputation? Describe what
happened and how you felt.
29. Describe the feelings of guilt you have about your use. How do you feel
about yourself?
30. How has using affected you financially? Give at least five examples of how
you wasted money in your addiction.
31. Has your ambition decreased due to your use? Give a few examples.
32. Has your addiction changed how you feel about yourself? How do you feel
when you are seeking the addiction or in withdrawal?
33. Are you as self-confident as you were before? How has the addiction
affected your faith in yourself?
34. List at least 10 reasons why you want treatment now.
35. List all of the chemicals you have used in the past 6 months.
36. List how often, and in what amounts, you have used each chemical in the past
6 months.
37. List the life events that have been affected by your chemical use (e.g., school,
marriage, job, children).
38. Have you ever had legal problems because of your use? List each problem.
39. How has your addiction affected your relationship with your parents and
other family members? List at least 10 reasons.
40. If you are in school, list at least five ways your addiction affected your
schoolwork and relationships with teachers and school administrators.
41. Have you ever lost a job or been suspended or expelled from school because
of your use? Describe each time.
42. Do you want treatment for your chemical problem? List at least 10 reasons
why.
Appendix 8: Honesty

Robert R. Perkinson, PhD

This is an exercise to help you get honest with yourself. In recovery, it is essential
to tell the truth. As you will hear at every 12-step meeting, this is a program of
rigorous honesty. “Those who do not recover are people who cannot or will not
completely give themselves to this simple program, usually men and women who
are constitutionally incapable of being honest with themselves” (Alcoholics
Anonymous [AA], 2001, p. 58).

Why is it so important to be honest? Because dishonesty to self and others distorts

reality. “Rigorous honesty is the most important tool in learning to live for today”
(Narcotics Anonymous [NA], 1988, p. 92). You never will solve problems if you
lie. You need to live in the facts. In sobriety, you must commit yourself to reality.
This means accepting everything that is real.

People who are chemically dependent think that they cannot tell the truth. They
believe that if they do, they will be rejected. The facts are exactly the opposite;
unless you tell the truth, no one can accept you. People have to know you to accept
you. If you keep secrets, then you never will feel known or loved. An old AA
saying states, “We are only as sick as our secrets.” If you keep secrets from
people, then you never will be close to them.

You cannot be a practicing alcoholic or drug addict without lying to yourself. You
must not lie—and believe the lies—or else the illness cannot continue. The lies
are attempts to protect you from the pain of the truth. If you had known the truth,
then you would have known that you were sick and needed treatment. This would
have been frightening, so you kept the truth from yourself and from others. “Let us
face it; when we were using, we were not honest with ourselves” (NA, 1988, p.
27).

There are many ways you lied to yourself. This exercise will teach you exactly
how you distorted reality, and it will start you toward a program of honesty.
Answer each of the following questions as completely as you can.

1. Denial: You have told yourself or others, “I do not have a problem.” Write
 down at least five examples of when you used this technique to avoid dealing
with the truth.
a.
b.
c.
d.
e.

2. Minimizing: This is making the problem smaller than it really was. You
might have told yourself, or someone else, that your problem was not that
bad. You might have told someone that you had a couple of beers when you
really had six. Write down at least five examples of when you distorted
reality by making it seem smaller than it actually was.
a.
b.
c.
d.
e.

3. Hostility: You became angry or made threats when someone confronted you
about your chemical use. Give at least five examples.
a.
b.
c.
d.
e.

4. Rationalization: You have made an excuse. “I had a hard day. Things are
bad. My relationship is bad. My financial situation is bad.” Give at least 10
examples of when you thought that you had a good reason to use chemicals.
a.
b.
c.
d.
e.
f.
g.
h.
i.
 j.

5. Blaming: You have shifted the responsibility to someone else. “The police
were out to get me. My wife is overreacting.” Give at least five examples of
when you blamed someone else for a problem you caused.
a.
b.
c.
d.
e.

6. Intellectualizing: You have overanalyzed and overthought about a problem.

This avoids doing something about it. “Sure I drink some, but everyone I
know drinks. I read this article, and it said that this is a drinking culture.”
Give at least five examples of how you use intellectual data and statistics to
justify your use.
a.
b.
c.
d.
e.

7. Diversion: You have brought up another topic of conversation to avoid the

issue. Give at least five examples.
a.
b.
c.
d.
e.

8. Make a list of five lies that you told to someone close to you about your
drinking or drug use.
a.
b.
c.
d.
e.

9. Make a list of five lies that you told yourself about your drug problem.
 a.
b.
c.
d.
e.

10. Make a list of 10 people you have lied to.

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.

11. How do you feel about your lying? Describe at least five ways you feel about
yourself when you lie.
a.
b.
c.
d.
e.

12. List five things you think will change in your life if you begin to tell the truth.
a.
b.
c.
d.
e.

13. List five ways you use lies in other areas of your life.
a.
b.
c.
d.
e.
14. When are you the most likely to lie? Is it when you have been drinking or
using addictive behavior?

15. Why do you lie? What does it get you? Give five reasons.
a.
b.
c.
d.
e.

16. Common lies of addiction are listed here. Give a personal example of each.
Be honest with yourself.
1. Breaking promises:
2. Pretending to be clean and sober when you are not:
3. Pretending you remember things when you do not remember because of
the addiction:
4. Minimizing use: Telling someone you drink or use no more than others
use:
5. Telling yourself that you were in control when you were not:
6. Telling someone that you never have been involved in addictive
behavior:
7. Hiding morning drinking:
8. Hiding your supply:
9. Substituting the addiction for food or things you or your family needs:
10. Saying that you had the flu when you were really hungover or sick from
the addiction:
11. Having someone else call into work to say that you are too sick to come
to work:
12. Pretending not to care about your addiction:

People who are addicted lie to avoid facing the truth. Lying makes them feel more
comfortable, but in the long run they end up feeling isolated and alone. Recovery
demands living in the truth. “I am an alcoholic or an addict. My life is
unmanageable. I am powerless over alcohol. I need help. I cannot do this alone.”
All of these are honest statements from someone who is living in reality.

Either you will get real and live in the real world, or you will live in a fantasy
world of your own creation. If you get honest, then you will begin to solve real
problems. You will be accepted for who you are.
Wake up tomorrow morning, and promise yourself that you are going to be honest
for the next hour. Then try it for a half day and then a whole day. Stop and check
your feelings, and write down five ways you feel different when you are honest.

Write down in a diary when you are tempted to lie. Watch your feelings when you
lie. How does it feel? How do you feel about yourself? Keep a list of five ways
you feel different about yourself when you lie. Keep a diary for 5 days and share it
with your group or counselor. Tell them why you lied and how you felt about
yourself when you lied. Then tell the group or counselor how it feels to be honest.

Take a piece of paper and write the word truth to place on your bathroom mirror.
Commit yourself to rigorous honesty. You deserve to live a life filled with love
and truth. You never need to lie again.
Appendix 9: Love, Trust, and Commitment

Robert R. Perkinson, PhD

It seems that going through life, we should be taught a few simple things about
relationships. After all, we have a relationship first with ourselves and then, if we
so choose, with others. How can we trust ourselves? How can we trust others?
When are we committed? When do we love? This exercise will start you thinking
about these essential parts of a relationship. Use this exercise to ask yourself some
important questions.
The First Relationship
An infant learns about love, trust, and commitment from its primary caregiver.
This usually is the mother. When the infant cries out, someone comes and
addresses its needs. The baby cannot see very well, so this someone comes out of
a haze, seemingly out of nowhere. Whenever the baby cries, this someone comes.
This someone comes every time, and a great trust develops between the infant and
its mother. As the infant grows older, it becomes aware that this someone has a
particular sight, smell, sound, taste, and feel. Soon this someone has a name—
mother.

The infant learns who he or she is by looking at the mother’s face, particularly her
eyes. Healthy mothers look at their children with a look that says, “You bring me
joy.” Therefore, a healthy child learns that he or she brings joy to the world. By
mirroring the mother’s facial expression, they learn that they are important,
accepted, and loved. The mother always comes when the infant cries out, at all
hours of the day or night, so in time a baby learns to trust that the caregiver will
always come.

As infants grow older, they learn that the mother does not have to come; she
chooses to come. Why does she come? Why, at all hours of the day or night, does
she choose to come? She comes because she is bonded with her child. Her child’s
pain is her pain, and her child’s joy is her joy. She cannot ignore her child’s pain
because when her child hurts, she hurts. In this bonding of mother and child, that
builds a healthy brain where there is love, trust, and commitment. “The child
knows mother will always be there for me.” The child’s very life depends on it.
The mother has to be so in tune with her child that her loving gaze cannot last too
long or the child will be overwhelmed. So she must look away every few seconds
and instinctively know when to look back reassuring her baby. Later in childhood,
the mother socializes the child by purposely looking away when the child does
something wrong. But she does not look away too long or she will raise an
anxious child—one who is unsure and uncomfortable about whether or not she or
he can trust the mother. Unhealthy children are uncertain, anxious, or even angry in
the mother’s presence. Some babies who are abused have to look dead in order to
make the abuse stop. Many of your clients will have a flat effect or look like they
have no feelings. This person may have been abused as an infant or an adult
(Schore, 2003). Some children never learn to trust, and this is one of the primary
characteristics of a child of an addict. Children from addicted homes never know
what is going to happen, so they live in fear, uncertainty, and chaos. They learn to
trust no one. They can love but have great difficulty feeling loved.

It is from this first relationship that we generalize what to expect from all of our
other relationships. We expect relationships to have certain core characteristics. If
the relationships are healthy, they will have love, trust, and commitment as
essential building blocks.
Trust
List at least five ways you can show yourself that you can trust yourself.

List at least five things you are going to do to prove to yourself that you are
trustworthy.

You will need to develop consistency of action in your own behalf.

If you act consistently in a manner that is in your best interest, then you have
gone a long way toward learning how to trust yourself.
You must be consistent even when times get rough.
You need to learn that no matter what, you are going to do things that are
good for you.
You are trustworthy to someone else when you consistently act in that other
person’s interest.
Commitment
Commitment means that you are faithful and loyal for an extended period. It means
that on a daily basis, you can count on yourself to follow through with your
promises.

You have plans to be good to yourself, and you are going to stick with these
plans.
You are going to hammer away at the things you want day by day.
You are not going to give up.
These same elements apply when you commit yourself to someone else.
Love
A good definition for love is that love is the interest in, and the active involvement
in, a person’s individual growth. Love for someone else needs trust and
commitment, but it needs something more.

Love needs empathy. You must feel the other person’s feelings as if they were
your own.
Empathy is the feeling that you share with another person. It is being in
harmony. “I feel your feelings.”
“When you feel sad, I feel sad. When you feel joy, I feel joy. To help you is
to help myself.”
“To love you is to love myself.”

Perhaps somewhere along the way you have lost the ability to experience normal
relationships. Maybe you never developed a trustworthy, committed relationship
with your primary caregiver. It could be that you never really felt accepted the
way in which you needed to be. Children need a lot of encouragement when they
try things, and they need a lot of praise. This makes them feel accepted, cherished,
and loved. If you take children, sit on their beds every day of their lives, and tell
them how wonderful they are, then maybe by the time they are 6 years old they
will be ready for school. Children need a lot of encouragement to develop a sense
of self-worth.
How to Be Caring to Yourself
To be caring to yourself, you must give yourself a lot of encouragement and a lot
of praise. If you missed this as a child, then your challenge is to reinforce
yourself.

Treat yourself the way in which you wanted to be treated.

Be your own healthy mother and your own healthy father.
Give yourself all of the love you have always wanted.

Imagine for a moment that you are a very young child with a fragile and
impressionable mind. Write down 10 things that you would need to see from your
parents.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Only you know what you need. It is up to you to meet your needs. Give to yourself
all of the love you need.
Relationship With Self
List the things that you need to see from yourself that will prove you can be trusted
to act in your own best interests.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

List the things that you need to see from yourself that will show you are committed
to your own growth. This is a day-by-day commitment.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

List the things that you will need to see from yourself that will show you love
yourself.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
How to Find Out the Good Things About Yourself
List the things about yourself that make you feel proud. Start with physical
appearance. What are some of your good physical qualities? List as many as you
can think of. Start with your hair, and move downward to the tips of your toes.
Admire the color, size, shape, feel, smell, sound, or whatever you can think of. Do
not let the old stinking thinking keep you feeling bad about yourself. Get accurate
by asking your counselor or group to help you.

Physical appearance: What do you like about how you look?

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Personality: List all of the personality characteristics that you like and admire
about yourself. What do people seem to like about you? What do you like about
yourself?

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

You need a lot of encouragement and praise. Now you have many accurate things
to say to yourself that make you feel good about yourself.

Things you enjoy: List the things you enjoy doing. How do you play? What do you
do for fun or entertainment? What would you like to start doing that will give you
pleasure?

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

People you enjoy: List some of the people you enjoy being around. Write down
what makes them feel special to you.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Take a long look at what you have written. See how wonderful you really are.
Say Good Things to Yourself
Now you have all of these good things to say to yourself. Start with 10 things, and
write them down on note cards. Carry these cards with you, and read them to
yourself periodically throughout the day. Look at yourself in the mirror, and say
these things to yourself. Practice until you have these 10 memorized and then list
10 more. Constantly bombard yourself with positive self-talk. When you find
yourself speaking harshly to yourself, stop and self-correct. Get out the note cards
if you have to, but do not continue to treat yourself poorly.
Do Good Things for Yourself
You are saying good things to yourself. That is healing and treating yourself well.
Now what can you do for yourself today that is really special?

Maybe take a long, hot bath.

Go for a relaxing walk.
Spend some time with a friend you enjoy.
Get some ice cream.
Read something you enjoy.
Take a nap.
Come up with a few special things to do for yourself today. Write all of these
things down and do them. When you are doing these things, think of why you
are doing them because you are a person of great worth. Do this every day.
Before you get up in the morning, commit yourself to treating yourself well
and then get up and get busy, enjoy life, and feel the pleasure of being alive.
You deserve it.
Relationship With Others
You have some things that you want from a significant other, a friend, or a lover. It
is your responsibility to ask for what you want. Be specific and give that person a
lot of encouragement when he or she tries to give these things to you. You know
the secret.

Be reinforcing.
Give encouragement.
Shower the person with praise—it is contagious.
If you give more, you will get more often.
Happiness is created when we unselfishly give to others.
How to Find Out If a Relationship Is Good for You
What are the things you need to see from someone that will show you he or she is
trustworthy and committed to you?

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
How to Get What You Want in a Relationship
If you have a friend or partner, then you must be specific.

Ask that person for what you want. The person cannot guess what you want
or need; you must tell him or her.
Remember to give the person a lot back when he or she gives you something.
Ask the person for what he or she wants, and do your best to give it to this
person.
As you give to this other person, you will feel good about yourself and you
will get more of your needs met in return.
The more you give, the more you will get.

After completing this exercise, you should be treating yourself well. You should
know what you need to see from yourself, and from others, to make you feel good.
You have learned that you directly influence how you feel. You are not helpless to
others or to your environment. You can love yourself. You are special. You are
worth it. Others can love you. You can love others. You can feel whole, healthy,
and complete. You have all of the skills that you need.
Appendix 10: Feelings

Robert R. Perkinson, PhD

Chemically dependent persons have a difficult time with their feelings. They never
have learned how to use their feelings appropriately. They have been chemically
altering their feelings for years. They do not know how they feel or what they
want. They do not know what to do when they do feel. Many chemically
dependent people were shamed for having normal feelings when they were
children. When they were afraid, they were told that there was no reason to be
afraid. When they were angry, they were told that there was no reason to be angry.
Children who are taught these things learn that their feelings cannot be trusted.
They learn that there is something wrong with their feelings. This exercise will
help you to identify your feelings and use your feelings appropriately.
The Purpose of Feelings
Feelings or emotions are physiological states that motivate action. Each feeling
gives you specific energy and direction for movement. This is how problems are
solved.

First, there is a situation that triggers thought.

Thoughts create feelings.
Feelings motivate action.

This is how all problems are solved. A person becomes involved in a problem,
thinks about the problem, has feelings generated by the thoughts, acts on the
feelings, and resolves the issue.
The Core Feelings
There are only a few core feelings. Feelings that are more complicated are
various combinations of the primary ones. Plutchik (1980) studied feelings and
found that there were eight primary emotions:

1. Joy
2. Acceptance
3. Anticipation
4. Surprise
5. Fear
6. Anger
7. Disgust
8. Sadness

Each of these feelings gives us specific energy and direction for movement. We
need to discuss each feeling carefully and have you learn specifically what each
feeling is like. Then you can recognize when the feeling occurs, and you will
know what the feeling is telling you to do. You need practice in experiencing the
subtle physiological changes that differentiate each feeling from the others.
Joy
Joy is that feeling we experience when we reach a goal. The harder we have been
working for the goal, and the more important the goal is to us, the more joy we
feel.

List at least five times when you felt joy in your life. As you write down each
situation, take a moment to reexperience the feeling you had at that moment in your
life. Feel the situation as if you were actually there.

1.
2.
3.
4.
5.

Joy gives us the energy and direction to celebrate, feel pleasure, and enjoy an
activity. It directs us to seek more of whatever is giving us this pleasure.
Acceptance
Acceptance is the feeling we get when someone likes us or approves of us. List
five times in your life when you felt accepted. Allow yourself to feel the feeling as
you remember each situation.

1.
2.
3.
4.
5.

The feeling of acceptance gives us the energy and direction to stay involved, or
become more intimately involved, with the person or group that is accepting. It is
a feeling that bonds people together.
Anticipation
Anticipation is the feeling we get when we prepare ourselves for change. It
mobilizes us for something new. We can anticipate something good or bad. List
five times when you felt an intense sense of anticipation. Try to reexperience the
feeling of each situation.

1.
2.
3.
4.
5.

Anticipation gives us the energy and direction to mobilize ourselves for change.
We prepare ourselves for something new.
Surprise
Surprise is the feeling we get when something unexpected happens. Surprise gives
us the energy to orient ourselves to a new situation. List five times when you felt
surprised. Feel the feeling that you felt each time.

1.
2.
3.
4.
5.

Surprise mobilizes our bodies to take in the new situation as quickly as possible.
The brain is very quickly deciding how to respond to the new stimuli.
Fear
Fear is the feeling we have when something is perceived as dangerous and to be
avoided. List five times when you felt fear. Allow yourself to feel the feeling
generated by each situation.

1.
2.
3.
4.
5.

Fear gives us the energy and direction to escape from a dangerous situation. It
mobilizes us to get away from the offending stimuli.
Anger
Anger is the feeling we feel when we are violated. This violation may be real or
imagined. You are hurt first and the anger is there to make the pain stop. List five
times when you were angry. Feel the anger you felt in each situation. Concentrate
on the physical changes in your body that occur when you get angry.

1.
2.
3.
4.
5.

Anger gives us the energy and direction to fight. It helps us to reestablish the
boundaries around ourselves. Anger is necessary to prevent people from violating
us.
Disgust
Disgust is the emotion we feel when something repels us. We loathe it; it is
repugnant. List five times when something disgusted you. Allow yourself to
reexperience the feeling of each situation.

1.
2.
3.
4.
5.

Disgust gives us the energy and direction to withdraw from the offending
stimulation. We need to move away from the object that repels us.
Sadness
Sadness is the feeling we get when we have lost something. We can lose a love
object or self-esteem. List five times when you felt sad. Allow yourself to
reexperience the sad feeling. Sense the subtle physiological changes that occur
when you feel sad.

1.
2.
3.
4.
5.

Sadness gives us the energy and direction to recover the lost object. If we are
unable to recover the object, then the sadness can deepen. Sadness can immobilize
an organism so that healing can begin to take place. The organism does not move
or do new things. It stays still and recovers from the loss.
How to Use Feelings Appropriately
Feelings can be used appropriately or inappropriately. They can be based on
accurate or inaccurate information. They can lead to adaptive behavior or
maladaptive behavior. It is important to know how you feel and what to do when
you feel. Feelings will help you to solve problems. Without using your feelings
appropriately, you never will be able to solve problems well.

When you feel, you will be experiencing one or more of the eight primary feelings.
Jealousy is feeling fear, anger, and sadness all at the same time. Each feeling
needs to be addressed for full resolution of the problem.

If you feel confused, then you are feeling many feelings at the same time. Some of
these feelings may be in conflict with each other, and you may be torn about what
to do. When confused, you must separate each feeling and examine it carefully.
What is each feeling telling you to do? What is the most rational thing to do?

When you have a feeling, you must decide how to act. The feeling is motivating
you to take action. Feelings need to flow naturally and spontaneously into adaptive
action. The actions must be appropriate to the situation. To always fight when you
are angry is not appropriate. Most of the time, it is necessary to stop and think
before you act. You want to use your feelings accurately. When you are having an
intense feeling, always ask yourself two questions:

1. What is the best thing I can do for myself?

2. What is the best thing I can do for the others?

For the most part, you must practice thinking and planning before you act. Plan
carefully how you are going to act when you have each feeling, and practice this
action until it flows naturally. It will help you to role play each feeling with others
in group. For example, one group member could play your father who is angry
with you and you try to respond to his anger appropriately. Each person role-plays
each feeling enough times that they automatically have the correct thoughts and the
correct motor movements. One of the best things you can do for someone who is
angry with you is to ask for more information about why they are hurt or angry.
Then try to reflect to them how they are feeling and why.

Father: I am very upset with you for being late.

Client: Dad, I know I promised to be home on time, but I lost track of the time.

Father: That is the problem. You always lose track of time.

Client: It sounds like you are having trouble trusting me.

Father: That’s right. You are always late.

Client: Dad, this is the only time I have been late this week, and I am willing to
experience the consequence we discussed in the behavioral contract.
Tomorrow I will come home one hour earlier.

Father: How about two hours earlier and washing the car.

Client: I will gladly come home two hours earlier and wash the car. It is very
important for me to know that you trust me, and I know I have to earn that trust.

Your feelings are important. They are great and wise counselors that need to be
heard. You do not need to hide from your feelings. You need to listen and learn.
Practice each feeling so you can get good at automatically knowing what to think
and do when you have each feeling. You will blow it sometimes; everyone does,
but the more you practice the better you will do, and you will have a more stable
recovery.
Appendix 11: Relationship Skills

Robert R. Perkinson, PhD

There are certain skills that are necessary to establish and maintain close
interpersonal relationships. The skills seem simple, but some of them can take
great courage. Love is not a feeling; it is an action. We must love in action and in
truth. To love someone, you must be actively involved in that other person’s
individual growth. Love is not self-oriented; it is other-oriented. There also is the
love that you show yourself. This is when you are involved in your own growth.
How to Love
The first skill is love. Love is an action. You are interested in and actively
involved in the other person’s individual growth. You are there for that other
person when he or she needs you. You respond to how the person feels and what
he or she wants. You tell the truth all of the time. You are willing to spend your
time and energy being involved in the other person’s well-being.

List five times when, because of your addictive behavior, you were not there for
someone when he or she needed you. Then list what you could have done, or
should have done, to help that other person at that moment. Sometimes you might
have been too intoxicated or hungover to be there for the other person. Sometimes
you might have used your time or money for the addiction rather than for a family
member.

1.
2.
3.
4.
5.

List five times when you lied to someone you loved. Love cannot exist where
there are lies. Love necessitates truth. Without the truth, the other person does not
know who you are.

1.
2.
3.
4.
5.
How to Commit
The second skill is commitment. You must commit yourself, on a daily basis, to
work on building a close relationship. This means that you work to provide a safe
atmosphere in which the relationship can grow. This is an atmosphere full of love
and trust. You dedicate yourself to the other person and the relationship. You must
take the time necessary to nourish yourself, the other person, and the relationship.
You consistently ask yourself what you can do for the other person, and then you
do it. Now make a plan. What do you think you need to do to make your
relationship grow?

1.
2.
3.
4.
5.
How to Be Encouraging
The third skill is being encouraging. You must encourage the other person to reach
his or her full potential in life. This takes a lot of reinforcement and praise. No
one needs to be punished and criticized. This dampens the spirit and weakens
interpersonal bonds. People need soothing, tender, and encouraging words. They
need to know that you have faith in them, that you trust them, and that you will help
them to grow. People need their good points praised. They need to hear what they
are doing right. Encourage five people today. Write down each of their names and
the situation. Watch their reactions, and make note of how they seem to feel and
how you feel.

1.
2.
3.
4.
5.
How to Share
The fourth skill is sharing. Intimacy means “into-me-see.” You must practice
sharing how you feel and what you think. You must ask for what you want. You
cannot keep these things to yourself. The relationship will falter if you withhold
the truth. As children, we might have been taught that asking for what we want is
selfish. It is not selfish in a healthy relationship; it is necessary. Happiness occurs
when you unselfishly give to others. How can your partner give to you if you do
not tell him or her what you want? How can the other person be encouraged to
grow and change unless you hold the person accountable for his or her actions? If
you keep your feelings and wants to yourself, then your relationship will not work.
Your partner cannot guess what you want. The other person is not capable of that.
List 10 important things you want from your relationship, and decide how you are
going to ask for these things.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Now list the feelings that you have difficulty sharing with your partner. What
feelings do you tend to keep secret?

1.
2.
3.
4.
5.

Make yourself a promise: The next time you have a sharing time with someone,
you are going to share how you feel and think. You are going to ask for what you
want. Practice in a skills group or with your counselor. Play the role of yourself
and your partner, and have another person play the other role. Then work through
some problems you have had in the past and see if telling the truth, the whole truth,
and nothing but the truth will help you solve problems. Practice rephrasing what
the other person has said until he or she agrees that you understand. Then respond
and have the other person rephrase what you said until you say he or she
understands. Many problems occur because the people are not understanding each
other and particularly understanding each other’s needs. Most of the time you think
you know what the other person needs but most of the time you will be wrong. You
need to ask and rephrase until you understand.
How to Compromise
The fifth skill is compromise. No one is going to get everything he or she wants in
a relationship. You have to create an atmosphere of give-and-take. You must be
willing to respond to how the other person feels and what he or she wants.
Always ask yourself what you would want if you were in the other person’s
position. Compromise creates an atmosphere of fairness and equality. List five
areas in your life where you have stubbornly wanted to have things your own way.
Then list what you are going to do to be more flexible in those situations.

1.
2.
3.
4.
5.
How to Show Respect
The sixth skill is establishing a relationship filled with respect. This means that
you show the other person that he or she is important to you. You do things that
make the person feel special, understood, and wanted. You care for how the
person feels and for what he or she wants. This person matters to you. This person
counts. You do not treat this person poorly; you love him or her too much for that.
You want this person to be happy. When this person feels happy, you feel happy.
List five ways in which you can show someone that he or she is special and
important to you.

1.
2.
3.
4.
5.

These relationship skills need practice. They will not come easily. You need to
work at telling the truth all of the time and role play in group and with your
counselor a wide variety of situations that have given you difficulty in the past.
You need to practice being encouraging. Practice sharing how you feel and asking
for what you want. You need to develop the skill of commitment. You will struggle
when you compromise. You need to work at showing someone that he or she is
important.

Keep a log every day for the next week. Detail how you did on each skill and
watch for the other person’s reaction. Look carefully at how the other person’s
response changes how you feel about yourself.
The Daily Relationship Plan
1. Encourage someone today.
1. Write down the situation. Exactly what happened?
2. How did the person feel when you encouraged him or her?
3. How did you feel?

2. Ask for something you want.

1. How did it work?
2. Did you get what you wanted?
3. How did you feel about asking?
4. How did the other person respond?

3. Share your feelings.

1. What was the situation?
2. How did you feel about yourself?
3. What response did you get?

4. Tell someone that he or she is important to you.

1. How did you feel about doing this?
2. How did the other person feel?

5. Evaluate yourself on honesty.

1. Did you lie or withhold truth today?
2. How do you feel about what you did?

6. Help someone, and watch his or her reaction.

1. How did the person respond?
2. How did you feel?

7. Give something to someone without expecting anything in return.

1. How did you feel about yourself?
2. How was your gift accepted?

8. Compromise with someone.

1. How did you feel?
2. How did the other person feel?
3. What was the result of your compromise?
The more you role-play and practice the skills, the more proficient you will
become. If you hit all of the skills accurately, then your relationships will be
stable. If you leave one of the skills out, then your relationships will be shaky and
you will feel frightened. These skills are just like riding a bicycle. The first few
times you try to ride, it feels awkward and clumsy; you may be worried about
getting hurt. With practice, the skills get easy, and you will be able to relax and
enjoy yourself.
Appendix 12: Addictive Relationships

Robert R. Perkinson, PhD

Relationships are our greatest challenge. Even the best relationships have periods
of intense strain. It takes hard work to get along. You have to be willing to give
and to think of the other person’s needs first. This is not easy. Chemically
dependent persons often are just as addicted to their sexual partners as they are to
their drugs of choice. Sometimes that “love” feeling is the drug. This should not
surprise you. Sexual feelings are created by powerful chemicals in the body
called hormones. These pleasure chemicals can be just as addictive as any drug,
and they can be just as destructive. The mesolimbic dopamine system that makes
up the reptilian brain is only interested in three things:

Eat.
Do not be eaten.
Procreate the species.

This center of the brain lies just over the brain stem, and it takes precedence over
higher ordered function because it deals with survival. An addictive brain is a
changed brain, and some people get addicted to a sexual partner. This relationship
is seen as necessary for survival. In other words, if I lose this relationship I would
die. This sets up an addictive relationship that is just as powerful as the strongest
drug.

Addictive relationships are very different from normal ones. You need to be able
to tell which is which. For stability and happiness, you want to get in and stay in a
healthy relationship. You want to get out of or treat an addictive one.
The Cycle of Addictive Relationships
The addictive relationship begins with very powerful sexual feelings. These
feelings may fool you because most of us are taught that these feelings are love.
They are not love; they are sexual motivators. These first feelings are extremely
powerful, and they draw you, seemingly irresistibly, toward that other person.
These are the “love at first sight” feelings. But do not be fooled; it is not love. We
can feel these feelings with a movie star or even with someone’s picture. Young
teens are notorious for feeling madly in love with an entertainer. In an addictive
relationship, you see someone across a crowded room. Your eyes are drawn to
that person. Sexual acting out can occur quickly because these feelings are so
powerful.

The feelings are so good that you will do anything to keep them. Here is where
addictive relationships begin to get sick. You are so thrilled and enchanted with
your new “love” that you begin to lie to keep the relationship going. You say
things that you do not mean, and you do things that you do not want to do. You just
want to keep these addictive hormones flowing in your system. This can be subtle,
but it is the clearest difference between addictive and normal relationships. In
addictive relationships, you lie. In normal relationships, you tell the truth.

People have an instinctive way of knowing when someone is being dishonest with
them. It might take them a while to catch on but soon reality begins to sink in.

Lies begin to show up.

Fear begins to build.
Fear feels uncomfortable, so the partners begin to test each other.
Jealousy begins to rear its ugly head.
The partners begin to accuse each other of being dishonest and unfaithful.
They suspiciously keep track of each other. “Where were you? Who were
you with? What did you do?”
Repeatedly, the accusations fly back and forth.
All of this fear, hurt, and anger gets its fuel from the lies. That is the problem.
There are lies to uncover, and both people feel it and need to uncover the
truth.

Eventually, there is an explosion. The fear, jealousy, and accusations reach a fever
pitch, and the relationship shatters. There is a violent argument. This usually is
verbally abusive and possibly physically abusive. The feelings are so intense—
both the pleasure and the pain—that things explode. There usually is screaming
and name calling. Demands are made as these two individuals try to reestablish
their individual boundaries and resolve the aching fear.

After the explosion, there is a short cooling-off period, and then the two are back
to the good feelings again. It is makeup time. The sex is just as good as it was
before, maybe even better. “How could we have fought? We love each other so
much. What could we have been thinking about?” This is the real thing. It feels so
good.

This vicious cycle repeats itself over and over again. There is incredible pain in
addictive relationships. You constantly feel desperately in love, scared, and angry.
It feels like a roller-coaster relationship that is out of control. The intensity of the
feelings and the lies are the primary factors that keep this sick relationship going
—round and round the couple goes in a cycle of agony and ecstasy.
Normal Relationships
A normal relationship begins when you meet someone who interests you as a
person. There is no intense sexual desire at first. You just want to spend time
together because you enjoy each other’s company. There is no reason to lie, so you
tell each other the truth.

Sharing the truth, you gradually draw closer together. The intimacy begins to grow.
The more you share, the closer you get. The closer you get, the more you share.

There is a genuine concern for each other. This relationship is based on trust and
friendship. There is no reason to be afraid. In this safe atmosphere, surrounded by
the truth, sexual feelings can begin and romance begins. This is not just a person
with whom you want to have sex. It is a person with whom you want to be and
share your life. They make you feel safe and comfortable, not always on a sexual
high.
Love
Love is an action. It is not a feeling. We must love in action and in truth. Love is
the active involvement in someone’s individual growth. If you love yourself, then
you will be actively involved in your own growth. Similarly, if you love someone
else, then you will be actively involved in that person’s growth. It is time to find
out where you are in your relationship. Is your relationship addictive or normal?

List all of the lies you can think of that exist in your current relationship. Start
with the big lies, such as infidelity, and work down from there. You will
immediately get the idea if there are major lies in your relationship. A normal
relationship cannot exist on a foundation of lies. Such a relationship will
falter, crumble, and fail.
Write down some things you are afraid of in your relationship. Are you afraid
of infidelity? Why? Do you have any information that your partner has been
unfaithful? If you do, what is it? Strong fears of infidelity are one of the core
components in addictive relationships. These fears can be based on good
evidence or can be groundless. It does not matter what causes the fear; it is
the fear itself that is the damaging factor.
Are you verbally or physically afraid of your partner? Abusive relationships
are extremely damaging. Abusive relationships need treatment. Verbal and
physical abuse is very common in addictive relationships.
Describe three major fights you have had with your partner. Pick the worst
ones that you can remember. What were the fights about? How did they
progress? Were the problems resolved, or did you tend to fight about the
same things repeatedly? How do you fight? What words are said? How does
each of you act when you are very angry?
Does your partner consistently care about how you feel? Does your partner
change what he or she does because of how you feel?
Is your partner interested and involved in what you want? Is your partner
committed to your individual growth? Some individuals are so caught up in
their own needs that they will not become involved in their partners’ needs.
These people may be incapable of love.

Now go over this information with your counselor or group. Do you believe that
you are involved in an addictive relationship? If you are, then you must do one of
two things: (1) You must get out of the relationship entirely or (2) get treatment.
Both people must go to treatment. If you continue on the way you are going, then
you are in for more misery. You now know what love is and what a normal
relationship is like. You deserve a relationship filled with love. Do not settle for
less.
Appendix 13: Communication Skills

Robert R. Perkinson, PhD

In developing good communication skills, you need to learn how to listen and how
to share. You need to understand where the other person is coming from, and you
need the ability to express yourself clearly. People communicate with words and
actions. Tears or an angry voice can say a lot. You need to be sensitive to both
verbal and nonverbal behavior.
Empathy
Empathy is the ability to mentally remove yourself from the situation and step into
another person’s world. Then you can see the world from that person’s
perspective. You can discover what the other person needs and understand how
the person feels. You get in harmony. To develop empathy, you practice
paraphrasing what the other person has said until you get the communication
correct. The other person needs to be encouraged to correct your mistakes until
you have the message correct. You need to practice communication skills in role
playing with your group or counselor. Keep listening, asking, probing, and
rephrasing what the other person said until you understand his or her needs. Once
you understand the other person, then and only then can you respond accurately.

Repeat what the other person said as exactly as you can—both the verbal and the
nonverbal message. Continue to repeat the message until the person agrees that
you have it right. This might take a few tries, but you will get better as you
practice. Include the verbal and nonverbal parts of the message. You might have to
ask questions as you go along. Try to be genuine, not sarcastic or punitive. Act as
a mirror, reflecting exactly what the other person is saying and how he or she is
saying it. Use the same tone of voice, facial expression, and body posture.
Practice getting the total communication correct. As time goes on, you will need to
ask for clarification less often—only when you are unsure of certain parts of the
communication.
Validation
The other person has a right to his or her opinion, and that opinion always should
be valuable to you. This is an essential element in healthy communication. The
other person needs to know that you believe he or she is important and you will
try to understand their point of view. People need to be validated often,
particularly when they disagree with you. Not everything that a person says is
wrong. Find the areas that you agree on and emphasize those areas. Always pick
out the things you have in common and bring out those points for discussion.
How to Use “I Feel” Statements
Practice beginning many of your communications with “I feel.” You might not
know what is right or wrong in a given situation, but you always know how you
feel. Start with your feelings, and then fill in what you think is creating those
feelings. If you are feeling confused, then you are having many feelings at the same
time. Try to break down the feelings and address each one separately. The “I feel”
statements prevent you from concentrating on the other person. Communications
that begin with “You” can be accusatory and punitive. Instead of pointing out what
the other person is doing, concentrate on how you feel and what you think. Imagine
that you are role-playing a discussion with your wife. One person in the group or
the counselor plays your wife and you play yourself. Your wife has a problem and
she is ready to discuss it.

Wife: I do not feel like you love me anymore.

Client: I do love you. I love you more each day. What makes you feel like I do
not love you?

Wife: You never help me around the house, or with the children, then when we
go to bed you want to have sex.

Counselor: (The counselor steps in to help the client.) So I am hearing that you
need me to help you around the house and with the children.

Wife: That’s right. You can help by cleaning up, washing the dishes once in a
while, putting the children to bed, and reading them a story. You could at least
pick up your own clothes and clean up after yourself.

Client: I can do all these things. I thought you wanted to do them all yourself.

Wife: Jack, I need you to help me. If you help me, I would feel like you love me.

Client: If you feel like I am loving you all day by helping out, you might even
feel like having sex more often.

Wife: Yes, more often. Much more often. I need a husband that makes love to me
all day. Then I would feel more like making love at night.
Be Positive
Always try to find something positive to say to the other person. Even when you
are disagreeing, you need to show the other person that you are going to be
reinforcing. This shows the other person that you respect and care about him or
her. In the previous conversation, you could have said, “Honey, I really appreciate
your doing all of this work, and I promise that I am going to help you a lot more
from now on. I will show you that I love you by helping you. I would show the
children that I love them by helping them. I see now what you mean. I am sorry,
Joyce, I did not understand before, but I understand now, and you are going to see
a new me.”

Be genuine in your compliment; do not say something that is not true. Continue to
be positive throughout your communications with others. Being positive is
contagious; the more you look at the bright side of things, the better things actually
become. A positive attitude can go a long way toward improving communication
skills. People like being around someone who is positive. It gives them a lift, and
they will want to be around you again.
How to Use Physical Proximity
One of the most important elements in whether a person will like you or not is
physical proximity. People who you are around more often are more likely to be
attracted to you. When you are talking with someone, stand or sit at a comfortable
distance from that person. In the United States, this is a little more than an arm’s
length apart. In other countries, this distance can be different, so you must be up on
the social norms. Do not have a piece of furniture or something else between you
and the other person as you communicate; this increases interpersonal distance. Be
conscious of how the other person is feeling. If the person seems uncomfortable,
then back up a little.
How to Use Touch
Touch is a very powerful communication tool. It is hard to act angry with someone
who you are touching. Touch increases intimacy and decreases fear. It shows the
other person that you value him or her and the relationship. You often can touch
someone during a conversation. Try to find that opportunity and take it. Even a
simple touch on the arm is a powerful message that says “I care.” If you ask for a
hug, it is very likely that you are going to get one.
How to Use Eye Contact
Good communication necessitates good eye contact. If you do not look at the other
person, then you will miss a good deal of what the person is saying. Focus on the
person as if he or she is the most important person in the world. Eye contact is a
lot like touch; it shows the person that you are interested. It also shows the person
that he or she is important enough to warrant your full attention.
Be Reinforcing
Compliment the other person often. Say something nice. Tell the person how much
you appreciate him or her. Point out how a color looks good on him or her. Say
you love his or her new suit or dress. Try to be tender and kind. Give the person
your full attention. Try to understand the person’s point of view. Dress
appropriately, and take good care of your appearance and personal hygiene. All of
these make you a reinforcing person.
How to Practice Communication Skills
Find two people, and ask them to do the following exercise with you. Watch each
of the communication skills in action as you go through the exercise. All of the
information disclosed during your conversation should be kept confidential. Each
person should have the opportunity to respond to each statement before continuing
on to the next item.

Sit close to each other and make eye contact before you speak. Read the first part
of the sentence and fill in the rest with your own words.

1. My name is . . .
2. My current hometown is . . .
3. My marital status is . . .
4. My occupation is . . .
5. The reason I am here is . . .
6. Right now, I am feeling . . .
Developing Empathy
1. When I think about the future, I see myself . . .
2. The second person repeats what the first person said until the first person
agrees that he or she has been heard correctly.
3. When I am in a new group . . .
4. The second person repeats what the first person said until the first person
agrees that he or she has been heard correctly.
5. When I enter a room full of people, I usually feel . . .
6. The second person repeats.
7. When I am feeling anxious in a new situation, I usually . . .
8. For the rest of the exercise, the second person will repeat or question only if
he or she does not understand the communication.
9. In groups, I feel the most comfortable when . . .
10. When I am confused, I . . .
11. I am happiest when . . .
12. The thing that turns me on the most is . . .
13. Right now, I am feeling . . .
14. The thing that concerns me the most is . . .
15. When I am rejected, I usually . . .
16. I feel loved when . . .
17. A forceful person makes me feel . . .
18. When I break the rules . . .
19. The thing that turns me off the most is . . .
20. Toward you right now, I feel . . .
21. When I feel lonely, I usually . . .
22. Make a listening check. Have the second person repeat the last
communication. “What I hear you saying is . . .”
23. I am rebellious when . . .
24. Take a few minutes to discuss the exercise so far. How do you feel you are
doing? Is the level of sharing deep enough? How can you improve the level
of sharing? Are you getting to know each other?
25. The emotion I find the most difficult to control is . . .
26. My most frequent daydreams are about . . .
27. My weakest point is . . .
28. I love . . .
29. When I feel jealous, I . . .
30. I am afraid of . . .
31. I believe in . . .
32. I am the most ashamed of . . .
33. Right now, I am the most afraid to discuss . . .
34. Reach out and touch the person on the arm.
35. When I touched you, I felt . . .

Take some time to evaluate each other’s communication skills. Talk about what
you did well and what you need to work on. Ask for help in developing your
skills. Discuss one or two other issues together (e.g., politics, religion, sports,
work, family).
Appendix 14: Self-Discipline

Robert R. Perkinson, PhD

Life is full of problems that need to be solved. We can reach our full potential in
life only when we meet our problems head-on, accept the responsibility for them,
and work toward resolution.

Problems cause us to feel pain.

This pain is not bad; it is good. It is a motivation for change.
Pain gives us energy and direction for action.
We can solve problems only if we learn how to endure pain and use it to
grow.
If we always seek immediate pain relief, then we never will stretch
ourselves and grow stronger.
If we can learn how to delay instant pleasure, then we can get higher quality
and more enduring pleasure later.
To get an A on an English test next week, we have to study this week.
Studying hurts.
We must learn how to endure the pain of work to get what we want later.
This is the pathway to excellence.
Delayed Gratification
Self-discipline requires training and practice. Work does not feel good. If it did,
then it would be called play. Work is the expenditure of energy. When we expend
energy, things change.

We all want to be champions, but to be champions, we have to work. Professional

athletes train every day. It is the only way of excelling. They cannot win a race
every day, but they can train for a race every day. They must constantly keep in
excellent physical and mental condition. They must be so practiced in their sport
that they do things automatically. So it is with us. To do something well, we must
practice and learn how to set long-term goals.

Take a piece of paper, and write down some things you wanted in your life that
you did not get because you did not work hard enough. Perhaps you wanted to get
on the football team, go to college, or get a certain job. Did you want a particular
car or friend? Did you want to go out with someone special? Did you want to play
a musical instrument? Find five things you wanted that you did not get. Write those
down, and take a long look at each of them.

1.
2.
3.
4.
5.

What would it have taken for you to achieve each of these goals? What work
needed to be done? Nothing reasonable is out of your grasp if you work hard
enough. Write down the steps you needed to take to achieve that goal. Spend time
thinking about exactly what needed to be done and think about why you did not do
it.

Suppose that you wanted to be a mechanic. The first thing that you would need is
training. You need the skills of a mechanic. Where would you get those? You
could start with the Internet, or you could call an employment service and ask.
Now this is work, and nobody likes it. You have to move and expend energy. It is
not fun. It hurts. You want the job as a mechanic, and you will have to work to get
it. It will happen one step at a time, not all at once. You cannot just wish it to be
true. You need to be patient and work hard. You need to delay pleasure and go
through some pain to get what you want.

Okay, suppose that you look online and find a mechanics school. Now you have to
get an application, fill it out, and mail or e-mail it in. This is getting to be hard
work. It is not fun, but it will pay off. You will not get what you want if you do not
work for it. If you quit, then you will get nothing, so do not quit. Keep trying. Stay
committed for what you want. You deserve the best. Do not settle for less.
The Impulsive Temperament
Some people have a harder time with discipline because they have an impulsive
temperament. They are born needing only a little bit of a feeling to initiate action.

For example, they do not need to feel much anger before they act angry.
Are you that kind of a person?
Do you feel anger easily and act angry quickly?
Do you do things impulsively that you feel sorry for later?
Impulsive people respond too quickly to their feelings.
This can be a problem because they do not naturally stop and think problems
through.
These individuals do not solve problems well, and they tend to have poor
self-discipline.

What would you do if you came home and saw the person you love kissing
someone else? “I would kill them,” you might say. This is a typical impulsive
response. It went immediately from feeling to action. Now stop and think about it.
What good is it going to do you to kill two people? Is this going to help you? Are
you going to feel better? Is your problem solved? You may get transient relief, but
what is the long-term consequence? The result of a double homicide will be years
of imprisonment. You will experience pain for a long time.

If you are a person with an impulsive temperament, then you need to learn
how to endure feelings before you act.
You need to stop, think, and plan before you act. Until you do this, you will
be helpless to circumstances.
These new skills do not come easily. They take practice.
When you feel a feeling, particularly an intense one, stop and think the
problems through, consider your options, plan your response, and then act.

For the next week, keep a log of five situations that give you strong feelings. Write
down the situation and the thoughts and feelings you had during the situation. Did
you respond appropriately, or did you act impulsively? Learn from your mistakes.
Practice.

1.
2.
3.
4.
5.
Rules
Rules do not exist to deny you pleasure. They exist to protect you from pain. If you
break the rules, then you will hurt. It is as simple as that. Consistently obeying the
rules takes self-discipline. You must decide that the rules are for your own good.
The legislature did not make the speed laws to deny you the pleasure of driving
fast. They made the rules to keep you safe.

Many of us who have a difficult time with self-discipline were raised in homes
where the rules were inconsistent. This is confusing to children. Sometimes our
parents would enforce the rules, and sometimes they would not. Sometimes we
would be punished (even abusively punished), and sometimes we would get no
punishment at all. Sometimes our parents would do the same things they told us not
to do. For example, they would tell us not to hit others, and then they would hit us.
This teaches children that rules are not important.

A person without rules is a person with no self-respect.

It is only when we respect ourselves that we set limits on what we will and
will not do.
Children know that people who love them set limits for them.
There is no one more unhappy than a child with no rules.
This child is the ruler of the home.
This king or queen of the house will demand more and more until the child
makes himself or herself miserable.
Are you important enough to keep safe? If you are, then you need rules.

Get a piece of paper and write down some rules that you have broken. For
example, write down three times when you lied or three times when you stole.
Write down each situation as completely as you can. You had some good reasons
for doing that thing, did you not? Why did you do it? What good came out of it?

1.
2.
3.

Now write down the consequences of breaking each of those rules. How did you
feel about yourself? How did you feel about the other people? What happened?
 1.
2.
3.

Now look at each situation, and ask yourself this question: Did breaking this rule
help me to grow and reach my full potential as a person? Did I honor others, my
Higher Power, and myself? You will find that breaking rules results in pain—your
pain.

Take lying as an example.

We lie to avoid getting into trouble.
In the short run this works, but in the end, it is interpersonal disaster.
We want people to love us.
If we lie, then people do not know us, so they cannot love us.
In the end, if you lie, then you will be lonely.

To love, you must be self-disciplined. Love is an action, not a feeling. Love is

work. Love takes time, energy, and commitment. To do unto others as you would
have them do unto you is not always easy, but you will not experience joy unless
you love like this. To love, you must be consistent. If you are selfish, and if you
always come first, then you will hurt and you will be deprived of the joy of giving
unselfishly to others.

Many parents love without discipline. They do not take time with their children,
and they do not solve problems with their children. It is important for children to
see their parents hurt with them when the children have a problem. The family
members feel the pain together, and they buckle down to solve the problem
together. In healthy homes, the family members have confidence that if they work
together, they can solve problems.
How to Solve Problems
Life is an endless puzzle of problems that need to be solved. Problem solving is
challenging, necessary, and fun. It needs to be practiced enough times that it gets to
be automatic. Get a piece of paper and write down a problem of yours, and we
will go through the problem solving steps together.

1. Write down the problem. What is the problem exactly? How do you feel
about it? What do you want to see happen?
2. Make a list of options. What are all of the possible ways in which you can
deal with this problem? Get input from others who you trust. Ask other
people to give you alternatives of action. You will be surprised. Other
people will come up with good ideas that you did not have.
3. Consider each option carefully and decide which choice will help you to
grow into the person you want to be. If another person is involved, remember
to treat that person the same way in which you would want to be treated.
4. Put the option you have chosen into action.
5. Evaluate the effect of your action on the original problem. This gives you
information about how to solve future problems.

Problem → Options → Decision → Action → Evaluation

Work through several problems with your counselor or group. Get in the habit of
writing down the problem and getting advice on options.
Responsibility
To solve a problem effectively, you must accept that problem as your problem. If
you blame the problem on something else, then you are helpless. It is easy to feel
this way, but it is self-defeating. “I would be okay if they would just leave me
alone” is a common cry in treatment. This is the cry of someone who is defeated
by life.

Blaming other people for your problems never is effective.

There always is something you can do to make things better.
You have great power and influence over your own life.
If you sit and do nothing, then nothing will change.

Take a piece of paper, and write down five times when you got into trouble.
Maybe you were arrested or got into trouble at home or at school.

1.
2.
3.
4.
5.

Think about all of your choices that led to this problem.

What did you do that ended up getting you in trouble?
Think about each choice you made along the way that led to the problem.
Do not blame anyone else.
Look at your own behavior.
Use your counselor and group to help you.
If you look closely, you will see that a series of choices—your choices—led
to these events.
Accidents do happen, but most of what happens to you is a result of your
choices.
Think of how scary the world would be if other people had the power to
make you happy or unhappy.
No one has that power but you.

Think of yourself as a gift to the world. There never has been anyone like you.
There never will be anyone like you again. You owe the world only one thing—to
be different. Only you can do this. Only you can be responsible for what you do.
You will change the course of history because you were here. Maybe you will
change things for the good, maybe for the bad. Maybe you will change things a
little, maybe a lot, but you definitely will change things. Things will be different
because you were here. You have a great responsibility to be yourself.
Appendix 15: Impulse Control

Robert R. Perkinson, PhD

You have problems controlling your impulses if you act too quickly on your
feelings. You suffer negative consequences because you act without careful
thought. If you had stopped to think, you would not have gotten into trouble. Maybe
you ended up in jail, struck someone you cared for, were kicked out of school, or
used drugs or alcohol. This set of exercises is for those people who lose control
over their behavior too quickly. It outlines the skills necessary to overcome
problems with impulse control.

The first thing you have to understand is that you are held accountable in our
society only for what you do.
You are not held accountable for what you think or for how you feel.
Your movements are what count. That is what people see. That is how people
judge you.
You can think about robbing a bank all day long, and you will not be arrested.
If you rob a bank, then you have committed a crime and are in big trouble.
To control your impulses, you must learn to control your movements.
How to Understand Your Feelings
To control your impulses, you need to understand your feelings.

Feelings motivate action. They are a powerful force. They direct behavior.

Each feeling is connected to a specific activity. Let us examine several

feelings and the actions they stimulate. There are only a few basic feelings:
fear, anger, sadness, surprise, joy, disgust, acceptance, and anticipation.
1. Fear motivates you to run.
2. Anger motivates you to make the pain stop.
3. Sadness motivates you to recover a lost object.
4. Surprise gets you ready to accept something new.
5. Joy motivates you to enjoy something rewarding and special.
6. Disgust motivates you to avoid the repulsive object.
7. Acceptance gives you the motivation to embrace something positive.
8. Anticipation gives you the energy and direction to understand and deal
with a new situation.
Examine each feeling and the movement to which it is attached. Learn that
each feeling motivates a specific action, and learn what each feeling is and
the action it initiates.
How to Develop Goals
Now it is time to take a close look at exactly what you want to change.
Remembering that behavior is movement, take a piece of paper and write down
five things you want to do differently. For example, someone who physically or
mentally hurts people would want to write down something like this: “I want to
stop hurting other people with my words and actions.”

1.
2.
3.
4.
5.

Study each of your goals. Is it reasonable that you can attain this goal? Make sure
that the goal is written in behavioral terms. It needs to be a movement you can see,
hear, or touch.

Now that you have the specific behavior you want to change, we can look at
exactly how you are going to change.
The Behavior Chain
Behavior can be analyzed by studying the behavior chain. This chain starts with a
stimulus or trigger that initiates a thought, the thought initiates a feeling, and the
feeling motivates action. All behavior results in a consequence. This consequence
may be positive or negative. The behavior chain looks like this:

Trigger → Thought → Feeling → Behavior → Consequence

There are many points along a behavior chain where you can do things differently.
Look at it like this: If you are on a train that is going to Kansas and stay on that
train, then you are going to end up in Kansas. Likewise, if you initiate an old
behavior chain and continue on that chain, then you are going to end up with the
same consequence. Now maybe that behavior got you into a lot of trouble, and
maybe you do not want to repeat the behavior. Next time, you want to do
something different. The key word here is doing. You have to do something
different if things are going to change.
Trigger
Let us take a close look at the behavior chain and see where you can change.
Behavior will surface under certain situations or triggers. We can group relapse
triggers into several categories.

Negative emotions
Social pressure
Interpersonal conflict
When something good happens
When you feel powerless
When your life seems unmanageable
Negative Feelings
Start by getting out a clean piece of paper and writing the heading “NEGATIVE
FEELINGS” at the top of the page. Under this heading, write all of the negative
feelings you can think of that lead to the behavior you want to change. Maybe you
lapse into old behavior when you are angry, bored, lonely, happy, embarrassed,
frustrated, irritable, or excited. Write down the feelings that seem to precede the
action you want to change.
Social Pressure
Make the heading “SOCIAL PRESSURE,” and list all of the social situations in
which you are likely to lapse into the old behavior. Remember that social pressure
can be direct (e.g., someone actively encouraging you to act in the old way) or
indirect (e.g., a social situation in which the behavior might normally occur).
Maybe you will be more likely to get back to the old behavior when you are with
certain friends or at certain places or events. Write down every social situation in
which you feel you will be vulnerable.
Interpersonal Conflict
The “INTERPERSONAL CONFLICT” heading comes next. Make that heading,
and under it write every situation you can think of where a conflict with someone
else leads to the behavior you want to change. Try to include the total situation.
Who said what and how? What happened? When did you lose control? What
preceded your behavior?
Positive Events
Now write “POSITIVE EVENTS” as a heading, and list the times when you acted
in that old way when feeling good, to celebrate, or to increase the good feeling.
Detail each situation and carefully study what you were after and what feelings
you wanted to enhance.
Feeling Powerless
Write down “FEELING POWERLESS.” Sometimes you feel powerless to resist
the impulse to return to old behavior, but remember you always have many
choices available to you when you are having a feeling. List five things you can do
when you are craving the return to the addiction.
Feeling Like My Life Is Unmanageable
Write down “FEELING LIKE MY LIFE IS UNMANAGEABLE.” You might be
feeling like everything is going wrong, that everything you do makes things worse.
Remember there are always many thoughts and behaviors available to you. There
is never only one choice. When you feel like everything is going wrong, write
down all the things that are going right. Make a list of all of the things you are
grateful for such as family, friends, your pet, and your relationship with your
Higher Power, the power of prayer, the clouds, trees, flowers, water, the sky, and
a bird. Look around you, and find beauty in the world. It is always there if you
look for it.
Thought
We will analyze thoughts next. These get a little tricky, so pay careful attention to
them. Beck, Rush, Shaw, and Emery (1979) developed cognitive therapy for
depression. Burns (1999) further developed this technique.

Many thoughts are very quick—so quick that they occur out of your awareness.
These thoughts are called automatic thoughts because they do not come from
anything you try to think. You think them automatically.

Take another piece of paper, and near the top write down a situation where you
lost control. Write the specific situation in as much detail as you can.

Now explore how you were feeling in that situation. Remember that the eight
primary feelings are (1) fear, (2) anger, (3) sadness, (4) surprise, (5) joy, (6)
disgust, (7) acceptance, and (8) anticipation. Write down each feeling, and score
the intensity of the feeling on a scale of 1 to 100 (1 = as little of the feeling as
possible, 100 = as much of the feeling as possible).

Let us take an example. Frank came home, and his spouse angrily asked him where
he had been. He was late coming home from work. Frank felt hurt at an intensity of
45, angry at 90, and frightened at 75.

Now it is your turn. You have the situation and all of the feelings you had during
that situation. You have scored how intensely you were feeling each feeling.

Now carefully process with your counselor what you were thinking between
the situation and the feelings.
This will take some time, so take it slow.
Try to think of all the thoughts that came to mind between the event and the
feelings.

Let us see how Frank did. “My wife asked me where I had been. I thought the
following: ‘Here we go again. She is mad. She thinks I have been drinking again.
She is always mad at me. She never trusts me. She does not love me. She has
never loved me.’”

Make as long a list of these thoughts as you can. You will be surprised at how
many thoughts you can have in a short period of time.

Next, look at the thoughts and check them out for accuracy. Which thoughts are
accurate, and which thoughts are inaccurate? Frank decided that his spouse was
mad and that she was worried that he had been drinking again. Those thoughts
were accurate, but she was not always mad at him and she trusted him plenty of
times. She does love him, and she has loved him for a long time. These thoughts
were inaccurate.

With your counselor or with your group, discover which thoughts are accurate and
which thoughts are inaccurate.

On another sheet, write down the situation again. Write only the accurate thoughts
you were having and then score all of the feelings you had listed on the previous
page.

Frank did it like this. “My wife asked me where I had been. She was frightened
that I had been drinking again and a little angry just at the thought of it. She is very
concerned for me. She loves me very much, and she is afraid for my health. That
does not hurt me at all, so I would put the hurt at 0. It still makes me a little mad,
but much less, so I would put that at 20. That does not scare me at all, so I would
rate the fear at 0.”

Now add up your scores on each sheet, coming up with a total score of all the
feelings when you were thinking inaccurately and when you were thinking
accurately. This is Frank’s sheet:

You can now see what we are after.

Many of your thoughts are automatic, are inaccurate, and lead to

uncomfortable feelings.
Some of these feelings are unnecessary because they are inaccurate
 assessments of reality.
If you see a situation inaccurately, then you will react inaccurately.
If you develop the skill of stopping and assessing the situation accurately,
then you will feel more comfortable and be able to deal with the situation
with more precision and skill.

For the next few days, keep a running account of any situation that makes you feel
uncomfortable, and do this exercise again. After a few days, you will notice
patterns in your thinking. You will see that you think the same inaccurate thoughts
in many different situations. These are thoughts that need to be challenged
repeatedly in treatment. Address them carefully with your group and your
counselor, and begin to watch out for them. When they resurface, stop and correct
yourself. Try to keep your thinking accurate. Write down 10 positive things about
yourself, and carry this card around with you reading it to yourself many times a
day. Soon you will memorize the accurate thoughts, and then come up with 10
more. Begin to say positive accurate things to yourself all day every day.
Feelings
All feelings are friendly, even the painful ones. They help us adapt to our
environment and give us energy and direction for action.

The skill necessary for dealing with feelings appropriately is to learn exactly
what coping skills to use when having a particular feeling.
Feelings should not be ignored; they should be acted on.
Which action to take is the skill you want to learn.
Spend some time with each feeling and learn coping skills for dealing with
each one.
Then practice the new skills until they become automatic. You cannot just
learn what to do. You must practice the new behavior until it becomes second
nature. This will take a lot of time and practice. Do not try to do this
perfectly; just make progress.
Anger
Anger gives chemically dependent persons more problems than does any other
feeling. You can relapse into old behavior when you feel angry and frustrated.
Anger gives you the energy and direction to fight. Anger is there to make the pain
stop. Anger is good, and acting angry can be good, so long as the actions are
appropriate. The problems arise when we fight all the time or at inappropriate
times.

Anger is friendly. It needs to be listened to and expressed. You need to learn how
to use your anger assertively rather than aggressively. Much of this work is taken
from Your Perfect Right, an assertive guide by Alberti and Emmons (1995).

Physical aggression rarely is necessary and can even be harmful.

Acting on your anger assertively is a much more effective means of getting

what you want. Here is an assertive formula that you should memorize and
practice until it becomes automatic.
I feel . . .
When you . . .
I would prefer it if . . .

When you feel angry with someone, you start by describing how you feel. Then, in
behavioral terms, describe what the person did that led to your feelings. Then,
again in behavioral terms, tell the person what you want him or her to do.

Let us try it in a situation to show how the assertive formula works.

The Aggressive Response

Bob comes home from work 1 hour late. Barbara, his spouse, is hurt and angry.

Barbara: Where have you been? You are such an incredible jerk!

How is Bob going to be feeling—attacked, hurt, angry, defensive? He might

retaliate and say something like this:

Bob: What a nag! You are always mad at me!

The Assertive Response
Barbara: I feel hurt and angry when you are late. I would prefer it if you would
call me and tell me when you are not going to be on time.

The assertive formula gives the other person accurate information that he or she
can use to remedy the situation. The person knows what he or she did and knows
what to do differently.

Try the assertive formula at least two times today. After each use, write down the
situation and how it turned out. Notice the feelings that you have. If you are like
most people, you will feel much more in control of your feelings. You also will
get more of what you want. This will lead to less anger. Role-play several
situations with your counselor or group. Role-play the situation acting too passive,
too aggressive, and assertive. Being assertive just means you look at the other
person in the eyes and tell them the truth in a normal tone of voice with a kind
facial expression.
Fear
Fear is another difficult feeling for people.

Fear motivates you to run or withdraw from a dangerous situation.

Fear is friendly.
Withdrawal is friendly, and it can be adaptive, but it also can be
inappropriate.
It is important to think accurately and consider the consequences before you
withdraw.
What are the pros and cons of withdrawing from the situation?
It is not appropriate to run from all of your problems even if they are scary. If
you did, then you would not solve many of them.
You must learn to stand your ground even in a painful situation. That way, you
can work a problem through to resolution.
If you find that you always are running away, then you must find other coping
skills to use when you feel frightened. The same assertive formula works
here. “I feel, when you, I would prefer it if” works as well with fear as it
does with anger.
If people know you are frightened, they often will respond positively to your
fear.
It even helps to share your fear with someone who is not involved with the
immediate situation.
Remember to share your feelings. This is a major coping skill. It can be used
with all feelings.
Behavior
Now you know that using the right behavior at the right time is the real secret to
success when dealing with impulse control problems. It is the movements—the
behavior—that people are responsible for, so you must practice not moving
quickly.

Practice delaying action until you have time to think and plan.
Some people have to back away from the situation entirely to give them the
time to think.
They might have to go for a walk, a run, or a drive.
They might have to leave the house, or the places of conflict, and give
themselves some space.
You know yourself the best, and you know beforehand when you are getting
ready to lose control.
Practice catching this increase in your feelings before you lose control. At
this point, you must move away from the situation. You cannot stay there and
hope to achieve control. That is too dangerous.
Do not worry. You are going to come back to the problem and the situation is
going to be addressed, but you need some time away from the problem. If you
stay in a situation where you have lost control, then you are playing with fire.
Do not do that to yourself.

Exactly what coping skills to use in a particular situation will take some planning.
This planning must take place before the situation, and it must be practiced until it
becomes automatic.

Get out another piece of paper, and write down the situation you are having
difficulty with.

Now brainstorm with your counselor and your group. What else could you do in
that situation? For example, Barbara is trying to control her tendency to yell at her
children. She made this plan when she feels angry with them again:

When I am getting angry, I am going to do the following:

1. Recognize my anger.
2. Step back from the situation as far as necessary to feel the anger go down and
then:
1. Go in another room.
2. Go for a walk.
3. Go for a drive.
4. Go to my mother’s house.
5. Go talk to a friend next door.
6. Call my sponsor.
3. When I am thinking clearly, I will plan my response. I might have to do this
with someone I trust.
4. Come back to my children and try my plan.
5. If I get too angry again, I will go back and repeat the whole procedure.
Consequence
It is important to take a careful look at the consequence of your behavior.

You will not learn from your actions unless you see clearly what happens
when you act in a certain manner.
On another piece of paper, write briefly what happened each time you lost
control of your actions. Under each situation, write down the negative
consequence that resulted from that loss of control. This must be done in
great detail. Take a lot of time and think.
Do not blame anyone else for what happened. Concentrate on your own
actions. Use every situation you can think of. The more clearly you can see
the negative consequence of your behavior, the more you will tell yourself
never to act that way again. You can learn from your behavior if you stop,
think, and plan before you act.

We have looked carefully at the behavior you want to change. We have studied the
trigger, thought, feeling, behavior, and consequence. Now let us go over what you
are going to do when you are in a high-risk situation. What is your plan when you
feel impulsive? First, think of the word stop.

S = stop: Stop and commit yourself to a rational response.

T = think:

1. What is the situation?

2. What is at stake?
3. Get your thinking accurate.

O = options:

1. What are the options?

2. What are the pros and cons of each option?
3. Choose the best option.

P = plan: Carry out the plan.

With your counselor and group, work through the situations and feelings that you
are having the most difficulty with. If you are having a difficult time with anger,
then discuss your anger carefully in individual sessions and in group. Role-play
specific coping skills to deal with each feeling. Exactly what are you going to do?
List options available to you, and carry them in your pocket or purse. Now
practice, practice, practice. When you lapse into the old behavior, do not give up.
Use the lapse as an education. What happened? What coping skill could you have
used? How can you do things differently next time? You can do this. You no longer
have to be a slave to your impulses. You can change your behavior. You have all
of the necessary skills.
Appendix 16: Relapse Prevention

Robert R. Perkinson, PhD

There is some bad news and some good news about relapse. The bad news is that
many clients have problems with relapse in early sobriety. About two thirds of
clients coming out of addiction programs relapse within 3 months of leaving
treatment (Hunt, Barnett, & Branch, 1971). The good news is that most people
who go through treatment ultimately achieve a stable recovery (Frances, Bucky, &
Alexopolos, 1984). Relapse does not have to happen to you, and even if it does,
you can do something about it. Relapse prevention is a daily program that can help
prevent relapse. It also can stop a lapse from becoming a disaster. This exercise
has been developed using a combination of the models. This uses the disease
concept model in combination with motivational enhancement, cognitive
behavioral therapy, skills training, and 12-step facilitation.
Relapse Is a Process
Relapse is a process that begins long before you use drugs or alcohol. There are
symptoms that precede the first use of chemicals. This exercise teaches you how
to identify and control these symptoms before they lead to actual drug or alcohol
use. If you allow these symptoms to go on without acting on them, then serious
problems will result.
The Relapse Warning Signs
All relapse begins with warning signs that will signal for you that you are in
trouble. If you do not recognize these signs, you will decompensate and finally use
chemicals. All of the signs are a reaction to stress, and they are a reemergence of
the disease. They are a means by which your body and mind are telling you that
you are in trouble. You might not have all of these symptoms, but you will have
some of them long before you actually use chemicals. You must determine which
symptoms are the most characteristic of you, and you must come up with coping
skills for dealing with each symptom.
Interpersonal Factors
Self-efficacy is the degree you feel capable of performing a task like
preventing relapse. Do you feel confident that you have the skills necessary
to say no to the addiction when confronted with a high-risk situation
including intense craving? Do you have the skills necessary to say no to
alcohol, drugs, or addictive behavior?

Make a list of 10 things you can do when you feel craving. There are people
you can call, meetings you can attend, things you can read, a Higher Power
you can pray to, family members, friends or people in the program you can
share your feelings with, Alcoholics Anonymous (AA)/Narcotics Anonymous
(NA)/Gamblers Anonymous (GA) hotlines you can call, physical exercise
you can do, meditations you can perform, etc.
1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
4. ___________________________________________________________________
5. ___________________________________________________________________
6. ___________________________________________________________________
7. ___________________________________________________________________
8. ___________________________________________________________________
9. ___________________________________________________________________
10. ___________________________________________________________________

Practice each of these 10 things at least five times in group, with your counselor,
your sponsor/mentor/coach. You need to get used to thinking and moving in a
certain way when faced with craving. If these behaviors are not practiced in skills
training sessions they are unlikely to be used when you get into trouble. Just
knowing what to do is not enough; you need to practice the thoughts and motor
movements to get good at the skill.

Think about the first time you learned how to ride a bike. Your teacher probably
taught you all of the things you had to do to ride, but it was only after you
practiced riding repeatedly that you began to trust yourself to ride a bike safely.

Make a list of five things in your life that you had to practice. Maybe it was
basketball, baseball, soccer, or starting a conversation with someone you did not
know.

1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
4. ________________________________________________________________________
5. ________________________________________________________________________

At first, you were terrible, making mostly mistakes, but after practicing thousands
of times, you got better. Maybe you had to learn how to shoot a basket from the
free throw line. The first times you tried, you missed most every shot. As you
practiced, and particularly after you were coached, you got better. After thousands
of shots, you got so you could make the shot most of the time. Then there came the
big game and the score was tied and you had to shoot the final basket. If you made
the shot your team won; if you missed, you lost. Now you need to go on automatic,
athletes call this getting in the zone, where all of the fans and other players
disappear and it is only you and that simple shot you have practiced so many
times. If you miss the shot or relapse, it is not the end of the world; it just means
you need more practice until the skill becomes automatic.

Higher levels of self-efficacy predict improved addiction treatment outcomes

(Burling, Reilly, Molten, & Ziff, 1989; Greenfield et al., 2000).
What to Do When You Experience a Warning Sign
When you recognize you are in trouble, you need to take action. Make a list of the
coping skills you can use when you experience a high-risk situation that is
common for you. It might be interpersonal conflict, anger, boredom, certain music
or parts of town, seeing old friends, social pressure, negative emotions, or a
celebration. This will happen. You will have high-risk situations in recovery.
Your task is to take affirmative action. Remember, craving is a danger signal. You
are in trouble. Make a list of what you are going to do. Are you going to call your
sponsor, go to a meeting, call your counselor, call someone in AA/NA, tell
someone, exercise, read the “Big Book” (AA, 2002), pray, become involved in an
activity you enjoy, turn it over, or go into treatment? List five telephone numbers
of people you can call if you are in trouble. Remember what AA says: “What we
cannot do alone, we can do together.”

Plan 1.
Plan 2.
Plan 3.
Plan 4.
Plan 5.
Positive Outcome Expectations
This means the positive things we think will happen if we drink or use. These are
dangerous thoughts, and if not corrected, they may lead to relapse. Write down
five positive thoughts about what the addiction can do for you: things such as one
drink will not hurt, I deserve to relax with a few drinks, I would only have one
drink, I have had a hard day, I need to relax at the casino, nobody will know, I am
going to show them, I am going to get even, I am going to make them sorry, I am
under too much stress, I need a break, etc.

1. _______________________________________________________________________
2. _______________________________________________________________________
3. _______________________________________________________________________
4. _______________________________________________________________________
5. _______________________________________________________________________

Now write down 10 accurate thoughts that will keep you clean and sober, such as
I cannot drink one drink, I am an alcoholic; if I start gambling, I would never stop;
I would use drugs again; I would go right back into that addiction misery again; I
can go home and talk to my wife; I can go for a walk; I can meditate; I can go to a
12-step meeting; I can call my sponsor or spiritual leader and go out for a cup of
coffee; I can read some AA/NA/GA material. I can cope with this feeling. If I just
wait for 15 minutes, the craving will pass. If I move away from the high-risk
situation, I would feel better soon.

1. _______________________________________________________________________
2. _______________________________________________________________________
3. _______________________________________________________________________
4. _______________________________________________________________________
5. _______________________________________________________________________
6. _______________________________________________________________________
7. _______________________________________________________________________
8. _______________________________________________________________________
9. _______________________________________________________________________
10. _______________________________________________________________________

Write down these 10 alternative behaviors and carry them with you. Remember
that you have to practice these skills until they become automatic. Practice saying
and doing these things with your group, counselor, sponsor, mentor, coach, spouse,
friend, or 12-step member. Practice, practice, practice until you feel comfortable
with the new skill.

You need to check warning signs daily in your personal inventory. You also need
to have other people check you daily. You will not always pick up the symptoms
in yourself. You might be denying the problem again. Your spouse, your sponsor,
and/or a fellow 12-step member can warn you when they believe that you might be
in trouble. Listen to these people. If they tell you that they sense a problem, then
take action. You might need professional help in working the problem through. Do
not hesitate to call and ask for help. Anything is better than relapsing. If you
overreact to a warning sign, you are not going to be in trouble. If you underreact,
you might be headed for real problems. Addiction is a deadly disease. Your life is
at stake. Relapse is more likely to occur in certain situations. These situations can
trigger relapse. People relapse when faced with high-risk situations that they
could not cope with except by drinking or using. Your job in treatment is to
develop coping skills for dealing with each high-risk situation.
Motivation
Motivation is the conscious or unconscious stimulus leading to the energy that
gives you the power to act. Either you can act in an adaptive or a maladaptive
way; both can be positive or negative reinforcers. You can have motivation to stay
clean and sober, and you can have motivation to return to your addiction.

Prochaska and DiClemente (1984) proposed a model for motivation that goes
through five stages, or readiness for change: (1) precontemplation, (2)
contemplation, (3) preparation, (4) action, and (5) maintenance. Each stage
characterizes a different level of motivational readiness for change.

Interventions that cause ambivalence, evaluating the pros and cons of change
may increase motivation by allowing clients to explore their own morals and
values and how they may differ if they institute change. For example, people
who are in the precontemplative stage have no interest in behavior change. If
they explore the pros and cons of the addictive behavior, they might become
more willing to think about the positive aspects of changing.
This moves them into contemplation where you discuss all of the positive
and negative aspects of using or stopping the addiction. Once the decision is
made to try to stop the addictive behavior then we must concentrate on what
needs to change to stop the addictive behavior.
Then the action phase begins where we begin to change the thoughts and
behaviors that cause addiction.
Once the addiction stops, then we need skills to maintain this new lifestyle.
Negative Emotions
Many people relapse when feeling negative feelings that they cannot cope with.
Most feel angry or frustrated, but some feel anxious, bored, lonely, or depressed.
Almost any negative feeling can lead to relapse if you do not learn how to cope
with the feeling. Feelings motivate you to take action. You must act to solve any
problem.

Circle any of the following feelings that seem to lead you to use chemicals:

1. Loneliness
2. Anger
3. Rejection
4. Emptiness
5. Annoyance
6. Sadness
7. Exasperation
8. Betrayal
9. Cheated
10. Frustration
11. Envious
12. Exhaustion
13. Boredom
14. Anxious
15. Ashamed
16. Bitter
17. Burdened
18. Foolish
19. Jealous
20. Left out
21. Selfish
22. Restless
23. Weak
24. Sorrowful
25. Greediness
26. Aggravation
27. Miserable
28. Unloved
29. Worry
30. Scared
31. Spiteful
32. Sorrowful
33. Helpless
34. Neglected
35. Grief
36. Confusion
37. Crushed
38. Discontent
39. Sleeplessness
40. Irritation
41. Overwhelmed
42. Panicked
43. Trapped
44. Unsure
45. Intimidated
46. Distraught
47. Uneasy
48. Guilty
49. Threatened
50. Submissive
A Plan to Deal With Negative Emotions
These are just a few of the feeling words. Add more if you need to do so. Develop
coping skills for dealing with each feeling that makes you vulnerable to relapse.
Exactly what are you going to do when you have this feeling? Detail your specific
plan of action. Some options are talking to your sponsor, calling a friend in the
program, going to a meeting, calling your counselor, reading some recovery
material, turning it over to your Higher Power, and getting some exercise. For
each feeling, develop a specific plan of action.

Feeling
_______________________________________________________________________
Plan 1.
_______________________________________________________________________
Plan 2.
_______________________________________________________________________
Plan 3.
_______________________________________________________________________
Feeling
_______________________________________________________________________
Plan 1.
_______________________________________________________________________
Plan 2.
_______________________________________________________________________
Plan 3.
_______________________________________________________________________
Feeling
_______________________________________________________________________
Plan 1.
_______________________________________________________________________
Plan 2.
_______________________________________________________________________
Plan 3.
_______________________________________________________________________

Continue to fill out these feeling forms until you have all of the feelings that give
you trouble and you have coping skills for dealing with each feeling.
Social Pressure
Social pressure can be direct (where someone directly encourages you to use
chemicals) or indirect (a social situation where people are using). Both of these
situations can trigger intense craving, and this can lead to relapse. More than 60%
of alcoholics relapse in bars.

Certain friends are more likely to encourage you to use chemicals. These people
do not want to hurt you. They want you to relax and have a good time. They want
their old friend back. They do not understand the nature of your disease. Perhaps
they are chemically dependent themselves and are in denial.
High-Risk Friends
Make a list of the friends who might encourage you to use drugs or alcohol.

1. _______________________________________________________________________
2. _______________________________________________________________________
3. _______________________________________________________________________
4. _______________________________________________________________________
5. _______________________________________________________________________

What are you going to do when they offer you drugs? What are you going to say?
In group, set up a situation where the whole group encourages you to use
chemicals. Look carefully at how you feel when the group members are
encouraging you. Look at what you say. Have them help you to develop
appropriate ways of saying no. The skills of saying no are the following:

Look at the person and say, no thank you.

Suggest another alternative behavior.
If the person persists, tell him or her that you are trying to stop behavior that
has been harming you. Then ask the person to help you by respecting your
choice not to use.
If the person persists, leave the situation. “Well, I have got to be going. Nice
to see you.”
High-Risk Social Situations
Certain social situations will trigger cravings. These are the situations where you
have used chemicals in the past. Certain bars or restaurants, a particular part of
town, certain music, athletic events, parties, weddings, and family events—all of
these situations can trigger intense cravings. Make a list of five social situations
where you will be vulnerable to relapse.

1. _______________________________________________________________________
2. _______________________________________________________________________
3. _______________________________________________________________________
4. _______________________________________________________________________
5. _______________________________________________________________________

In early sobriety, you will need to avoid these situations and friends. To put
yourself in a high-risk situation is asking for trouble. If you have to attend a
function where there will be people using chemicals, take someone with you who
is in the program. Take someone with you who will support you in your sobriety.
Make sure that you have a way to get home. You do not have to stay and torture
yourself. You can leave if you feel uncomfortable. Avoid all situations where your
sobriety feels shaky.
Interpersonal Conflict
Many addicts relapse when in a conflict with some other person. They have a
problem with someone and have no idea of how to cope with conflict so they
might revert to old behavior and use the addiction to deal with the uncomfortable
feelings. The stress of the problem builds and leads to using. This conflict usually
happens with someone who they are closely involved with—wife, husband, child,
parent, sibling, friend, boss, and so on.

You can have a serious problem with anyone—even a stranger—so you must have
a plan for dealing with interpersonal conflict. You will develop specific skills in
treatment that will help you to communicate even when you are under stress.

You need to learn and practice the following interpersonal skills repeatedly.

1. Tell the truth all of the time.

2. Share how you feel.
3. Ask for what you want.
4. Find some truth in what the other person is saying.
5. Be willing to compromise.

If you can stay in the conflict and work it out, that is great. If you cannot, then you
have to leave the situation and take care of yourself. You might have to go for a
walk, a run, or a drive. You might need to cool down. You must stop the conflict.
You cannot continue to try to deal with a situation that you believe is too much for
you. Do not feel bad about this. Interpersonal relationships are the hardest
challenge we face. Carry a card with you that lists the telephone numbers of
people who you can contact. You might want to call your sponsor, minister, or
counselor or a fellow AA/NA/GA member, friend, family member, doctor, or
anyone else who may support you.

In an interpersonal conflict, you will fear abandonment. You need to get accurate
and reassure yourself that people can disagree with you and still care about you.
Remember that your Higher Power cares about you. A Higher Power created you
and loves you. Remember the other people in your life who love you. This is one
of the main reasons for talking with someone else. When the other person listens
to you, that person gives you the feeling that you are accepted and loved.
If you still feel afraid or angry, then get with someone you trust and stay with that
person until you feel safe. Do not struggle out there all by yourself. Any member
of your 12-step group will understand how you are feeling. We all have had these
problems. We all have felt lost, helpless, hopeless, and angry.

Make an emergency card that lists all of the people who you can call if you are
having difficulty. Write down their phone numbers and carry this card with you at
all times. Show this card to your counselor. Practice asking someone for help in
treatment once each day. Write down the situation and show it to your counselor.
Get into the habit of asking for help. When you get out of treatment, call someone
every day just to stay in touch and keep the lines of communication open. Get used
to it. Do not wait to ask for help at the last minute. This makes asking more
difficult.
Positive Feelings
Some people relapse when they are feeling positive emotions. Think of all the
times you used drugs and alcohol to celebrate. That has gotten to be such a habit
that when something good happens, you will immediately think about using. You
need to be ready when you feel like a winner. This may be at a wedding, birth,
promotion, or any event where you feel good. How are you going to celebrate
without drugs and alcohol? Make a celebration plan. You might have to take
someone with you to a celebration, particularly in early recovery.

Positive feelings also can work when you are by yourself. A beautiful spring day
can be enough to get you thinking about drinking or using. You need an action plan
for when these thoughts pass through your mind. You must immediately get
accurate and get real. In recovery, we are committed to reality. Do not sit there
and recall how wonderful you will feel if you get high. Tell yourself the truth.
Think about all of the pain that addiction has caused you. If you toy with positive
feelings, then you ultimately will use chemicals.

Circle the positive feelings that may make you vulnerable to relapse.

1. Affection
2. Boldness
3. Bravery
4. Calmness
5. Capableness
6. Cheerful
7. Confident
8. Delightful
9. Desire
10. Enchanted
11. Joy
12. Free
13. Glad
14. Glee
15. Happy
16. Honored
17. Horny
18. Infatuated
19. Inspired
20. Kinky
21. Lazy
22. Loving
23. Peaceful
24. Pleasant
25. Pleased
26. Sexy
27. Wonderful
28. Cool
29. Relaxed
30. Reverent
31. Silly
32. Vivacious
33. Adequate
34. Efficient
35. Successful
36. Accomplished
37. Hopeful
38. Cheery
39. Elated
40. Merry
41. Ecstatic
42. Upbeat
43. Splendid
44. Yearning
45. Bliss
46. Excitement
47. Exhilaration
48. Proud
49. Aroused
50. Festive
A Plan to Cope With Positive Feelings
These are the feelings that may make you vulnerable to relapse. You must be
careful when you are feeling good because pleasure triggers the same part of the
brain that triggers addiction. Make an action plan for dealing with each positive
emotion that makes you vulnerable to using chemicals.

Feeling
_______________________________________________________________________
Plan 1.
_______________________________________________________________________
Plan 2.
_______________________________________________________________________
Plan 3.
_______________________________________________________________________
Feeling
_______________________________________________________________________
Plan 1.
_______________________________________________________________________
Plan 2.
_______________________________________________________________________
Plan 3.
_______________________________________________________________________
Feeling
_______________________________________________________________________
Plan 1.
_______________________________________________________________________
Plan 2.
_______________________________________________________________________
Plan 3.
_______________________________________________________________________

Continue this planning until you develop a plan for each of the positive feelings
that make you vulnerable. Practice what you are going to do when you experience
positive feelings.
Test Control
Some people relapse to test whether they can use the addiction again. They fool
themselves into thinking that they might be able to use normally. This time they
will use only a little. This time they will be able to stay in control of themselves.
People who fool themselves this way are in for big trouble. From the first use,
most people are in full-blown relapse within 30 days.

Testing personal control begins with inaccurate thinking. It takes you back to Step
One. You need to think accurately. You are powerless over mood-altering
chemicals. If you use, then you will lose. It is as simple as that. You are
physiologically, psychologically, and socially addicted. The cells in your body
will not suddenly change no matter how long you are clean and sober. You are
chemically dependent in your cells. This never will change.
How to See Through the First Use
You need to look at how the illness part of yourself will try to convince you that
you are not chemically dependent. The illness will flash on the screen of your
consciousness all the good things that the addiction did for you. Make a list of
these things. In the first column, marked “Early Use,” write down some of the
good things that you were getting out of using chemicals. Why were you using?
What good came out of it? Did it make you feel social, smart, pretty, intelligent,
brave, popular, desirable, relaxed, or sexy? Did it help you to sleep? Did it make
you feel confident? Did it help you to forget your problems? Make a long list.
These are the good things that you were getting when you first started using. This
is why you were using.

Now go back and place in the second column, marked “Late Use,” how you were
doing in that area once you became addicted. How were you doing in that same
area right before you came into treatment? Did you still feel social, or did you feel
alone? Did you still feel intelligent, or did you feel stupid? You will find that a
great change has taken place. The very things that you were using for in early use,
you get the opposite of in late use. If you were drinking for sleep, then you cannot
sleep. If you were using to be more popular, then you are more isolated, insecure,
and alone. If you were using to feel brave, then you are feeling more afraid. This
is a major characteristic of addiction. The good things you got at first you get the
opposite of in addiction. You can never go back to early use because your brain
has permanently changed in chemistry, structure, and genetics.

Take a long look at both of these lists, and think about how the illness is going to
try to work inside of your thinking. The addicted part of yourself will present to
you all of the good things you got in early use. This is how the disease will
encourage you to use. You must see through the first use to the consequences that
are dead ahead.

Look at that second list. You must see the misery that is coming if you use
chemicals. For most people who relapse, there are only a few days of controlled
use before loss of control sets in. There usually is only a few hours or days before
all of the bad stuff begins to click back into place. Relapse is terrible. It is the
most intense misery that you can imagine.
Lapse and Relapse
A lapse is the use of any addictive substance or behavior. A relapse is continuing
to use the behavior until the full biological, psychological, and social disease is
present. All of the complex biological, psychological, and social components of
the disease become evident very quickly.
The Lapse Plan
You must have a plan in case you lapse. It is foolish to think that you never will
have a problem again. You must plan what you are going to do if you have a
problem. Hunt and colleagues (1971), in a study of recovering addicts, found that
33% of clients lapsed within 2 weeks of leaving treatment, and 60% lapsed within
3 months. At the end of 8 months, 63% had used. At the end of 12 months, 67%
had used.

The worst thing you can do when you have a lapse is to think that you have
completely failed in recovery. This is inaccurate thinking. You are not a total
failure. You have not lost everything. A lapse is a great learning opportunity. You
have made a mistake, and you can learn from it. You let some part of your program
go, and you are paying for it. You need to examine exactly what happened and get
back into recovery.

A lapse is an emergency. It is a matter of life or death. You must take immediate

action to prevent the lapse from becoming a full relapse. You must call someone in
the program, preferably your sponsor, and tell that person what happened. You
need to examine why you had a problem. You cannot use the addiction and the
tools of recovery at the same time. Something went wrong. You did not use your
new skills. You must make a plan of action to recover from your lapse. You cannot
do this by yourself. You are in denial. You do not know the whole truth. If you did,
you would not have relapsed.

Call your sponsor or a professional counselor, and have that person develop a
new treatment plan for you. You may need to attend more meetings. You may need
to see a counselor. You may need outpatient treatment. You may need inpatient
treatment. You have to get honest with yourself. You need to develop a plan and
follow it. You need someone else to agree to keep an eye on you for a while. Do
not try to do this alone. What we cannot do alone, we can do together.
The Behavior Chain
All behavior occurs in a certain sequence. First, there is the trigger. This is the
external event that starts the behavioral sequence. After the trigger, there comes
thinking. Much of this thinking is very fast, and you will not consciously pick it up
unless you stop and think about it. The thoughts trigger feeling, which gives you
energy and direction for action. Next comes the behavior, or the action initiated
by the trigger. Lastly, there always is a consequence for any action.

Diagrammed, the behavior chain looks like this:

Trigger → Thinking → Feeling → Behavior → Consequence

Let us go through a behavioral sequence and see how it works. On the way home
from work, Bob, a recovering alcoholic, passes the local bar. (This is the trigger.)
He thinks, “I have had a hard day. I need a couple of beers to unwind.” (The
trigger initiates thinking.) Bob craves a beer. (The thinking initiates feeling.) Bob
turns into the bar and begins drinking. (The feeling initiates behavior.) Bob
relapses. (The behavior has a consequence.)

Let us work through another example. It is 11:00 pm, and Bob is not asleep
(trigger). He thinks, “I would never get to sleep tonight unless I have a few
drinks” (thinking). He feels an increase in his anxiety about not sleeping (feeling).
He gets up and consumes a few drinks (behavior). He gets drunk and wakes up
hungover and unable to work the next morning (consequence).
How to Cope With Triggers
At every point along the behavior chain, you can work on preventing relapse.
First, you need to carefully examine your triggers. What environmental events lead
you to using chemicals? We went over some of these when we examined high-risk
situations. Determine what people, places, or things make you vulnerable to
relapse. Stay away from these triggers as much as possible. If a trigger occurs,
then use your new coping skills.

Do not let the trigger initiate old behavior. Stop and think. Do not let your thinking
get out of control. Challenge your thinking and get accurate about what is real. Let
us look at some common inaccurate thoughts.

1. It is not going to hurt.

2. No one is going to know.
3. I need to relax.
4. I am just going to have a couple.
5. I have had a hard day.
6. My friends want me to drink.
7. I never had a problem with pot.
8. It is the only way I can sleep.
9. I can do anything I want to.
10. I am lonely.

All of these inaccurate thoughts can be used to fuel the craving that leads to
relapse. You must stop and challenge your thinking until you are thinking
accurately. You must replace inaccurate thoughts with accurate ones. You are
chemically dependent. If you drink or use drugs, then you will die. That is the
truth. Think through the first drink. Get honest with yourself.
How to Cope With Craving
If you think inaccurately, then you will begin craving. This is the powerful feeling
that drives compulsive drug use. Craving is like an ocean wave; it will build and
then wash over you. Craving does not last long if you move away from your drug
of choice. If you move closer to the drug, then the craving will increase until you
are compelled to use. Immediately on feeling a desire to use, think this thought:

“Drinking/using drugs/gambling is no longer an option for me.”

Now drinking and using drugs no longer is an option. What are your options? You
are in trouble. You are craving. What are you going to do to prevent relapse? You
must move away from your drug of choice. Perhaps you need to call your sponsor,
go to a meeting, turn it over, call the AA/NA/GA hotline, call the treatment center,
call your counselor, go for a walk, run, or visit someone. You must do something
else other than thinking about chemicals. Do not sit there and ponder using. You
will lose that debate. This illness is called the great debater. If you leave it
unchecked, it will seduce you into using chemicals.

Remember that the illness must lie to work. You must uncover the lie as quickly as
possible and get back to the truth. You must take the appropriate action necessary
to maintain your sobriety.
Develop a Daily Relapse Prevention Plan
If you work a daily program of recovery, then your chances of success increase
greatly. You need to evaluate your recovery daily and keep a log. This is your
daily inventory.

1. Assess all relapse warning signs.

1. What symptoms did I see in myself today?
2. What am I going to do about them?

2. Assess love of self.

1. What did I do to love myself today?
2. What am I going to do tomorrow?

3. Assess love of others.

1. What did I do to love others today?
2. What am I going to do tomorrow?

4. Assess love of God.

1. What did I do to love God today?
2. What am I going to do tomorrow?

5. Assess sleep pattern.

1. How am I sleeping?

6. Assess exercise.
1. Am I getting enough exercise?

7. Assess nutrition.
1. Am I eating right?

8. Review total recovery program.

1. How am I doing in recovery?
2. What is the next step in my recovery program?
9. Read the Twenty-Four Hours a Day book (Walker, 1992).

10. Make conscious contact with God.

1. Pray and meditate for a few minutes.
2. Relax completely.
Social Support System
Every client needs to build a social support system. Positive social support is
highly predictive of long-term abstinence rates across many addictive behaviors.
You need to write down specifically who is going to be your advocate at home,
work, community, and school. This person needs to talk to your counselor and
understand exactly what being an advocate means. This person will have different
tasks depending upon whether or not they are a school teacher, parent, spouse,
pastor, sponsor, mentor, coach, community leader, school counselor, doctor, nurse,
counselor, etc. You need to make a list of all of these people and decide who is
going to do what. Someone needs to run up to three urine drug screens every week
for the first 6 months and up to one drug screen a week for the next 5 years. This
person who is best is the continuing care case manager. The client calls in every
morning to see if this is one of their drug testing days or not. If so, the client goes
to the clinic and gives a urine sample.

1. Case manager _____________________________________ phone

________________________________

The continuing care case manager makes sure everyone on the team is
working together to keep the client clean and sober. This person keeps a
record of all therapy meetings, 12-step groups, and drug screens. They have a
contract with the client that outlines exactly what is expected of the client and
what the consequences are if the client does not follow through with the
recovery program.

2. Parent or spouse __________________________________ phone

_________________________________

The parent or spouse will be the person who knows what behavior is
adaptive and maladaptive. What friends are to be avoided? If an adolescent
develops the behavioral contract and is responsible for rewards and
consequences

3. The teacher ______________________________________ phone

________________________________ or employer
______________________________________ phone
________________________________
 The teacher or employer knows about what behavior is to be expected and
what is not to be tolerated. Members of the team often call each other to
check up on the facts and make sure everyone is on the same team.

4. The sponsor/mentor/coach ______________________________ phone

____________________________

The sponsor, mentor, or coach guides the client through recovery. They have
been or are in a 12-step program themselves and take the client to meetings
and meet regularly to discuss the recovery process.

5. The physician _____________________________________ phone

________________________________

The physician orders the medication and does history and physical
examinations to maintain good health.
6. The spiritual guide ________________________________ phone
_________________________________

The spiritual guide helps the patient discuss and grow in his or her spiritual
journey. The client shares his or her spiritual journey and maybe keeps a spiritual
prayer journal.

Fill out this inventory every day following treatment, and keep a journal about
how you are doing. You will be amazed as you read back over your journal from
time to time. You will be surprised at how much you have grown.

Make a list of 10 reasons why you want to stay clean and sober.

1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
4. ________________________________________________________________________
5. ________________________________________________________________________
6. ________________________________________________________________________
7. ________________________________________________________________________
8. ________________________________________________________________________
9. ________________________________________________________________________
10. ________________________________________________________________________
Never forget these reasons. Read this list over and over to yourself. Carry a copy
with you and memorize them. If you are struggling in sobriety, then take it out and
read it to yourself. You are important. No one has to live a life of misery. You can
recover and live a clean and sober life.
Appendix 17: Step One

Robert R. Perkinson, PhD

We admitted that we were powerless over alcohol—that our lives had

become unmanageable.

—Alcoholics Anonymous [AA] (2001, p. 59)

Before beginning this exercise, please read Step One in Twelve Steps and Twelve
Traditions (AA, 2002b).

No one likes to admit defeat. Our minds rebel at the very thought that we have lost
control. We are big, strong, intelligent, and capable. How can it be that we are
powerless? How can it be that our lives are unmanageable? This exercise will
help you to sort through your life and make some important decisions. Answer
each question that applies to you as completely as you can. This is an opportunity
for you to get accurate. You need to see the truth about yourself.

Let us pretend for a moment that you are the commander in a nuclear missile silo.
You are in charge of a 10-megaton bomb. If you think about it, this is exactly the
kind of control you want over your life. You want to be in control of your thinking,
feeling, and behavior. You want to be in control all of the time, not just some of
the time. If you do something by accident or do something foolishly, you might kill
many people. You never want to be out of control of your behavior, not even for a
second.

People who are powerless over alcohol or drugs occasionally will be under the
influence of the chemical when they are doing something physically hazardous.
They may be intoxicated or hungover when they are working, using dangerous
equipment, or driving. Over 40,000 Americans are killed each year in alcohol-
related accidents. If you have ever done anything like this, then you have been out
of control. You have risked your own life and the lives of others. Surely you
cannot drive better when you are intoxicated than when you are sober. Now it is
time to get honest with yourself.
Powerlessness
Have you ever been intoxicated when you were doing something dangerous?
For example, have you ever driven a car when you were using? Give five
examples.

1.
2.
3.
4.
5.

Did you think that you were placing your life and the lives of others in
jeopardy? What were you thinking?
Whose lives did you risk? Make a list of 10 people you endangered.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

How do you feel about putting all of those lives at risk?

People who are powerless occasionally will do things while intoxicated or

hungover that they feel bad or guilty about later. They might act foolishly at a
party, act out sexually, get angry, or say things they do not mean. Have you ever
done anything while intoxicated that you felt guilty or bad about later? Make a list
of five things that made you feel the most uncomfortable. Be specific about what
happened.

1.
2.
 3.
4.
5.

People who are powerless gradually will lose respect for themselves. They will
have difficulty in trusting themselves. In what ways have you lost respect for
yourself due to drug or alcohol use?

1.
2.
3.
4.
5.

People who are powerless will do things that they do not remember doing. If you
drink enough or use enough drugs, you cannot remember things properly. You
might have people come up to you after a party and tell you something you did that
you do not remember doing. You might wake up and not know where you are. You
might not remember how you got home. This is a blackout, and it is very scary.
You could have done anything. Most blackouts last a few minutes, but some can go
on for hours or days.

1. Describe any blackouts you have had. Be specific about what you were doing
and what happened.
2. How does it feel to know that you did something that you do not remember?
3. Think for a minute of what you could have done. You could have done
anything and forgotten it.

People who are powerless cannot keep promises that they make to themselves or
others. They promise that they will cut down on their drinking, and they do not.
They promise that they will not use, and they do. They promise to be home, to
work, to be at the Cub Scout meeting, or to go to school, but they do not make it.
They cannot always do what they want to do because sometimes they are too
intoxicated or hungover. They disappoint themselves, and they lose trust in
themselves. Other people lose trust in them. They can count on themselves some of
the time, but they cannot count on themselves all of the time.

1. Did you ever promise yourself that you would cut down your drug or alcohol
use?
 Yes No
2. What happened to these promises?

3. Did you ever promise yourself that you would quit entirely?
Yes No
4. What happened to your promise?
5. Did you ever make a promise to someone that you did not keep because you
were intoxicated or hungover? Give a few examples.

6. Are you reliable when you are intoxicated?

Yes No

People who are powerless have accidents. They fall down, or have accidents with
their cars, when they are intoxicated. Evidence proves that drugs profoundly affect
thinking, coordination, and reaction time. Have you ever had an accident while
intoxicated? Describe each accident in detail.

People who are powerless lose control of their behavior. They do things that they
would not normally do when they are clean and sober. They might get into fights.
They might hit or yell at people they love—a spouse, child, parent, or friend. They
might say things that they do not mean.

Have you ever gotten into a fight when you were intoxicated? Describe each
instance, and describe what happened.

People who are powerless say things that they do not mean. They might say sexual
or angry things that they feel bad about later. They might not remember everything
they said, but the other people do remember. Have you ever said something you
did not mean while intoxicated? What did you say? What did you do?

People are powerless when they have feelings that they cannot deal with. They
might drink or use drugs because they feel frightened, angry, or sad. They medicate
their feelings. Have you ever used drugs to cover up your feelings? Give a few
examples.

What feelings do you have difficulty coping with?

People are powerless when they are not safe. List 10 reasons why you can no
longer use drugs or alcohol.
 1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

People are powerless when they know that they should do something but they
cannot do it. They may make a great effort, but they just cannot seem to finish what
they started out to do.

1. Could you cut down on your drug or alcohol use every time you wanted and
for as long as you wanted?
Yes No
2. Did being intoxicated or hungover ever keep you from doing something at
home that you thought you should do? Give five examples.
3. Did being intoxicated or hungover ever keep you from going to work? Give a
few examples.
4. Did you ever lose a job because of your drinking or drug use? Write down
exactly what happened.

People are powerless when other people have to warn them that they are in
trouble. You may have felt as if you were fine, but people close to you noticed that
something was wrong. It probably was difficult for them to put their finger on just
what was wrong, but they were worried about you. It is difficult to confront
someone when the person is wrong, so people avoid doing so until they cannot
stand the behavior anymore. When addicts are confronted with their behavior, they
feel annoyed and irritated. They want to be left alone with the lies that they are
telling themselves. Has anyone ever talked to you about your drinking or using
drugs? Who? How did you feel?

People are powerless when they do not know the truth about themselves. Addicts
lie to themselves about how much they are drinking or using. They lie to
themselves about how often they use. They lie to themselves about their problems,
even when the problems are obvious. They blame others for their problems. Here
are some common lies they tell themselves:

“I can quit anytime I want to.”

“I only had a couple.”
“The police were out to get me.”
“I only use when I need it.”
“Everybody does it.”
“I was drinking, but I was not drunk.”
“Anybody can get arrested for drunk driving.”
“My friends will not like me if I do not use.”
“I never have problems when I drink beer.”
“I will not drink until after 5:00 pm.”
“From now on, I would only smoke pot.”
“I am going to cut down to five pills a day.”

Addicts continue to lie to themselves to the very end. They hold on to their
delusional thinking, and they believe that their lies are the truth. They deliberately
lie to those close to them. They hide their use. They make their problems seem
smaller than they actually are. They make excuses for why they are using. They
refuse to see the truth.

Have you ever lied to yourself about your chemical use? List 10 lies you told
yourself.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

1. List five ways in which you tried to convince yourself that you did not have a
problem.
2. List five ways in which you tried to convince others that you did not have a
problem.
Unmanageability
Imagine that you are the manager of a large corporation. You are responsible for
how everything runs. If you are not a good manager, then your business will fail.
You must carefully plan everything and carry out those plans well. You must be
alert. You must know exactly where you are and where you are going. These are
the skills you need to manage your life effectively.

Chemically dependent persons are not good managers. They keep losing control.
Their plans fall through. They cannot devise and stick to things long enough to see
a solution. They are lying to themselves, so they do not know where they are and
they are too confused to decide where they want to go next. Their feelings are
being medicated, so they cannot use their feelings to give them energy and
direction for problem solving. Problems are not solved; they escalate.

You do not have to be a bad manager all of the time to be a bad manager. It is
worse to be a bad manager some of the time. It is very confusing. Most chemically
dependent persons have flurries of productive activity when they work too much.
They work themselves to the bone, and then they let things slide. It is like being on
a roller-coaster. Sometimes things are in control; sometimes things are out of
control. Things are up and down, and they never can predict which way things are
going to be tomorrow.

People’s lives are unmanageable when they have plans fall apart because they
were too intoxicated or hungover to complete them. Make a list of the plans you
failed to complete because of your chemical use.

People’s lives are unmanageable when they cannot manage their finances
consistently.

1. List the money problems you are having.

2. Are any of these problems the result of your addiction? Explain how
chemicals have contributed to the problems.

People’s lives are unmanageable when they cannot trust their own judgment.

1. Have you ever been so intoxicated that you did not know what was
happening? Explain.
 2. Did you ever lie to yourself about your chemical use? Explain how your lies
contributed to your being unable to manage your life.
3. Have you ever made a decision while intoxicated that you were sorry about
later? Explain.

People’s lives are unmanageable if people cannot work or play normally. Addicts
miss work and recreational activities because of their drug use. They make
excuses, but the real reason that they missed these events was they were too
intoxicated or hungover.

1. Have you ever missed work because you were too intoxicated or hungover?
List at least five times.
2. Have you ever missed recreational or family activities because you were too
drunk or hungover? List at least five times.

People’s lives are unmanageable if they are in trouble with other people or
society. Chemically dependent persons will break the rules to get their own way.
They have problems with authority.

1. Have you ever been in legal trouble when you were drinking or using drugs?
Describe the legal problems that you have had.
2. Have you ever had problems with your parents because of your drinking or
using drugs? Explain.
3. Have you ever had problems in school because of your chemical use?
Explain.

People’s lives are unmanageable if people cannot consistently achieve their goals.
Chemically dependent people reach out for what they want, but something keeps
getting in the way. It does not seem fair. They keep falling short of their goals.
Finally, they give up completely. They may have had the goal of going to school,
getting a better job, improving their family problems, getting in good physical
condition, or going on a diet. No matter what the goals are, something keeps going
wrong. Chemically dependent people always will try to blame other people, but
they cannot work hard enough or long enough to reach their goals. Alcoholics and
drug addicts are good starters, but they are poor finishers.

List 10 goals that you had for yourself that you did not achieve due to the
addiction.

1.
 2.
3.
4.
5.
6.
7.
8.
9.
10.

People’s lives are unmanageable if people cannot use their feelings appropriately.
Feelings give us energy and direction for problem solving. Chemically dependent
people medicate their feelings with drugs or alcohol. The substance gives them a
different feeling—a chemically induced feeling. Chemically dependent people
become very confused about how they feel.

1. What feelings have you tried to cope with addictive behavior?

2. What feelings are created by your drug of choice? How do you feel when you
are intoxicated or hungover?

People’s lives are unmanageable if they violate their own rules, morals, and
values. Chemically dependent persons compromise their values to continue using
chemicals. They have the value not to lie, but they lie anyway. They have the value
not to steal, but they steal anyway. They have the value to be loyal to their spouses
or friends, but when they are intoxicated or hungover, they do not remain loyal.
Their values and morals fall away, one by one. They end up doing things that they
do not believe in. They know that they are doing the wrong thing, but they do it
anyway.

1. Did you ever lie to cover up your addictive behavior? How did you feel
about yourself?
2. Were you ever disloyal to friends or family when using chemicals? List five
times, and discuss exactly what happened and how you felt about yourself.
3. Did you ever steal to get your drugs? Explain what you did and how you felt
about yourself later.
4. Did you ever break the law when intoxicated? Exactly what did you do?
5. Did you ever hit or hurt someone you loved while intoxicated or hungover.
Explain each time in detail.
6. Did you treat yourself poorly by refusing to stop drinking or using drugs?
 Explain how you were feeling about yourself.
7. Did you stop going to church? How did that make you feel about yourself?

People’s lives are unmanageable when they continue to do things that give them
problems. Chemicals create physical problems, headaches, ulcers, nausea,
vomiting, cirrhosis, and many other physical problems. Even if chemically
dependent persons are aware of physical problems caused by chemicals, they
keep on using anyway.

Chemicals cause psychological problems. They can make people feel depressed,
fearful, anxious, or overly angry. Even if addicts are aware of these symptoms,
they will continue to use.

Chemicals create relationship problems. They cause family problems such as

family fights and verbal and physical abuse. They cause interpersonal conflicts at
work, with family, and with friends. Chemically dependent persons withdraw and
become more isolated and alone. Even if they believe that the problems are
caused by the alcohol or drugs, they continue to use.

1. Did you have any persistent physical problems that were caused by your
chemical use? Describe each problem.
2. Did you have any persistent psychological problems, such as anger, fear,
hurt, depression, that were caused by your chemical use? Describe each
problem in detail.
3. Did you have persistent interpersonal conflicts that were made worse by
your chemical use? Describe each problem in detail.

You must have good reasons to work toward a clean and sober lifestyle. Look
over this exercise, and list 10 reasons why you want to continue to remain clean
and sober.

1.
2.
3.
4.
5.
6.
7.
8.
 9.
10.

Make a list of these 10 things, and carry them around with you until you memorize
them. Then when you think about becoming involved in the addiction again repeat
the list over to yourself 10 times. After completing this exercise, take a long look
at yourself.

1. I am powerless over my addiction.

Yes No

2. When I become involved in addictive behavior, my life becomes

unmanageable.
Yes No
Appendix 18: Step Two

Robert R. Perkinson, PhD

[We] came to believe that a power greater than ourselves could restore us
to sanity.

—Alcoholics Anonymous [AA] (2001, p. 59)

Before beginning this exercise, please read Step Two in the Twelve Steps and
Twelve Traditions (AA, 2002b).

In Step One, you admitted that you were powerless over drugs or alcohol and that
your life was unmanageable. In Step Two, you need to see the insanity of your
disease and seek power to help you. If you are powerless, then you need power. If
your life is unmanageable, then you need a manager. Step Two will help you to
decide who that manager can be.

Most alcoholics and drug addicts who see the phrase restore to sanity revolt.
They think that they may have a drinking or drug problem, but they do not feel as
though they have a mental illness. They do not think that they have been insane.

In 12-step programs, the word sanity means being of sound mind. Someone with a
sound mind knows what is real and knows how to adapt to reality. A sound mind
feels stable, safe, and secure. Someone who is insane cannot see reality and is
unable to adapt. A person does not have to have all of his or her reality distorted
to be in trouble. If you miss a significant part of the journey ahead of you, then you
will get lost. It only takes one wrong turn to end up in the ditch.

Going through life is like going on a long journey. You have a map given to you by
your parents and significant others. The map shows the way to be happy and live
your life in full. If you make significant wrong turns along the way, then you will
end up unhappy and live an unfulfilling life. This is what happens in addiction.
Searching for happiness, you make wrong turns. You think the addiction helps you
to be and to feel better, but later you find out that this map is defective. Even if you
followed your old map to perfection, you still would be lost. What you need is a
new map. When you engage in addictive behavior the brain always says, “Good
choice.” Later you find the addiction has trapped you into a life full of incredible
pain. Using this map, you have lost everything you wanted and broken every one
of your own rules, morals, and values. The addiction has hijacked your brain, and
you cannot say no to the addictive behavior or substance. Even in the face of
profound negative consequences, you keep doing what you hate doing. You
promise yourself that you will stop and get on a new road but every time you try,
you find yourself back to the old road, the old map, the addiction. You are blocked
in, lost, desperate, helpless, hopeless, and trapped. You find yourself in a muddy
ditch, and the harder you try to get out the deeper you sink in.

Twelve-step programs give you a new map. It puts up 12 signposts to show the
way. If you follow this map as millions of people have done, then you will find the
joy and happiness that you have been seeking. You have reached and passed the
first signpost, Step One. You have decided that your life is powerless and
unmanageable. Now you need a new source of power. You need someone else to
help you get out of the ditch. You need to find some other person that can manage
your life.

This is a spiritual program, and it directs you toward a spiritual answer to your
problems. It is not a religious program. Spirituality is the intimate relationship you
have with yourself and all else. Religion is an organized system of faith and
worship. Everyone has spirituality, but not everyone has religion.

You need to explore three relationships very carefully in Step Two: the
relationships with yourself, with others, and with a Higher Power. This Higher
Power can be any Higher Power of your choice. If you do not have a Higher
Power right now, do not worry. Most of us started that way. Just be willing to
consider that there is a power greater than yourself in the universe.

To explore these relationships, you need to see the truth about yourself. If you see
the truth, then you can find the way. First, you must decide whether you were
insane. Did you have a sound mind or not? Let us look at this issue carefully.

People do not have a sound mind when they cannot remember what they did. They
have memory problems. They do not have to have memory problems all of the
time, just some of the time. People who abuse chemicals might not remember what
happened to them last night when they were intoxicated. Gamblers can lose hours
of time without knowing the amount of time that has gone by. They can even
gamble for 24 hours and think they just got to the casino. Alcoholics can wake up
in another town or not know where they parked their car.

List any blackouts or memory problems you have had while being involved in
your addictive behavior. You might have to think hard because you forgot but if
you try you can remember when you lost time, money, or cannot remember some
event. Try to list five times, and be as specific as you can.

1.
2.
3.
4.
5.

People who are insane lose control over their behavior. They do things when they
are intoxicated or addicted that they never would do when they are sober.

List three times when you lost control over your behavior when intoxicated.

1.
2.
3.

List three times when you could not control your addictive behavior. You used
more or longer than you intended.

1.
2.
3.

People who are insane consider self-destruction.

Did you ever consider hurting yourself when you were depressed about your
addictive behavior?

Yes No

Describe in detail what happened.

People who are insane feel emotionally unstable.

Have you ever thought that you were going crazy?

Yes No

Describe this time.

Have you felt emotionally unstable recently?

Yes No

Describe how you have been feeling about yourself and what you have done to
those that have tried to love you.

People who are insane are so confused that they cannot get their lives in order.
They may frantically try to fix things, but problems stay out of control.

List five personal, family, work, or school problems that you have not been able to
control.

1.
2.
3.
4.
5.

People who are insane cannot see the truth about what is happening to them.
People who are addicted hide their addictive behavior from themselves and from
others. They minimize, rationalize, and deny that there are problems.

Do you believe that you have been completely honest with yourself about your
addiction?

Yes No

List 10 lies that you have told yourself.

1.
2.
 3.
4.
5.
6.
7.
8.
9.
10.

People who are insane cut themselves off from healthy relationships. They might
find that they do not communicate with significant others as well as they used to.
They do not see their friends as often. They feel uncomfortable answering the
phone or a knock at the door, or opening the mail. More and more of their lives
center on the addiction.

List three people who you have stopped seeing.

1.
2.
3.

As your drinking and drug use increased, did you go to church less often?

Yes No

List five relationships you have damaged in your drinking and drug use.

1.
2.
3.
4.
5.

People who are insane cannot deal with their feelings. Alcoholics and drug
addicts cannot deal with their feelings. They do not like how they feel, so they
medicate their feelings. They may drink or use drugs to feel less afraid or sad.
They may drink to feel more powerful or more social.

List five feelings that you tried to change by drinking or using drugs.
 1.
2.
3.
4.
5.

Now look back over your responses. Get out your Step One exercise and read it.
Look at the truth about yourself. Look carefully at how you were thinking, feeling,
and behaving when you were drinking, gambling, or using drugs. Make a decision.
Do you think when you were involved in your addictive behavior that you had a
sound mind? If you were unsound at least some of the time, then AA and Narcotics
Anonymous (NA) would say you were insane. If you believe this to be true, then
say this to yourself: “I am powerless. My life is unmanageable. My mind is
unsound. I have been insane.”
A Power Greater Than Yourself
Consider a power greater than yourself. What exists in the world that has greater
power than you do—a river, the wind, the universe, the sun?

List five things that have greater power than you do.

1.
2.
3.
4.
5.

The first Higher Power that you need to consider is the power of the group. The
group is more powerful than you are. Ten hands are more powerful than two. Two
heads are better than one. AA and NA operate in groups. The group works like a
family. The group process is founded in love and trust. All members share their
experiences, strengths, and hopes in an attempt to help themselves and others.
There is an atmosphere of anonymity. What you hear in group is confidential.

The group acts as a mirror reflecting you to yourself. The group members will
help you to discover the truth about who and what you are. You have been
deceiving yourself for a long time. The group will help you to uncover the lies.
You will come to understand the old AA saying: “What we cannot do alone, we
can do together.” In group, you will have greater power over the disease because
the group will see the whole truth better than you can. They will give you a new
map, and this map will lead you to a new life full of happiness, joy, and peace.

You were not lying to hurt yourself. You were lying to protect yourself. In the
process of building your lies, you cut yourself off from others and reality. This is
how addiction works. You cannot recover from addiction by yourself. You need
power coming from somewhere else. Begin by trusting your group.
Keep an Open Mind
You need to share in your group. The more you share, the closer you will get and
the closer you will get the more you can share. If you take risks and share your
experience, strength, and hope then you will reap the rewards. You do not have to
tell the group everything, but you need to share as much as you can. The group can
help you to straighten out your thinking and can help restore you to sanity.

Many chemically dependent persons are afraid of a Higher Power. They believe
that a Higher Power will punish them or treat them in the same way as their fathers
did. They might fear losing control. List five fears that you have about connecting
with a Higher Power.

1.
2.
3.
4.
5.

Some chemically dependent persons have difficulty in trusting anyone. They have
been so hurt by others that they do not want to take the chance of being hurt again.
List five things that have happened in your life that makes it difficult for you to
trust others.

1.
2.
3.
4.
5.

What are at least five things that you will need to see from a Higher Power that
will show you that the Higher Power can be trusted?

1.
2.
3.
4.
5.
Who was the most trustworthy person you ever knew?

Name:
How did this person treat you?
How did you learn to trust him or her?
List five things you hope to gain by accepting a Higher Power.

1.
2.
3.
4.
5.

AA wants you to come to believe in a power greater than yourself. You can accept
any Higher Power that you feel can restore you to sanity. Your group, your
counselor, your sponsor, and nature all can be used to give you this restoration.
You must pick this Higher Power carefully. It is suggested that you use AA or NA
as your Higher Power for now. Here is a group of millions of people who are
recovering. They have found the way.

This program will direct you toward some sort of a God of your own
understanding. The Big Book states, “That we were alcoholic and could not
manage our own lives. That probably no human power could have removed our
alcoholism. That God could and would if He were sought” (AA, 2001, p. 60).

Millions of chemically dependent persons have recovered because they were

willing to reach out for God. AA makes it clear that nothing else will remove the
obsession to use chemicals. Some of us have so glorified our own lives that we
have shut out God. Now you have a new opportunity and a new need. You have a
choice, and you need a manager. You are at a major turning point. You can try to
open your heart and let God in, or you can try to keep God out.

Remember that this is the beginning of a new life. To be new, you have to do
things differently. All that the program is asking you to do is to be open to the
possibility that there is a power greater than you are. AA does not demand that you
believe in anything. The 12 steps are but suggestions. You do not have to accept
all of this now, but you need to be open-minded and willing. Most recovering
persons take Step Two a piece at a time.

First, you need to learn how to trust yourself. You must learn how to treat yourself
well. What are five things you need to see from yourself that will show you that
you are trustworthy?

1.
2.
3.
4.
5.

Then you need to try to trust your group. See whether the group members act
consistently in your interest. They will not always tell you what you want to hear.
No real friend would do that. They will give you the opportunity and encourage
you to grow. What are at least five things you need to see from the group members
that will show you that they are trustworthy?

Every person has a unique spiritual journey. No one can start this journey with a
closed mind. What is it going to take from God to show you that God exists? List
as many as you can think of.

Step Two does not mean that we believe in God as God is presented in any
religion. Remember that religion is an organized system of worship. Religion is
created by humans. Worship means assigning worth to something. Many people
have been so turned off by religion that the idea of God is unacceptable. Describe
the religious environment of your childhood. What was it like? What did you learn
about God from your parents, friends, or culture?

How did these early experiences influence the beliefs you have today?

What experiences have caused you to doubt God?

Your willingness is essential to your recovery. Give some examples of your

willingness to trust in a Higher Power of your choice. What are you willing to do
to try to be open-minded about a relationship with a Higher Power?

Describe your current religious beliefs.

Explain the God of your own understanding.

List five reasons why a Higher Power will be good for you.
 1.
2.
3.
4.
5.

If you asked the people in your AA/NA group to describe a Higher Power, you
would get a variety of answers. Each person has his or her own understanding of a
Higher Power. It is this unique understanding that allows a Higher Power to work
individually for each of us. God comes to each of us differently.

The God shown to us in scripture knows that love necessitates freedom. God
created you and gave you the freedom to make your own decisions. You can do
things that God does not want you to do. If God placed his face in the sky or was
so obvious that everyone worshipped him, then no one would have a free choice.
This is why God exists in a gentle whisper inside of your thoughts. You have to
stop and listen to hear God. It is incredibly easy to keep God out, and it is
incredibly easy to let God in. When you were abusing yourself, God was there
encouraging you to love yourself. When you were lying to others and treating
others poorly, God was there encouraging you to love others. God has loved you
from the beginning.

It is difficult to deny God because God lives inside of you. To deny God is to deny
an essential part of yourself. We all know instinctively what is right and what is
wrong. We do not have to be taught these things. The rules are the same across
every culture and group. No matter where or how you were raised, the moral laws
are the same and everyone knows them. We know not to lie or steal. We know to
help others. We know to love ourselves.

Bad things happen because God allows free will. People hurt each other when
they make choices independent of God’s will. They can break God’s law, and
when this happens, there is great suffering. You probably have done some things
that make you feel ashamed. You never would have felt this shame if you had
followed God’s plan.

“Where was God when I needed God?” many people cry. “Where was God when
all those bad things were happening to me?” Well, the answer to those questions is
that God was right there encouraging you to see the truth. God never promises that
life is not going to hurt. God promises that he is there, teaching you, educating you,
and supporting you.

Do not be discouraged if you doubt God. Your doubt about God is not bad; it is
good. It means that you think and reason. You should not blindly accept things
without proof. That would be foolish. What you must know is this: Only God can
overcome your doubt. There is nothing you can do to make doubt go away. You
can only trust that if you seek God, then God will find you. Once God finds you,
your doubt will be removed. Only by swimming in the sea of doubt can you learn
how to swim with strong strokes. This is how your faith gets strong. No one is
asking you to accept God blindly. Follow your AA/NA group. The group members
know the way. Be willing to seek God. Open your heart and your mind in every
way you know how. Seek the God of your understanding. Ask your clergy or your
counselor for some reading. Go at your own rate. Follow God in your own way.
Soon you will find a peace that will surpass your understanding. This is the peace
that we call serenity.
Appendix 19: Step Three

Robert R. Perkinson, PhD

[We] made a decision to turn our will and our lives over to the care of God
as we understood Him.

—Alcoholics Anonymous [AA] (2001, p. 59)

Before beginning this exercise, please read Step Three in the Twelve Steps and
Twelve Traditions (AA, 2002b).

You have come a long way in the program, and you can feel proud of yourself. You
have decided that you are powerless over mood-altering chemicals and that your
life is unmanageable. You have decided that a Higher Power of some sort can
restore you to sanity. In Step Three, you will reach toward God—the God of your
own understanding. You will consider using God as your Higher Power. This is
the miracle. It is the major focus of the 12-step program. This is a spiritual
program that directs you toward the ultimate truth. It is important that you be open
to the possibility that there is a God. It is vital that you give this concept room to
blossom and grow. The “Big Book” says, “That probably no human power could
have relieved our alcoholism. That God could and would if He were sought”
(AA, 2001, p. 60).

Step Three should not confuse you. It calls for a decision to correct your character
defects under spiritual supervision. You must make an honest effort to change your
life and you are responsible for all of your choices. You have made some choices
before that have hurt yourself and others. List 10 choices you made that hurt
yourself or someone else.

1.
2.
3.
4.
5.
 6.
7.
8.
9.
10.

Now it is time to make some different choices that will set you off on a new
direction. Think about each choice carefully, and do not make a choice until you
have carefully thought through the possible positive and negative consequences of
your decision. The AA program is a spiritual program. About the Big Book, it
states, “Its main object is to enable you to find a power greater than yourself that
will solve your problem” (AA, 2001, p. 45). Both AA and Narcotics Anonymous
(NA) clearly state that the God of your understanding is probably the answer to
your problems. If you are willing to seek God, then you will find God. That is
God’s promise.
Understanding the Moral Law
All spirituality has, at its core, what is already inside of you. You do not have to
look very far for God. Your Higher Power lives inside of you. Inside of all of us,
there is inherent goodness. In all cultures, and in all lands, this goodness is
expressed in what we call the moral law. God has put his law inside of
everyone’s mind, body, and spirit. The law asks you to love yourself, others, and
God in action and in truth. It is simply stated as follows: Love God all you can,
love others all you can, and love yourself all you can. This law is very powerful.
If some stranger were drowning in a pool next to you, then this internal law would
motivate you to help. Instinctively, you would feel driven to help, even if it put
your own life at risk. The moral law is so important that it transcends our instinct
for survival. You would try to save that drowning person. This moral law is
exactly the same everywhere and in every culture. It exists inside of everyone. It is
written on your heart. Even among thieves, honesty is valued.

When we survey religious thought, we come up with many different ideas about
God, but if we look at the saints of the religions, they are living practically
indistinguishable lives. They all are doing the same things with their lives. They
do not lie, cheat, or steal; they believe in giving to others before giving to
themselves; they are humble; and they try not to be envious of what other people
have. They are content with their life, grateful for everything they have, and good
to themselves and others. To believe in your Higher Power, you must believe that
this good exists inside of you. You also must believe that there is more of this
goodness at work outside of you. If you do not believe in a living and breathing
God at this point, do not worry. Every one of us has started where you are.

All people have a basic problem: We break the moral law, even if we believe in
it.

This fact means that there is something wrong with us. We are incapable of
following the moral law as we want to. Even though we would consider it unfair
for someone to lie to us, occasionally we lie to someone else. If we see someone
dressed in clothes that make the person look terrible, we might tell that person that
he or she looks good. This is a lie, and we would not want other people lying to
us like that. In this and other situations, we do not obey the very moral law that we
know is good.
You must ask yourself several questions. Where did we get this moral law? How
did these laws of behavior get started? Did they just evolve over time, or were
they set by someone? If it was set by someone, how did this someone set the same
laws in every heart in every part of the world? The program of AA/NA believes
that these good laws come from something good and that there is more of this good
at work in the universe. People in the program believe that people can
communicate with this good, and they call this good God.

Do you believe that there is something good in the Universe?

Yes No
Do you believe that there is something good inside of you?
Yes No

We do not know everything about the Higher Power. Much of God remains a
mystery. If we look at science, we find the same thing: Most of science is a
mystery. We know very little about the primary elements of science such as gravity
or electromagnetic energy, but we can make judgments about these elements using
our experience. No one has ever seen an electron, but we are sure that it exists
because we have some experience of it. It is the same thing with the Higher
Power. We can know that there is a power greater than we are if we have some
experience of this power. Both science and spirituality necessitate a faith based on
direct human experience.

There seems to emerge in people, as naturally as the ability to love, the ability to
experience God. The experience cannot be taught. It is already there, and it must
be awakened. It is primal, already planted, and awaiting growth. God is
experienced as a force that is alive. This force is above and more capable than
humans are. God is so good, pure, and perfect that God obeys the moral law all of
the time. The experience of the Higher Power brings with it a feeling of great
power and energy. This can be both attractive and frightening, but mainly you will
find that God is loving. God has contacted humans through the ages and has said,
“I am. I exist.”

Do you believe that some sort of a supreme being exists?

Yes No

Instinctively, people know that if they can get more of this goodness, then they will
have better lives. Spirituality must be practical. It must make your life better or
else you will discard it. If you open yourself up to the spiritual part of the
program, then you will feel better immediately.

God knows that if you follow the law of love, then you will be happy. God makes
love known to all people. It is born in everyone. The consequence for breaking the
moral law is separation from God. This is experienced as deep emotional pain.
We feel isolated, empty, frightened, and lonely.

Scripture tells us that God is hungry for your love. God desires a deep, personal
relationship with you. All people have a similar instinctive hunger for God. By
reading this exercise, you can begin to develop your relationship with God. You
will find true joy here if you try. Without some sort of a Higher Power, your
recovery will be more difficult. A Higher Power can relieve your addiction
problem like nothing else can. Many people achieve stable recovery without
calling their Higher Power God. That certainly is possible. There are many
wonderful atheists and agnostics in our program, but the AA/NA way is to reach
for some sort of a God of your own understanding.

You can change things in your life. You really can. You do not have to drown in
despair any longer. No matter who you are, God loves you. God is willing to help
you. Perhaps God has been waiting for you for a long time. Think of how
wonderful it is. There is a God. God created you. God loves you. God has a
purpose for your life and God will show you the way. God wants you to be happy.
Try to open yourself up to this experience.
The Key to Step Three
The key to working Step Three is willingness—the willingness to turn your life
over to the care of God as you understand God. This is difficult for many of us
because we think that we are in control of everything and everyone. We are
completely fooled by this delusion. We believe that we know the right thing to do.
We believe that everything would be fine if others would just do things our way.
This leads us to deep feelings of resentment and self-pity. People in our lives
would not cooperate with all of our plans. No matter how hard we tried to control
everything, things kept getting out of control. Sometimes the harder we worked,
the nicer or meaner we acted, the worse things got.

You are not in control of the universe, and you never have been in control. Your
Higher Power is in control. God is the only one that knows about everything. God
created you and the universe. Chemically dependent persons, in many ways, are
trying to be God. They want the universe to revolve around them. “Above
everything, we alcoholics must be rid of this selfishness” (AA, 2001, p. 62).
How to Turn It Over
To arrest addiction, you have to stop playing God and let your Higher Power take
control. If you sincerely want this and you try, it is easy to do so. Go to a quiet
place and talk to your Higher Power about your addiction. Say something like this:

“God I do not know if you are out there or not but if you are, come into my
life and help me. I cannot do this by myself anymore.”
Then ask God this question, “God, what is the next step in my relationship
with you?”
Wait and tune your mind, body, and spirit. Do not be afraid. Wait for one
word or phrase to come into your mind. This will not be audible but an
inaudible, tender thought. You might get words inside of your mind or see an
image.

Write down exactly what came into your mind.

_______________________________________________________________________
_______________________________________________________________________

This communication will be accompanied with a feeling of peace. The next time
you have a problem, stop and turn the problem over to your Higher Power. Say
something like this: “God, I cannot deal with this problem. You deal with it.”
Describe three times when this happened.

1.
2.
3.

As you ask for God’s will to be done, you will find the right direction. God knows
the way for you. If you follow your Higher Power, then you never will be lost
again. God will encourage you to see the truth, and then God will leave the
choices up to you. You always can decide. God wants you to be free. God wants
you to make all of your own decisions, but God wants to have input into your
decisions. Your Higher Power wants to show you the way. If you try to find the
way by yourself, then you will ultimately slip off the path and find yourself lost.
God promises that if you will follow God’s plan, then God will see to it that you
receive all of the desires of your heart. God knows exactly what you need.
Step Three offers no compromise. It calls for a decision. Exactly how you
surrender and turn things over is not the point. The important thing is that you are
willing to try.

Can you see that it is necessary to give up your self-centeredness?

Yes No

Do you see that it is time to turn things over to a power greater than you are?

Yes No

List 10 things that you have to gain by turning your will and your life over to a
Higher Power. Get your group or counselor to help you.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

List five reasons why you need to turn things over to a power greater than
yourself.

1.
2.
3.
4.
5.

We should not confuse organized religion with spirituality. In Step Two, you
learned that spirituality deals with your relationship with yourself, others, and
God. Religion is an organized system of faith and worship. It is person-made, not
God-made. It is humans’ way of interpreting God’s plan. Religion can be
confusing or helpful. It can even drive people away from God. Are old, religious
ideas keeping you away from trusting God? If so, then how?

A great barrier to your finding God may be impatience. You may want to find God
right now. You must understand that your spiritual growth is set by God and not by
you. You will grow spiritually when God knows you are ready. Remember that we
are turning this whole thing over. Each person has his or her own unique spiritual
journey. Each person must have his or her own individual walk. Spiritual growth,
not perfection, is your goal. All you can do is seek the God of your understanding.
When God knows that you are ready, God will find you. Finally, you will want to
surrender to God’s will for your life. If you are holding back, then you need to let
go absolutely. Faith, willingness, and prayer will overcome all of the obstacles.
Do not worry about your doubt. Just keep seeking in every way you know how.

List 10 ways in which you can seek God. Ask your friends or counselor to help
you.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

What does the AA saying “Let go and let God” mean to you?

List five ways in which you can put Step Three to work in your life.

1.
2.
3.
4.
5.

List the things in your life you still want to control.

How can these things be handled better by turning them over to your Higher
Power?

List five ways in which you allowed chemicals to be the God in your life.

1.
2.
3.
4.
5.

List three ways your chemical use separated you from God.

1.
2.
3.

What changes have you noticed in yourself since you entered the program?

Of these changes, which of them occurred because you listened to someone else
other than yourself?

Make a list of the things that are holding you back from turning things over.

1.
2.
3.
4.
5.

List five ways you see God taking care of you.

1.
2.
3.
4.
5.

Describe how you understand God now.

How to Pray
Pray by reading the Step Three prayer once each day for a week. Say the words
carefully aloud, and listen to yourself as you speak. Feel God’s presence with you,
and when you are ready, begin to talk to God. Make prayer a dialogue, not a
monologue. Talk to God, and then listen for God’s answer to come to you inside of
your mind.

God I offer myself to Thee—to build with me and to do with me as Thou

wilt. Relieve me of the bondage of self, that I may better do Thy will. Take
away my difficulties, that victory over them may bear witness to those I
would help of Thy Power, Thy Love, and Thy Way of Life. May I do Thy will
always! (AA, 2001, p. 63)

Listen for God in others. God may speak to you through them. Look for God’s
actions in the group, in the weather, and in nature. Read scripture, and seek God
through your reading. Ask your counselor or your clergyperson for some
suggestions.
How to Meditate
Take time to meditate each day. Sit in a quiet place for about 10 to 20 minutes, and
pay attention to your breathing. Ask God this question: “God, what do you have to
say to me today?” Then empty your mind. Do not be nervous if there is only
silence for a while. Listen for God’s message for you. Write down any words or
images that come into your mind. Keep a log of each meditation for a week.

Day 1.
Day 2.
Day 3.
Day 4.
Day 5.
Day 6.
Day 7.

Make a list of what are you going to do on a daily basis to help your spiritual
program grow.

Trust that if you seek God then God will find you—no matter who you are, no
matter where you are. God loves you more than you can imagine. You are God’s
perfect child, created in God’s image. God has great plans for you.
Appendix 20: Step Four

Robert R. Perkinson, PhD

[We] made a searching and fearless moral inventory of ourselves.

—Alcoholics Anonymous [AA] (2001, p. 59)

Before beginning this exercise, please read Step Four in Twelve Steps and Twelve
Traditions (AA, 2002b).

Congratulations! You are doing well in the program. You have admitted your
powerlessness over alcohol or drugs, and you have found a Higher Power that can
restore you to sanity. Now you must up your maladaptive thoughts and behavior by
taking a careful inventory of yourself. You must know exactly what resources you
have available, and you must examine the exact nature of your wrongs. You need
to be detailed about the good things about your choices and the bad choices you
have made. Only by taking this inventory will you know exactly where you are.
Then you can decide where you are going.

In taking this inventory, you must be detailed and specific. It is the only way of
seeing the complete impact of your disease. A part of the truth might be, “I told
lies to my children.” The complete truth might be, “I told my children that I had
cancer. They were terrified and cried for a long time.” These two statements
would be very different. Only the second statement tells the exact nature of the
wrong, and the client felt the full impact of the disclosure. You can see how
important it is to put the whole truth before you at one time.

Remember, the truth will set you free from the slavery to the addiction.

The Fourth Step is a long autobiography of your life. Read this exercise before
you start, and underline things that pertain to you. You will want to come back and
cover each of these issues in detail as you write your whole story down. If the
problem does not relate to you, then leave it blank. Examine exactly what you did
wrong. Look for your mistakes even though the situation was not totally your fault.
Try to disregard what the other person did and to concentrate on what you did. It
is also important to write down what you were thinking that led to your bad
choices. In time, you will realize that the person who hurt you was as spiritually
sick as you were. You need to ask your Higher Power to help you forgive that
person or to show that person the same forgiveness that you would want for
yourself. You can honestly pray that the other person finds out the truth about what
he or she did to you.

Review your natural desires carefully and think about how you acted on them. You
will see that some of them became the Higher Powers of your life. Sex, food,
money, relationships, power, influence, education, and many others can become
the major focus of your life. The pursuit of these desires can take total control and
can become the center of our existence. That is when we insult God. We say that
these objects can make us happy and save us. Making good choices sets us free
from the old behavior of the past. Once we begin to think, feel, and act accurately,
we enjoy the positive consequences of our actions. If we continue to think
inaccurately, we will feel and act in a way that hurts others and ourselves. We can
always stop, think, and plan before we act. It helps to role-play difficulties we
have had in the past in skills group so we can learn new ways of thinking and
acting. Many of us have one feeling that leads to one action. The truth is we can
stop when we feel, get our thoughts and feelings accurate, and then find many
ways we can cope with the situation.

In working through the Fourth Step inventory, you will experience pain. You will
feel angry, sad, fearful, ashamed, embarrassed, guilty, and lonely. The Fourth Step
is a grieving process. As you see clearly your inaccurate thoughts, feelings, and
behaviors, you may feel that no one will ever love you again, but remember that
God created you in perfection. You are God’s perfect child: God’s masterpiece,
God’s work of art. There is nothing wrong with you. You have everything that you
need to be happy, joyous, and free. Sure, you made some mistakes. That is an
essential part of life. We learn from our mistakes. Once you clean house, you can
begin to purify yourself by shedding your defects of character. These are our old
sick ways of thinking, feeling, and acting. These character defects will not go
away easily, and you will feel the old behaviors fight for life. You have grown
comfortable in the lies, and now you are walking into the truth. You are walking
out of the darkness and into the light—out of the fear and into the peace that AA
calls serenity.
Now let us take a basic look at right and wrong. We cover the following areas.

1. Did God come first in your life? Did you seek and follow God’s will at all
times?
1. List your idols—money, fame, position, alcohol, drugs, sex, power,
relationships.
2. Have you always honored God with your language? List three ways you
dishonored God with your actions or words.
3. Have you always set aside a day to improve your relationship with
God?
4. Have you loved, honored, and respected your parents? List at least five
ways you dishonored your mother and father.
5. Make a list of your unresolved hate, anger, and resentments.
6. List your adulterous acts or thoughts.
7. List when you cheated, misrepresented yourself, made pressure deals,
or had bad debts.
8. List the times you slandered another person or spread gossip.
9. List the times you lusted after something that belonged to someone else
or felt envious or overly competitive.

2. Take a close look at any false pride.

Egotistical vanity is having too great an admiration of yourself. Pride makes

you your own law, moral judge, and Higher Power.
1. List three times you boasted or self-glorified yourself with lies.
2. Discuss your love of publicity.
3. List five times you lied to pretend to be better than others are.
4. List three times you refused to give up your will.
5. List at least three times you resented someone who you thought crossed
you.
6. List three times when you quarreled when another person challenged
your wishes.
7. List five times when you knew you were disobeying or refusing to
submit your will to the will of your superiors or to God.

3. Take a close look at any greed.

Do you desire wealth, such as money or other things, as an end in itself
rather than as a means to an end? In acquiring wealth in any form, do
you disregard the rights of others? Do you give an honest day’s work for
 an honest day’s pay? How do you use what you have? Are you stingy
with your friends and family? Do you love money and possessions for
these things in themselves? How excessive is your love of luxury? Do
you stoop to devices such as fraud, perjury, dishonesty, and sharp
practices in dealing with others? Do you try to fool yourself in these
regards? Do you call questionable business “Big Business”? Do you
call unreasonable hoarding “security”? Will you do almost anything to
attain these things and kid yourself by giving your methods innocent
names?

4. Take a close look at any lust.

Lust is inordinate love and desire of the pleasures of the flesh. Are you
guilty of lust in any of its forms? Do you tell yourself that improper or
undue indulgence in sexual activities is okay? Do you treat people as
objects of your desire other than as God’s perfect creations? Do you use
pornography or think unhealthy sexual thoughts? Do you treat other
people sexually the same way in which you would want to be treated?
Do you love others the same way in which you want them to love you?

5. Take a close look at any envy.

Do you dislike seeing others happy or successful, as though they had
stolen something from you? Do you resent those who are smarter than
you are? Do you criticize the good done by others because you secretly
wish that you had done it yourself? Are you ever envious enough to try
to lower another person’s reputation by starting or engaging in gossip
about that person? Do you call religious people “hypocrites” because
they go to church and try to be religiously good even though they are
subject to human failings? Do you ever accuse the educated, wise, or
learned of being highbrow because you envy their advantages? Do you
genuinely love other people, or do you find them distasteful because you
envy them?

6. Take a close look at any anger.

Do you ever fly into a rage of temper, become revengeful, or entertain
urges to “get even” or an “I would not let him get away with it” attitude?
Do you ever resort to violence, clench your fists, or stomp about in a
temper flare-up? Are you touchy, unduly sensitive, or impatient at the
smallest slight? Do you ever murmur or grumble even in small matters?
Do you ignore the fact that anger prevents development of personality
 and halts spiritual progress? Do you realize that anger often ruins good
judgment? Do you permit anger to rule you when you know that it blinds
you to the rights of others? Do you permit yourself to become angry
when others are weak and become angry with you? Do you find yourself
in a rage when someone criticizes you even for small things?

7. Take a close look at any overindulgence.

Do you weaken your moral and intellectual life by excessive use of food
and drink? Do you generally eat to excess and, thus, enslave your soul
and character to the pleasures of the body beyond the reasonable needs
of the body? Did you ever, when drinking or using drugs, become
nauseated and vomit, only to immediately return and drink or use some
more? Did you use so much that your intellect and personality
deteriorated? So much that memory, judgment, and concentration were
affected? So much that personal pride and social judgment vanished? So
much that you developed a spirit of despair?

8. Take a look at any laziness.

Are you finding yourself being lazy or given to idleness,
procrastination, nonchalance, and indifference in material things? Are
you lukewarm in prayer? Do you hold the self-discipline of others in
contempt? Are you fainthearted in performance of those things that are
morally or spiritually difficult? Are you ever listless with aversion to
effort in any form? Are you easily distracted from things spiritual,
quickly turning to things temporal?
Personality Defects
1. Selfishness

This is taking care of one’s own needs without regard for others.
1. Example: The family would like an outing. Dad would like drinking,
golfing, or fishing, or he has a hangover. Who wins?
2. Example: Your child needs a new pair of shoes. You put it off until
payday but get a fifth that same night.
3. You are afraid to dance because you might appear awkward.

2. Alibis

This is the highly developed art of justifying our chemical use and behavior
through excuses such as the following:
1. “A few will straighten me out.”
2. “Starting tomorrow, I am going to change.”
3. “If I did not have a wife and family . . . ”
4. “If I could start all over again . . . ”
5. “A drink will help me think.”
6. “Nobody cares anyway.”
7. “I had a hard day.”

3. Dishonest thinking

We take truths or facts and twist them to come up with the conclusions we
need such as the following examples:
1. My secret love is going to raise the roof if I drop her. It is not fair to
burden my wife with that sort of knowledge. Therefore, I will hang on to
my girlfriend. This mess is not her fault.
2. If I tell my family about the $500 bonus, it will all go for bills. I have
got to have some drinking money. Why start a family argument? I would
leave well enough alone.
3. My spouse dresses well and eats well, and the kids are getting a good
education. What more do they want from me?

4. Shame
 This is the feeling that something irreparable is wrong with us.
1. No matter how many people tell you that it is okay, you continue to
berate yourself. List the things you cannot forgive yourself for doing.
2. You keep going over and over your mistakes, wallowing in what a
terrible person you are.

5. Resentment

This is displeasure aroused by a real or imagined wrong or injury

accompanied by irritation.
1. You are fired from work. You hate the boss.
2. Your sister warns you about excessive drinking. You get fighting mad at
her.
3. A coworker is doing a good job and gets accolades. You have a drug
record and fear that this coworker might have been promoted over you.
You hate his guts.
4. You may have resentment toward a person or a group of people, or you
may resent an institution, a religion, and so on.

Anger and resentment lead to bickering, friction, hatred, and unjust revenge.
It brings out the worst in our immaturity and produces misery for ourselves
and all concerned.

6. Intolerance

This is the refusal to put up with beliefs, practices, customs, or habits that
differ from our own.
1. Do you hate other people because they are of another race, come from a
different country, or have a different religion?
2. Did you have any choice in being born a particular color or nationality?
3. Isn’t our religion usually “inherited”?

7. Impatience

This is an unwillingness to calmly bear delay, opposition, pain, or bother.

1. A chemically dependent person is someone who jumps on a horse and
gallops off madly in all directions at the same time.
2. Do you blow your stack when someone keeps you waiting over the
“allotted time” you gave that person?
3. Did anyone ever have to wait for you?
 8. Phoniness

This is a manifestation of our false pride or the old false front.

1. I present my love with a present as evidence of my love. Just by pure
coincidence, it helps to smooth over my last binge.
2. I buy new clothes because my business position demands it. Meanwhile,
the family also could use food and clothes.

9. Procrastination

This is putting off or postponing things that need to be done—the familiar “I

would do it tomorrow.”
1. Did little jobs that were put off become big and almost impossible
later?
2. Do you pamper yourself by doing things “my way”?
3. Can you handle little jobs that you are asked to take care of, or do you
feel picked on?
4. Little things, done for God, make them great. Are you doing the little
things for God?

10. Self-pity
1. These people at the party are having fun with their drinking. Why can’t I
be like that? This is the “woe is me” syndrome.
2. If I had that person’s money, then I would not have any problems. This is
a similar attitude.

11. Feelings too easily hurt

1. I walk down the street and say hello to someone. The person does not
answer. I am hurt and furious.
2. I am expecting my turn at the AA meeting, but the time runs out. I feel
rejected.

12. Fear

This is an inner foreboding, whether real or imagined, of doom ahead. We

suspect that our use of chemicals, behavior, negligence, and so on are
catching up with us. We fear the worst.

When we learn to accept our powerlessness, ask our Higher Power for help,
and face ourselves with honesty, the nightmare will be gone.
13. Depression

This is feeling sad or down most of the day.

1. You keep going over all of the things that are going wrong.
2. You tend to think the worst.

14. Feelings of inadequacy

This is feeling as though you cannot do it.

You hold on to a negative self-image even when you succeed.

15. Perfectionism

You have to do everything perfect all of the time.

1. Even when you have done a good job, you find something wrong with it.
2. Someone compliments you on something. You feel terrible because it
could have been better.
Physical Liabilities
1. Diseases, disabilities, and other physical limitations about how you look or
how your body functions
2. Sexual problems or hang-ups
3. Negative feelings about your appearance
4. Negative feelings about your age
5. Negative feelings about your sex
Time-Out
If you have gone through the exercise to this point without coming up for air—it
figures. We did our drinking and drugging the same way. Whoa! Easy does it! Take
this in reasonable stages. Assimilate each portion of the exercise thoughtfully. The
reading of this is important, but the application of it is even more important. Take
some time to think and rest, and let this entire exercise settle in. Develop some
sort of a workable daily plan. Include plenty of rest.

When chemically dependent people stop using, part of their lives is taken away
from them. This is a terrible loss to sustain unless it is replaced by something else.
We cannot just boot the chemicals out the window. They meant too much to us.
They were how we faced life, the key to escape, and the tool for solving life’s
problems. In approaching a new way of life, a new set of tools is substituted.
These are the 12 steps and the AA/Narcotics Anonymous (NA) way of life.

The same principle applies when we eliminate our character defects. We replace
them by substituting assets that are better adapted to a healthy lifestyle. As with
substance use, you do not fight a defect. You replace it with something that works
better. Use what follows for further character analysis and as a guide for character
building. These are the new tools. The objective is not perfection but rather
progress. You will be happy with the type of living that produces self-respect,
respect and love for others, and security from the nightmare of addiction.
The Way to Recovery
1. FaithS

This is the act of leaving that part of our lives to the care of a power greater
than ourselves with assurance that it will work out. This will be shaky at
first, but with it comes a deep spiritual connection.
1. Faith is acquired through application—acceptance, daily prayer, and
meditation.
2. We depend on faith. We have faith that the lights will come on, that the
car will start, and that our coworkers will handle their end of things.
3. Spiritual faith is the acceptance of our gifts, limitations, problems, and
trials with equal gratitude, knowing that God has a plan for us. With
“Thy will be done” as our daily guide, we will lose our fear and find
ourselves.

2. Hope

Faith suggests reliance. We came to believe that a power greater than

ourselves would restore us to sanity. We hope to stay clean and sober, regain
our self-respect, and love our families. Hope resolves itself into a driving
force. It gives purpose to our daily living.
1. Faith gives us direction, and hope gives us the steam to take action.
2. Hope reflects a positive attitude. Things are going to work out for us if
we work the program.

3. Love

This is the active involvement in someone’s individual growth.

1. Love must occur in action and in truth.
2. “Love is patient, love is kind.”
3. In its deeper sense, love is the art of living realistically and fully,
guided by spiritual awareness of our responsibilities and our debt of
gratitude to God and to others.

Analysis. Have you used the qualities of faith, hope, and love in your past? How
will they apply to your new way of life?
We Stay on Track Through Action
1. Courtesy: Some of us are actually afraid to be gentle persons.
2. Cheerfulness: Circumstances do not determine our frame of mind; we do.
“Today I will be cheerful. I will look for the beauty in life.”
3. Order: Live today only. Organize one day at a time.
4. Loyalty: Be faithful to whom you believe in.
5. Use of time: Use your time wisely.
6. Punctuality: This includes self-discipline, order, and consideration for
others.
7. Sincerity: This is the mark of self-respect and genuineness. Sincerity carries
conviction and generates enthusiasm. It is contagious.
8. Caution in speech: Watch your tongue. We can be vicious and thoughtless.
Too often, the damage is irreparable.
9. Kindness: This is one of life’s great satisfactions. We do not have real
happiness until we have given of ourselves. Practice this daily.
10. Patience: This is the antidote to resentments, self-pity, and impulsiveness.
11. Tolerance: This requires common courtesy, courage, and a “live and let live”
attitude.
12. Integrity: This includes the ultimate qualifications of a person—honesty,
loyalty, and sincerity.
13. Balance: Do not take yourself too seriously. We get a better perspective
when we can laugh at ourselves.
14. Gratitude: The person without gratitude is filled with false pride. Gratitude
is the honest recognition of help received. Use it often.

Analysis. In considering the little virtues, where did I fail and how did that
contribute to my accumulated problem? What virtues should I pay attention to in
this rebuilding program?
Physical Assets
1. Physical health: How healthy am I despite any ailments?
2. Talents: What am I good at?
3. Age: At my age, what can I offer to others?
4. Sexuality: How can I use my sexuality to express my love?
5. Knowledge: How can I use my knowledge and experience to help myself and
others?
Mental Assets
1. Despite your problems, how healthy are you emotionally?
2. Do you care for others? Make a list of the ways you can share your
experience, strength, and hope.
3. Are you kind?
4. Can you be patient? List some ways you can give others the time to think,
plan, and act.
5. Are you basically a good person? In detail, describe the person you want to
be.
6. Do you want to help others? List five ways you can help other people.
7. Do you try to tell the truth?
8. Do you try to be forgiving? List the people you are still having trouble
forgiving, and turn them over to God.
9. Can you be enthusiastic?
10. Are you sensitive to the needs of others?
11. Can you be serene? Make plans to meditate every day by reading AA/NA
material, scripture, or other recovery reading.
12. Sincerity: How are you going to try to be sincere?
13. Self-discipline: List the ways you are going to try to bring order and self-
control into your life.
14. Are you going to accept the responsibility for your own behavior and stop
blaming others?
15. How are you going to use your intelligence?
16. Are you going to seek the will of God?
17. Education: How might you improve your mind in furthering your education?
18. Are you going to be grateful for what you have?
19. Integrity: How can you improve your honesty and reliability?
20. Joy: In what areas of your life do you find happiness?
21. Are you humble and working on your false pride?
22. Are you seeking the Higher Power of your own understanding?
23. Acceptance: In what ways can you better accept your own limitations and the
limitations of others?
24. Courage: Are you willing to trust and follow the God of your understanding?
The Autobiography
Using this exercise, write the story of your life. Cover your experiences in 5-year
intervals. Be brief, but try not to miss anything. Tell the whole truth. Write down
exactly what you thought and did. Consider all of the things that you marked during
the exercise. Read the exercise again if you need to do so. Make an exhaustive and
honest consideration of your past and present. Cover both assets and liabilities
carefully. You will rebuild your life on the solid building blocks of your assets.
These are the tools of recovery. Omit nothing because of shame, embarrassment,
or fear. Determine the thoughts, feelings, and actions that plagued you. You want to
meet these problems face-to-face and see them in writing. If you wish, you may
destroy your inventory after completing the Fifth Step. Many clients hold a
ceremony in which they burn the Fourth Step inventory. This symbolizes that they
are leaving the old life behind. They are starting a new life free of the past.
Appendix 21: Step Five

Robert R. Perkinson, PhD

[We] admitted to God, ourselves, and to another human being the exact
nature of our wrongs.

—Alcoholics Anonymous [AA] (2001, p. 57)

Before beginning this exercise, please read Step Five in Twelve Steps and Twelve
Traditions (AA, 2002b).

With Steps One to Four behind you, it is now time to clean house and start over.
You must free yourself of the guilt and shame and go forward in a new life full of
faith and hope. The Fifth Step is meant to right the wrongs with your Higher
Power, yourself, and others. You will develop a new attitude and a new
relationship, particularly with yourself. You have admitted your powerlessness,
and you have identified your liabilities and assets in the personal inventory. Now
it is time to get right with your Higher Power. You will do this by admitting to
God, to yourself, and to another person the exact nature of your wrongs. You are
going to cover all of your assets and liabilities in the Fifth Step. You are going to
tell someone the whole truth at one time. This person is important because he or
she is a symbol of God and everyone else. You must watch this person’s face. The
illness has been telling you that if you tell anyone the whole truth about you,
people will not like you. That is a lie, and you are going to prove that it is a lie.
The truth is this: Unless you tell people the truth, they cannot like you because they
do not know you. You must see yourself tell someone the truth and watch that
person’s reaction.

It is very difficult to discuss your faults with someone. It is hard enough just
thinking about them yourself, but this is a necessary step. It will help to free you
from the shame and guilt of the addictive behavior. You must tell this person
everything, the whole story, all of the things that you are afraid to share. If you
withhold anything, then you will not get the relief you need to start over. You will
be carrying around excess baggage. You do not need to do this to yourself. God
loves you and wants you to be free of guilt, shame, and hurt. God wants you to be
happy and to reach your full potential.

Time after time, newcomers have tried to keep to themselves certain facts
about their lives. Trying to avoid this humbling experience, they have turned
to easier methods. Almost invariably, they got drunk. Having persevered with
the rest of the program, they wondered why they fell. We think the reason is
that they never completed their housecleaning. They took inventory all right
but hung on to some of the worst items in stock. They only thought they had
lost their egotism and fear; they only thought they had humbled themselves.
But they had not learned enough of humility, fearlessness, and honesty, in the
sense we find necessary, until they told someone else all their life story.
(AA, 2001, pp. 72–73)

By finally telling someone the whole truth, you will rid yourself of that terrible
sense of isolation and loneliness. You will feel a new sense of belonging,
acceptance, and freedom. If you do not immediately feel relief, do not worry. If
you have been completely honest, then the relief will come. “The dammed-up
emotions of years break out of their confinement and miraculously vanish when
they are exposed” (AA, 2001, p. 62). You can be forgiven, no matter what you
have done. You are God’s child, and he wants to make you into a new person who
is dedicated to helping others.

The Fifth Step will develop within you a new humbleness of character that is
necessary for normal living. You will come to recognize who and what you are.
When you are honest with another person, it confirms that you have been honest
with yourself and with God.

The person with whom you will share your Fifth Step has been chosen carefully
for you. You will meet with this person several times before you do the step. You
need to decide whether you can trust this person. Do you believe that this person
is confidential? Do you feel comfortable with this person? Do you believe that
this person will understand?

Once you have chosen that person, put your false pride aside and go for it. Tell
this person everything about yourself. Do not leave one dark act untold. Tell this
person about all of the good things as well as all of the bad things you have done.
Share the details, and do not leave anything out. If it troubles you even a little, then
share it. Let it all hang out to be examined by God, by you, and by that other
person. Every good and bad part needs to be revealed. When you are finished, say
a prayer to your Higher Power. Tell God that you are sorry for what you have
done wrong, and commit yourself to a new way of life following the God of your
understanding. Many clients like to say the Seventh Step prayer.

My Creator, I am now willing that you should have all of me, good and bad. I
pray that you now remove from me every single defect of character, which
stands in the way of my usefulness to you and my fellows. Grant me strength,
as I go out from here, to do your bidding. (AA, 2001, p. 76)
Appendix 22: Adolescent Unit Level System

The adolescent unit uses the level system as a way to earn privileges and trust
here. There are four levels. Each has its own set of criteria and privileges. You
will be assigned the level the staff sees you meeting. Your level is entirely up to
your willingness to work. The higher the level, the more freedom you will get, as
well as responsibility.

Level 1: To move to the next level, you will need to do the following:

Complete at least the first 7 days of treatment.

Read and review the client handbook, and come to an understanding of the
rights, rules, and expectations of the treatment program.
Finish all assessments.
Undergo lab work, have a physical examination, and complete detoxification
(if needed).
Participate in two sessions, including an initial interview with a primary
counselor.
Attend all groups as scheduled, and participate appropriately.
Fulfill any additional criteria set for you by the clinical staff.

Possible privileges: At this level, you may . . .

Earn up to 1,000 points per day.

Go to the Point Store two times a week and get up to two food items, two
drink items, and one other item.
Attend off-campus spiritual activities if you have completed at least 7 days
of treatment and the clinical staff has given approval.
Use points to make one 10-minute phone call home (on speakerphone) each
week.

Level 2: To move to the next level, you will need to do the following:

Complete the following assignments or their equivalents (Why Am I Here?

Are Alcohol and Drugs Causing My Problems, Honesty, and Step One), and
discuss them in individual and group sessions.
Participate in individual sessions with your primary counselor, two times per
 week.
Attend groups as scheduled, and participate without staff always telling you
to do so.
Be in control of your behaviors, such as no physically or verbally aggressive
behaviors.
Accept consequences and feedback from staff and peers, taking
responsibility for your actions.
Consistently follow unit rules.
Understand addiction in terms of the disease concept, and apply it to your
life.
Begin using healthy coping skills (journaling, time-outs, pushups, talking,
etc.).
Fulfill any additional criteria set for you by the clinical staff.

Possible privileges: At this level, you may . . .

Earn up to 1,500 points per day.

Go to the Point Store two times a week and get up to two food items, two
drink items, and one other item.
Attend off-campus activities at staff discretion.
Use points to make two 10-minute or one 20-minute phone call home each
week.
Have approved free reading and drawing materials in the room at noon study
time (and return them).
Get a haircut with your own money.

Level 3: To move to the next level, you will need to do the following:

Complete Steps Two, Three, Four, and Five as assigned, in a complete and
timely manner, and discuss them in individual and group sessions as
assigned.
Participate in individual sessions with your primary counselor two times per
week.
Attend groups as scheduled and be an active participant on your own without
staff having to ask.
Accept consequences without talking back, fighting, or getting angry beyond
control.
Give honest and assertive feedback to peers.
Behave in a manner consistent with what you say.
 Demonstrate willingness to help others, be an ally to others, and still work
on self.
Consistently use healthy coping skills (I feel statements, journaling, time-
outs, etc.).
Fulfill any additional criteria set by the clinical staff.

Possible privileges: At this level, you may . . .

Earn up to 2,000 points per day

Go to the Point Store two times a week and get up to two food items, two
drink items, and one other item.
Attend all off-campus activities.
Use points to make two 10-minute or one 20-minute phone call home each
week.
Watch television during community time (based on staff availability).
Have approved free reading and drawing materials in the room.
Play a musical instrument or listen to music (approved by staff) in our
serenity room for 30 minutes during noon self-time.
Study at your desk in your room for last hour of study time.
Add an extended family member to call and visitor list (must be approved by
staff).

Level 4: To keep this level, you will need to do the following:

Complete Steps Two, Three, Four, and Five as assigned, in a complete and
timely manner, and discuss them in individual and group sessions as
assigned.
Complete additional treatment plan assignments as given.
Be open-minded to aftercare and discharge plans, including behavior
contract.
Participate in individual sessions with your primary counselor two times per
week.
Attend groups as scheduled, taking a leadership role, showing by example
how groups are done well.
Take your own time-outs, not being placed there by staff direction.
Give honest and assertive feedback to peers; help peers make positive
choices.
Be welcoming and positive to new peers, encouraging them to be positive
about treatment.
 Demonstrate willingness to help others, be an ally to peers, and still work on
self.
Consistently use healthy coping skills (I feel statements, journaling, time-
outs, etc.).
Fulfill any additional criteria set by the clinical staff.

Possible privileges: At this level, you may . . .

Earn up to 2,500 points per day.

Go to the Point Store three times a week and get up to two food items, two
drink items, and one other item.
Attend all off-campus activities.
Use points to make two 10-minute or one 20-minute phone call home each
week.
Use points to eat a meal at a local restaurant with staff.
Watch television during community time (based on staff availability).
Have approved free reading and drawing materials in the room.
Play a musical instrument or listen to music (approved by staff) in our
serenity room for 30 minutes during noon self-time.
Study at the desk in your room for the entire study time.
Have supervised time on the computer—no e-mail or chatting.
Be a peer leader, helping other peers learn rules and feel welcomed here.
When possible, attend an outside Alcoholics Anonymous (AA) or Narcotics
Anonymous (NA) meeting with staff.
Add a second extended family member to call and visitor list (must be
approved by staff).
Request other privileges that can be worked out with staff.
Use the STOP level—a special level used to help you look at poor choices
you may be making while here.

You may be placed on the STOP level due to the following:

Major rule violations (such as smoking, engaging in physical or verbal

aggression, and running away)
Continued violation of rules
Refusing to do what is asked of you by staff on several different occasions
Hurting others’ treatment program

While on the STOP level, you will . . .

 Earn no privileges or points for the time you are on the level.
Work at completing the requirements for this level at the think table, or in the
serenity room.

General criteria: At this level, you will . . .

Identify the behaviors that led to you being placed on the STOP level.
Complete assignments given by the staff and present those assignments to
staff and/or peers.
Accept consequences for your behavior without losing control of your
behaviors.
Make a plan to do things differently next time.
Fulfill any additional criteria set for you by the clinical staff.

When criteria for the STOP Level are met, you will . . .

Be placed at the level that staff will decide.

Resume regular participation in the treatment program.
Be able to earn privileges again as normal.
Level One Daily Point Card
Goal for the Day:

To move to the next level, you will need to do the

following:
Complete at least the first 7 days of treatment.
Read and review the client handbook, and come to an understanding of the
rights, rules, and expectations of the treatment program.
Finish all assessments.
Undergo lab work, have a physical examination, and complete detoxification
(if needed).
Participate in two sessions including an initial interview with the primary
counselor.
Attend all groups as scheduled and participate appropriately.
Fulfill any additional criteria set for you by the clinical staff.

Possible privileges: At this level, you may . . .

Earn up to 1,000 points per day.
Go to the Point Store two times a week and get up to two food items, two
drink items, and one other item.
Attend off-campus spiritual activities (such as church and Inipi) if you have
completed at least 7 days of treatment and the clinical staff has given
approval.
Use points to make one 10-minute phone call home (on speakerphone) each
week.
Total Points to Begin the Day:

Total Points for the Day:

Level Two Daily Point Card
Goal for the Day:

To move to the next level, you will need to do the

following:
Complete the following assignments or their equivalents (Why Am I Here?
Are Alcohol and Drugs Causing My Problems, Honesty, and Step 1), and
discuss them in individual and group sessions.
Participate in individual sessions with your primary counselor two times per
week.
Attend groups as scheduled, and participate without staff always telling you
to do so.
Be in control of your behaviors, such as no physically or verbally aggressive
behaviors.
Accept consequences and feedback from staff and peers, taking
responsibility for your actions.
Consistently follow unit rules.
Understand addiction in terms of the disease concept, and apply it to your
life.
Begin using healthy coping skills (journaling, time-outs, pushups, talking,
etc.).
Fulfill any additional criteria set for you by the clinical staff.

Possible privileges: At this level, you may . . .

Earn up to 1,500 points per day.
Go to the Point Store two times a week and get up to two food items, two
drink items, and one other item.
Attend off-campus activities at staff discretion.
Use points to make two 10-minute or one 20-minute phone call home each
week.
Have approved free reading and drawing materials in room at noon self-time
(they must be returned).
Get a haircut with your own money.
Total Points to Begin the Day:

Total Points for the Day:

Level Three Daily Point Card
Goal for the Day:

To move to the next level, you will need to do the

following:
Complete Steps Two, Three, Four, and Five as assigned, in a complete and
timely manner, and discuss them in individual and group sessions as
assigned.
Participate in individual sessions with your primary counselor two times per
week.
Attend groups as scheduled, and be an active participant on your own
without staff having to ask.
Accept consequences without talking back, fighting, or getting angry beyond
control.
Give honest and assertive feedback to peers.
Behave in a manner consistent with what you say.
Demonstrate willingness to help others, be an ally to others, and still work
on self.
Consistently use healthy coping skills (I feel statements, journaling, time-
outs, etc.).
Fulfill any additional criteria set by the clinical staff.

Possible privileges: At this level, you may . . .

Earn up to 2,000 points per day
Go to the Point Store two times a week and get up to two food items, two
drink items, and one other item.
Attend all off-campus activities.
Use points to make two 10-minute or one 20-minute phone call home each
week.
Watch television during community time (based on staff availability).
Have approved free reading and drawing materials in room.
Play a musical instrument or listen to music (approved by staff) in our
serenity room for 30 minutes during noon self-time.
Study at your desk in your room for the last hour of study time.
Add an extended family member to call and visitor list (must be approved by
staff).
Total Points to Begin the Day:

Total Points for the Day:

Level Four Daily Point Card
Goal for the Day:

To maintain this level, you will need to do the

following:
Complete Steps Two, Three, Four, and Five as assigned, in a complete and
timely manner, and discuss them in individual and group sessions as
assigned.
Complete additional treatment plan assignments as given.
Be open-minded to aftercare and discharge plans, including behavior
contract.
Participate in individual sessions with your primary counselor two times per
week.
Attend groups as scheduled, taking a leadership role, showing by example
how groups are done well.
Take your own time-outs, not being placed there by staff direction.
Give honest and assertive feedback to peers, and help peers make positive
choices.
Be welcoming and positive to new peers, encouraging them to be positive
about treatment.
Demonstrate willingness to help others, be an ally to peers, and still work on
self.
Consistently use healthy coping skills (I feel statements, journaling, time-
outs, etc.).
Fulfill any additional criteria set by the clinical staff.

Possible privileges: At this level, you may . . .

Earn up to 2,500 points per day.
Go to the Point Store three times a week and get up to two food items, two
drink items, and one other item.
Attend all off-campus activities.
Use points to make two 10-minute or one 20-minute phone call home each
week.
Use points to eat a meal at a local restaurant with staff.
Watch television during community time (based on staff availability).
Have approved free reading and drawing materials in the room.
Play a musical instrument or listen to music (approved by staff) in the
serenity room for 30 minutes during noon self-time.
Study at a desk in your room for the entire study time.
Have supervised time on the computer—no e-mail or chatting.
Be a peer leader, helping other peers learn rules and feel welcomed here.
When possible, attend an outside AA or NA meeting with staff.
Add a second extended family member to call and visitor list (must be
approved by staff).
Request other privileges that can be worked out with staff.
Total Points to Begin the Day:

Total Points for the Day:

Appendix 23: Peer Pressure

Robert R. Perkinson, PhD

You want your friends to accept you. Sure you do. That is normal. You want to be
liked. You want to be loved and accepted by your peers. In treatment, it is
important to learn about peer pressure, where it comes from, what is good about
it, and what can be dangerous about it. There are things that you need to watch out
for in recovery. If you are not careful, then the pressure of your peer group can get
you back to drinking or using drugs. Your friends are not trying to hurt you. They
just want their old friend back. These friends may have a chemical problem
themselves. They may see your recovery as a threat to them.
How Peer Pressure Evolved
The roots of peer pressure evolved in the birds. Birds learned that they were safer
if they gathered together in flocks. They could warn others of danger more easily
if they stuck together. In a group, they were less likely to be singled out as prey.
Birds learned how to stay together for safety. Because this worked so well, over
thousands of years, birds developed a feeling of wanting to be together. They
developed social skills used to keep together. They began to make social noises
and movements to keep together. Anyone who has heard a flock of geese fly
overhead will testify to the active communication patterns of these birds.
Communications became more complicated over the years. The birds developed a
particular sound for relaxation and a particular sound for danger. They developed
the feeling of wanting to be together in groups. It felt better to be together. These
feelings are what we now call emotions.

Higher ordered social activity continued to evolve in mammals. Baboons, for

example, have very complicated social rituals. These animals groom each other to
keep the troop together. The grooming serves to rid them of irritating insects, and
it helps them to feel closer together. It is like a back scratch; it says, If you scratch
my back, then I would scratch yours. These social rituals hold a group of animals
together. When you go to the zoo, you will see animals rubbing and stroking each
other. You will see mothers holding and licking their babies. As such, the species
becomes bonded together. A touch says, I will help you carry the load.

Acceptance is a very important feeling because animals depend on acceptance by

the group for survival. If they are rejected by the herd, then they have a higher
chance of being killed by predators. All animals are safer if they are in a group.

As we move up the evolutionary scale, we finally get to humans. Early people, as

we know them, were social creatures. They gathered together in groups or tribes
for safety. A tribe could function better with people together. Tribe members could
specialize and reap the benefits of other people’s expertise. It was easier to hunt,
fish, and gather food if the tribe members worked together. Some would do the
hunting, and some would make tools. Each tribe member specialized in a
particular function. It was very important for early people to be accepted by their
tribes. If they were banished, then they would have to fend for themselves. Being
alone in the world would put individuals at great risk. Humans developed a deep
desire, a wish, or a need to be accepted. This was essential for survival.
The Importance of Peer Pressure
You are beginning to see why peer pressure is so important. If you are rejected by
the group, you fear death. Without the acceptance of the group, people feel more
vulnerable to the world. Now you can see why we try so hard to get our friends to
like us. We need our friends so that we can survive.

It is very clear that being liked and being accepted by the group is important and
good. It is important for all of us to learn the skills necessary to establish and
maintain close interpersonal relationships. These are the skills that keep the group
together.

There often are symbols or gestures that identify groups. Groups may have flags or
jesters, or they may wear certain colors or uniforms. Group members all may ride
a certain kind of motorcycle or wear a particular hat. Every group has a particular
language that is unique to that group. Medical doctors do not use the same words
as do auto mechanics.
How Peer Pressure Can Risk Your Sobriety
There are a few things about peer pressure that can get you into trouble. Groups
can get you to do things that you would not normally do. They might talk you into
doing something that you do not want to do—things such as stealing, drinking, and
even playing a practical joke on someone. If we always follow the group, then we
can be led into behavior that we know is wrong.

List five times when you were talked into doing something that you did not really
want to do because of peer pressure.

1.
2.
3.
4.
5.
How the Group Uses Peer Pressure
The group will have a means of pressuring you into cooperating. In formal society,
there are laws that govern group behavior. In most groups, members are subject to
ridicule or even group expulsion if they do not cooperate. “Do not be chicken!
What are you scared of?” There are any number of ways of encouraging
individuals to do what the group wants them to do. In some gangs, it is blood in
and blood out. This may mean you must kill or injure someone to join a gang, and
the gang will hurt or kill you if you decide to leave.

List five ways your friends try to get you to cooperate with them.

1.
2.
3.
4.
5.

Today peers may use verbal, physical, or Internet bullying to control the behavior
of others. This can be extremely painful, and surprisingly enough, the bully usually
suffers the most. Bullies end up getting rejected by peers and failing in school and
career achievement. They are avoided because people are afraid of them. Bullies
harm others out of fear, and they tend to have good leadership skills that can be
positively directed through treatment.
How to Cope With Peer Pressure
It is important to stay in the group, but it also is important for you to make your
own decisions. If you do not make all of your decisions, then you will be held
accountable for the decisions of others.

Here is a new concept for you to ponder in your heart.

The only thing that you owe anyone else is to be different.

You must be different from anyone that ever was or anyone that ever will be. You
were created to be unique. The only way in which you can reach your full
potential in life is to make all of your own decisions and be responsible for them.
If you always follow a group, then you cannot be yourself. It is important for you
to have the skill to say no. You need to be able to go against the group sometimes.
If you are going to be responsible, then you have to make all of you own decisions
and live with the consequences. That is the only way in which you can take your
own direction. You must think about every choice you make. You cannot let other
people make your decisions for you.

When you decide to do something that is different from what the group wants, the
group will apply peer pressure. The group will try to get you to conform. The
group members may threaten you or make fun of you. They may get angry with you.
Remember that it is your responsibility to yourself, and to everyone else, to be
different. Once you make a decision and you believe in it, you must be able to
stick to it. If you cannot do this, then the group always will manipulate your
choices and you will be their slave. You need to develop the skill of going your
own way, even in the face of group opposition.

You do not have to have a good reason for not doing what the group wants. It can
just be your choice. You do not have to explain yourself or your opinions to
anybody. You do not need an excuse. You can simply say “because I want to.” This
is reason enough. Practice in skills group or with your counselor three times when
the group or counselor is encouraging you to do one thing but you decide to do
another. Discuss each role play and how you felt during the peer pressure and
after you decided to stick to your own decision.
 1.
2.
3.

You must keep the group informed about how you are feeling if it tries to pressure
you. This holds the group members accountable for their behavior.

If the group members are causing you to feel uncomfortable, then you must
express this feeling. This will keep their behavior in line: “It makes me feel
uncomfortable when you ask me to drink when you know that I am recovering
from addiction.”
Honest statements usually will bring people under control. You must
constantly keep people informed about how you are feeling and what you
want from them: “I do not want any pot. I would prefer it if you would stop
asking me.”
A simple no or no thank you is enough in most circumstances. Say no and
stand your ground. You do not have to explain yourself further.
If the group continues to coerce you even after you have said no, then you
might have to leave the situation.
If the group members do not respect your wishes, you do not want to be with
those people anyway.
Just excuse yourself and go home. You have not lost anything. If the group
does not care for how you feel, then it is not the group for you.

People always can get you to feel a certain way if they try. They can get you to
feel angry or guilty if they work at it, but even if they have some control over your
feelings, they cannot control your actions. That is up to you. If they can get control
over your actions by controlling your feelings, then you are their slave. They can
get you to do anything. Group members often will try to lay guilt on you if you do
not cooperate with them, but they cannot make you do anything with this guilt. You
are in control of your actions.
Make a Plan to Say No
List 10 ways in which you are going to say no to alcohol and drugs.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Here are some important points to remember. The desire to be accepted by the
group is normal and very powerful. The feeling of wanting to be accepted exists
deep inside all of us, and this feeling helps us to gather together in groups for
everyone’s mutual gain. Being a part of a group feels good, but our primary
responsibility to ourselves and to everyone else is to be different—to be one of a
kind. Therefore, it is crucially important that you take your own direction, make
all of your own decisions, and be yourself.
Appendix 24: The Behavioral Contract

Robert R. Perkinson, PhD

Behavioral contracting has been found to be a powerful means of directly
influencing behavior (Stuart, 1971). Developing a behavioral contract and living
within its limits will create a stable family situation for you and your child.
Behavior is defined as any movement. When anyone acts or speaks, it is behavior.
Counselors often are asked by frustrated parents, Why doesn’t my child
cooperate? The answer to this question is simple: No behavior exists, nor does it
continue to exist, without reward. Children get good things for their behavior.
They might get more freedom by arguing than they do by behaving in a more
sociable manner. Many children have been reinforced for antisocial behavior.
Parents do not mean to do this. It seems to happen on its own. Psychological laws
are at play in all learning.
Reward and Punishment
A reward is anything that increases the frequency of a behavior. Behavior is
reinforced when it gets children something they want or removes something they
do not want. A reward might be money, praise, or free time. You cannot always
tell what is reinforcing to children. You have to watch the behavior to determine
this. If the behavior increases, then you can assume that what you have done is
reinforcing. To most children, a hug is reinforcing. To some children, it is not
reinforcing and might even be punitive.

A punishment decreases the frequency of a behavior. You can punish children by

giving them something they do not want or taking away something they do want.
You can verbally reprimand them, send them to their room, or take away their use
of the family car. Again, you have to watch the behavior to see what a punishment
is. If the behavior decreases, then you can assume that you have punished it. The
problem with punishment is that you cannot teach children anything new and that
you get the children’s minds off what they did and onto what you are doing to
them. If you want to change children, reinforcement is much more powerful.
Habits
If children are reinforced for a behavior over a period of time, then the behavior
will get to be a habit. It will develop a life of its own. This behavior will not go
away easily. It will stick like glue. It will take time for new behavior to replace it.
In behavioral contracting, you teach children new behavior by carefully
scheduling when they are reinforced. You want to think before you act. Give the
children good things when they are acting the way in which you want them to act.
This means that your behavior must change as well as theirs.

The family is a powerful force in teaching children new behavior. All children
want to be loved, and you can use this desire to develop the behavior you want. A
behavioral contract is a means by which you control the exchange of positive
reinforcement. The contract specifies who is going to do what, for whom, and
under what circumstances. The contract makes explicit the expectations of each
party. It gives the parent and the child the opportunity to get the things they want. It
clarifies the benefits of cooperation by making each person’s role in the family
clear. The contract makes it more likely that each person will live up to his or her
responsibilities. This leads to family harmony and stability.
Love
Love is the active involvement in someone’s individual growth. To love, you must
be actively involved in your children reaching their full potential. Rewards must
be earned. They should not be given randomly. If you give your children good
things just because they exist, then you give them no direction and you do not teach
them what works in life. They will think that the world owes them things. This is
not fair to the children, and it is not an accurate view of the world.

Each member in a family has rights and duties to each other, and rewards must be
exchanged equally. Many times, parents feel that they are doing all of the giving
and the children are doing all of the taking. This is a mistake. Happiness comes
from giving to others. If parents do not teach their children to give, then the
children will not be happy.

In a healthy family, if you give something, then you get something in return. The
more you give, the more you get. Each member of a family should want to give all
that he or she can. In the behavioral contract, if children act responsible, they earn
specific rewards. Some examples of rewards include free time, time with friends,
television time, spending money, and use of the family car. Each child will have a
different set of rewards, and the child should actively ask for what he or she
wants.
How to Develop a Behavioral Contract
The behavioral contract details the behavior necessary for earning each reward.
Let us say that you are having problems with your child coming home from school
on time. For a variety of reasons, the child is late and you worry about him or her.
You decide to put this behavior into the behavioral contract. If the child gets home
from school every day on time, then he or she earns a certain amount of television
time. If the child misses coming home, then he or she does not earn that privilege.
Behaviors of interest might include minimum school attendance and performance,
curfew hours, and completion of household chores. The responsibilities required
must be monitored. You must be able to see whether the behavior is occurring. It
would be useless for you to forbid your child from seeing a person at school
because you could not monitor the behavior. If you want your child to be at school
on time and to cooperate with school authorities, then you can have the teacher
keep track for you. You could check with the teacher each week to be sure of
compliance. You could send a school performance chart with your child to give to
the teacher each day. It might look something like this:
The School Performance Chart
Name of Student Date

To keep my parents informed about my school progress, I am asking all of my

teachers to complete this form at the end of each class period. Thank you.

Subject:

Teachers, please place a check mark beside each point in the contract to indicate
yes or no.

1. Student was on time for class Yes No

2. Student completed homework assignment (mark only if applicable) Yes
No
3. Student obeyed class rules Yes No
4. Student was attentive to task Yes No
5. Student was cooperative with teacher Yes No

You must be sure that you are giving your child enough rewards to keep him or her
cooperating with the contract. If the child believes that the contract is not good for
him or her, then the child will resist the whole idea. All parties in the contract
must have a full say about what they want, and everyone must be willing to
compromise. All parties must agree to the contract and sign it. You must include
the consequences that will occur if the child does not comply with the terms of the
contract.

Get together with your child and come up with 10 ways to reinforce him or her.

1.
2.
3.
4.
5.
6.
7.
8.
9.
 10.

Make sure that you verbally reinforce your child as he or she complies. We are
striving for progress, not perfection. Statements such as “Good job! You are doing
great! I am proud of you!” go a long way toward getting your child to cooperate
cheerfully.
Detailing What Each Party Wants
The first thing you need to do is determine what all parties want from the family.
The child might want to go out on weekend nights and stay out until 11:00 pm. The
child might want to use the family car. The child might want to go out without
explaining where he or she is going. The child might want a new bike. The child
might want to choose his or her own clothes or hairstyle without your input.
Brainstorm with your child about what he or she wants from you. Then decide
what you want from your child. You might want the child to improve in school.
You might want the child to come home on time. You might want the child to keep
you informed about where he or she is. You might want the child to help out with
the household chores.

Write down all of these things. With the counselor, work out what each person is
willing to give to get what he or she wants from each other. It is important that
each person get the reasonable things that they want from the contract. All parties
mutually exchange things that they want from each other. The contract might look
something like this.
A Sample Contract

In this contract, the parents will need to keep a written record of when Robert
comes home, and Robert will have to provide the parents with a school
performance chart each day.

The contract can include anything you want so long as everyone agrees to it. Let
the primary counselor help you. If you have any problems with the contract, then
you can discuss the issues in the continuing care group.
Appendix 25: Family Questionnaire

Robert R. Perkinson, PhD

Your name Date

Client name Relationship

Address

Home phone

Work phone

Best time for you to be contacted by the family program counselor

Addiction affects everyone it touches. Chemically dependent persons and

everyone close to them are adversely affected. No one wants a loved one to be
sick, so the family members pretend that the disease is not there. The average
chemically dependent person has been ill for years before the family finally
realizes that there is a problem. After the problem has been identified, there are
even more years before the average chemically dependent person receives
treatment.

The person you care for is in treatment. That is great! You can relax and know that
this person is safe. This person stands at the turning point, and there is an excellent
chance that he or she will achieve a stable sobriety. The person might have further
problems, but this is a major step in the right direction. You have done the right
thing, and you can feel good about it.

The client might not feel good about coming to treatment right now. The client
might feel angry or rejected. The client might still believe that he or she does not
have a problem. This is denial. It is very common, and it is one of the best signs
that the disease is present. Addiction demands that these people lie to themselves.
They are fooled into believing that they are okay even when their lives are falling
apart.
It is important for you to understand that it is not only the chemically dependent
person who is having problems. If you have lived close to a chemically dependent
person, then you are having problems, too. All of these problems have, at their
source, subtle distortions of reality. Family members change reality into something
that does not make them so nervous. Trying to keep the reality of addiction hidden
is like hiding an elephant in your living room. The problem is there, and it is big.
It takes large distortions of reality to keep it hidden. The family tries to pretend
that there is not a problem. As the problem gets bigger, it takes distortions of
reality to keep it secret.

The distorting begins with minimizing. Family members pretend that the problem
is not so bad. They believe that other people have more problems than they do.
They think that the drinking is not that bad. It could be worse. They minimize to the
point where they cannot see the real effect of the illness on themselves and on the
other family members. The problem is big. They focus on the chemically
dependent person, and they become cut off from their own feelings. They have no
time for themselves. This sinks the family deeper into an unreal world.

The next lie that families tell themselves is that there is a good excuse for the
problem. This is called rationalization. It is not the drugs. It is the job, the boss,
or maybe even me. The family members, even the children, may feel responsible
for the chemically dependent person’s drinking or drug use. They blame
themselves, other people, institutions, and money—whatever it takes to take their
minds off the real problem. The family actually believes that it is these other
things that are the problem. It is not the chemicals.

The last distortion of reality is called denial. This is where the family members do
not experience the full impact of their lives. They have developed such a tolerance
for the craziness that they think it is normal. Their lives may be coming apart, but
they still think that things are under control.

Now is the time for the client to get honest with himself or herself. Do not make
things seem smaller than they were. Do not make excuses. Write down exactly
what happened.

Why did the client decide to seek treatment at this time?

What mood-altering chemicals does the client currently use? Mark all that
apply.
What is the client’s awareness of the problem?
No awareness: “I do not have a problem. It is no worse than anyone
else.”
Minimal awareness: “Sure, I have had a problem, but I can take it or
leave it.”
 Moderate awareness: “I have a problem, but I can handle it on my
own.”
Admits to a problem and accepts the responsibility for change.

What is the duration of the problem?

0 to 6 months
6 months to 1 year
1 to 2 years
2 to 5 years
More than 5 years (specify number of years: )

What is the longest period of abstinence?

Days
Weeks
A month at a time
6 to 12 months at a time
When the client was abstinent, what was the reason why he or she stopped
using?

Which of the following symptoms of dependency apply to the client?

Blackouts (cannot remember what he or she did while drinking)
Hides or protects supply of drugs or alcohol
Cannot stop once he or she starts
Makes excuses for using alcohol or drugs
Has a physical problem associated with use (e.g., tremors, nausea, or
headache)
Personality changes while using
Other (explain):

Which of the following behaviors has the client demonstrated?

Violent, aggressive, or abusive behavior
Unreasonable resentments (e.g., holds grudges)
Changing type of friends (e.g., changing to friends who use)
Poor school or work performance
Unable to join in family activities
Unable to do things that he or she should do (e.g., unable to keep
appointments or to get things done at home or at work)

How does the client obtain money to buy alcohol or other drugs?
How much do you think the client spends on alcohol or other drugs? Has this
created a problem for you, your family, or the client?

How has the chemical use changed family activities?

What does the client think about Alcoholics Anonymous (AA)/Narcotics

Anonymous (NA)?

Critical of AA/NA members

“Good program, but it is not for me”
AA/NA is the answer to the problem
Has no knowledge of AA/NA

Previous treatment: Has the client participated in any of the following treatments
for addiction?

Attended a few AA/NA meetings

Participated regularly for a brief period
General hospital
Psychiatric treatment
Outpatient treatment
Inpatient treatment

Give a brief history of treatment dates.

Are there any other problems in connection with or related to the chemical
problem?

Not to my knowledge
School problems
Work problems
Legal problems
Financial problems
Family problems
Psychiatric problems

Explain:

Have you or other family members experienced any of the following?

 Health problems
School or work problems
Legal problems
Financial problems
Difficulty in expressing feelings

Explain:

What treatment have you sought for yourself and your family?

AA/NA
Al-Anon/Alateen
Counseling
Psychiatric visits

Explain:

Have any of your children been referred to the following?

Social services
Juvenile detention center
Court services
Psychological services
Addiction treatment

Explain:

Can you see anything that might interfere with the evaluation or treatment of your
family member(s)?

What do you believe are the problem areas that need to be addressed while the
client is in treatment?

In addition to the questions that have already been covered, is there any other
information that we should know about the client?

Which types of abuse have occurred in your current family?

Emotional
Verbal
 Physical
Sexual

Explain:

Did any of the following types of abuse occur in the family where you were
growing up?

Emotional
Verbal
Physical
Sexual

Explain:

Do you believe that addiction is a disease?

Yes No

Explain how the chemical problem has affected your relationship with the client.

Write down the names of all members of your family and rate them on how they
use mood-altering chemicals.

No Use = 0; Infrequent Use = 2; Social Use = 3; Misuse/Abuse = 4;

Dependency = 5
Appendix 26: Codependency

Robert R. Perkinson, PhD

Codependency is what happens to someone who is trying to control someone who
is addicted. If your loved one is an addict, then you probably have tried to help
him or her. You have attempted to fix the problem. But you could not fix it any
more than you could fix your loved one if he or she had cancer. Addiction is a
disease for which no one is to blame. The causes of addiction are so varied and
complex that no one has been able to figure it all out. It is too complicated.

In your love for the client, you might have done some things that were not good for
you. It is very common for codependent persons to take better care of the addict
than they do of themselves. You may have been so concentrated on the other
person’s problems that you had no time for your own. This is a mistake. This is
your turn to stop and concentrate on yourself. What has happened to you in your
struggle against this disease? Our experience shows us that the family member
who looks at his or her own life will immeasurably help the client to achieve a
stable recovery. If only the client is treated, then the chance of success is reduced.

There are a variety of codependent traits. These are maladaptive thoughts and
behaviors that have been learned in response to the addiction. It is important that
you take a look at each of these traits because they inhibit you from being able to
live a normal life. You cannot solve problems accurately when these traits are at
work. They distract you. They keep you from seeing the truth.
Defense Mechanisms
Defense mechanisms are mental states where we refuse to see reality. We cut
ourselves off from reality because the real world is too painful for us. We need to
live in a fantasy world of our own creation. The more we use defense
mechanisms, the more cut off from reality we are. We feel lonely and helpless
because no one can reach us in our self-deceived world.
Minimization
It begins with minimization. When we minimize, we take reality and make it
smaller than it really is. We pretend that the problem is not bad when it is bad. We
may have become so deluded that we think that drinking a six pack of beer every
night is normal. Doesn’t everyone drink like this? We may minimize about the
financial problems. They do not seem so bad either. Doesn’t everyone struggle
like this? We minimize about verbal and physical abuse. This person was just
mad, out of control, or drunk. That was not really him or her. This person is not
really like that. We may minimize by telling ourselves that the addicted person just
overdid it at the party. This individual is really a good person. He or she did not
mean it. When we minimize, we tell ourselves that we have no reason to feel
afraid or angry. If the problem were bad, then we would have to feel bad and do
something about it. It is not so bad, so we can relax.

List five times when you told yourself that things were not bad when they really
were.

1.
2.
3.
4.
5.
Rationalization
The next defense mechanism we use is rationalization. This is where we make an
excuse for the client. The client is addicted because he or she has had a hard life,
had a fight with his or her mother, had a bad childhood, was fired, has financial
problems, has problems with a sibling, or just is not understood. Codependents
can think of a million reasons why the person is acting strangely, but the real
reason is that the person is an addict. The person is sick and needs help. We do
not want to see this truth because it is frightening. We do not want to believe that
our loved one is ill. We want to believe that this person is just fine or is only
having temporary difficulty.

A rationalization is a lie. It is an excuse for the real problem. Did you ever make
an excuse for the chemically dependent person? Did you ever tell the boss that this
person was sick or tell the children that the person was not feeling well when you
knew that he or she was intoxicated or too hung over to function? If you did, you
may have believed some of this yourself.

List five times when you made an excuse for the client’s addictive behavior.

1.
2.
3.
4.
5.

You can see what is happening to the family. By minimizing and rationalizing,
family members get more and more cut off from reality. They cannot accurately
see what is going on anymore. They are using the defense mechanisms to cut
themselves off from the painful truth.
Denial
The most characteristic form of defense used in addiction is denial. This is where
the mind refuses to experience the full emotional impact of what is happening.
Your life is falling apart. Your relationship is shot. You cannot talk to your family
anymore. You are in severe financial trouble, and you still think that you can fix
these things. You still think that all of these problems are something else other than
addiction. You might even be so fooled that you think that the problems are your
fault. If you were a better wife, husband, child, or parent, then the addict would
not be having problems.

List five of the worst things that have happened during the past few years with the
addicted person.

1.
2.
3.
4.
5.

In each of these situations, what were you telling yourself that convinced you that
things were all right?

1.
2.
3.
4.
5.
Caretaking
Codependent people focus on the other person. They are obsessed with taking
care of the addicted person to the point where they lose contact with reality. They
actually think that everything will be all right if they do the right things. They plan
everything for everyone. They scold and control. They read self-help books. They
feel responsible for everyone’s feelings. They go to extraordinary lengths to help.
They feel much drained, as if there is not enough time in the day. They threaten,
cry, lie, scream, blame, and shame. They seek counseling, pray, and manipulate.
All of these behaviors, and many more, are designed to bring control to an out-of-
control situation. Codependent people think that they can fix things if they just
work hard enough. The fact of the matter is that they cannot control someone else’s
behavior, no matter how much they try. The more they try, the more frustrating it
becomes.

List five ways in which you tried to control the addicted person.

1.
2.
3.
4.
5.
Enabling
In treatment, you must understand that you cannot control anyone but yourself. You
are responsible for only your own actions. If you keep the addicted person out of
trouble, then you keep that person from suffering the natural consequences of his
or her behavior. If you call the boss and make excuses, then the client does not
learn from his or her mistakes. This is called enabling. By protecting the client
from the consequences of his or her addiction, you help the client stay sick. You
must stop protecting the client from his or her maladaptive behavior. You must not
pay the client’s bad checks or debts, make excuses, or smooth over ruffled
feathers. You must let the client be responsible.

By caretaking and enabling, codependent people constantly get the chemically

dependent person out of trouble. They protect the client from the consequences of
his or her actions. They may call the boss and say that the client is sick when, if
fact, the client is too intoxicated, hungover, or busy gambling to come to work.
They may tell the children that their dad or mom needs to rest when, in fact, the
client has passed out on the couch. They may pay the bail or the bad checks. They
may call the creditors who are clamoring for payment. They may comfort abused
family members and try to make everything better.

List five times when you got the addicted person out of trouble.

1.
2.
3.
4.
5.

You were taking the responsibility for someone else’s behavior. By protecting the
client from the logical consequences of his or her own actions, you helped the
client avoid the pain of the disease. This prevented the client from learning that he
or she was sick and needed help. You enabled the illness to stay hidden. You
helped the client to avoid reality. By protecting the client from pain, you prevented
him or her from seeing the severity of the problem. This has to stop. Each person
in a family has to accept the responsibility for his or her own behavior. Everyone
must make his or her own decisions and live with the consequences.
Inability to Know Feelings
People who are codependent do not know how they feel. They are so focused on
the other person’s feelings that they ignore their own. They know how the other
person is doing, but they do not know much about themselves. For the most part,
codependent people think that they are fine, but what they are really feeling is
frustrated, frightened, and depressed. They are desperately trying to bring order to
disorder and confusion.

People who live in an addicted home do not trust how they feel. They feel as
though something is wrong with them. They try to block out the reality of the
nightmare that they are living. They might even make up what their family is like.
Bradshaw (1988, 1990) described this as a fantasy bond. Children or family
members create an idealized family in their minds. They might feel that their father
is warm when, in fact, he is actually abusive. They might feel their mother is a
good mother when, in fact, she always is away drinking at the bar.

In addicted homes, family members learn that feelings are dangerous. If they share
how they feel, then bad things will happen. They keep their fear, sadness, anger,
disgust, and hurt to themselves. They keep the secrets, sharing them with no one.

List some situations where you kept your real feelings to yourself. Whom were
you trying to protect by keeping these feelings secret?

1.
2.
3.
4.
5.
Inability to Know What You Want
Codependent people are so obsessed with the wants and wishes of the addicted
person that they lose what they want for themselves. They become experts at
manipulating the family to get the sick person what he or she wants, but they
become less and less skilled at getting what they themselves want. They believe
that they have no wants. They are trying so desperately to control the situation that
they have no time for their own needs.

Stop and think for a minute. What do you want out of life? List five things that you
want.

1.
2.
3.
4.
5.

Now write a letter to the chemically dependent person telling him or her how you
feel and share what you want. Be thorough. Do not leave out any of your feelings,
wishes, hopes, dreams, or wants. Be completely honest with yourself and the other
person. When you have the letter written, put it aside. We will use it later.
Lack of Trust
Family members from an addicted home have been living in a situation where they
could not trust anything or anyone. They did not know what was going to happen.
Family rules changed when the addicted person was using addictive behavior. A
father who was once loving could turn into a monster. A mother who was quiet
could turn loud, aggressive, and pushy. Someone who usually was happy could
sob hopelessly. There was nothing that the family could trust. Addiction could
change any rule at any time. This is an atmosphere permeated by fear. The family
members live in a constant state of tension. When they come home, they do not
know what to expect. When the car drives up in the driveway, they do not know
what is going to happen. Things can get out of control in a hurry, and the behaviors
can be life threatening. The addicted person and the people around that person
constantly lie about what the addicted person is doing. They hide how the
addicted person is behaving. They lie about what the addicted person is doing. No
one in the home can be trusted. No one knows the truth.

This lack of trust builds an atmosphere heavy with fear. The family members are
constantly worried about what is going to happen next. What makes this even
worse is that they try to hide the family secret from everyone. This increases their
feelings of isolation and helplessness.

List five things that happened in your family that convinced you that you could not
trust your family members.

1.
2.
3.
4.
5.
People Pleasing
Codependent people are people pleasers. They will do virtually anything to keep
everyone happy. They feel personally responsible for other people’s feelings.
People pleasers never are interested in what they themselves want. They are
interested in what the other person wants. They want to keep the other person
happy. They do not care about how they themselves feel. People pleasers will go
to incredible lengths to keep the other person feeling comfortable. They tell
people that they are feeling fine when, in fact, they are coming apart at the seams.
They have a smile for everybody. They are nice, nice, and nice. They rarely, if
ever, go against the flow of things. They are almost incapable of saying no. If they
say no, then they feel guilty. They will allow people to violate their boundaries.
They never rock the boat.

List five times when you did something you did not want to do just to please some
other person.

1.
2.
3.
4.
5.
Feelings of Worthlessness
Codependent persons feel worthless compared to other people. They do not feel
as though they deserve the good stuff. They have been treated so badly, been taken
advantage of so many times, and given of themselves without getting anything back
so often that they have given up. They are tired. They feel burdened. It is like
carrying the world around on their shoulders. Somewhere, deep down in a secret
part of their minds, they fear that they deserve to be treated poorly. They feel like
they are small persons of little worth. They feel like they do not matter. They are
not important. These codependent people think that they are stupid, unattractive,
inadequate, and incompetent. They do not feel capable of dealing with the world.
They feel vulnerable, lost, and alone.

When you look at yourself in the mirror, what do you see? Circle all that apply.

1. I am stupid.
2. I am ugly.
3. I am old.
4. Other people are smarter than I am.
5. I never get the breaks.
6. I hate myself.
7. No one loves me.
8. No one knows me.
9. God made a mistake when God made me.
10. I am inadequate.

We could go on with the negative self-statements, but you get the idea.
Codependent people constantly bombard themselves with negative self-talk. The
talk is inaccurate and extremely self-damaging. If you use any of the preceding
statements, you must feel terrible about yourself.

Treatment is a time to get accurate. You must learn to live in the real world and to
see the positive as well as the negative. List 10 positive things about yourself. If
you have difficulty, then ask your counselor or group to help you.

1.
2.
3.
 4.
5.
6.
7.
8.
9.
10.

Write these down on a piece of paper, and tape it to your mirror. Read them to
yourself at least once a day.
Dependent
Codependent persons are overly dependent. They feel incapable of making good
decisions. They do not trust themselves. They get their self-worth from someone
else. They may coerce and threaten to leave an addicted significant other, but the
thought of leaving fills them with panic. They feel overly vulnerable to the world
and everything in it. They do not feel as though they can do things on their own.
Even if a spouse is incapacitated from the disease, a codependent person can still
feel dependent on the spouse. “What would I do on my own? What would happen
to the children? How would I support myself?” These all are serious questions,
and it leaves codependent persons stuck in an intolerable situation. They cannot
stay, and they cannot leave. Dependency is fueled by deep-seated feelings of
inadequacy and shame. Codependent persons do not feel capable of doing
anything other than holding on.

Do you feel competent to handle life on your own? Yes ____ No ____
Poor Communication Skills
Codependent people have poor communication skills. They cannot ask for what
they want or share how they feel. This leaves them incapable of communicating
effectively. They are so concerned with how the other person feels and with what
the other person wants that they do not even think about their own needs.
Closeness in interpersonal relationships depends on the ability to share the whole
truth with someone. You have to be able to tell that person how you feel and ask
him or her for what you want. To be a good communicator, you have to be a good
listener. You have to probe and question the other person to bring out the whole
truth. Codependents do not want to know the truth. The truth is too painful. They
are busy keeping the truth from themselves and from everyone else. If they knew
the whole truth, then they would be terrified.

Codependents feel lonely because they feel as though no one knows them. They
feel as though no one understands them. They try to communicate but feel as though
the message never really gets across. They feel isolated and trapped.

When is the last time you felt really understood by anybody? Describe the time,
person, and what it meant to you.

Do you believe that the client understands you? Yes ____ No ____

Explain in detail your answer:

List five roadblocks in the way of your communicating openly with others.

1.
2.
3.
4.
5.
The Tools of Recovery
In treatment, you will learn the tools of recovery. The first of these tools is
honesty. Without rigorous honesty, this program will not work for you. You must
tell the truth all of the time. You will need to hold family members accountable by
constantly sharing your feelings. This takes practice. In treatment, you must accept
your powerlessness over the disease. If you still think that you can figure it out or
work it out, then you are still acting codependent.

Alcoholics Anonymous (AA) says that probably no human power can remove this
disease. The second tool of recovery is going to meetings. You must attend regular
Al-Anon meetings to continue your recovery. If you think that it is only the
chemically dependent person who needs to attend meetings, then you are off track.
You have problems, too. You need treatment to get back on track. Al-Anon groups
will give you the support, encouragement, and education that you need for
continued recovery.

The third tool of recovery is a Higher Power. You must turn the problem over to a
power greater than yourself. If you continue to try to handle the problem by
yourself, then you will fail. If you turn the problem over to God, then you will
succeed. Practice whenever you are faced with a problem. Stop and seek God’s
will in that matter. Do not try to figure it out for yourself. Ask for God’s guidance.

The fourth tool of recovery is using good interpersonal relationship skills. This
means that you have to share how you feel and ask for what you want. You have to
listen and take the time that is necessary to develop healthy communication skills.
This will not come easily. You have many habits to overcome. You no longer can
just do what the other person wants. You no longer can live to please the other
person in your life. You must accept the responsibility for your own behavior and
allow the other person to accept the responsibility for his or her own behavior.
You must allow the person to suffer the consequences for his or her actions. You
have to stop living for the other person and start living for yourself.

Many of you are thinking, How selfish! You were taught to let the other person
come first. You were taught that it is not right to ask for what you wanted. You
have to love yourself to be happy. If you leave yourself out, then you will suffer.
God says to love God all you can, love yourself all you can, and love others all
you can. That is all that we are asking you to do. Bring this exercise and the letter
to your family member to the family program.
Appendix 27: Personal Recovery Plan

Robert R. Perkinson, PhD

Name: Home phone:
Admission date: Work phone:
Discharge date: Phone:
Name of significant other:

It is important to your recovery to continue to work through your problems on

discharge. Your recovery never can stand still. You must be constantly moving
forward in your program. Working with your counselor, you must detail exactly
what you need to do following inpatient treatment. Each psychological problem or
family problem will need a specific plan of action. You must commit yourself to
following this recovery plan to the letter. Do not think that just because you have
completed treatment, your problems are over. Your recovery is just beginning, and
you need to work diligently to stay clean and sober.

Make a list of the problems that you need to address in continuing care. Any
emotional, family, legal, social, physical, leisure, work, spiritual, or school
problem will have to have a plan. How are you going to address that problem in
recovery? What is the goal? What do you want to achieve? Develop your personal
recovery plan with your counselor’s assistance.

1. Treatment plan for continued sobriety

1. Problem 1:
Goal:
Plan:

2. Problem 2:
Goal:
Plan:

3. Problem 3:
Goal:
Plan:
 4. Problem 4:
Goal:
Plan:

5. Problem 5:
Goal:
Plan:

2. Relapse

In the event of a relapse, list five steps that you will take to deal with the
problem.
1.
2.
3.
4.
5.

3. Support in recovery

Indicate the 12-step meetings that you will attend each week after discharge.
We recommend that you attend 90 meetings in 90 days at first and at least
three to five meetings per week for the remainder of that year, and then you
can attend once a week for at least the next 5 years.
Day:
Time:
Location:

4. Indicate when you will attend continuing care group.

Day:
Time:
Location:

5. Who are three 12-step contact persons who can provide you with support in
early recovery?
Name: Phone:
Name: Phone:
Name: Phone:

6. If you have any problems or concerns in sobriety, you always can call the
 treatment center staff at the following number:
Counselor:
Phone:

7. If you and your counselor have arranged for further counseling or treatment
following discharge, then complete the following:
Name of agency:
Address: Phone:
First appointment:
Day:
Time:

8. List 10 things that you are going to do daily to stay clean and sober.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

9. You are changing your lifestyle. It will be important to avoid certain people
and situations that will put you at high risk. List 10 people and places you
need to avoid in early recovery.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

You will need a series of advocates that know your story and commitment to stay
clean and sober. You sign a release with each of these people so they can talk to
each other about your recovery. It helps to have someone at home, work, school,
and community. List their names and numbers, contact them, and ask them to be an
advocate for you in your community.

Home advocate: person phone address

School advocate: person phone address
Work advocate: name phone address
Community advocate: name phone address
Case manager: name phone address

You will call the case manager every day to see if this is a day for you to come in
for drug testing. You will get up to three drug tests per week for the first 6 months
and up to one drug test for the next 5 years. You will send in a monthly log of 12-
step meetings to your case manager by the 10th of each month. Each meeting has to
be dated and signed by the meeting leader. The case manager will receive reports
from all of the treatment that was recommended by the treatment center, such as
anger management, marriage counseling, etc. You will sign a contract with the
case manager that gives consequences if you do not follow the continuing care
program. This will mean the manager will contact your boss, probation officer,
family members, licensing board, or another person or agency that is dedicated to
your successful treatment.
Statement of Commitment
I understand that the success of my recovery depends on adherence to my recovery
plan. The continuing care program has been explained to me, and I understand
fully what I must do in recovery. I commit to myself that I will follow this plan.

With your continuing care manager write out your continuing care plan and then
have all mentors/sponsors/coaches and advocates sign it.

Client’s signature:
Physician signature:
Sponsor signature:
Employer signature:
Significant other signature:
Licensing board signature:
Community advocate signature:
School advocate signature:
Case manager signature:
Counselor signature:
Date:
Appendix 28: Sample Discharge Summary

IDENTIFYING INFORMATION: Mary Louise Roberts is a 45-year-old, married

white female. She has two children. She lives in Thomas, Maryland, with her
husband, Mark, and her two daughters. She has lived in Thomas for the past 5
years. She is currently employed as a secretary for Morton Electronics. She was
admitted to Keystone Treatment Center on 9-9-01. She was referred by Marcie
Frankle, a counselor at the Mandel Mental Health Clinic.

CHIEF COMPLAINT: “Drinking.”

ASSESSMENT OF PROBLEM AREAS: The following problems were identified

by the clinical staff as needing to be addressed in treatment.

Problem 1: Pathological relationship to alcohol

Problem 2: Depression
Problem 3: Poor interpersonal relationship skills
Problem 4: Unresolved grief
Problem 5: Borderline personality disorder
The following problems were identified and treated by the medical staff.
Problem 2: Depression
Problem 6: Fractured finger

MEDICAL REPORT (this report is completed by the medical staff): Mary’s

admission lab work and urinalysis were within normal limits. An admission
physical was completed with no significant findings noted. While in treatment,
Mary hit a door with her right hand. An X-ray was taken on 9-15-01, and it found
evidence of a transverse hairline fracture on the radial side of the distal neck of
the right fifth metacarpal. No specific treatment was needed. At discharge, Mary
voiced no physical complaints. Her hand was observed to be healing. In treatment,
the client received a daily multivitamin. We have recommended that the client
continue her multivitamin therapy for at least 6 months following discharge.

Problem 2: Depression

Progress notes: For her major depression, Mary was started on Prozac (20 mg
q.d.) on 9-22-01. No side effects were noted. The medication was reviewed with
the client prior to discharge, and a 1-week supply of Prozac was sent home with
her. We have recommended that the client continue to take the medication daily
and to see Dr. Frank Smith of the Mandel Mental Health Clinic in Thomas,
Maryland. She has an appointment on 10-5-01 at 3:45 pm for a follow-up visit.

TREATMENT PLAN AND PROGRESS NOTES:

Goal 1: Begin a program of recovery congruent to a sober lifestyle.

Progress notes: When Mary first entered treatment, she minimized her drinking
behavior and denied the need to be in treatment. She stated that she did not have a
problem with alcohol that was severe enough to require treatment. She completed
the Honesty exercise (see Appendix 8), and she began to see how she was
deceiving herself about the extent of her alcohol problem. She was able to trace
the family problems that were a direct cause of her drinking behavior. The client
was able to see that the DWI she received last year was directly related to her
drinking. In her first step, Mary was able to share her powerlessness to quit
drinking on her own and the unmanageability of her life. Mary began to accept her
alcoholism during the second week of treatment. She recognized that she would
have to change her attitudes and behaviors if she was going to be able to maintain
a sober lifestyle. A major obstacle to Mary’s treatment was her lack of trust. It
was difficult for her to trust her interpersonal group for the first few weeks of
treatment. As Mary was able to share more in group, she was able to see that the
group could be trusted. This was a great relief to the client, and this was a
significant move forward in her treatment program. Mary struggled with the same
trust issue when she worked through her Second Step and Third Step. She began to
practice prayer and meditation in treatment, and this convinced her that there was
a Higher Power called God. She completed a Fifth Step with the staff clergy, and
this significantly relieved her. She stated that this was the first time that she had
ever told anyone the whole truth. Mary was able to assess high-risk situations for
relapse by working through the Relapse Prevention exercise (see Appendix 16).
Her situation of greatest risk appears to be her tendency to become depressed, and
this leads her to further drinking. The client has committed herself to call this
treatment center, her sponsor, or her therapist if she begins to feel depressed in
continuing care. Mary does state a sincere desire to maintain a sober lifestyle and
to live a happy life without alcohol.

Goal 2: Alleviate symptoms of depression.

Progress notes: Mary stated on admission that she had been feeling severely
depressed for the past 6 months. She had experienced suicidal ideation and had
made two suicide attempts before coming into treatment. While in treatment, she
visited with the staff psychologist and took the Hamilton Depression Rating Scale
weekly. She read Coping With Depression (Beck & Greenberg, 1974) and logged
her dysfunctional thoughts. The client’s negative thinking centered on thinking that
she was ugly, stupid, and inadequate. Once these thoughts were challenged for
accuracy, the client could see that she was pretty; bright; and a capable wife,
mother, and secretary. The client was placed on medication for her depression.
Mary is aware that she has to stay on this medication for at least 6 months. Two
weeks after starting the medication and working on correcting her thinking her
Hamilton Depression Rating Scale scores began to improve. Her score dropped
from severe depression to mild depression over her 4 weeks of treatment. Mary
still shows some excessive sadness, and she continues to feel overly tired and
fatigued. She is sleeping through the night.

Goal 3: Learn and practice healthy interpersonal relationship skills.

Progress notes: Mary has been unable to establish and maintain healthy
interpersonal relationships. Her relationship with her husband has been
dysfunctional for a number of years. Mary tends to become quickly attracted to
men and to think that they are the answer to her problems. When she gets closer to
them, she realizes that they have as many problems as she does. She has been
involved in several extramarital affairs. In one-to-one counseling, Mary was able
to see how alcohol played a significant role in her relationship problems. When
she was drunk, she usually fought with her husband and became involved with
other men at the bar. The client was able to see how her parents taught her to keep
her feelings to herself. She learned never to ask for anything. The client completed
the Relationship Skills exercise (see Appendix 11) and began to use these skills
with her treatment peers. Mary was able to share her feelings with her
interpersonal group. Again, the trust issue was a hurdle for her. Gradually, she
was able to ask for what she wanted without feeling guilty. She found out that
other people in the program were trustworthy and loyal to her; they could keep
information in confidence. Mary was able to work though the Communication
Skills exercise (see Appendix 13) and was able to improve her active listening
skills. She began to stop manipulating to get what she wanted and began to ask for
what she wanted. She worked on developing assertiveness skills and was able to
confront people in group about behavior that troubled her. Mary was able to
establish many meaningful relationships while in treatment.
 Goal 4: Identify losses and share feelings with others. Develop an
understanding of the grief process, and learn healthy ways of coping with her
grief.

Progress notes: Mary lost her mother to cancer 2 years ago and lost her brother to
an automobile accident last March. It became clear to the clinical staff that Mary
had not appropriately grieved through these losses in her life. The pain was still
very evident in Mary’s behavior whenever she would talk about her mother or
brother. She would cry for long periods of time whenever these issues were
discussed in group. Mary talked about her grief and began to share her feelings in
one-to-one counseling and in interpersonal group. Several of her treatment peers
had similar losses to report, and Mary began to take an active role in getting them
to talk about their losses. As she was able to share her pain with the group,
Mary’s grief began to ease. She wrote letters of closure to her mother and brother
and read these letters to several treatment peers. Mary spoke on several occasions
with the staff clergy about the deaths, and she began to turn the situation over to
the care of God. She began to believe that God was taking good care of her mother
and brother and that she would see them again. Mary stated that she felt that her
mother and brother would want her to continue with her life and to let go of the
grief she was feeling. At the end of treatment, Mary was able to talk about the
deaths in her family without crying and with new hope about her dependence on
God.

Goal 5: Learn coping skills for dealing with symptoms of borderline

personality disorder.

Progress notes: Mary has had a persistent affective problem all of her life. She
experiences rapid extreme shifts in her feelings, from feeling relatively normal to
feeling severely angry, depressed, or frightened. The client had been drinking to
relieve herself of these uncomfortable feelings. Her interpersonal relationships
have been severely dysfunctional, and the client has felt chronically empty and
bored. Mary becomes suicidal and has cut her wrists and arms to relieve herself
of her pain. During treatment, Mary met regularly with the staff psychologist. She
learned to identify her feelings and learned what action to take when she was
feeling intense feelings. The client practiced talking to a staff member or a
treatment peer when she was angry or frightened. She learned to get some exercise
when she was feeling intense feelings. The client worked through the Relationship
Skills exercise (see Appendix 11) and the Communication Skills exercise (see
Appendix 13). She learned how to communicate with others. The client met with
her husband once a week with her primary counselor to work on her marital
problems. The client was referred to Dr. Frank Smith, a psychiatrist who will
follow the client once a week in continuing care.

FAMILY PROGRAM: Mary’s husband, Mark, and her two children, Kathy and
Tina, attended the family program. Mary participated in all of the family sessions.
Mark shared that he has been very frightened by Mary’s drinking behavior. He
tends to keep his feelings to himself and to not share what he wants from his wife.
Mark expressed that he thought that Mary would come around if he could get her
to address her alcohol problem. Mark was able to make significant progress in
sharing his feelings in the family program. He was able to tell Mary of the hurt and
fear that he had been feeling when she would go out and stay out all night. He
expressed how angry he was at the extramarital affairs, one of which was with his
best friend. Mark often openly wept as he shared his feelings. Kathy, the oldest
child (age 10), was able to share how she had to take care of her younger sister
when Mary was passed out on the couch. She explained how frightening it was to
see her mother intoxicated and out of control. Kathy had witnessed one of her
mother’s suicide attempts and had to call the police to get Mary under control.
This child had been more of a mother to Mary than Mary had been to her. It was
obvious in the family sessions that this was a very responsible little girl. The
youngest child, Tina (age 6), was very quiet during the sessions. She was able to
express how frightened she was seeing her father and mother fight. She also had
witnessed the suicide attempt. The family had problems severe enough that these
family members were referred to the Mandel Mental Health Clinic for further
family counseling. They have an appointment with Marcie Frankle, a marriage and
family counselor, on 10-31-01 at 4:00 pm.

SUMMARY: While in treatment, Mary completed the Steps One to Five of the
Alcoholics Anonymous (AA) 12-step program. She has been introduced to Steps
Six to Twelve. She has worked a daily program of recovery while in treatment,
and she understands what she needs to do to stay sober. Mary has developed a
good understanding of her disease and has made significant changes in her
attitudes and behaviors that can be used in a sober lifestyle. She is more honest
with herself and with others, and she has learned good problem solving skills.
Mary can now use her feelings to help her solve problems. Mary has begun to
resolve her depression and will continue to work on her psychological problems
in continuing care with Dr. Margaret Fine. Her marriage is more stable, and she is
going to continue marriage counseling with Mel Thompson, licensed marriage and
family therapist. She will be followed by Laurie Johnson as her continuing care
manager who will arrange for random drug screening and regular attendance at
12-step meetings. She knows how to cope with her feelings without drinking. She
has worked though her grief issues and has established conscious contact with her
Higher Power. Mary is willing to take the responsibility for her own life and
behavior.

PROGNOSIS: The client’s prognosis is good. Mary has a positive attitude toward
recovery. She made progress in treatment in many areas, and she worked hard.
She has shown that she is willing to work to maintain her sobriety. She established
many supportive relationships in treatment, and she plans to build on these
friendships in recovery. She has plans to attend AA meetings with a good friend of
hers who has 12 solid years of sobriety. Mary will need positive reinforcement in
recovery, and she will have to address her depression until it clears. She will
need to continue family counseling to stabilize her relationship with her husband
and children. She is aware that she will need to stick close to AA to stay in
recovery.

CONTINUING CARE:

Maintain complete abstinence from all mood-altering chemicals.

Attend AA meetings on a regular basis and get an AA sponsor who makes her
feel comfortable. Mary does have an AA contact person: Cheryl M., 336-
2281.
Attend continuing care group for a minimum of 12 months on Monday
evenings at 7:00 pm at the Thompson Alcohol and Drug Center, 303 Fuller
Lane, Thomas, Maryland. Her first appointment has been set with Charlene
Schultz on 10-25-01 at 1:00 pm.
Continue to work on a daily spiritual program that she began in treatment.
Mary will attend church at the Good Faith Lutheran Church. Reverend Bob
Luce is the pastor.
Continue to check the relapse symptoms daily and work a daily program of
relapse prevention.
Develop honest and open relationships with others who can aid her in
recovery.
Avoid people and places that could trigger relapse symptoms.
Continue Prozac therapy and continue to see Dr. Frank Smith for
psychotherapy for her depression. Her first appointment is on 10-22-01 at
2:30 pm at the Mandel Mental Health Clinic, 12 Tigar Street, Thomas,
Maryland.
 Continue family counseling with Marcie Frankle of the Mandel Mental
Health Clinic, 12 Tigar Street, Thomas, Maryland. The first appointment is
on 10-22-01 at 1:30 pm.
Continue to trust and praise herself in recovery. Practice self-affirmations
daily.
Work her continuing care program with her case manager, submitting up to
three random drug screens per week for the first 6 months and up to one
random drug screen for the next 5 years.
Meet regularly with each advocate and keep the advocacy group informed
about her recovery, asking for help when needed.

DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM–

IV–TR) DIAGNOSIS:

Axis I: 303.90 Alcohol Use Disorder, severe

296.25 Major depression, single episode in partial remission
Axis II: 301.83 Borderline personality disorder
Axis III: Asthma
Axis IV: Severity of psychosocial stressors: Personal illness, death in the
family, Severity 4 (severe)
Axis V: Current global assessment of functioning: 70
Appendix 29: Stress Management

Robert R. Perkinson, PhD

Unresolved stress fuels addiction. Addicted individuals deal with stress by using
chemicals or addictive behavior rather than using other more appropriate coping
skills. Everyone has stress, and everyone needs to learn how to cope with stress
in daily life. Stress is the generalized physiological response to a stressor. A
stressor is any demand made on the body.

A stressor can be anything that mobilizes the body for change. This can include
psychological or physiological loss, absence of stimulation, excessive
stimulation, frustration of an anticipated reward, conflict, and presentation or
anticipation of painful events (Zegans, 1982).

The stress response is good and adaptive. It activates the body for problem
solving. Stress is destructive only when it is chronic. The overly stressed body
produces harmful chemicals such as cortisol that trigger inflammation, and soon
the person gets sick. Initially, the body produces certain chemicals to handle the
stressful situation. Initially, these chemical changes are adaptive. In the end, they
are destructive. Severe or chronic stress has been linked to irreversible disease
including kidney impairment, hypertension, arteriosclerosis, type 2 diabetes,
ulcers, and a compromised immune system that can result in increased infections
and cancer (Selye, 1956).

When animals encounter an unsolvable problem, they ultimately get sick. They fall
victim to a wide variety of physical and mental disorders. Under chronic stress,
these organisms ultimately die.

It seems that everyone has a genetic predisposition to break down in a certain

organ system when under chronic stress. Some people get depressed; there are
ulcers, heart attacks, strokes; and some become chemically dependent.

In treatment, you must learn how to deal with stress in ways other than by using
your addiction. You must learn to use the stress signals that your body gives you to
help you solve problems. If you cannot solve the problem yourself, then you need
to get some help.
Most people who are addicted are dealing with unresolved pain. They begin
drinking, gambling, or using chemicals to ease the pain, and soon they become
dependent. Addiction is a primary disease. It takes over people’s lives and makes
everything worse.

Stress management techniques help addicted individuals to regain the control they
have lost in their lives. By establishing and maintaining a daily program of
recovery, they learn how to cope with stress. If you are dealing with stress better,
then you are not as likely to relapse. There are three elements necessary to reduce
your overall stress level: (1) a regular exercise program, (2) regular relaxation,
and (3) creating a more rewarding lifestyle.
Relaxation
For centuries, people have relaxed or used meditation to quiet their minds and
reach a state of peace. When animals have enough to eat and they are safe, they lay
down. People do not do that because humans are the only animals that worry about
the future. Humans fear that if they relax today, then they will be in trouble
tomorrow.

Benson (1975, 2000) showed that when people relax twice a day for 10 to 20
minutes, it has a major impact on their overall stress levels. People who do this
have fewer illnesses, feel better, and are healthier. Illness such as high blood
pressure, ulcers, and headaches can go away completely with a regular relaxation
program.

Benson maintained that the relaxation technique is simple.

Sit or lie down in a quiet place.

Pay attention to your breathing.
Every time you exhale, say the word one over quietly to yourself. It is normal
for other ideas to come, but when they do, just return to the word or words
you have chosen.
Do this for 10 to 20 minutes twice a day.

You do not have to use the word one. You can use any other word or phrase of
your choice, but it has to be the same word or phrase repeated repeatedly. You can
get some relaxation tapes or music that you find relaxing. You can pray or
meditate. The most important thing is to relax as completely as you can. If you do
this, then your stress level will be lower and you will be better able to mobilize
yourself to deal with stress when it occurs. I have created a meditation exercise
CD that you might find helpful. You can find this at
[Link]/cd/godtalks2. This tape has two tracks. Track 1 is a 20-minute
spiritual exercise followed by relaxing music. Track 2 is a 12-minute meditation
exercise followed by relaxing music. Many of our clients find this to be the turning
point in their spiritual connection because it is the first time they experience the
presence of God.

Progressive relaxation is tightening each muscle group and then relaxing them. For
example, you tighten your right arm and feel the tension. Then let the muscle go
and feel it deeply relax. Concentrate on the feeling of tension and relaxation. Soon
you will not have to tighten the muscle group as often; you will just have to
concentrate on it relaxing. As you practice relaxation, you will learn how it feels
to be relaxed. Try to keep this feeling all day long.

When you feel stressed, stop and take two deep breaths.
Breathe in through your nose and out through your mouth.
As you exhale, feel a warm wave of relaxation flow down your body.
Once you have regained your state of relaxation, return to your day and move
a little slower this time.
Remember, nothing is ever done too well or too slowly. You do not have to
do things quickly to succeed.

When you come to some new task that you think you have to complete, ask
yourself several important questions.

Do I have to do this?
Do I have to do it now?
Is this going to make a difference in 5 years?

If the new stressor is not that important, perhaps you should not do it at all. Do not
overly stress yourself. That does not make any sense. Know your limits. Achieve a
state of relaxation in the morning, and listen to your body all day long. If anything
threatens your serenity, turn it over and let God deal with it.

For the next week, set aside two times a day for relaxation. Go through the
meditation exercise we discussed or some other relaxation exercise. Score the
level of relaxation you achieved from 1 (as little as possible) to 100 (as much as
possible). Then score your general stress level during the day in the same way.
Write down any comments about your stress. List the situations when you felt the
most tension.
Day 1
Relaxation Score
Daily Stress Score
Comments
Day 2
Relaxation Score
Daily Stress Score
Comments
Day 3
Relaxation Score
Daily Stress Score
Comments
Day 4
Relaxation Score
Daily Stress Score
Comments
Day 5
Relaxation Score
Daily Stress Score
Comments
Day 6
Relaxation Score
Daily Stress Score
Comments
Day 7
Relaxation Score
Daily Stress Score
Comments
Exercise
The role of exercise in the treatment of addiction has been well established.
Significant improvements in physical fitness can occur in as short a period as 20
days. People who maintain a regular exercise program feel less depressed and
less anxious, improve their self-concepts, and enhance the quality of their lives
(Folkins & Sime, 1981).

Most addicted people come into treatment in poor physical and mental shape.
They gave up on exercise a long time ago. Even if they were in good physical
condition at one time in their lives, the addiction has taken its toll. These people
are unable to maintain a consistent level of physical fitness. The mind and body
cannot maintain a regular exercise program when a person chronically abuses
drugs, alcohol, or other addictive behaviors.

An exercise program, although difficult to develop, can be fun. You get a natural
high from exercise that you do not get in any other way. It feels good, and it feels
good all day.

A good exercise program includes three elements: (1) stretching, (2) strength, and
(3) cardiovascular fitness. The recreational therapist or personal trainer will
assist you in developing an individualized program specific to you.

Stretching means that you increase a muscle’s range of motion until you become
supple and flexible. Never stretch your muscles to the point of pain. The body will
warn you well before you go too far. Let the exercise therapist show you how to
stretch each major muscle group. Get into a habit of stretching before all exercise.

In a strength program, you gradually lift more weight until you become stronger.
Do not lift more often than every other day. The muscles need a full day of rest to
repair them. Soon you can increase the load. Three sets of 8 to 12 repetitions each
is a standard exercise for each muscle group. The exercise therapist will show
you how to complete each exercise. Correct technique is very important.

Endurance training means that you exercise at a training heart rate for an extended
period of time. This is where the cardiovascular system gets stronger. Your
training heart rate is calculated by subtracting your age from 220, then multiplying
the answer by .75.
Cardiovascular fitness is attained when you exercise at a training heart rate, for 20
to 30 minutes, at least three times a week. Have the exercise therapist help you to
determine your training heart rate and develop a program in which you gradually
increase your cardiovascular fitness. Usually, you will be increasing your
exercise by 10% each week.

Many forms of exercise can be beneficial for cardiovascular training. The key
point is this: It must be sustained exercise for at least 20 to 30 minutes. Walking is
probably the best exercise to start with. It is easy to do, and you do not need any
specialized equipment. The exercise cannot be a stop–start exercise such as tennis
or golf. It must be something that you can sustain. These include exercises such as
walking, jogging, swimming, and biking.

After you have worked out your exercise program, keep a daily log of your
exercise. Reinforce yourself when you reach one of your goals. You might have a
goal of running a mile by the end of the month. If you reach your goal, then buy
yourself something you want or treat yourself to a movie to celebrate. Write down
your exercise schedule for the next month.
Exercise Program
Date Training Heart Rate
Strength
Stretching
Cardiovascular fitness
Changing Your Lifestyle
Along with maintaining a regular relaxation and exercise time, you must change
other aspects of your life to improve your stress management skills.
Problem Solving Skills
You need to be able to identify and respond to the problems in your life. Unsolved
problems increase your stress level. Problems are a normal part of life, and you
need specific skills to deal with them effectively. For each problem that you
encounter, work through the following steps:

Identify the problem.

Clarify your goals. What do you want?
Consider all the alternatives of action.
Think through each alternative, eliminating one at a time, until you have the
best alternative.
Act on the problem.
Evaluate the effect of your action.

Work through several problems with your counselor or group while in treatment.
See how effective it is to seek the advice and counsel of others. You need to ask
for help.
Developing Pleasurable Activities
One of the things that chemically dependent people fear the most is not being able
to have fun when clean and sober. Chemicals have been involved in pleasurable
activities for so long that they are directly equated with all pleasure. To look
forward to a life without being able to have fun is intolerable.

You do not give up fun in sobriety. You change the way in which you have fun. You
cannot use chemicals for pleasure anymore. This is not good for you. You can
enjoy many pleasant activities without drugs or alcohol. If you think about it, this
is real fun anyway. The fun you are missing is based on a false chemically created
feeling. Once you see how much fun you can have when clean and sober, you will
be amazed.

Increasing pleasurable activities will elevate your mood and decrease your
overall stress level. If you are not feeling well in recovery, it is likely that you are
not involved in enough pleasurable activities. If you increase the level of
pleasure, then you will feel better and be less vulnerable to relapse.

First, identify the things that you might enjoy doing, and then make a list of the
things that you are going to do more often. Make a list of the activities that you
plan to do for yourself each day. Write down your plan. The more pleasurable
things you do, the better you will feel.

Being in the country

Wearing expensive clothes
Talking about sports
Meeting someone new
Going to a concert
Playing baseball or softball
Planning trips or vacations
Buying things for yourself
Going to the beach
Doing artwork
Rock climbing or mountaineering
Playing golf
Reading
Rearranging or redecorating your room or house
Playing basketball or volleyball
Going to a lecture
Breathing the clean air
Writing a song
Boating
Pleasing your parents
Watching television
Thinking quietly
Camping
Working on machines (e.g., cars, bikes, motors)
Working in politics
Thinking about something good in the future
Playing cards
Laughing
Working puzzles or crosswords
Having lunch with a friend or an associate
Playing tennis
Taking a bath
Going for a drive
Woodworking
Writing a letter
Being with animals
Riding in an airplane
Walking in the woods
Having a conversation with someone
Working at your job
Going to a party
Going to church functions
Visiting relatives
Going to a meeting
Playing a musical instrument
Having a snack
Taking a nap
Singing
Acting
Working on crafts
Being with your children
Playing a game of chess or checkers
Putting on makeup or fixing your hair
Visiting people who are sick or shut in
Bowling
Talking with your sponsor
Gardening or doing lawn work
Dancing
Sitting in the sun
Sitting and thinking
Praying
Meditating
Listening to the sounds of nature
Going on a date
Listening to the radio
Giving a gift
Reaching out to someone who is suffering
Getting or giving a massage or back rub
Talking to your spouse
Talking to a friend
Watching the clouds
Lying in the grass
Helping someone
Hearing or telling jokes
Going to church
Eating a good meal
Hunting
Fishing
Looking at the scenery
Working on improving your health
Going downtown
Watching a sporting event
Going to a health club
Learning something new
Horseback riding
Going out to eat
Talking on the telephone
Daydreaming
Going to the movies
Being alone
Feeling the presence of God
Smelling a flower
Looking at a sunrise
Doing a favor for a friend
Meeting a stranger
Reading the newspaper
Swimming
Walking barefoot
Playing catch or with a Frisbee
Cleaning your house or room
Listening to music
Knitting or crocheting
Having house guests
Being with someone you love
Having sexual relations
Going to the library
Watching people
Repairing something
Bicycling
Smiling at people
Caring for houseplants
Collecting things
Sewing
Going to garage sales
Water skiing
Surfing
Traveling
Teaching someone
Washing your car
Eating ice cream
Social Skills
What you do socially can turn people off or turn them on. If you do any of the
following, you might be turning people off.

Not smiling
Failing to make eye contact
Not talking
Complaining
Telling everyone your troubles
Not responding to people
Whining
Being critical
Poor grooming
Not showing interest in people
Ignoring people
Having an angry look
Using nervous gestures
Feeling sorry for yourself
Always talking about the negative

You are turning people on if you do the following:

Smiling
Looking at people in the eyes
Expressing your concern
Talking about pleasant things
Being reinforcing
Telling people how nice they look
Being appreciative
Telling people that you care
Listening
Touching
Asking people to do something with you
Acting interested
Using people’s names
Talking about the positive
 Grooming yourself well

To have good social skills, you have to be assertive. You cannot be passive or
aggressive. This means that you have to tell people the truth about how you feel
and ask for what you want. You must tell the truth at all times. If you withhold or
distort information, then you never will be close to anyone.

Do not tell other people what to do; instead, ask them what they want to do. Do
not let other people tell you what to do; instead, negotiate. Do not yell; instead,
explain. Do not throw your weight around. When you are wrong, promptly admit
it. Happiness is giving to others. The more you give, the more you get.

In a 12-step program, you never have to be alone. Your Higher Power always is
with you. Learn to enjoy the presence of God, and communicate with God as if
God were standing right beside you. Call someone in the program every day. Go
to many meetings. Reach out to those who are still suffering. There are many
people in jails or hospitals who need your help. Volunteer to work on the 12-step
hotline. Ask people out for coffee after meetings. Do not worry if you are doing
all of the asking at first. The reason you are doing this is for you. Most people,
particularly men, feel very uncomfortable asking others to go out with them. Do
not let that stop you. If you do not ask, then you will not have the experience of
someone saying yes.

Using the pleasant activities list, make a plan for how you are going to increase
your social interaction this month. Write all of it down, and reward yourself when
you make progress. Here are a few hints to get you going:

Read the activities and entertainment section of your local newspaper. Mark
down events that fit into your schedule and attend them.
Offer to become more involved in your 12-step group.
Ask the local chamber of commerce for information about groups and
activities in the area.
Spend your weekends exploring new parts of town.
Smile.
Join another self-help support group such as an Adult Children of Alcoholics
group or a singles group.
Join a church and get involved. Tell the pastor that you want to do something
to help.
Volunteer your services with a local charity or hospital. Help others and
 share your experiences, strengths, and hopes.
Join a group that does interesting things in the area—hiking, skydiving,
hunting, bird watching, acting, playing sports, joining a senior center, and so
on. Check the local library for a list of such clubs and activities.
Ask someone in the program for interesting things to do in the area.
Go to an intergroup dance.
Go to an Alcoholics Anonymous (AA)/Narcotics Anonymous (NA)
conference.

The most important thing to remember is that you are in recovery. You are starting
a new life. To do this, you must take risks. You must reach out as you have never
done before.
Appendix 30: Hamilton Depression Rating
Scale

The total Hamilton Depression Rating Scale (HAM-D) provides an indication of

depression and, over time, provides a valuable guide to progress.

Classification of symptoms that may be difficult to obtain can be scored as

follows:

0 = absent; 1 = doubtful or trivial; 2 = present

Classification of symptoms where more detail can be obtained can be

expanded to the following:

0 = absent; 1 = mild; 2 = moderate; 3 = severe; 4 = incapacitating

In general, the higher the total score, the more severe the depression.

HAM-D score level of depression as follows:

10−13 = mild; 14−17 = mild to moderate; >17 = moderate to severe

Assessment is recommended at 2 weekly intervals.

Source: Hamilton, M. (1979). The Hamilton rating scale for depression. Journal
of Operational Psychiatry, 10(2): 149–165.
Appendix 31: Biopsychosocial Assessment

Robert R. Perkinson, PhD

DATE:
CLIENT NAME:
DEMOGRAPHIC DATA:
Age Marital status Race Sex Children
Others in residence:
Length of residence:
Education:
□ Less than sixth grade □ High school graduate
□ Sixth grade □ Some college
□ Seventh grade □ College graduate
□ Eighth grade □ Postgraduate work
□ Some high school □ Postgraduate degree
Occupation:
Characteristics of informant:
□ Reliable □ Unreliable
CHIEF COMPLAINT:
BIOPSYCHOSOCIAL ASSESSMENT:

HISTORY OF THE PRESENT ILLNESS (age of onset, duration, patterns and

consequences of use, current use, last use, previous treatments, tolerance,
blackouts, and symptoms of abuse or dependence):

PAST HISTORY

Place of birth: Date of birth:

Developmental milestones:

□ Normal □ Reading
□ Walking □ Spelling
□ Talking □ Arithmetic
□ Toilet training
Specific disabilities:

Raised with:

□ Mother □ Brothers
□ Father □ Sisters

Birth order:

Significant others:

Ethnic/cultural heritage:

Description of home life:

Grade school:

High school:

College:

Military history:

Branch
Highest rank
Discharge status
Problems

Occupational history:

Longest job held

Length of time at current job
Employment satisfaction
Work problems

Financial history:

□ Good □ Fair □ Poor

Current annual income:

Gambling history:

□ None □ Gambling problems (Explain)

Sexual history:

Sexual orientation
Physical abuse
Sexual abuse
Current sexual history
Relationship history
Recovery environment: □ Family □ Friends

Spiritual history:

□ Believes in God □ Agnostic

□ Higher Power □ Atheist

Religious activities:

Church Denomination

Attends:

□ Weekly □ Rarely
□ Occasionally □ Never

Legal history:

Arrests
Pending litigation

Self-identified strengths:

Self-identified weaknesses:

Self-identified needs:

Self-identified abilities:

Self-identified personal preferences:

Leisure activities:

Depression:

Mania:

Anxiety:

Panic attacks:

Agoraphobia:

Phobias:

Eating disorder:

MEDICAL HISTORY

Illnesses:

□ Measles □ Pneumonia
□ Mumps □ Tonsillitis
□ Chicken pox □ Appendicitis
□ Whooping cough □ Others

Hospitalizations:

□ Tonsillectomy and adenoidectomy □ Appendectomy

□ Chemical dependency

Allergies Environmental allergens

Medications at present:

FAMILY HISTORY

Father:

Age
Health:
□ Good □ Fair □ Poor
 Description

Mother:

Age
Health:
□ Good □ Fair □ Poor
Description

Other relatives with significant psychopathology

MENTAL STATUS EXAMINATION

Description:

□ Well developed and well nourished □ Thin

□ Obese □ Underweight

Age Race Sex Hair Eyes

Distinguishing marks or characteristics

Appearance:

□ Same as stated age □ Older than stated age

□ Younger than stated age

Dress:

□ Casual □ Meticulously neat

□ Appropriate □ Seductive
□ Disheveled □ Eccentric
□ Other

Personal hygiene:

□ Good □ Fair □ Poor

Sensorium:

□ Clear □ Lethargic
 □ Alert □ Drowsy
□ Vigilant □ Other

Factors affecting sensorium:

□ Alcohol □ Medications
□ Drugs □ Withdrawal symptoms
□ Other

Orientation:

Person
Place
Time
Situation

Attitude toward the examiner:

□ Cooperative □ Distant
□ Friendly □ Aloof
□ Pleasant □ Casual
□ Suspicious □ Overly intellectual
□ Hostile □ Neutral
□ Passive □ Apprehensive
□ Dependent □ Seductive
□ Withdrawn

Motor behavior:

□ Normal □ Physical agitation

□ Continuous movements or restlessness □ Tremor

Unusual and inappropriate movements:

□ Slow or retarded □ Inappropriate

□ Tics □ Hand wringing
□ Tearful □ Pacing
□ Rigid □ Apprehensive
□ Tense □ Angry
□ Slouched
Eye contact:

□ Appropriate □ Poor

Gait:

□ Normal □ Wide based

□ Shuffling □ Unsteady
□ Other

Primary facial expression during interview:

□ Normal and responsive □ Hostile

□ Sad □ Worried
□ Neutral □ Other

Speech quantity:

□ Normal □ Unspontaneous
□ Talkative □ Spontaneous
□ Garrulous □ Minimally responsive

Speech quality:

□ Normal □ Monotonous
□ Slow □ Soft
□ Rapid □ Loud
□ Pressured □ Slurred
□ Hesitant □ Mumbled
□ Emotional

Speech impairment:

□ None □ Marked by accent

□ Stuttering □ Articulation problem
□ Other

Mood:

□ Calm □ Neutral
 □ Cheerful □ Optimistic
□ Anxious □ Elated
□ Depressed □ Euphoric
□ Fearful □ Irritable
□ Tearful □ Angry
□ Pessimistic □ Other

Client report of depression:

□ None □ Moderate
□ Mild □ Severe

Episodes of depression:

□ None □ Frequently during past 6 months

□ One or two episodes during past 6 months □ Continuously during past 6
months

Client report of symptoms of depression:

□ None □ Sleep disturbance

□ Poor appetite □ Fatigue
□ Loss of interests □ Weight loss
□ Guilt □ Loss of interest in sex
□ Motor retardation □ Other

Observed signs of anxiety during interview:

□ None □ Apprehensive manner

□ Physical indications □ Problems in attention
□ Other

Client report of anxiety:

□ None □ Moderate
□ Mild □ Severe

Episodes of anxiety:

□ None □ Frequently during past 6 months

 □ One or two episodes during past 6 months □ Continuously during past 6
months

Client report of symptoms of anxiety:

□ None □ Paresthesias
□ Shortness of breath □ Muscle aches
□ Palpitations □ Cold hands
□ Chest pain □ Gastrointestinal symptoms
□ Dizziness □ Muscle twitching
□ Faintness □ Dry mouth
□ Sweating □ Other

Range of affect:

□ Appropriate □ Labile
□ Blunted □ Dramatized
□ Restricted □ Flat
□ Contradictory □ Other

Thought processes:

□ Logical and coherent □ Neologisms

□ Blocking □ Preservation
□ Circumstantial □ Evasive
□ Tangential □ Distracted
□ Flight of ideas □ Loose associations
□ Incoherent □ Clang associations
□ Other

Thought content—preoccupations:

□ None □ Violent acts

□ Presenting problem □ Somatic symptoms
□ Obsessions □ Guilt
□ Compulsions □ Worthlessness
□ Phobias □ Religious issues
□ Suicide □ Sex
□ Other
Thought content—delusions:

□ None □ Jealousy
□ Persecution □ Grandiosity
□ Somatic □ Religious
□ Ideas of reference □ Influence by others
□ Thought broadcasting □ Control
□ Other

Description of delusional material

Quality of delusional material:

□ Systematized □ Poorly organized

Disorders of perception:

□ None □ Tactile hallucinations

□ Auditory hallucinations □ Gustatory hallucinations incorporated into
delusions
□ Visual hallucinations □ Fragmented and not incorporated into delusions
□ Olfactory hallucinations

Suicidal ideation:

□ None □ Ideation □ Plan

Details of current plans

History of suicidal acts

Homicidal ideation:

□ None □ Ideation □ Plan

Details of current plans

History of violent acts

Obsessions:
 □ None □ Death
□ Illness □ Contamination
□ Violence □ Doubt
□ Other

Compulsions:

□ None □ Checking
□ Hand washing □ Touching
□ Counting □ Other

Phobias:

□ None □ Insects
□ Public places □ Dogs
□ Closed spaces □ Social security
□ Heights □ Rodents
□ Snakes □ Travel
□ Flying □ Other

Estimated range of intellectual ability:

□ Normal □ Below average

□ Above average □ Borderline retarded
□ Superior □ Retarded

Abstracting ability:

□ Normal □ Impaired

Disturbances in consciousness:

□ No recent disturbances □ Recent history of seizures

□ Recent history of loss of consciousness □ Recent history of blackouts

Concentration:

□ Normal □ Moderately impaired

□ Mildly impaired □ Severely impaired
Memory functions:

□ Intact □ Recent memory deficit

□ Immediate memory deficit □ Remote memory deficit

Confabulations:

□ None □ Suspected □ Definite

Amnesia:

□ None □ Less than 1 month

□ Less than 1 day □ Several months
□ Less than 1 week □ Years

Impulse control:

□ Good □ Fair □ Poor

Judgment:

□ Good □ Fair □ Poor

Insight:

□ Minimal: No understanding of problem or acceptance of personal

responsibility
□ Insightful: Accepts personal responsibility and desires professional
assistance
Appendix 32: Anger Management

Robert R. Perkinson, PhD

Anger is a feeling that helps you to adapt to your environment. It is designed to
make stress stop. It helps you to establish and maintain boundaries around
yourself. It gives you the energy and direction to defend yourself from a physical
attack.

Chronic anger is painful. It results in broken relationships. It does not help; it

hurts. Studies show that people who are chronically angry die years earlier than
they should. They have more colds and bouts with the flu as well as more mental
and physical illnesses. Chronic anger has many painful consequences.

The reason why you are reading this exercise is that your anger sometimes gets out
of control. When you are angry, you do things that you feel guilty about later.
Chronic anger is a shameful cycle of pain. You do not want to hurt others, but you
find yourself doing it anyway—repeatedly.

A lot of this exercise was taken from When Anger Hurts (McKay, Rogers, &
McKay, 1989). When you get the opportunity, get that book and read it. This
exercise will help you to manage your anger. This will not be easy, and you will
have to work very hard. Learning new behaviors takes a lot of practice. You have
had years of training in how to act angry. Now you need to learn new skills to deal
with problems. Using the techniques described here, you will feel angry less
often. When you feel angry, you will be able to solve problems rather then make
them worse.
Anger Journal
Keep an anger journal every day. Write down every time that you feel angry. Write
down exactly what happened in detail, and rate your angry feelings on a scale
from 1 (as little anger as possible) to 100 (as much anger as possible). Rate
your aggressiveness, angry words or actions, from 1 to 100. The more you look at
each situation, the more you will learn about yourself and the more you will learn
to control your behavior. Your journal might look something like this:

December 4: 8:00 am—Kathy asked me to take out the garbage three times
while I was watching TV. I felt like she was trying to drive me crazy. She
knew I had had a hard day and needed some time alone. At the same time, the
kids were fighting in the other room.

Intensity of anger felt: 100

Aggressiveness: 90. I told her to shut up and leave me alone. I threw a
pillow against the wall.

December 4: The sales meeting ended before I got a chance to share my

concerns with the boss. I needed to talk to him and reassure him about my
work. I know my sales have been falling off a bit lately. I felt more hurt than
anything else.

Intensity of anger felt: 75

Aggressiveness: 0. I did not do anything, but boy was I fuming.

By monitoring your anger, you will be able to observe your progress. You will
feel successful as you see yourself handling your anger better.
The Anger Myth
There is a myth that anger has to be expressed or else you will explode into a
violent rage. The anger will build up like water behind a dam. If you do not
express it, then it will come bursting out all at once and destroy everything in the
process. Research strongly disagrees with this myth. The research shows that
anger does not help. The more you act angry or think angry thoughts, the more you
feel angry. Anger feeds on itself. It never helps to hit walls or pillows or to yell. It
just makes you act angrier.
What Does Anger Do to People?
1. Anger stuns and frightens people.
2. Anger makes people feel bad about themselves.
3. The more anger you express, the less effective your anger becomes. People
get used to your anger and shrug it off.
4. People distance themselves from you.
5. Anger cuts you off from genuine closeness.
6. The more you act aggressively, the more you want to continue the attack and
really rub people’s noses in it.
7. Anger causes continued aggression from both parties.
8. Anger does not stop. It goes on and on, fueling itself in the process.
9. You resort to anger repeatedly. Each episode gets worse.
10. Anger leads to rigidity. Both parties become stuck and inflexible.
11. Anger breeds the desire for revenge.
12. Anger is trying to control the other person, but inevitably you lose control.
13. Anger causes the other person to act defensive and resistive.
14. People shield themselves from your anger by avoiding you.
15. People who are aggressive overestimate other people’s aggression. Every
word or action can seem like a threat. They also underestimate their own
aggressive behavior.
16. To manage your anger, you have to get accurate in your thinking and learn
other coping skills to use when you feel hurt or angry.

Angry people feel like victims caught in a trap. They desire closeness but have a
fear of abandonment. Their friends seem selfish and insensitive, their employers
seem cheap and uncaring, and their lovers seem unappreciative and withholding.
Life is no fun.

Anger leads to helplessness in four steps:

1. You think that something is wrong with you.

2. You think that the other person should fix you, but he or she will not.
3. You blow up at that person.
4. The other person withdraws even further.
Anger Is a Choice
You do not have to act angry. You can solve your problems in other ways. Until
now, anger has been automatic. It has been a decision made without thinking or a
choice made out of habit. You spent years thinking that anger was saving you or
helping you, while all the time it was hurting you. You want to be loved and
accepted. Anger never will get you that. You can feel angry and act in a way that is
more productive. Remember that the function of anger is to stop stress. Your
problem is stress, not anger.

Anger helps you to cope with stress in several ways:

1. Anger blocks the awareness of pain.

2. Anger discharges high levels of fear, hurt, guilt, and sadness.
3. Anger discharges the pain that develops when your needs are frustrated.
4. Anger erases guilt.
5. Anger places the blame on someone else.

There are many ways of discharging stress other than acting angry. You can cry,
exercise, work, make a joke, write in your journal, meditate, verbalize your
feelings, talk to your counselor/sponsor/mentor/coach or friend, ask for what you
want, problem solve, listen to music, and do many other things.
Anger Is a Two-Step Process
1. You become aware of stress.
2. You blame someone else.

What will not help you is blaming someone or thinking about what he or she
should have done differently.

To blame, you have to believe the following: The other person purposely did
something wrong that hurt me. To should, you have to believe the following: The
other person should have known better than to do what he or she did.

The should and blame are inaccurate thinking. The truth is that if the person had
known better, he or she would not have done it. The other person was not trying to
hurt you. The other person was trying to meet his or her own needs. If you will
slow situations down and look at them closely, you will find out this is true.

To rid yourself of anger, you must stop blaming others.

The only thing that always is true when you are angry is that you are in pain. The
trigger thoughts that fuel your anger usually are false. Your anger may have no
legitimate basis. If you use inaccurate thinking, then you will generate a storm of
inaccurate feelings. Armed with the real facts, you might not get angry at all.

It is not that anger builds; it is stress that builds. You need coping skills to deal
with stress.
What Is Stressing You?
Go back to your anger journal, and look at each anger-producing situation.

1. Figure out what was stressing you before you got angry. What was the
emotional pain, physical pain, frustration, or threat that preceded the anger?
Prior to feeling angry, were you aware of any internal feeling of hurt, fear,
sadness, or guilt? Did you feel uncomfortable physically or psychologically?
Write down these things, and ask your counselor or group to help you
uncover your automatic thinking.
2. Try to figure out the trigger thoughts. What were you thinking between the
situation and the anger? Did you use the blame or should? Write down
exactly what you were thinking.

Bob came home from work to find several soda cans lying in the middle of the
living room floor. He thought, The kids know better than this. They only think
about themselves. Nobody appreciates what I do around here. They do not care if
I come home to a dirty house. Bob rated his anger at 100. He yelled at the kids and
scored himself aggressively at 85. Later he felt guilty about yelling at the children
and had to apologize.

Look at how Bob’s inaccurate thinking inflamed his anger:

The kids should know better.

They only think about themselves.
They do not care about me.
Nobody appreciates what I do around here.
I live in a dirty house.

Thinking like that, it is no wonder Bob got angry. He was not thinking accurately.
His angry feelings came from inaccurate thinking. He ended up feeling angry
because of how he interpreted the actions of others.
Blaming
The impulse to assign blame lies at the root of all chronic anger. When you decide
who is responsible for your pain, you feel justified in acting aggressively. You see
yourself threatened, and you need to protect yourself. You are the helpless victim
of another person’s stupidity or selfishness.

There is pleasure in blaming. You can escape the responsibility for your own
problems by blaming someone else. You can turn the focus off your mistakes and
concentrate on the other person’s mistakes. The problem with blaming is that it is
not true. The truth is that other people are not responsible for your life; you are.

1. You are the only one who understands what you need.
2. Other people need to focus on their own needs.
3. People’s needs occasionally will come into conflict with yours.
4. Your satisfaction in life depends on how well you meet your needs.
Strategies for Getting Your Needs Met
You must develop new skills for meeting your needs better. With your counselor’s
help, develop the following coping skills and practice them often.

1. Learn to give people rewards when they do something that you want them to
do. Reinforce each person often. The more reinforcing you act toward others,
the more reinforcing they will act toward you. List five times when you did
this.
2. Learn to take care of your needs yourself. Do not count on others to meet your
needs.
3. Develop new sources for support, nourishment, and appreciation. Join that
Alcoholics Anonymous (AA)/Narcotics Anonymous (NA) group and go
often. Take someone out for coffee. Call your sponsor. List 10 things you are
going to do to support, nourish, and appreciate yourself.
4. Learn to say no. Practice in skills group a situation where you had a difficult
time saying no to someone. Have other people in the group play the parts of
the other people in the situation. Then act out the situation as if it happened.
Then brainstorm with the group many other ways you could have responded.
Then practice this situation using the other coping skills. Describe your
saying no to your skills group and the other coping skills you learned.
5. Learn how to share how you feel and to ask for what you want. Practice in
skills group three times when you kept your feelings to yourself. Set up the
situations and role-play them in group. Get feedback from your counselor or
group about why you need to share your feelings and the various ways you
can share them. Practice sharing your feelings too passively, too
aggressively, and assertively. Describe what happened in group and what you
learned.
6. Learn to let go and let God. Set up an argument in skills group; when you are
feeling angry, take two deep breaths. As you exhale, relax your body, have it
go loose and limp, and then say over to yourself, “Let go and let God.” Then
practice removing yourself from the situation in a relaxed, comfortable
manner. Describe to your skills group in detail.
Taking Back the Responsibility
Go to your journal and examine your anger-generating situations. Ask for help
from your counselor or group. Use them to help you to get accurate and uncover
your automatic thoughts that lead to anger. Make a list of eight anger-generating
situations, and process them with your group or counselor.

1. What was stressing you at the time?

2. What were your trigger thoughts?
3. What could you have done differently?
4. How could you have met your own needs?
5. How could you have found other sources of support?
6. What limits did you fail to set? Were you unable to say no?
7. How could you have negotiated better for what you wanted?
8. How could you have let go and let God?
Combating Trigger Thoughts
Inaccurate thinking leads you to feel inaccurate pain. If you blame, then you judge
people all day by your own rules. Someone cuts in front of you in traffic and you
fume, “That idiot knows better than that!” The fact is that many drivers think it is
fine to cut in line. The problem with blaming is that people rarely agree with you.
People all have their own sets of rules and judge themselves by their own
standards. People often do not do what they think they should do; they do what
works for them.
The Entitlement Fallacy
The entitlement fallacy is the belief that you deserve things because you want them
very badly. Your need justifies the demand that someone give you what you want.
The feeling of entitlement engulfs you. How can the other person say no? The truth
is that people will give you what they want to give you and nothing more. They are
trying to meet their own needs, not yours.
The Fallacy of Fairness
The idea here is that there is an absolute standard of conduct that everyone has to
follow. Everyone should know these rules and follow them. If they do not, then
they are bad and deserve to be punished. The problem with this thinking is that
there is no absolute right and wrong standard of conduct. What is fair is very
subjective. The other person could be functioning from an entirely different set of
values.
Blame
Assigning blame lets you escape the responsibility of handing your problems.
Blaming triggers anger by making your pain other people’s fault. Blaming labels
people as bad when they are doing all that they can with the coping skills they
have at their disposal. By blaming, you punish people for doing things that they
could not help doing.
Mind Reading
Sometimes you get angry when you try to read someone’s mind. You think that you
know what a person did and why he or she did it. You think that you have the
person all figured out. You assume that the person did something deliberately to
harm you. This rarely is true. The other person almost always is trying to meet his
or her own needs.
Changing Your Trigger Thoughts
Go back to your anger journal, and determine what you were thinking between
each situation and the anger. Pull out as many of these trigger thoughts as you can
and write them down. Let your counselor or group help you. This is uncovering
your automatic thinking.

Once you have a list of the trigger thoughts, go back and develop thoughts that are
accurate. What thinking would have been appropriate for each situation?

You will be amazed at how your inaccurate thinking fuels your anger. Keep a
record of anger situations and your thinking for at least 12 weeks. In time, you will
be able to catch yourself in the old thinking and correct yourself. Once you are
thinking accurately, you will act appropriately. Soon the old thinking will not
sound so convincing and so right. You will not feel like a victim anymore.
Stopping Escalation
Gerald Patterson of the Oregon Social Learning Center found that anger between
people depends on aversive chains of behavior where people attempt to influence
each other through a rapid exchange of punishing communications. These chains
are more likely to occur when the people have relatively equal power such as like
husband and wife, parents and children, peers, friends and coworkers. Aversive
chains usually begin with small events and develop along predictable lines. Early
exchanges often are overlooked because they seem unimportant.

Aversive chains are the building blocks to violence.

Most aversive chains never pass beyond the first link. Someone teases or insults
another, and there is no response. Because no one reacts to the provocation, the
problem stops after a few seconds. Three- or four-link chains usually last no
longer than a half minute and exist even in healthy homes and relationships. If an
aversive chain lasts longer than a half minute, then yelling, threatening, or hitting
may occur. The longer a chain lasts, the more likely it is that things are going to get
out of control.

Stop an aversive chain at the earliest possible moment.

The last link in an aversive chain is a trigger behavior. These behaviors usually
precede violence. Triggers are verbal or nonverbal behaviors that bring up
feelings of abandonment or rejection. These feelings are too painful to deal with,
and the person feeling them needs them to stop right now.

A variety of statements can put the last link in an aversive chain. These are the
responses that you need to eliminate, replacing them with your new coping skills.
Verbal Trigger Behaviors
1. Giving sarcastic advice: “Tell them to give you a raise. We need the money.”
2. Engaging in global labeling: “All women are like that.”
3. Criticizing: “You did not shovel the walk. You made a little path.”
4. Blaming: “If you’d just do some work around here . . . ”
5. Setting abrupt limits: “That’s it. I am out of here.”
6. Threatening: “If you do not like it, then get out.”
7. Cursing: “Shut the hell up.”
8. Complaining: “Ever since I married you, I have been unhappy.”
9. Mind reading: “You are trying to drive me crazy.”
10. Stonewalling: “There’s nothing more to talk about.”
11. Making sarcastic observations: “Did you dump the trash in your room?”
12. Making humiliating statements: “When we got married, you were better
looking.”
13. Giving dismissing statements: “Get out.”
14. Giving put-downs: “Is this what you call clean?”
15. Accusing: “You did it again, didn’t you?”
16. Laying on the guilt: “You know I cannot stand that.”
17. Giving ultimatums: “If you do not shape up, I am leaving.”
Nonverbal Trigger Sounds
1. Groaning: “I have had it with you.”
2. Sighing: “You are such a burden.”
3. Making a fist: “If you do not shut up, I am going to knock your head off.”
4. Getting in a person’s face: “You are going to get hurt if you keep this up!”
Voice Quality Triggers
1. Whining (irritating tone)
2. Flatness in voice (as though you checked out a long time ago)
3. Cold tone (the other person will never reach you)
4. Throaty constriction (barely controlled rage)
5. Loud and harsh tone (threatening)
6. Mocking and contemptuous tone (shaming)
7. Mumbling under your breath (the other person has to guess what you said)
8. Snickering (laughing at the other person)
9. Snarling (you had better back off)
Trigger Gestures
1. Finger-pointing
2. Shaking a fist
3. Flipping the bird
4. Folding arms
5. Waving away
Trigger Facial Expressions
1. Looking away
2. Rolling the eyes
3. Narrowing the eyes
4. Opening eyes wide
5. Grimacing
6. Sneering
7. Frowning
8. Tightening the lips
9. Raising an eyebrow
10. Scowling
Trigger Body Movements
1. Shaking the head
2. Shrugging the shoulders
3. Tapping a foot or finger
4. Leaning forward (intimidating)
5. Turning away
6. Putting hands on hips
7. Making quick and sudden movements
8. Kicking or throwing an object
9. Pushing or grabbing

Spend time each evening reviewing your anger journal. Write down your verbal
and nonverbal trigger behaviors. In time, you will be able to recognize your
patterns. Begin eliminating your trigger behaviors and using your new coping
skills instead.
Example of an Aversive Chain
Bob comes home from the office and sees his spouse, Patty, sitting quietly on the
couch. The boss got on his case again today, and Bob needs some support. Rather
than asking Patty for what he needs, here is how the conversation goes:

Bob: I can see you had a hard day in front of the television.

Patty: I have been working my tail off. (Patty is instantly defensive.)

Bob: I know what you do. You lay around all day. (Bob crosses his arms
sarcastically.)

Patty: I work every bit as hard as you do. (Patty looks at him angrily.)

Bob: Do I have to cook dinner, too? (Bob walks into the kitchen.)

Patty: What is wrong with you today? (Patty gets up and follows him.)

Bob: Don’t yell at me!

Patty: Nothing I do pleases you anymore. (Patty begins to cry.)

Bob: If you don’t like it, then get the hell out! (Bob is out of control, shaking in
fury.)

Bob will not get Patty’s support this way. He needed his wife to help him, but he
got the exact opposite of what he wanted. Now his needs are more frustrated. He
fumes and primes himself for the next battle.

At every point along this aversive chain, Bob and Patty could have de-escalated
the conflict. Remember that anger is a choice.
Breaking Aversive Chains
Time-Out
The best thing you can do when you find yourself in an aversive chain is to call a
time-out. This is a contract that two people make when they are not angry. The
first party to recognize an aversive chain makes a time-out sign (a T made with
both hands in front of the body). This person says, “Time-out.” The other person
only returns the gesture and says, “Okay, time-out.” The person who called time-
out then leaves the aversive situation for a predetermined amount of time, usually
an hour. The person who leaves agrees to return and work on the problem after the
time is up or to make an appointment to work on it later. Time-out never should be
used to avoid a problem. Time-out is meant to avoid escalating stress. Time-out
says, “It is time to separate. I will be right back.”

Each person should know exactly what is going to happen after a time-out has
been called. They need to be certain that the other person is going to return.
Abandonment and rejection issues are involved here, and they create a lot of fear.
A time-out contract needs to be written and signed by both parties. The couple
needs to role-play using the time-out several times in a nonthreatening situation.

After a called time-out, wait for your feelings to cool down and then try to get
accurate in your thinking. Take out these coping statements and read them to
yourself.

“Do not blame.”

“Do not try to fix the other person.”
“What can I do differently?”
“The other person is not trying to hurt me. The other person is meeting his or
her own needs.”
“The other person is doing the only thing that he or she knows how to do at
the moment.”
“If I want the situation to change, then I need to change my behavior.”
“What can I say to start the conversation off on a positive note?”
“I need to relax and stay relaxed.”
Rechannel
If you see yourself in an aversive chain, rechannel the conversation to a subject
that is nonthreatening. The earlier in the aversive chain this is done, the more
effective it will be. Sometimes you can just keep quiet and that is enough. Do not
fuel the anger with your old trigger behaviors. Defuse it with your new coping
statements.

“There is no absolutely right or wrong answer here.”

“We both are partially right.”
“It is time to rechannel this discussion.”
“Let us go over this later.”
“Can we talk about this in an hour?”
Inquiry
When you see yourself in an aversive chain, pull information from the other
person. This makes the other person feel important and loved. Remember that
anger is a response to pain. Ask the person about how he or she is feeling and
thinking.

“What is hurting you?”

“I am concerned about you.”
“Tell me what is causing you to feel bad.”
“What do you think we need to do to solve this problem?”
Old Road Map
An old road map takes events from our past and places it unrealistically over the
present. We expect people to respond to us in the same way as others have in the
past. If our parents were not trustworthy, then we assume that other people are not
trustworthy. If we got hurt by a past relationship, then we expect the same thing
from the next relationship.

The key to preventing mind reading is to check it out with the other person. Do not
assume that you know what the other person is thinking. Ask the other person.

Once you begin asking the other person how he or she feels and what he or she
thinks, you will learn a lot about yourself. You will learn about your old maps and
how they are inaccurate.

“How do you feel?”

“What do you want me to do?”
“Tell me more about what you are thinking.”
“What do you suggest we do to resolve the problem?”
Improving Self-Talk
You need to develop many positive things to say to yourself. Make a list of 10
positive self-statements and keep them with you. When you are feeling
uncomfortable, take them out and read them over to yourself. Some work better
than others do. Memorize the ones that work for you.

“I am a good person.”
“I am smart and capable.”
“I am God’s child and he loves me.”
“No matter what happens, I am going to be all right.”
“I can take care of myself.”
Reassure Yourself
You may have to reassure yourself that you are going to be able to get through an
aversive chain.

“I can handle this.”

“I can call a time-out if I need to.”
“If I find myself getting angry, I can deal with it.”
“I can find the appropriate coping strategy.”
“I believe in myself.”
Stop Trigger Thoughts
Do not allow yourself to fall back into old thinking. You are not a victim. You
always have a choice.

“I am responsible for what happens to me.”

“I am never a victim. I have a choice.”
“I can take care of my own needs.”
“Do not blame.”
“People never do what they should do.”
“I am free to do anything I want.”
“There is no right or wrong answer.”
“The amount of support that I am getting is all I can get at the moment.”
“Anger never will get me what I want.”
“Do not mind read.”
Physiological Coping
Monitor your physiological functioning. If you feel uptight, then tell yourself to
relax. This reduces your stress and makes you deal with the situation more
accurately.

“Take a deep breath.”

“Relax.”
“Feel your arms and legs become loose and limp.”
“Stay calm.”
“Visualize one of your favorite places.”
“Meditate or relax for 20 to 30 minutes. Get in a quiet place, sit or lie down,
and pay attention to your breathing. Each time you exhale, say the word one
over to yourself. When other ideas come, just return to the number one.”
Problem Solving
When you have a problem, use these problem solving skills. Continue to process
through the options until everyone agrees to try a solution.

1. Write down the problem.

2. Communicate your feelings.
3. Ask for what you want.
4. Acknowledge the other person’s point of view.
5. Develop a list of options.
6. Discuss the pros and cons of each option.
7. Keep working until you reach a consensus.
Coping Script
Prepare for an angry situation with a set of coping statements. Pick the coping
statements that seem to work best for you. You might have to change them from
time to time and from situation to situation. What are you going to say to yourself
the next time you find yourself getting angry?

List five ways to reassure yourself:

1.
2.
3.
4.
5.

List five ways to stop the trigger thoughts:

1.
2.
3.
4.
5.

List five ways to cope physiologically:

1.
2.
3.
4.
5.

List five ways to move to problem solving:

1.
2.
3.
4.
5.
List five accurate sentences. When you find yourself in an aversive chain, say
them over to yourself.

1.
2.
3.
4.
5.
Motivating Yourself
Each morning, go over the costs of your anger. Explore its toll on you and on those
you love. Review the consequences of your last anger episode. Make a contract
with your significant other to work on practicing the new coping skills and
practice them often. You can do it.
The Time-Out Contract
When I realize that my (or my partner’s) anger is rising, I will give a “T” time-out
sign and leave at once. I will not hit or kick anything, and I will not slam the door.

I will return in no more than 1 hour. I will take a walk to use up the energy, and I
will not drink or use drugs while I am away. I will try not to focus on resentments.

When I return, I will start the conversation with the following: “I know that I was
partly wrong and partly right.” I will then admit to a mistake that I made.

If my partner gives a “T” sign and leaves, then I will return the sign and let my
partner go without a hassle no matter what is going on. I will not drink or use
drugs while my partner is away. I will try to avoid focusing on resentments. When
my partner returns, I will start the conversation with the following: “I know that I
was partly wrong and partly right.” I will then admit to a mistake that I made.

Signature ________________________________________ Date

_____________

Signature ________________________________________ Date

_____________
Appendix 33: Narcissism

Robert R. Perkinson, PhD

This might be a difficult exercise for you to read, so you need to be open-minded
and willing to learn something new about yourself. You seem to have some
narcissistic traits that get you into trouble and lead you to addiction. For example,
you tend to be too sensitive to criticism. Whenever someone criticizes you even a
little, you get very hurt and sometimes retaliate: “How dare you criticize me?”
Underneath the anger, you feel wounded. You think that to be loved, you have to be
the best, the brightest, the most beautiful, or the most successful. You do not know
how to be genuinely close to others, but you have a great need for people to love
you. The real problem is that, underneath it all, you do not feel good about
yourself. You feel ashamed of who you are and what you have done. You fear that
other people are better than you are.

Narcissus was a beautiful man in Greek mythology that refused to love others. As
punishment for his indifference, the gods made him fall in love with himself. He
became so enamored with himself that he could not stop gazing at his reflection in
a pool of water. Finally, he fell into the water and drowned. Narcissism is a term
for people who have an exaggerated need to be admired. Because of this need,
they develop an exaggerated sense of their own importance. They exaggerate their
talents, accomplishments, and achievements so as to be respected. They stretch the
truth to build their fragile self-images. Narcissistic individuals develop an
overwhelming need to feel special, and they expect to be treated in special ways.
They become excessively concerned with themselves and their needs, losing the
capacity to be sensitive to the needs of others. Their relationships start out in great
hope and pleasure but end up in disaster. At first, everything seems fine, and the
love is wonderful. When the other person begins to have his or her own needs and
make demands, the anger gets going.

Alcoholics Anonymous (AA) (2002a) says that this self-centeredness is at the root
of our addiction:

Each person is like an actor who wants to run the whole show [and] is
forever trying to arrange the lights, the ballet, the scenery, and the rest of the
 players in his own way. If his arrangements would only stay put, if only
people would do as he wished, the show would be great. Everybody,
including himself, would be pleased. Life would be wonderful. In trying to
make these arrangements, our actor may sometimes be quite virtuous. He may
be kind, considerate, patient, generous, even modest and self-sacrificing. On
the other hand, he may be mean, egotistical, selfish, and dishonest. As with
most humans, he is more likely to have varied traits.

What usually happens? The show does not come off very well. He begins to
think life does not treat him right. He decides to exert himself more. He
becomes, on the next occasion, still more demanding or gracious, as the case
may be. Still, the play does not suit him. Admitting he may be somewhat at
fault, he is sure that other people are more to blame. He becomes angry,
indignant, [and] self-pitying. What is his basic trouble? Is he not really a
self-seeker even when trying to be kind? Is he not a victim of the delusion
that he can wrest satisfaction and happiness of this world if he only managed
well? (p. 61)

As you read this exercise, you might not think that you are self-centered. The very
idea may make you feel angry. To have any flaw would dent that perfect image you
have of yourself. That is the problem. So long as you need to be perfect, criticism
sends you tumbling into shame. If you need to be right all of the time, others never
seem to respect you. This is what happens. You think that you need to be the best
at everything, and then someone comes along who is as good as, or better than,
you are. Then you feel humiliated. Critical comments by others send you off the
edge of sanity. You fume, you rage, and you get even. You cannot stand the
suggestion that you are not perfect in every way.

To understand the trap of narcissism, you need to understand the narcissistic traits.
Let us look at a few and circle any of them that fit you.

1. Do you often desire to be the center of attention?

2. Do you want to be the life of the party?
3. Do you feel resentful when your friends achieve something?
4. Do you feel unappreciated?
5. Do you want a beautiful woman or man to hang all over you so that other
people can see how wonderful you are?
6. Do you think that you are more intelligent than most?
 7. Do you tend to brag about and exaggerate your accomplishments?
8. Do you make a good first impression but have difficulty following through?
9. Do you think people would be better off if they would follow your direction?
10. Do you tend to resent authority figures?
11. Do you try to control people close to you?
12. Do you have difficulty accepting criticism?
13. Do you tend to be unsatisfied in interpersonal relationships?
14. Are you obsessed with money and material things?
15. Are you good at charming others to get what you want?
16. Do you fantasize about big plans and schemes?
17. Do you relish being the big shot?
18. Do you feel that you do not get the respect you deserve?
19. Do you believe that the rules and laws are made for other people?
20. Do you want to be God?

If you circled any of these statements, you have some narcissism. These are the
immature narcissistic needs, or the infantile needs, of an individual who wants to
be in control. They are the needs of someone who is desperate for attention. No
amount of love would be enough for you. You always would need more and more
love. Other people have tried to love you, and they always have fallen short,
haven’t they? Then you blame them without looking at yourself. It is always the
other person’s fault and never your own. If the other person would just recognize
you for the great person that you are and do what you want him or her to do, then
things would go fine.

Narcissistic traits are why you are spiritually bankrupt. This is why you have been
feeling so empty. This is why you never fit in and you used the addiction to ease
the pain.

Now let us look at the crux of the issue. When you look at these characteristics
carefully, you can see that you have been trying to be God. You are not God, and
you never will be God, so as long as you try being God, you will feel like a
failure.
A Feeling of Worthlessness
Underneath your need to be in control is the feeling of worthlessness you learned
as a small child. Somewhere in development, you learned you were a totally
worthless person who is incapable of loving others like you should. These
thoughts are intolerable, so you began to cover them with a false front. You are not
worthless; you are the king, leader, star, director, best friend, and lover of all.
With these two conflicting ideas in your mind, you vacillate between being the
greatest person and the worst person. There is no middle ground. You are either
on the top or on the bottom—never in between, never normal. The reason why you
need constant reassurance from others is that you do not feel good about yourself.
You feel inadequate. To counteract this feeling, you exaggerate your talents and
accomplishments. This is a vain attempt to get people to love you. Give 10
examples of when you lied about your accomplishments or talents to get someone
to like you.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Because you feel worthless, you have a difficult time hearing the word no. When
someone says no, you feel that you are bad. Either you are the best or the worst.
When someone says no, you get angry and go into a rage. That makes everything
worse.

Give five examples of when someone told you no and you got furious.

1.
2.
3.
4.
 5.

Because of your feelings of worthlessness, you need to feel special and other
people need to recognize your unique abilities. You believe that only special
people of high status can really understand you. Because you have a need to be
perfect, you routinely overestimate your capabilities. For example, you think that
you are going to make all As in your classes and get angry at the teacher when you
get lower grades. It is always the teacher’s fault, or the boss’s fault, or the
spouse’s fault—never your own fault. You need to be admired and respected even
when you have not worked for it. You expect to start at the top rather than work
your way up like other people must do.

Give five examples of when you expected to be loved and respected and you did
not deserve it.

1.
2.
3.
4.
5.

It is important for you to see how these unrealistic ideals set you up to fail. No one
is perfect, so when you expect this of yourself, you always fail. When you think
that your work has to be perfect, you end up feeling humiliated when someone
points out that you did something wrong.

Give five examples of when someone criticized you and you felt hurt and angry.

1.
2.
3.
4.
5.

Because of your feelings of worthlessness, you spend a lot of time fantasizing

about success, power, brilliance, and/or ideal love. You thought how wonderful
this new job will be, or this new love, or this new ability. This immature need for
unlimited success sets you up to fail. You end up feeling more miserable.

Discuss the last romance you had and what happened. Describe how perfect you
thought it was at first and how it actually turned out. Concentrate on how you
judged the relationship unrealistically from the beginning and see how you
unrealistically judged the relationship in the end. Have your counselor or group
help you. Both of these judgments were inaccurate.

Love and sex put you at high risk because you put unrealistic expectations on the
relationship. You expect the other person to meet your needs to feel important,
special, loved, powerful, brilliant, and beautiful. There is no way in which a
person can make you feel like that, so the relationship fails and you sink into
despair.

Give five examples of how relationship problems lead to addictive behavior.

1.
2.
3.
4.
5.

A narcissistic person feels jealous of others and their accomplishments. By

constantly comparing yourself to others, you end up feeling bad.

List five people who you are envious of, and write down exactly what they have
that you want.

1.
2.
3.
4.
5.

It is important for you to recognize how you constantly compare yourself to others
and how you end up feeling either superior or inferior to them. Either way, you
have separated yourself from the truth and made love impossible. Intimacy
necessitates truth, commitment, love, trust, and openness. Both partners need to
come into a relationship feeling good about themselves. Love is the active
involvement in the other person’s growth.
To Loosen the Narcissistic Bonds
These narcissistic traits enslave you. You never will be perfect. You never will be
the most brilliant, or the most beautiful, or the most powerful, or the most loved,
or the most wonderful, or the most special. Not everyone will worship you. You
believe that to be accepted, you have to be the greatest, but you do not. Narcissism
is a life built on lies.
You Must Get Honest
Honesty is a wonderful thing. You cannot solve problems without the facts. If you
make up the facts, then the problems never will be solved and you will be back to
the misery. You never will feel loved if you make up who you are. Even if you
fool the other person, you know that the person does not love you. You never will
feel known until you tell the truth.

• The first thing that you need to do is not tell the old lies—you know, as if you
are someone special with special talents. If you never worked for the CIA, then do
not tell people that you did. If you did not make a lot of money, then do not tell
people that you did. If you did not save a person from drowning, then do not say
that you did. You get what I mean. You have a million stories that are not true. You
have to stop lying. If you do not stop lying, then you will be unhappy.

List 10 lies you tell to get people to like you.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Promise yourself that you never will tell these lies again. Wake up every morning,
and be grateful that you have not lied that day. Then try to get through the next hour
without lying. If you make it, then congratulate yourself. That is a victory. Check
out how you feel. You will be feeling good about yourself. When you lie, check
out how you feel. You will be feeling fear and shame. Dishonesty is the main
reason why you have been isolated. Only by being honest will you ever feel
accepted and loved.
You Must Go to Meetings
To loosen the bonds of narcissism, you must go to meetings and trust others to help
you. This is very difficult because the only person you trust is yourself. In this
illness, if you rely only on yourself, then you will die. You need to turn your will
and your life over to someone who can manage your life. Start with anyone you
can such as your counselor, group, or sponsor. Lay your trust in that person, and
whatever you do, do not trust yourself. Your best judgment got you into this mess.
You do not know the way out. Someone else is going to have to show you the way.
Name the person(s) who you are going to try to trust.

Name: _____________________________________ Phone:

_________________
Name: _____________________________________ Phone:
_________________
Name: _____________________________________ Phone:
_________________

When you feel like taking the controls back again, do not do so. When someone
makes a suggestion, try it.
You Must Seek a Higher Power
You need to seek a Higher Power of your own understanding. There is only one
you, and you are special. You are not better than everyone; everyone is equal. This
makes life better, not worse. This alone gives you the opportunity to love rather
than rule. Everyone has his or her unique place in God’s plan. Whatever you do,
God will be there for you, supporting you, educating you, and caring for you. Take
a risk, and ask God to come into your life. Say something like this: “God, I do not
know if you are out there or not, but if you are, please come into my life and help
me.” Then ask God a question: “God, what is the next step in my relationship with
you?” Now be quiet. Do not be afraid. Wait. A word or phrase will come through
your mind. It will be something like this: “Trust me” or “Pray.” That is God
speaking to you inside of your thinking.

Write down what word, phrase, image, or feeling came to mind and what this
means to your relationship with God.

If you take that step, then you will feel the peace that AA calls serenity. God will
tell you the next step, not the second or the third step. If you follow God’s plan
systematically, then you are free.
Appendix 34: Honesty for Gamblers

Robert R. Perkinson, PhD

This is an exercise to help you get honest with yourself. In recovery, it is essential
to tell the truth. As you will hear at every Gamblers Anonymous (GA) meeting,
this is a program of rigorous honesty. Those who do not recover are people who
cannot, or will not, completely give themselves to this simple program.

Dishonesty to self and others distorts reality. You never will solve problems if
you lie. You need to live in the facts. You must commit yourself to reality. This
means accepting everything that is real.

Gamblers lie to themselves when they think they can beat a game of chance.
Chance means you cannot manipulate the outcome of a game. Gamblers constantly
think they can figure a game out, which machine will win, which numbers will
come up, which horse will win, which card they will draw, or which number will
come up in roulette or bingo. The actual odds are this: The house gets 6% of every
dollar you bet, so if you continue to gamble, you will lose every penny you have.
Gambling establishments are not fancy because of the winners; they are fancy
because they can predict that the odds are always in their favor. The casino will
always win. All of the games are stacked in their favor, and there is no way you
can predict a game of chance. Each time you play each game, the odds are exactly
the same. There is no way to predict which horse, number, color, or machine will
win. The odds are exactly the same each time you play. Gamblers constantly think
they can figure a game out and increase the odds of winning, but this is never true.
Memorize this sentence, and say it over and over to yourself: “If I continue to
gamble, there is a 100% chance that I will lose everything.”

A video lottery machine has a random number generator that randomly generates
the next numbers. Let us say the odds on one machine are 200 to 1 big win. So
imagine that you have 200 white marbles in a bin and one red marble. You spin the
bin and draw out one marble. The odds of choosing the red marble are 200 to 1.
Now you put the marble back in the bin, spin the bin, and draw out a marble. The
odds are exactly the same 200 to 1. All gambling is a game of chance, and there is
no way to predict when the machine, game, or player is going to change the odds.
In the marble game, there will always be a 200 to 1 chance that you will win. The
real odds are that if you continue to gamble you will be penniless. A casino only
offers games of chance—never games of skill. The house would not let you play a
game of skill because you could learn the skill and increase your odds of winning.
The house never makes this mistake. The odds are always in favor of the casino. If
you continue to gamble, the casino will always win. If you continue to gamble, you
will always lose everything.

Here is a list of 10 statements you may have said to yourself that gave you the
illusion that you could figure out a game of chance.

1. This machine has not paid out all day; it is ready to pay. No, the odds are
always the same.
2. This horse always wins on a muddy track. No, the odds of one horse winning
are always the same.
3. This blackjack dealer is unlucky; this is the table to play. I would win here.
No, with every deal the odds are always the same.
4. If I keep playing this color it has to win soon. No, the odds are always
random.
5. This roulette dealer spins too fast, the ball runs too fast, and this makes it
more likely that the ball will fall on number 22. No, the odds are random and
always the same. If you continue to gamble, you will be penniless.
6. If I keep count of the numbers, I can figure this game out and increase my
odds of winning. No, games of chance are not games of skill. The odds are
the same every time you play the game.
7. I always use this machine. It pays out the best. No, a machine has a random
number generator, and each time you play you have the same odds of
winning.
8. If I keep playing the numbers of my birthday, I will win every time. No, the
odds are if you continue to gamble you will lose every cent you have.
9. If I do not want to win, I win every time. No, the odds are always the same.
10. This is my lucky day. I cannot lose. No, the odds are random; you cannot
predict or use a skill to change the odds at a game of chance.

People who are pathological gamblers think that they cannot tell the truth. They
believe that if they do, then they will be rejected. The facts, however, are exactly
the opposite. Unless you tell the truth, no one can accept you. People have to know
you to accept you. If you keep secrets, then you never will feel known or loved.
You are only as sick as your secrets. If you keep secrets from people, then you
never will be close to them.
You cannot be a practicing gambling addict without lying to yourself. You must lie
and believe the lies or else the illness cannot operate. All of the lies are attempts
to protect you from the truth. If you had known the truth, then you would have
known that you were sick and needed treatment. This would have been frightening,
so you kept the truth from yourself and from others. Let us face it. When we were
gambling, we were not honest with ourselves.

There are many ways in which you lied to yourself. This exercise will teach you
exactly how you distorted reality, and it will start you toward a program of
honesty. Respond to each of the following as completely as you can.

1. Denying: This is telling yourself or others, “I do not have a problem.” Write

down five examples of when you used this technique to avoid the anxiety of
the truth.
2. Minimizing: This is making the problem smaller than it really is. You may
have told yourself, or someone else, that your problem was not that bad. You
may have told someone that you lost a little money when, in fact, you lost a
lot. Write down five examples of when you distorted reality by making the
problem seem smaller than it actually was.
3. Being hostile: This is getting angry, shutting people out, or making threats
when someone confronts you about your gambling. Give five examples of
when you expressed such hostility.
4. Rationalizing: This is making an excuse. “I had a hard day. Things are bad.
My relationship is bad. My financial situation is bad. The only way I can
recover my losses is to gamble.” Give five examples of when you thought
that you had a good reason to gamble.
5. Blaming: This is shifting the responsibility to someone else. “The police
were out to get me. My wife is overreacting, my boss is a pain.” Give five
examples of when you blamed someone else for a problem that you caused
by gambling.
6. Intellectualizing: This is overanalyzing and thinking to excess about a
problem. This avoids doing something about it. “Sure, I gamble some, but
everyone I know gambles. I read this article that said this is a gambling
culture. I know this machine is ready to pay out.” Give five examples of how
you use intellectual data and statistics to justify your gambling.
7. Diverting: This is bringing up another topic of conversation to avoid being
confronted with your gambling. Give five examples.

Make a list of five lies about your gambling problem that you told to someone
close to you.

1.
2.
3.
4.
5.

Make a list of five lies about your gambling problem that you told to yourself.

1.
2.
3.
4.
5.

Make a list of 10 people to whom you have lied.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

How do you feel about your lying? Describe how you feel about yourself
when you lie.
List five things you think will change in your life if you stop gambling and
tell the truth.

1.
2.
3.
4.
5.
 How do you use lies in other areas of your life?
When are you the most likely to lie? Is it when you have been gambling?
Why do you lie? What does it get you? Give five reasons.

1.
2.
3.
4.
5.

Common lies of gamblers are listed here. Give a personal example of each.

1. Breaking promises:
2. Pretending you have not gambled when, in fact, you have:
3. Pretending that you remember how long you had been gambling when, in fact,
you lost all track of time:
4. Telling someone that you gamble no more than others do:
5. Telling yourself that you were in control of your gambling:
6. Telling someone that you rarely gamble:
7. Hiding your gambling:
8. Hiding money for gambling:
9. Substituting gambling for other activities and then telling someone that you
were not interested in doing what that person wanted to do:
10. Saying that you were too sick to do something when, in fact, you really
wanted to gamble:
11. Pretending not to care about your gambling problem:

People who are pathological gamblers lie to avoid facing the pain of the truth.
Lying makes them feel more comfortable, but in the end they end up feeling
isolated and alone. Recovery demands living in the truth. “I am a pathological
gambler. My life is unmanageable. I am powerless over gambling. I need help. I
cannot do this alone.” All of these are honest statements from someone who is
living in reality.

You can either get real and live in the real world or live in a fantasy world of your
own creation. If you get honest, then you will begin to solve real problems. You
will be accepted for who you are.

Wake up tomorrow morning and promise yourself that you are going to be honest
all day. Write down in a diary when you are tempted to lie. Watch your emotions
when you lie. How does it feel? How do you feel about yourself? Write it all
down. Keep a diary for 5 days, and then share it with your group. Tell the group
members how it feels to be honest.

Write the word truth on a piece of paper and hang it on your bathroom mirror.
Commit yourself to rigorous honesty. You deserve to live a life filled with love
and truth. You never need to lie again.

List 10 reasons you want to stop gambling.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Appendix 35: Step One for Gamblers

Robert R. Perkinson, PhD

We admitted we were powerless over gambling—that our lives had become

unmanageable.

—Gamblers Anonymous (GA) (1989b, p. 38)

Before beginning this exercise, please read Step One in G.A.: A New Beginning
(GA, 1989b).

No one likes to admit defeat. Our minds rebel at the very thought that we have lost
control. We are big, strong, intelligent, and capable. How can it be that we are
powerless? How can our lives be unmanageable? This exercise will help you to
sort through your life and to make some important decisions. Answer as
completely as you can each question that applies to you. This is an opportunity for
you to get accurate. You need to see the truth about yourself.

Let us pretend for a moment that you are the commander in a nuclear missile silo.
You are in charge of a bomb. If you think about it, this is exactly the kind of
control that you want over your life. You want to be in control of your thinking,
feeling, and behavior. You want to be in control all of the time, not just some of
the time. If you do something by accident, or if you do something foolishly, then
you might kill many people.

What is the first thing a compulsive gambler ought to do in order to stop

gambling? The compulsive gambler needs to accept the fact that he or she is
in the grip of a progressive illness and has a desire to get well. (GA, 1989a,
p. 8)

To accept powerlessness and unmanageability, a gambler must look at the truth.

People who are powerless over gambling do things that are harmful to themselves
and others. They do most anything to stay in action—to keep gambling. Gamblers
do not consider the consequences of their behavior, and they keep gambling until
they are on the verge of death.

Gamblers are in action when they plan a bet, make a bet, or wait for a bet to come
in. Once the bet is in, they are out of action. Being in action is a primary goal of
compulsive gamblers. By staying in action, gamblers feel how they want to feel.
They escape reality. They live in a fantasy world of their own creation. Some
gamblers gamble for the thrill and some to escape. Now it is time to get honest
with yourself.
Powerlessness
People who are powerless do things that they feel bad or guilty about later. To
gamble, they may lie, cheat, steal, hurt their family members, or do poor work.
Make a list of five things that made you feel the most uncomfortable about
gambling in the past.

1.
2.
3.
4.
5.

People who are powerless gradually lose respect for themselves. They will have
difficulty in trusting themselves. List five ways you have lost respect for yourself
due to gambling.

1.
2.
3.
4.
5.

People who are powerless will do things that they do not remember doing. When
gamblers gamble, they can lose all track of time. They might think that they have
been gambling for only a few minutes when, in fact, they have been gambling for
many hours. If you gamble enough, you cannot remember things properly. Describe
five situations when you lost track of time while you were gambling.

1.
2.
3.
4.
5.

People who are powerless cannot keep promises they make to themselves or
others. They promise that they will cut down on their gambling, and they do not.
They promise that they will not gamble, and they do. They promise to be home, to
be at work, to be at the Cub Scout meeting, or to go to school, but they do not
make it. They cannot always do what they want to do. They disappoint themselves,
and they lose trust in themselves. Other people lose trust in them. Gamblers can
count on themselves some of the time, but they cannot count on themselves all of
the time.

1. List five times you promised yourself that you would cut down on your
gambling.
2. What happened to each of these promises?

3. Did you ever promise yourself that you would quit entirely?
Yes No
4. What happened to your promise?
5. Did you ever make a promise to someone that you did not keep because you
were gambling? Give five examples.

6. Are you reliable when you are gambling?

Yes No

People who are powerless lose control of their behavior. They do things that they
would not normally do when not in action. They might get into fights. They might
yell at people they love—their spouses, children, parents, or friends. They might
say things that they do not mean.

Have you ever gotten into an argument with someone because you were gambling?
Describe five times.

1.
2.
3.
4.
5.

The desire to gamble is very powerful. It makes a gambler feel irritable and
impatient. People who are powerless say things that they do not mean. They say
things that they feel guilty about later. We might not remember everything we said,
but the other person does remember. List five times when you said something or
did something that you did not mean when gambling or craving gambling? What
did you say? What did you do?
 1.
2.
3.
4.
5.

People are powerless when they cannot deal with their feelings. They may gamble
because they feel frightened, angry, or sad. They medicate their feelings with
gambling.

1. Have you ever gambled to cover up your feelings? Give three examples.
a.
b.
c.
2. List the feelings that you have difficulty dealing with.

People are powerless when they are not safe. What convinces you that you no
longer can gamble safely?

People are powerless when they know that they should do something, but they
cannot make themselves do it. They might make a great effort to do the right thing,
but they keep doing the wrong thing.

1. Could you cut down on your gambling every time you wanted for as long as
you wanted?
Yes No

2. Did gambling ever keep you from doing something at home that you thought
you should do? Give five examples.
a.
b.
c.
d.
e.

3. Did gambling ever keep you from going to work? Give five examples.
a.
b.
c.
d.
 e.
4. Did you ever lose a job because of your gambling? Write down what
happened.

People are powerless when other people have to warn them that they are in
trouble. You may have felt as though you were fine, but people close to you
noticed that something was wrong. It probably was difficult for them to define just
what was wrong, but they worried about you. It is difficult to confront people
when they are wrong, so most people avoid the problem until they cannot stand the
behavior anymore. When gamblers are confronted with their behavior, they feel
annoyed and irritated. They want to be left alone with the lies that they are telling
themselves. Has anyone ever talked to you about your gambling? Who was this?
How did you feel?

People are powerless when they do not know the truth about themselves.
Gamblers lie to themselves about how much they are gambling. They lie to
themselves about how often they gamble. They lie to themselves about the amount
of money they are losing, even when the losses are obvious. They blame others for
their problems. Some common lies that they tell themselves include the following:

“I can quit anytime I want to.”

“I only gamble a little.”
“The police are out to get me.”
“I only gamble when I want to.”
“Everybody does it.”
“I gamble, but I do not have a problem.”
“Anybody can have financial problems.”
“My friends will not like me if I do not gamble.”
“I never have problems when I gamble.”
“I can pay the money back later.”
“From now on, I would just gamble a little.”
“When I win, I am going to buy a present for my family.”

Gamblers continue to lie to themselves to the very end. They hold on to their
delusional thinking, and they believe that their lies are the truth. They deliberately
lie to those close to them. They hide their gambling. They make their problems
seem smaller than they actually are. They make excuses for why they are
gambling. They refuse to see the truth.
1. Have you ever lied to yourself about your gambling? List five lies that you
told yourself.
2. List five ways in which you tried to convince yourself that you did not have a
problem.
3. List five ways in which you tried to convince others that you did not have a
problem.

Therefore, it is not surprising that our gambling careers have been

characterized by countless vain attempts to prove we could gamble like other
people. The idea that somehow, someday, we will control our gambling is
the great obsession of every compulsive gambler. The persistence of this
illusion is astonishing. Many pursue it to the gates of prison, insanity, or
death (GA, 1989a, p. 2).
Unmanageability
Imagine that you are the manager of a large corporation. You are responsible for
how everything runs. If you are not a good manager, then the business will fail.
You must carefully plan everything and carry out those plans well. You must be
alert. You must know exactly where you are and where you are going. These are
the skills that you need to manage your life effectively.

Gamblers are not good managers. They keep losing control. Their plans fall
through. They cannot devise and stick to things long enough to see a solution. They
are lying to themselves, so they do not know who they are. They feel confused.
Their feelings are being changed by gambling, so they cannot use their feelings to
give them energy and direction for problem solving.

You do not have to be a bad manager all of the time. It is worse to be a bad
manager some of the time. It is very confusing. Most gamblers have flurries of
productive activity during which they work too much. They work themselves to
the bone, and then they let things slide. It is like being on a roller coaster.
Sometimes things are in control, and sometimes things are out of control. Things
are up and down, and gamblers never can predict which way things are going to
be tomorrow.

People’s lives are unmanageable when they have plans fall apart because they are
gambling. Make a list of 5 plans that you failed to complete because of your
gambling.

1.
2.
3.
4.
5.

People’s lives are unmanageable when they cannot manage their finances
consistently.

1. List the money problems that you are having.

2. Explain how gambling has contributed to these problems.
People’s lives are unmanageable when they cannot trust their own judgments.

1. Have you ever been so absorbed in your gambling that you did not know
what was happening around you? Explain.
2. Did you ever lie to yourself about your gambling? Explain how your lies
contributed to your being unable to manage your life.
3. Have you ever made a decision while gambling that you were sorry about
later? List five times.

People’s lives are unmanageable when they cannot work or play normally.
Gamblers miss work and recreational activities because of their gambling.

List five times when you missed work because you were gambling.

1.
2.
3.
4.
5.

List five recreational or family activities you missed because you were gambling.

1.
2.
3.
4.
5.

People’s lives are unmanageable when they are in trouble with other people or
society. Gamblers break the rules of society to get their own way. They have
problems with authority.

1. Have you ever been in legal trouble when you were gambling? Explain the
legal problems you have had.
2. Have you ever had problems with your parents because of your gambling?
Explain.
3. Have you ever had problems in school because of your gambling? Explain.

People’s lives are unmanageable when they cannot consistently achieve goals.
Gamblers reach out for what they want, but something keeps getting in the way. It
does not seem fair. They keep falling short of their goals. Finally, they give up
completely. They may have had the goals of going to school, getting a better job,
working on family problems, getting in good physical condition, and/or going on a
diet. No matter what the goals are, something keeps going wrong with the plans.
Gamblers constantly try to blame someone else, but they cannot work long enough
to reach their goals. Gamblers are good starters, but they are poor finishers.

List five goals that you had for yourself that you did not achieve because of
gambling.

1.
2.
3.
4.
5.

People’s lives are unmanageable when they cannot use their feelings
appropriately. Feelings give us energy and direction for problem solving.
Gamblers change their feelings by staying in action. Gambling gives them a
different feeling. Gamblers become very confused about how they feel.

1. What feelings have you tried to alter with gambling?

2. How do you feel when you are gambling? Describe them in detail.

People’s lives are unmanageable when they violate their own rules by violating
their own morals and values. Gamblers compromise their values to continue
gambling. They have the value not to lie, but they lie anyway. They have the value
not to steal, but they steal anyway. They have the value to be loyal to spouses or
friends, but when they are gambling they do not remain loyal. Their values and
morals fall away, one by one. They end up doing things that they do not believe in.
They know that they are doing the wrong things, but they do them anyway.

1. Did you ever lie to cover up your gambling? How did you feel about
yourself?
2. Were you ever disloyal when gambling? Explain.
3. Did you ever steal or write bad checks to gamble? Explain what you did and
how you felt about yourself later.
4. Did you ever break the law when gambling? What did you do?
5. Did you ever hurt someone you loved while gambling? Explain.
 6. Did you treat yourself poorly by refusing to stop gambling when you knew
that it was bad for you? Explain how you were feeling about yourself.
7. Did you stop going to church? How did this make you feel about yourself?

People’s lives are unmanageable when they continue to do something that gives
them problems. Gambling creates severe financial problems. Even if gamblers are
aware of the problems, they gamble anyway. They see gambling as the solution.

Gambling causes psychological problems. Compulsive gambling makes people

feel depressed, fearful, anxious, and/or angry. Even when gamblers are aware of
these symptoms, they continue to gamble.

Gambling creates relationship problems. It causes family problems in the form of

family fights as well as verbal and physical abuse. It causes interpersonal conflict
at work, with family, and with friends. Gamblers withdraw and become isolated
and alone.

1. Did you have any persistent physical problems caused by, or made worse by,
gambling? Describe the problems.
2. Did you have any persistent psychological problems, such as depression, that
were caused by your gambling? Describe the problems.
3. Did you have persistent interpersonal conflicts that were made worse by
gambling? Describe the problems.

We know that no real compulsive gambler ever regains control. All of us felt
at times we were regaining control, but such intervals—usually brief—were
inevitably followed by still less control, which led in time to pitiful and
incomprehensible demoralization. We are convinced that gamblers of our
type are in the grip of a progressive illness. Over any considerable period of
time, we get worse, never better. (GA, 1989a, p. 3)

You must have good reasons to work toward a new life free from gambling. Look
over this exercise, and list 10 reasons why you want to stop gambling.

1.
2.
3.
4.
 5.
6.
7.
8.
9.
10.

After completing this exercise, take a long look at yourself. What is the truth?

1. Have there been times when you were powerless over gambling?
Yes No

2. Have there been times when your life was unmanageable?

Yes No
Appendix 36: Step Two for Gamblers

Robert R. Perkinson, PhD

[We] came to believe that a power greater than ourselves could restore us
to a normal way of thinking and living.

—Gamblers Anonymous (GA) (1989b, p. 39)

Before beginning this exercise, please read Step Two in G.A.: A New Beginning
(GA, 1989b).

In Step One, you admitted that you were powerless over gambling and that your
life was unmanageable. In Step Two, you need to see the insanity of your disease
and seek a power greater than yourself. If you are powerless, then you need
power. If your life is unmanageable, then you need a manager. Step Two will help
you to decide who that manager can be.

Most gamblers revolt at the implications of the phrase “restore to a normal way of
thinking and living.” They think that they may have a gambling problem, but they
do not feel as though they have been abnormal.

In GA, the word normal means being of sound mind. Someone with a sound mind
knows what is real and knows how to adapt to reality. A sound mind feels stable,
safe, and secure. Someone who is abnormal cannot see reality and is unable to
adapt. A person does not have to have all of reality distorted to be in trouble. If
you miss some reality, then you ultimately will get lost. One wrong turn is all that
it takes to end up in a ditch.

Going through life is like a long journey. You have a map given to you by your
parents. The map shows the way in which to be happy. If you make some wrong
turns along the way, then you will end up unhappy. This is what happens in
gambling. Searching for happiness, we make wrong turns. We find out that our
map is defective. Even if we followed our map to perfection, we still would be
lost. What we need is a new map.
GA gives us this new map. It puts up 12 signposts to show us the way. If you
follow this map as millions of people have, then you will find the joy and
happiness that you have been seeking. You have reached and passed the first
signpost, Step One. You have decided that your life is powerless and
unmanageable over gambling. Now you need a new power source. You need to
find someone else who can manage your life.

GA is a spiritual program, and it directs you toward a spiritual solution. It is not a

religious program. Spirituality is defined as the relationship you have with
yourself and all else. Religion is an organized system of faith and worship.
Everyone has spirituality, but not everyone has religion.

You need to explore three relationships very carefully in Step Two: the
relationships with yourself, with others, and with a Higher Power. This Higher
Power can be any Higher Power of your choice. If you do not have a Higher
Power right now, do not worry. Most of us started that way. Just be willing to
consider that there is a power greater than you in the universe.

To explore these three relationships, you need to see the truth about yourself. If
you see the truth, then you can find the way. First you must decide whether you
were abnormal. Did you have a sound mind or not? Let us look at this issue
carefully.

People are abnormal when they cannot remember what they did. They have
memory problems. To be abnormal, they do not have to have memory problems all
of the time; they just need to have them some of the time. People who gamble
might not remember what happened to them when they were gambling. Long
periods of time can pass during which gamblers are relatively unaware of their
environment.

List any memory problems that you have had while gambling. Did you ever find
that you had spent more time gambling that you remembered?

People who are abnormal lose control over their behavior. They do things when
they are gambling that they never would do otherwise.

List three times when you lost control over your behavior while gambling.

1.
2.
 3.

List three times when you could not control your gambling—when you told
yourself to stop but you could not.

1.
2.
3.

People who are abnormal consider self-destruction.

Did you ever consider hurting yourself when you were gambling or suffering from
gambling losses?

Yes No

Describe what happened.

People who are abnormal feel emotionally unstable.

Have you ever thought that you were going crazy because of your gambling?

Yes No

Describe some of these times.

Have you recently felt emotionally unstable?

Yes No

Describe how you have been feeling.

People who are abnormal are so confused that they cannot get their lives in order.
They frantically try to fix things, but problems remain out of control.
List 10 personal, family, work, or school problems that you have not been able to
control.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

People who are abnormal cannot see the truth about what is happening to them.
People who are gambling hide their gambling from themselves and from others.
They minimize, rationalize, and deny that there are problems.

Do you feel that you have been completely honest with yourself?

Yes No

List five lies that you told yourself so you could continue gambling.

1.
2.
3.
4.
5.

People who are abnormal cut themselves off from healthy relationships. You might
find that you cannot communicate with your spouse as well as you used to. You
might not see your friends as often. More and more of your life centers around
gambling.

List three people you do not see anymore because of your gambling.

1.
 2.
3.

As your gambling increased, did you go to church less often?

Yes No

List five relationships that you have damaged in your gambling.

1.
2.
3.
4.
5.

People who are abnormal cannot deal with their feelings. Problem gamblers
cannot deal with their feelings. They do not like how they feel, so they gamble to
control their feelings. Some people gamble to feel excited and some people
gamble to escape.

List the feelings that you wanted to change by gambling.

Now look back over your responses. Get out your Step One exercise and read it.
Look at the truth about yourself. Look carefully at how you were thinking, feeling,
and behaving when you were gambling. Make a decision. Do you think that you
had a sound mind? If you were unsound at least some of the time, then you were
abnormal. If you believe this to be true, then say this to yourself: “I am powerless.
My life is unmanageable. My mind is unsound. I have been abnormal in thinking
and living.”
A Power Greater Than Ourselves
Consider a power greater than yourself. What exists in the world that has greater
power than you do—a river, the wind, the universe, the sun?

List five things that have greater power than you do.

1.
2.
3.
4.
5.

The first Higher Power that you need to consider is the power of the GA group.
The group is more powerful than you are. Ten hands are more powerful than two
are. Two heads are better than one. GA operates in groups. The group works like
a family. The group process is founded in love and trust. Each member shares his
or her experiences, strengths, and hopes in an attempt to help him or her and
others. There is an atmosphere of anonymity. What you hear in group is
confidential.

The group acts as a mirror reflecting you to yourself. The group members will
help you to discover the truth about whom and what you are. You have been
deceiving yourself for a long time. The group will help you to uncover the lies.
You will come to understand the old GA saying, What we cannot do alone, we can
do together. In group, you will have greater power over the disease because the
group will see the whole truth better than you can.

You were not lying to hurt yourself; you were lying to protect yourself. In the
process of building your lies, you cut yourself off from reality. This is how
compulsive gambling works. You cannot recover from addiction by yourself. You
need power coming from somewhere else. Begin by trusting your group. Keep an
open mind.

You need to share in your group. The more you share, the closer you will get and
the more trust you will develop. If you take risks, then you will reap the rewards.
You do not have to tell the group everything, but you need to share as much as you
can. The group can help you to straighten out your thinking and restore you to
sanity.

Many gamblers are afraid of a Higher Power. They fear that a Higher Power will
punish them or treat them in the same way that their fathers or mothers did. They
might fear losing control. List some of the fears that you have about a Higher
Power.

Some gamblers have difficulty in trusting anyone. They have been so hurt by
others that they do not want to take the chance of being hurt again. What has
happened in your life that makes it difficult for you to trust?

What are some of the things you will need to see from a Higher Power that
will show you that the Higher Power can be trusted?
Who was the most trustworthy person you ever knew?
How did this person treat you?
What do you hope to gain by accepting a Higher Power?

GA wants you to come to believe in a power greater than yourself. You can accept
any Higher Power that you feel can restore you to sanity. Your group, nature, your
counselor, and your sponsor all can be used to give you this restoration. You must
pick this Higher Power carefully. We suggest that you use GA as your Higher
Power for now. Here is a group of people who are recovering. They have found
the way. This program ultimately will direct you toward a God of your own
understanding.

Millions of gamblers have recovered because they were willing to reach out for
God. GA makes it clear that nothing else will remove the obsession to gamble.
Some of us have so glorified our own lives that we have shut out God. Now is
your opportunity. You are at a major turning point. You can begin to open your
heart and let God in, or you can keep God out. God tells us that all who seek will
find.

Remember that this is the beginning of a new life. To be new, you have to do
things differently. All that the program is asking you to do is be open to the
possibility that there is a power greater than you are. GA does not demand that you
believe in anything. The 12 steps are simply suggestions. You do not have to
swallow all of this now, but you need to be open. Most recovering persons take
the Second Step a piece at a time.

First you need to learn how to trust yourself. You must learn how to treat yourself
well. What do you need to see from yourself that will show you that you are
trustworthy?

Then you need to begin to trust your group. See whether the group members act
consistently in your interest. They will not always tell you what you want to hear.
No real friend would do that. They will give you the opportunity and
encouragement to grow. What will you need to see from the group members that
will show you that they are trustworthy?

Every person has a unique spiritual journey. No one can start this journey with a
closed mind. What is it going to take to show you that God exists?

Step Two does not mean that we believe in God as God is presented in any
religion. Remember that religion is an organized system of worship. It is human-
made. Worship is a means of assigning worth to something. Many people have
been so turned off by religion that the idea of God is unacceptable. “We found that
some of the obstacles preventing us from attempting to believe were pride, ego,
fear, self-centeredness, defiance, and grandiosity” (GA, 1989b, p. 40).

Describe the religious environment of your childhood. What was it like?

What did you learn about God?
How did these early experiences influence the beliefs that you have today?
What experiences have caused you to doubt God?
Your willingness is essential to your recovery. Give some examples of your
willingness to trust in a Higher Power of your choice. What are you willing
to do?
Describe your current religious beliefs.
Explain the God of your own understanding.

List five reasons why a Higher Power will be good for you.

1.
2.
3.
4.
5.

If you asked the people in your GA group to describe God, you would get a
variety of answers. Each person has his or her own understanding of God. It is this
unique understanding that allows God to work individually for each of us. God
comes to each of us differently.
Appendix 37: Step Three for Gamblers

Robert R. Perkinson, PhD

[We] made a decision to turn our will and our lives over to the care of this
power of our own understanding.

—Gamblers Anonymous (GA) (1989b, p. 40)

Before beginning this exercise, please read Step Three in G.A.: A New Beginning
(GA, 1989b).

You have come a long way in the program, and you can feel proud of yourself. You
have decided that you are powerless over gambling and that your life is
unmanageable. You have decided that a Higher Power of some sort can restore
you to normal thinking and living.

In Step Three, you will reach toward a Higher Power of your own understanding.
This is the miracle. It is the major focus of the GA program. This is a spiritual
program that directs you toward the ultimate in truth. It is important that you be
open to the possibility that there is a God. It is vital that you give this concept
room to blossom and grow.

Many of us used our sponsor, other members, or the fellowship as this Higher
Power, but eventually, as we proceeded with the work required in these
steps, we came to believe this Higher Power to be a God of our own
understanding. (GA, 1989b, p. 40)

Step Three should not confuse you. It calls for a decision to correct your character
defects under spiritual supervision. You must make an honest effort to change your
life.

The GA program is a spiritual one. Gamblers in recovery must have the honesty to
look at their illness, the open-mindedness to apply the solution being told to
themselves, and the willingness to apply this solution by proceeding on with the
recovery process. If you are willing to seek God, then you will find God. That is
GA’s promise.
Understanding the Moral Law
All spirituality has, at its core, what is already inside of you. Your Higher Power
lives inside of you. Inside of all of us, there is inherent goodness. In all cultures,
and in all lands, this goodness is expressed in what we call the moral law.
Morality demands love in action and in truth. It is simply stated as follows: Love
God all you can, love others all you can, and love yourself all you can. This law
is very powerful. If some stranger were drowning in a pool next to you, then this
law would motivate you to help. Instinctively, you would feel driven to help, even
if it put your own life at risk. The moral law is so important that it transcends our
instinct for survival. You would try to save that drowning person at your own risk.
This moral law is exactly the same everywhere—in every culture. It exists inside
of everyone. It is written on our hearts. Even among thieves, honesty is valued.

When we survey religious thought, we come up with many different ideas about
God and about how to worship God. When we look at saints of the various
religions, we see that they are living practically indistinguishable lives. They all
are doing the same things. They do not lie, cheat, or steal. They believe in giving
to others before they give to themselves. They try not to be envious of others. To
believe in a Higher Power, you must believe that this good exists inside of you.
You also must believe that there is more of this good outside of you. If you do not
believe in a living, breathing God at this point, do not worry. Every one of us has
started where you are.

All people have a basic problem: We break the moral law, even if we believe in
it. This fact means that something is wrong with us. We are incapable of following
the moral law. Even though we would deem it unfair for someone to lie to us,
occasionally we lie to someone else. If we see someone dressed in clothes that
look terrible, then we might tell the person that he or she looks good. This is a lie.
We would not want other people lying to us like that. In this and other situations,
we do not obey the very moral law that we know is good.

You must ask yourself several questions. Where did we get this moral law? How
did this law of behavior get started? Did it just evolve? The GA program believes
that these good laws come from something good. People in the program believe
that you can communicate with this goodness.

Much of God remains a mystery. If we look at science, we find the same thing;
most of science is a mystery. We know very little about the primary elements of
science such as gravity, but we make judgments about these elements using our
experience. No one has ever seen an electron, but we are sure that it exists
because we have some experience of it. It is the same with the Higher Power. We
can know that there is a power greater than we are if we have some experience of
this power. Both science and spirituality necessitate a faith based on experience.

Instinctively, people know that if they can get more goodness, they will have better
lives. Spirituality must be practical. It must make your life better, or you will
discard it. If you open yourself up to the spiritual part of the program, then you
will feel better immediately.

By reading this exercise, you can begin to develop your relationship with a Higher
Power. You will find true joy here if you try. Without some sort of a Higher
Power, your recovery will be more difficult. A Higher Power can relieve your
gambling problem as nothing else can. Many people achieve stable recovery
without calling their Higher Power “God.” That certainly is possible. There are
many wonderful atheists and agnostics in our program. The GA way is to reach for
a God of your own understanding.

You can change things in your life. You really can. You do not have to drown in
despair any longer.
The Key to Step Three
The key to working Step Three is willingness. You must have the willingness to
turn your life over to the care of God as you understand God. This is difficult for
many of us because we think that we are still in control. We are completely fooled
by this delusion. We feel as though we know the right thing to do. We feel that
everything would be fine if others would just do things our way. This leads us to
deep feelings of resentment and self-pity. People would not cooperate with our
plan. No matter how hard we tried to control everything, things kept getting out of
control. Sometimes the harder we worked, the worse things got.
How to Turn It Over
To arrest gambling, you have to stop playing God and let the God of your own
understanding take control. If you sincerely want this and you try, then it is easy.
Go to a quiet place, and talk to your Higher Power about your gambling. Say
something like this: “God, I am lost. I cannot do this anymore. I turn this situation
over to you.” Watch how you feel when you say this prayer. The next time you
have a problem, stop and turn the problem over to your Higher Power. Say
something like this: “God, I cannot deal with this problem. You deal with it.” See
what happens.

Your Higher Power wants to show you the way. If you try to find the way yourself,
you will be constantly lost.

Step Three offers no compromise. It calls for a decision. Exactly how we

surrender and turn things over is not the point. The important thing is that you be
willing to try. Can you see that it is necessary to give up your self-centeredness?
Do you feel that it is time to turn things over to a power greater than you are?

List five things you have to gain by turning your will and your life over to a Higher
Power.

1.
2.
3.
4.
5.

Why do you need to turn things over to a Higher Power?

We should not confuse organized religion with spirituality. In Step Two, you
learned that spirituality deals with your relationships with yourself, with others,
and with your Higher Power. Religion is an organized system of faith and
worship. It is human-made, not God-made. It is humans’ way of interpreting God.
Religion can be very confusing, and it can drive people away from God. Are old
religious ideas keeping you from God? If so, then how?

A great barrier to finding your Higher Power may be impatience. You may want to
find God right now. You must understand that your spiritual growth is not set by
you. You will grow spiritually when God feels that you are ready. Remember that
we are turning this whole thing over. Each person has his or her unique spiritual
journey. Each individual must have his or her own walk. Spiritual growth, not
perfection, is your goal. All that you can do is seek the God of your understanding.
When God knows that you are ready, God will find you.

Total surrender is necessary. If you are holding back, then you need to let go
absolutely. Faith, willingness, and prayer will overcome all of the obstacles. Do
not worry about your doubt. Just keep seeking.

List 10 ways in which you can seek God. Ask someone in the program, a
clergyperson, or your counselor to help you.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

What does the saying, “Let go and let God,” mean to you?

What are five ways in which you can put Step Three to work in your life?

1.
2.
3.
4.
5.

What things in your life do you still want to control?

How can these things be handled better by turning them over to your Higher
Power?
List five ways in which you allowed gambling to be the God in your life.

1.
2.
3.
4.
5.

How did gambling separate you from God?

What changes have you noticed in yourself since you entered the program?

Of these changes, which of them occurred because you listened to someone other
than yourself?

Make a list of five things that are holding you back from turning things over to
God.

1.
2.
3.
4.
5.

How do you see God caring for you?

How do you understand God now?

Write down your spiritual plan. What five things are you going to do on a daily
basis to help your spiritual program grow?

1.
2.
3.
4.
5.
Appendix 38: Step Four for Gamblers

Robert R. Perkinson, PhD

[We] made a searching and fearless moral and financial inventory of

ourselves.

—Gamblers Anonymous (GA) (1989b, p. 68)

Before beginning this exercise, please read Step Four in G.A.: A New Beginning
(GA, 1989b).

You are doing well in the program. You have admitted your powerlessness over
gambling, and you have found a Higher Power that can restore you to normal
thinking and living. Now you must take an inventory of yourself. You must know
exactly what resources you have available, and you must examine the exact nature
of your wrongs. You need to be detailed about the good things about you as well
as the bad things about you. Only by taking this inventory will you know exactly
where you are. Then you can decide where you are going.

In taking this inventory, you must be detailed and specific. It is the only way of
seeing the complete impact of your disease. A part of the truth might be, “I told
lies to my children.” The complete truth might be, “I told my children that I had
cancer. They were terrified and cried for a long time.” These two statements
would be very different. Only the second statement tells the exact nature of the
wrong, and the client felt the full impact of the disclosure. You can see how
important it is to put the whole truth before you at one time—the truth that will set
you free.

The Fourth Step is a long autobiography. You can write it down carefully. Read
this exercise before you start, and underline things that pertain to you. You will
want to come back and cover each of these issues in detail as you write it down. If
the problem does not relate to you, then leave it blank. Examine exactly what you
did wrong. Look for your mistakes, even where the situations were not totally your
fault. Try to disregard what the other person did, and concentrate on yourself
instead. In time, you will realize that the person who hurt you was spiritually sick.
You need to ask God to help you forgive that person and to show that person the
same understanding that you would want for yourself. You can pray that this
person finds out the truth about himself or herself.

Review your natural desires carefully, and think about how you acted on them.
You will see that some of them became the God of your life. Sex, food, money,
relationships, sleep, power, and influence all can become the major focus of our
lives. The pursuit of these desires can take total control and can become the center
of our existence.

Review your sexuality as you move through the inventory. Did you ever use
someone else selfishly? Did you ever lie to get what you wanted? Did you coerce
or force someone into doing something that he or she did not want to do? Whom
did you hurt, and exactly what did you do?

In working through the inventory, you will experience some pain. You will feel
angry, sad, afraid, ashamed, embarrassed, guilty, and lonely. The Fourth Step is a
grieving process. As you see your wrongs clearly, you may feel that no one will
ever love you again. Remember that God created you in perfection. You are God’s
masterpiece. There is nothing wrong with you. You just made some mistakes.

Now let us take a basic look at right and wrong.

1. Pride: Too great an admiration of yourself

Pride makes you your own law, your own moral judge, and your own God.
Pride produces criticism, backstabbing, slander, barbed words, and
character assassinations that elevate your own ego. Pride makes you
condemn as fools those who criticize you. Pride gives you excuses. It
produces the following:
1. Boasting or self-glorification
2. Love of publicity
3. Hypocrisy or pretending to be better than you are
4. Hardheadedness or refusing to give up your will
5. Discord or resenting anyone who crosses you
6. Quarrelsomeness or quarreling whenever another person challenges
your wishes
7. Disobedience or refusing to submit your will to the will of superiors or
 to God

2. Covetousness or avarice: Perversion of humans’ God-given right to own

things

Do you desire wealth in the form of money or other things as an end in itself
rather than as a means to an end such as taking care of the soul and body? In
acquiring wealth in any form, do you disregard the rights of others? Are you
dishonest? If so, then to what degree and in what fashion? Do you give an
honest day’s work for an honest day’s pay? How do you use what you have?
Are you stingy with your family? Do you love money and possessions for
these things in themselves? How excessive is your love of luxury? How do
you preserve your wealth or increase it? Do you stoop to devices such as
fraud, perjury, dishonesty, and sharp practices in dealing with others? Do you
try to fool yourself in these regards? Do you call stinginess “thrift”? Do you
call questionable business “big business” or “drive”? Do you call
unreasonable hoarding “security”? If you currently have no money and little
other wealth, then how and by what practice will you go about getting it
later? Will you do almost anything to attain these things and kid yourself by
giving your methods innocent names?

3. Lust: Inordinate love and desires of the pleasures of the flesh

Are you guilty of lust in any of its forms? Do you tell yourself that improper
or undue indulgence in sexual activities is required? Do you treat people as
objects of your desire rather than as God’s perfect creations? Do you use
pornography or think unhealthy sexual thoughts? Do you treat other people
sexually the same way in which you want to be treated?

4. Envy: Sadness at another person’s good

How envious are you? Do you dislike seeing others happy or successful,
almost as though they have taken from you? Do you resent those who are
smarter than you are? Do you ever criticize the good done by others because
you secretly wish you had done it yourself for the honor or prestige to be
gained? Are you ever envious enough to try to lower another person’s
reputation by starting, or engaging in, gossip about that person? Being
envious includes calling religious people “hypocrites” because they go to
church and try to be religiously good even though they are subject to human
 failings. Do you depreciate well-bred people by saying or feeling that they
put on airs? Do you ever accuse educated, wise, or learned people of being
conceited because you envy their advantages? Do you genuinely love other
people, or do you find them distasteful because you envy them?

5. Anger: A violent desire to punish others

Do you ever fly into rages of temper, become revengeful, entertain urges to
“get even,” or express an “I will not let him get away with it” attitude? Do
you ever resort to violence, clench your fists, or stomp about in a temper
flare-up? Are you touchy, unduly sensitive, or impatient at the smallest
slight? Do you ever murmur or grumble, even regarding small matters? Do
you ignore the fact that anger prevents development of personality and halts
spiritual progress? Do you realize at all times that anger disrupts mental
poise and often ruins good judgment? Do you permit anger to rule you when
you know that it blinds you to the rights of others? How can you excuse even
small tantrums of temper when anger destroys the spirit of recollection that
you need for compliance with the inspirations of God? Do you permit
yourself to become angry when others are weak and become angry with you?
Can you hope to entertain the serene spirit of God within your soul when you
often are beset by angry flare-ups of even minor importance?

6. Gluttony: Abuse of lawful pleasures that God attached to eating and drinking
of foods required for self-preservation

Do you weaken your moral and intellectual life by excessive use of food and
drink? Do you generally eat to excess and, thus, enslave your soul and
character to the pleasures of the body beyond its reasonable needs? Do you
kid yourself that you can be a “hog” without affecting your moral life? When
gambling, did you ever win big, only to return and immediately gamble to
win more? Did you gamble so much that your intellect and personality
deteriorated? So much that memory, judgment, and concentration were
affected? So much that personal pride and social judgment vanished? So
much that you developed a spirit of despair?

7. Sloth: Laziness of the will that causes a neglect of duty

Are you lazy or given to idleness, procrastination, nonchalance, and

indifference in material things? Are you lukewarm in prayer? Do you hold
self-discipline in contempt? Would you rather read a novel than study
something requiring brain work such as the GA (1989b) book? Are you
fainthearted in performance of those things that are morally or spiritually
difficult? Are you ever listless with aversion to effort in any form? Are you
easily distracted from things spiritual, quickly turning to things temporal?
Are you ever indolent to the extent where you perform work carelessly?
Personality Defects
1. Selfishness: Taking care of your own needs without regard for others
1. The family would like an outing. Dad would like gambling, golfing, and
fishing. Who wins?
2. Your child needs a new pair of shoes. You put it off until payday but
then gamble away the paycheck.
3. You are afraid to dance because you might appear awkward. You fear
any new venture because it might injure the false front that you put on.

2. Alibis: The highly developed art of justifying gambling and behavior through
mental gymnastics
1. “A few dollars will not hurt anything.”
2. “Starting tomorrow, I am going to change.”
3. “If I did not have a wife and family . . . ”
4. “If I could start all over again.”
5. “A little gambling will help me to relax.”
6. “Nobody cares anyway.”
7. “I had a hard day.”

3. Dishonest thinking: Another way of lying

We may even take truths or facts and, through some phony hopscotch, come
up with exactly the conclusions that we had planned to arrive at. Boy, we are
great at that business.
1. “My secret love is going to raise the roof if I drop her. It is not fair to
burden my wife with that sort of knowledge. Therefore, I will hang on to
my girlfriend. This mess isn’t her fault.” (good, solid con)
2. “If I tell my family about the $500 bonus, then it will all go for bills,
clothes, the dentist, and so on. I have to have some gambling money.
Why start a family argument? I would leave well enough alone.”
3. “My husband dresses well, he eats well, and the kids are getting a good
education. What more do they want from me?”

4. Shame: The feeling that something irreparable is wrong with you

1. No matter how many people tell you it is okay, you continue to berate
yourself.
2. You keep going over and over your mistakes, wallowing in what a
 terrible person you are.

5. Resentment: Displeasure aroused by a real or imagined wrong or injury

accompanied by irritation, exasperation, and/or hate
1. You are fired from your job. Therefore, you hate the boss.
2. Your sister warns you about excessive gambling. You get fighting mad at
her.
3. A coworker is doing a good job and gets accolades. You have a legal
record and suspect that he might have been promoted over you. You hate
his guts.
4. You may have resentment toward a person or a group of people, or you
may resent institutions, religions, and so on. Anger and resentment lead
to bickering, friction, hatred, and unjust revenge. They bring out the
worst of our immaturity and produce misery to ourselves.

6. Intolerance: Refusal to put up with beliefs, practices, customs, or habits that

differ from our own
1. Do you hate other people because they are of another race, come from a
different country, or have a different religion? What would you do if you
were one of those other persons? Kill yourself?
2. Did you have any choice in being born a particular color or nationality?
3. Isn’t our religion usually “inherited”?

7. Impatience: Unwillingness to bear delay, opposition, pain, or bother

1. A pathological gambler is someone who jumps on a horse and gallops
off madly in all directions at the same time.
2. Do you blow your stack when someone keeps you waiting over the
“allotted time” that you gave that person?
3. Did anyone ever have to wait for you?

8. Phoniness: A manifestation of our great false pride; a form of lying; rank and
brash dishonesty; the old false front
1. “I give to my love a present as evidence of my love. Just by pure
coincidence, it helps to smooth over my last binge.”
2. “I buy new clothes because my business position demands it.
Meanwhile, the family also could use food and clothes.”
3. A joker may enthrall a GA audience with profound wisdom but not give
the time of day to his or her spouse or children.
 9. Procrastination: Putting off or postponing things that need to be done; the
familiar “I will do it tomorrow”
1. Did little jobs, when put off, become big and almost impossible later?
Did problems piling up contribute to gambling?
2. Do you pamper yourself by doing things “my way,” or do you attempt to
put order and discipline into your life?
3. Can you handle little jobs that you are asked to take care of, or do you
feel picked on? Are you just too lazy or proud?

10. Self-pity: An insidious personality defect and a danger signal to look for

Stop self-pity in a hurry. It is the buildup to trouble.

1. “These people at the party are having fun with their gambling. Why
can’t I be like that?” This is the “woe is me” syndrome.
2. “If I had that guy’s money, I would not have any problems.” When you
feel this way, visit a cancer ward or children’s hospital and then count
your blessings.

11. Feelings easily hurt: Overly sensitive to the slightest criticism

1. “I walk down the street and say hello to someone. They do not answer. I
am hurt and mad.”
2. “I am expecting my turn at the GA meeting, but the time runs out. I feel
as though that is a dirty trick.”
3. “I feel as though they are talking about me at meetings when they’re
really not.”

12. Fear: An inner foreboding, real or imagined, of doom ahead

We suspect that our use of gambling, behavior, negligence, and so on is
catching up with us. We fear the worst.
When we learn to accept our powerlessness, ask God for help, and face
ourselves with honesty, the nightmare will be over.

13. Depression: Feeling sad or down most of the day

1. You keep going over all of the things that are going wrong.
2. You tend to think that the worst is going to happen.

14. Feelings of inadequacy: Feeling as though you cannot do something

1. You hold on to a negative self-image, even when you succeed.
2. Feelings of failure will not go away.
15. Perfectionism: The need to do everything perfect all of the time
1. Even when you have done a good job, you find something wrong with it.
2. Someone compliments you on something. You feel terrible because it
could have been better.
3. You let your expectations get too high.
Physical Liabilities
1. Diseases, disabilities, and other physical limitations about how you look or
how your body functions
2. Sexual problems or hang-ups
3. Negative feelings about your appearance
4. Negative feelings about your age
5. Negative feelings about your gender
Time-Out
If you have gone through the exercise to this point without coming up for air, it
figures. We did our gambling the same way. Whoa! Easy does it! Take this in
reasonable stages. Assimilate each portion of the exercise thoughtfully. The
reading of this is important, but the application of it is even more important. Take
some time to think and rest, and let this settle in. Develop some sort of a workable
daily plan. Include plenty of rest.

When compulsive gamblers stop gambling, a part of their lives is taken away from
them. This is a terrible loss to sustain unless it is replaced by something else. We
cannot just boot gambling out the window. It meant too much to us. It was how we
faced life, the key to escape, and the tool for solving life’s problems. In
approaching a new way of life, a new set of tools is substituted. These are the 12
steps and the GA way of life.

The same principle applies when we eliminate our character defects. We replace
them by substituting assets that are better adapted to a healthy lifestyle. As with
substance use, you do not fight a defect; you replace it with something that works
better. Use what follows for further character analysis and as a guide for character
building. These are the new tools. The objective is not perfection; it is progress.
You will be happy with the type of living that produces self-respect, respect and
love for others, and security from the nightmare of gambling.
Virtues
1. Faith: The act of leaving the part of our lives that we cannot control (i.e., the
future) to the care of a power greater than ourselves, with the assurance that
it will work out for our well-being

This will be shaky at first, but with it comes a deep conviction.

1. Faith is acquired through application—acceptance, daily prayer, and
meditation.
2. We depend on faith. We have faith that the lights will come on, the car
will start, and our coworkers will handle their end of things. If we had
no faith, then we would come apart at the seams.
3. Spiritual faith is the acceptance of our gifts, limitations, problems, and
trials with equal gratitude, knowing that God has a plan for us. With
“Thy will be done” as our daily guide, we will lose our fear and find
ourselves.

2. Hope: The feeling that what is desired also is possible

Faith suggests reliance. We came to believe that a power greater than

ourselves would restore us to sanity. We hope to stay free of gambling, regain
our self-respect, and love our families. Hope resolves itself into a driving
force. It gives purpose to our daily living.
1. Faith gives us direction, hope, and stamina to take action.
2. Hope reflects a positive attitude. Things are going to work out for us if
we work the program.

3. Love: The active involvement in someone’s individual growth

1. Love must occur in action and in truth.
2. Love is gentle and kind.
3. In its deeper sense, love is the art of living realistically and fully,
guided by spiritual awareness of our responsibilities and our debt of
gratitude to God and to others.

Analysis. Have you used the qualities of faith, hope, and love in your past? How
will they apply to your new way of life?
The Little Virtues
1. Courtesy: Some of us are actually afraid to be gentle persons. We would
rather be boors or self-pampering types.
2. Cheerfulness: Circumstances do not determine our frames of mind. We do.
“Today I will be cheerful. I will look for the beauty in life.”
3. Order: Live today only. Organize one day at a time.
4. Loyalty: Be faithful to whom you believe in.
5. Use of time: “I will use my time wisely.”
6. Punctuality: This involves self-discipline, order, and consideration for
others.
7. Sincerity: This is the mark of self-respect and genuineness. Sincerity carries
conviction and generates enthusiasm. It is contagious.
8. Caution in speech: Watch your tongue. We can be vicious and thoughtless.
Too often, the damage is irreparable.
9. Kindness: This is one of life’s great satisfactions. We do not have real
happiness until we have given of ourselves. Practice this daily.
10. Patience: This is the antidote to resentments, self-pity, and impulsiveness.
11. Tolerance: This requires common courtesy, courage, and a “live and let live”
attitude.
12. Integrity: This involves the ultimate qualifications of a human—honesty,
loyalty, sincerity.
13. Balance: Do not take yourself too seriously. You get a better perspective
when you can laugh at yourself.
14. Gratitude: The person without gratitude is filled with false pride. Gratitude
is the honest recognition of help received. Use it often.

Analysis. In considering the little virtues, ask where you failed and how that
contributed to your accumulated problem. Ask what virtues you should pay
attention to in this rebuilding program.
Physical Assets
1. Physical health: How healthy am I despite any ailments?
2. Talents: What do I do that is good?
3. Age: At my age, what can I offer to others?
4. Sexuality: How can I use my sexuality to express my love?
5. Knowledge: How can I use my knowledge and experience to help others and
myself?
Mental Assets
1. Despite your problems, how healthy are you emotionally?
2. Do you care for others?
3. Are you kind?
4. Can you be patient?
5. Are you basically a good person?
6. Do you try to tell the truth?
7. Do you try to be forgiving?
8. Can you be enthusiastic?
9. Are you sensitive to the needs of others?
10. Can you be serene?
11. Are you going to try to be sincere?
12. Are you going to try to bring order and self-control into your life?
13. Are you going to accept the responsibility for your own behavior and stop
blaming others for everything?
14. How are you going to use your intelligence?
15. Are you going to seek God?
16. How might you improve your mind furthering your education?
17. Are you going to be grateful for what you have?
18. How can you improve your honesty, reliability, and integrity?
19. In what areas of your life do you find joy and happiness?
20. Are you humble and working on your false pride?
21. Are you seeking the God of your own understanding?
22. In what ways can you better accept your own limitations and the limitations
of others?
23. Are you willing to trust and follow the Higher Power of your own
understanding?
The Autobiography
Using this exercise, write your autobiography. Cover your life in 5-year intervals.
Be brief, but try not to miss anything. Tell the whole truth. Write down exactly
what you did. Consider all of the things you marked during the exercise. Read the
exercise again if you need to do so. Make an exhaustive and honest consideration
of your past and present. Make a complete financial inventory. Mark down all
debts. Exactly who do you owe, and what amount do you owe? Do not leave out
relatives or friends. List all persons or institutions that you harmed with your
gambling, and detail exactly how you were unfair. Cover both assets and
liabilities carefully. You will rebuild your life on the solid building blocks of your
assets. These are the tools of recovery. Omit nothing because of shame,
embarrassment, or fear. Determine the thoughts, feelings, and actions that plagued
you. You want to meet these problems face to face and see them in writing. If you
wish, you may destroy your inventory after completing the Fifth Step. Many
people hold a ceremony in which they burn their Fourth Step inventories. This
symbolizes that they are leaving the old life behind. They are starting a new life
free of the past.
Appendix 39: Step Five for Gamblers

Robert R. Perkinson, PhD

[We] admitted to ourselves and to another human being the exact nature of
our wrongs.

—Gamblers Anonymous (GA) (1989b, p. 69)

Before beginning this exercise, please read Step Five in G.A.: A New Beginning
(GA, 1989b).

With Steps One to Four behind you, it is now time to clean house and start over.
You must free yourself of all the guilt and shame and go forward in faith. The Fifth
Step is meant to right the wrongs with others and the Higher Power. You will
develop new attitudes and a new relationship with yourself, others, and the Higher
Power of your own understanding. You have admitted your powerlessness, and
you have identified your liabilities and assets in the personal inventory. Now it is
time to get right with yourself.

You will do this by admitting to yourself, and to another person, the exact nature of
your wrongs. In your Fifth Step, you are going to cover all of your assets and
liabilities detailed in the Fourth Step. You are going to tell one person the whole
truth at one time. This person is important because he or she is a symbol of the
Higher Power and all humankind. You must watch this person’s face. The illness
has been telling you that if you tell anyone the whole truth about you, then that
person will not like you. That is a lie, and you are going to prove that it is a lie.
The truth is this: Unless you tell people the whole truth, they cannot like you. You
must actually see yourself tell someone the whole truth at one time and watch that
individual’s reaction.

It is very difficult to discuss your faults with someone. It is hard enough just
thinking about them yourself. This is a necessary step. It will help to free you from
the disease. You must tell this person everything, the whole story, all of the things
that you are afraid to share. If you withhold anything, then you will not get the
relief you need to start over. You will be carrying around excess baggage. You do
not need to do this to yourself. Time after time, newcomers have tried to keep to
themselves certain facts about their lives. Trying to avoid this humbling
experience, they have turned to easier methods. Almost invariably, they wound up
gambling again. Having persevered with the rest of the program, they wondered
why they failed. The reason is that they never completed their housecleaning. They
took inventory all right, but they hung on to some of the worst items in stock. They
only thought that they had lost their egotism. They only thought that they had
humbled themselves. They had not learned enough of humility and honesty in the
sense necessary until they told someone their whole life stories.

By finally telling someone the whole truth, you will rid yourself of that terrible
sense of isolation and loneliness. You will feel a new sense of belonging,
acceptance, and freedom. If you do not feel relief immediately, do not worry. If
you have been completely honest, then the relief will come. The dammed-up
emotions of years will break out of their confinement and, miraculously, will
vanish as soon as they are exposed.

The Fifth Step will develop within you a new humbleness of character that is
necessary for normal living. You will come to recognize clearly who and what
you are. When you are honest with another person, it confirms that you can be
honest with yourself, others, and your Higher Power.

The person who you will share your Fifth Step with should be chosen carefully.
Many of us find a clergyperson, experienced in hearing Fifth Steps, to be a good
option. Someone further along in the GA program might also be a good choice. It
is recommended that you meet with this person several times before you do the
step. You need to decide whether you can trust this person. Do you feel that this
person is confidential? Do you feel comfortable with this person? Do you feel that
this person will understand?

Once you have chosen the person, put your false pride aside and go for it. Tell the
individual everything about yourself. Do not leave one rock unturned. Tell about
all of the good things and about all of the bad things that you have done. Share the
details, and do not leave anything out. If it troubles you even a little, then share it.
Let it all hang out to be examined by that other person. Every good and bad part
needs to be revealed. After you are done, you will be free of the slavery to lies.
The truth will set you free.
Appendix 40: Relapse Prevention for
Gamblers

Robert R. Perkinson, PhD

There is some bad news and some good news about relapse. The bad news is that
many clients have problems with relapse in early recovery. About two thirds of
clients coming out of addiction programs relapse within 3 months of leaving
treatment (Hunt, Barnett, & Branch, 1971). The good news is that most people
who go through treatment ultimately achieve a stable recovery (Frances, Bucky, &
Alexopolos, 1984). Relapse does not have to happen to you, and even if it does,
you can do something about it. Relapse prevention is a daily program that can help
prevent relapse. It also can stop a lapse from becoming a disaster. This exercise
has been developed using a combination of the models. This uses the disease
concept model in combination with motivational enhancement, cognitive
behavioral therapy, skills training, and 12-step facilitation.
Relapse Is a Process
Relapse is a process that begins long before you gamble. There are symptoms that
precede the first gambling episode. This exercise teaches you how to identify and
control these symptoms before they lead to gambling. If you allow these symptoms
to go on without acting on them, then serious problems will result.
The Relapse Warning Signs
All relapse begins with warning signs that will signal for you that you are in
trouble. If you do not recognize these signs, you will decompensate and finally
gamble. All of the signs are a reaction to stress, and they are a reemergence of the
disease. They are a means by which your body and mind are telling you that you
are in trouble. You might not have all of these symptoms, but you will have some
of them long before you actually gamble. You must determine which symptoms are
the most characteristic of you, and you must come up with coping skills for
dealing with each symptom.
Interpersonal factors
Self-efficacy is the degree you feel capable of performing a task like
preventing relapse. Do you feel confident that you have the skills necessary
to say no to the addiction when confronted with a high-risk situation
including intense craving? Do you have the skills necessary to say no to
gambling?
Make a list of 10 things you can do when you feel the urge to gamble. There
are people you can call, meetings you can attend, things you can read, a
Higher Power you can pray to, family members, friends or people in the
program you can share your feelings with, the Gamblers Anonymous (GA)
hotline, you can call someone in the program, physical exercise you can do,
meditations you can perform, etc.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Practice each of these 10 things at least a five times in group with your
counselor/sponsor/mentor/coach. You need to get used to thinking and moving in a
certain way when faced with craving. If these behaviors are not practiced in skills
training sessions, they are unlikely to be used when you get into trouble. Just
knowing what to do is not enough; you need to practice the thoughts and motor
movements to get good at the skill.

Think about the first time you learned how to ride a bike. Your teacher probably
taught you all of the things you had to do to ride, but it was only after you
practiced riding repeatedly that you began to trust yourself to ride a bike safely.

Make a list of five things in your life that you had to practice. Maybe it was
basketball, baseball, soccer, or starting a conversation with someone you did not
know.

1.
2.
3.
4.
5.

At first you were terrible, making mostly mistakes, but after practicing thousands
of times you got better. Maybe you had to learn how to shoot a basket from the free
throw line. The first times you tried you missed most every shot. As you practiced,
and particularly after you were coached, you got better. After thousands of shots,
you got so you could make the shot most of the time. Then there came the big
game, and the score was tied and you had to shoot the final basket. If you made the
shot your team won; if you missed, you lost. Now you need to practice so much
that you go on automatic—athletes call this getting in the zone—where all of the
fans and other players disappear and it is only you and that simple shot you have
practiced so many times. If you miss the shot or lapse, it is not the end of the
world; it just means you need more practice until the skill becomes automatic.

Higher levels of self-efficacy predict improved addiction treatment outcomes

(Burling et al., 1989; Greenfield et al., 2000).
What to Do When You Experience a Warning Sign
When you recognize you are in trouble, you need to take action. Make a list of the
coping skills you can use when you experience a high-risk situation that is
common for you. It might be interpersonal conflict, anger, boredom, certain music
or parts of town, seeing old friends, social pressure, negative emotions or a
celebration. This will happen. You will have high-risk situations in recovery.
Your task is to take affirmative action. Remember, craving is a danger signal. You
are in trouble. Make a list of what you are going to do. Are you going to call your
sponsor, go to a meeting, call your counselor, call someone in GA, tell someone,
exercise, read the problem gambling material, pray, become involved in an
activity you enjoy, turn it over, or go into treatment? List five telephone numbers
of people you can call if you are in trouble. Remember what GA says, “What we
cannot do alone, we can do together.”

Plan 1.
Plan 2.
Plan 3.
Plan 4.
Plan 5.
Positive Outcome Expectations
This means the positive things we think will happen if we gamble. These are
dangerous thoughts, and if not corrected, they may lead to relapse. Write down
five positive thoughts about what gambling can do for you—things such as the
following: One bet will not hurt. I deserve to relax. I would only bet one time. I
have had a hard day. I need to relax at the casino; nobody will know. I am going to
show them. I am going to get even. I am going to make them sorry. I am under too
much stress. I need a break.

1.
2.
3.
4.
5.

Now write down 10 accurate thoughts that will keep you from gambling, such as
the following: I cannot make one bet; I am a pathological gambler. If I start
gambling, I would never stop; I would go right back into that addiction misery
again. I can go home and talk to my wife. I can go for a walk. I can meditate. I can
go to a 12-step meeting. I can call my sponsor or spiritual leader and go out for a
cup of coffee. I can cope with this feeling. If I just wait for 15 minutes, the craving
will pass. If I move away from the high-risk situation, I would feel better soon.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Write down these 10 alternative behaviors, and carry them with you. Remember
that you have to practice these skills until they become automatic. Practice saying
and doing these things with your group, counselor, sponsor, mentor, coach, spouse,
friend, or 12-step member. Practice, practice, practice until you feel comfortable
with the new skill.

You need to check warning signs daily in your personal inventory. You also need
to have other people check you daily. You will not always pick up the symptoms
in yourself. You might be denying the problem again. Your spouse, your sponsor,
and/or a fellow 12-step member can warn you when they believe that you might be
in trouble. Listen to these people. If they tell you that they sense a problem, then
they take action. You might need professional help in working the problem
through. Do not hesitate to call and ask for help. Anything is better than relapsing.
If you overreact to a warning sign, you are not going to be in trouble. If you
underreact, you might be headed for real problems. Addiction is a deadly disease.
Your life is at stake.
High-Risk Situations
Relapse is more likely to occur in certain situations. These situations can trigger
relapse. People relapse when faced with high-risk situations that they could not
cope with except by gambling. Your job in treatment is to develop coping skills
for dealing with each high-risk situation.

Motivation
Motivation is the conscious or unconscious stimulus leading to the energy that
gives you the power to act. Either you can act in an adaptive or a maladaptive
way; both can be positive or negative reinforcers. You can have motivation to stay
clean and sober and you can have motivation to return to your addiction.

Prochaska and DiClemente (1984) proposed a model for motivation that goes
through five stages or readiness for change: (1) precontemplation, (2)
contemplation, (3) preparation, (4) action, and (5) maintenance. Each stage
characterizes a different level of motivational readiness for change.

Interventions that cause ambivalence, evaluating the pros and cons of change
may increase motivation by allowing clients to explore their own morals and
values and how they may differ if they institute change. For example, people
who are in the precontemplative stage have no interest in behavior change. If
they explore the pros and cons of the addictive behavior, they might become
more willing to think about the positive aspects of changing.
This moves them into contemplation where you discuss all of the positive
and negative aspects of using or stopping the addiction. Once the decision is
made to try to stop the addictive behavior, then we must concentrate on what
needs to change to stop the addictive behavior.
Then the action phase begins where we begin to change the thoughts and
behaviors that cause addiction.
Once the addiction stops, then we need skills to maintain this new lifestyle.
Negative Emotions
Many people relapse when feeling negative feelings that they cannot cope with.
Most feel angry or frustrated, but some feel anxious, bored, lonely, or depressed.
Almost any negative feeling can lead to relapse if you do not learn how to cope
with the feeling. Feelings motivate you to take action. You must act to solve any
problem.

Circle any of the following feelings that seem to lead you to gambling.

1. Loneliness
2. Anger
3. Rejection
4. Emptiness
5. Annoyed
6. Sad
7. Exasperated
8. Betrayed
9. Cheated
10. Frustrated
11. Envious
12. Exhausted
13. Bored
14. Anxious
15. Ashamed
16. Bitter
17. Burdened
18. Foolish
19. Jealous
20. Left out
21. Selfish
22. Restless
23. Weak
24. Sorrowful
25. Greedy
26. Aggravated
27. Sleeplessness
28. Miserable
29. Unloved
30. Worried
31. Scared
32. Spiteful
33. Sorrowful
34. Helpless
35. Neglected
36. Grief
37. Confused
38. Crushed
39. Discontented
40. Restless
41. Irritated
42. Overwhelmed
43. Panicked
44. Trapped
45. Unsure
46. Intimidated
47. Distraught
48. Uneasy
49. Guilty
50. Threatened
A Plan to Deal With Negative Emotions
These are just a few of the feeling words. Add more if you need to do so. Develop
coping skills for dealing with each feeling that makes you vulnerable to relapse.
Exactly what are you going to do when you have this feeling? Detail your specific
plan of action. Some options are talking to your sponsor, calling a friend in the
program, going to a meeting, calling your counselor, reading some recovery
material, turning it over to your Higher Power, and getting some exercise. For
each feeling, develop a specific plan of action.

Feeling
_______________________________________________________________________
Plan 1.
___________________________________________________________________
Plan 2.
___________________________________________________________________
Plan 3.
___________________________________________________________________

Feeling
_______________________________________________________________________
Plan 1.
___________________________________________________________________
Plan 2.
___________________________________________________________________
Plan 3.
___________________________________________________________________

Feeling
_______________________________________________________________________
Plan 1.
___________________________________________________________________
Plan 2.
___________________________________________________________________
Plan 3.
___________________________________________________________________

Continue to fill out these feeling forms until you have all of the feelings that give
you trouble and you have coping skills for dealing with each feeling.
Social Pressure
Social pressure can be direct (where someone directly encourages you to gamble)
or indirect (a social situation where people are gambling). Both of these situations
can trigger intense craving, and this can lead to relapse.

Certain friends are more likely to encourage you to gamble. These people do not
want to hurt you. They want you to relax and have a good time. They want their
old friend back. They do not understand the nature of your disease. Perhaps they
are problem gamblers themselves and are in denial.
High-Risk Friends
Make a list of the friends who might encourage you to gamble.

1.
2.
3.
4.
5.

What are you going to do when they ask you to come with them to gamble? What
are you going to say? In skills group, set up a situation where the whole group
encourages you to gamble. Look carefully at how you feel when the group
members are encouraging you. Look at what you say. Have them help you to
develop appropriate ways of saying no. The skills of saying no are the following:

Look at the person and say no thank you.

Suggest another alternative behavior.
If the person persists, tell him or her that you are trying to stop behavior that
has been harming you. Then ask the person to help you by respecting your
choice not to use.
If the person persists, leave the situation. “Well, I have got to be going. Nice
to see you.”
High-Risk Social Situations
Certain social situations will trigger craving. These are the situations where you
have gambled in the past. Certain casinos, bars, or restaurants with video lottery
machines, service stations with video lottery terminals, a particular part of town,
certain music, athletic events, parties, weddings, family events—all of these
situations can trigger intense cravings. Make a list of five social situations where
you will be vulnerable to relapse.

1.
2.
3.
4.
5.

In early sobriety, you will need to avoid these situations and friends. To put
yourself in a high-risk situation is asking for trouble. If you have to attend a
function where there will be people gambling, then take someone with you who is
in the program. Take someone with you who will support you in your recovery.
Make sure that you have a way to get home. You do not have to stay and torture
yourself. You can leave if you feel uncomfortable. Avoid all situations where your
sobriety feels shaky.
Interpersonal Conflict
Many addicts relapse when in a conflict with some other person. They have a
problem with someone and have no idea of how to cope with conflict so they
might revert to old behavior and use the addiction to deal with the uncomfortable
feelings. The stress of the problem builds and leads to gambling. This conflict
usually happens with someone who they are closely involved with—wife,
husband, child, parent, sibling, friend, boss, and so on.

You can have a serious problem with anyone—even a stranger—so you must have
a plan for dealing with interpersonal conflict. You will develop specific skills in
treatment that will help you to communicate even when you are under stress.

You need to learn and practice the following interpersonal skills repeatedly.

1. Tell the truth all of the time.

2. Share how you feel.
3. Ask for what you want.
4. Find some truth in what the other person is saying.
5. Be willing to compromise.

If you can stay in the conflict and work it out, that is great. If you cannot, then you
have to leave the situation and take care of yourself. You might have to go for a
walk, a run, or a drive. You might need to cool down. You must stop the conflict.
You cannot continue to try to deal with a situation that you believe is too much for
you. Do not feel bad about this. Interpersonal relationships are the hardest
challenge we face. Carry a card with you that lists the telephone numbers of
people who you can contact. You might want to call your sponsor, minister, or
counselor or a fellow GA member, friend, family member, doctor, or anyone else
who may support you.

In an interpersonal conflict, you will fear abandonment. You need to get accurate
and reassure yourself that people can disagree with you and still care about you.
Remember that your Higher Power cares about you. A Higher Power created you
and loves you. Remember the other people in your life who love you. This is one
of the main reasons for talking with someone else. When the other person listens
to you, that person gives you the feeling that you are accepted and loved.
If you still feel afraid or angry, then get with someone you trust and stay with that
person until you feel safe. Do not struggle out there all by yourself. Any member
of your 12-step group will understand how you are feeling. We all have had these
problems. We all have felt lost, helpless, hopeless, and angry.

Make an emergency card that lists all of the people who you can call if you are
having difficulty. Write down their phone numbers and carry this card with you at
all times. Show this card to your counselor. Practice asking someone for help in
treatment once each day. Write down the situation, and show it to your counselor.
Get into the habit of asking for help. When you get out of treatment, call someone
every day just to stay in touch and keep the lines of communication open. Get used
to it. Do not wait to ask for help at the last minute. This makes asking more
difficult.
Positive Feelings
Some people relapse when they are feeling positive emotions. Think of all the
times you used gambling to celebrate. That has gotten to be such a habit that when
something good happens, you will immediately think about gambling. You need to
be ready when you feel like a winner. This may be at a wedding, birth, promotion,
or any event where you feel good. How are you going to celebrate without
gambling? Make a celebration plan. You might have to take someone with you to a
celebration, particularly in early recovery.

Positive feelings also can work when you are by yourself. A beautiful spring day
can be enough to get you thinking about gambling. You need an action plan for
when these thoughts pass through your mind. You must immediately get accurate
and get real. In recovery, we are committed to reality. Do not sit there and recall
how wonderful you will feel if you get high. Tell yourself the truth. Think about all
of the pain that addiction has caused you. If you toy with positive feelings, then
you ultimately will gamble.

Circle the positive feelings that may make you vulnerable to relapse.

1. Affection
2. Boldness
3. Braveness
4. Calmness
5. Capableness
6. Cheerful
7. Confident
8. Delightful
9. Desire
10. Enchanted
11. Joy
12. Free
13. Gladness
14. Glee
15. Happy
16. Honored
17. Horny
18. Infatuated
19. Inspired
20. Kinky
21. Lazy
22. Loving
23. Peaceful
24. Pleasant
25. Pleased
26. Sexy
27. Wonderful
28. Cool
29. Relaxed
30. Reverent
31. Silly
32. Vivacious
33. Adequate
34. Efficient
35. Successful
36. Accomplished
37. Hopeful
38. Cheery
39. Elated
40. Merry
41. Ecstatic
42. Upbeat
43. Splendid
44. Yearning
45. Bliss
46. Excitement
47. Exhilaration
48. Proud
49. Arousal
50. Festive
A Plan to Cope With Positive Feelings
These are the feelings that may make you vulnerable to relapse. You must be
careful when you are feeling good because pleasure triggers the same part of the
brain that triggers addiction. Make an action plan for dealing with each positive
emotion that makes you vulnerable to gambling.

Feeling
_______________________________________________________________________
Plan 1.
___________________________________________________________________
Plan 2.
___________________________________________________________________
Plan 3.
___________________________________________________________________

Feeling
_______________________________________________________________________
Plan 1.
___________________________________________________________________
Plan 2.
___________________________________________________________________
Plan 3.
___________________________________________________________________

Feeling
_______________________________________________________________________
Plan 1.
___________________________________________________________________
Plan 2.
___________________________________________________________________
Plan 3.
___________________________________________________________________

Continue this planning until you develop a plan for each of the positive feelings
that make you vulnerable. Practice what you are going to do when you experience
positive feelings.
Test Control
Some people gamble to test whether they can gamble safely again. They fool
themselves into thinking that they might be able to gamble normally. This time they
will gamble only a little. This time they will be able to stay in control of
themselves. People who fool themselves this way are in for big trouble. From the
first use, most people are in full-blown relapse within 30 days.

Testing personal control begins with inaccurate thinking. It takes you back to Step
One. You need to think accurately. You are powerless over gambling. If you use,
then you will lose. It is as simple as that. You are physiologically,
psychologically, and socially addicted. The cells in your body will not suddenly
change no matter how long you are in recovery. You are addicted in your cells.
There are physical highways in the brain that will always think inaccurately that
you can gamble safely.

How to See Through the First Use

You need to look at how the illness part of yourself will try to convince you that
you are not a pathological gambler. The illness will flash on the screen of your
consciousness all the good things that the addiction did for you. Make a list of
these things. In the first column, marked “Early Gambling,” write down some of
the good things that you were getting out of gambling. Why were you using? What
good came out of it? Did it make you feel social, smart, pretty, intelligent, brave,
popular, desirable, relaxed, or sexy? Did it help you to sleep? Did it make you
feel confident? Did it help you to forget your problems? Make a long list. These
are the good things that you were getting when you first started using. This is why
you were using.

Now go back and place in the second column, marked “Late Gambling,” how you
were doing in that area once you became addicted. How were you doing in that
same area right before you came into treatment? Did you still feel social, or did
you feel alone? Did you still feel intelligent, or did you feel stupid? You will find
that a great change has taken place. The very things that you were using for in
early use, you get the opposite of in late use. If you were gambling for relaxation,
then you cannot relax. If you were gambling to be more popular, then you are more
isolated, insecure, and alone. If you were gambling to feel powerful, then you are
feeling more afraid. This is a major characteristic of addiction. The good things
you got at first you get the opposite of in addiction. You can never go back to early
use because your brain has permanently changed in chemistry, structure, and
genetics.

Take a long look at both of these lists, and think about how the illness is going to
try to work inside of your thinking. The addicted part of yourself will present to
you all of the good things you got in early gambling. This is how the disease will
encourage you to gamble. You must see through the first gambling to the
consequences that are dead ahead.

Look at that second list. You must see the misery that is coming if you gamble. For
most people who relapse, there are only a few days of controlled use before loss
of control sets in. There usually are only a few hours or days before all of the bad
stuff begins to click back into place. Relapse is terrible. It is the most intense
misery that you can imagine.
Lapse and Relapse
A lapse is the use of any addictive behavior. A relapse is continuing to use the
behavior until the full biological, psychological, and social disease is present. All
of the complex biological, psychological, and social components of the disease
become evident very quickly.

The Lapse Plan

You must have a plan in case you lapse. It is foolish to think that you never will
have a problem again. You must plan what you are going to do if you have a
problem. Hunt et al. (1971), in a study of recovering addicts, found that 33% of
clients lapsed within 2 weeks of leaving treatment and 60% lapsed within 3
months. At the end of 8 months, 63% had lapsed. At the end of 12 months, 67%
had lapsed.

The worst thing you can do when you have a lapse is to think that you have
completely failed in recovery. This is inaccurate thinking. You are not a total
failure. You have not lost everything. A lapse is a great learning opportunity. You
have made a mistake, and you can learn from it. You let some part of your program
go, and you are paying for it. You need to examine exactly what happened and get
back into recovery.

A lapse is an emergency. It is a matter of life or death. You must take immediate

action to prevent the lapse from becoming a full relapse. You must call someone in
the program, preferably your sponsor, and tell that person what happened. You
need to examine why you had a problem. You cannot use the addiction and the
tools of recovery at the same time. Something went wrong. You did not use your
new skills. You must make a plan of action to recover from your lapse. You cannot
do this by yourself. You are in denial. You do not know the whole truth. If you did,
you would not have relapsed.

Call your sponsor or a professional counselor, and have that person develop a
new treatment plan for you. You may need to attend more meetings. You may need
to see a counselor. You may need outpatient treatment. You may need inpatient
treatment. You have to get honest with yourself. You need to develop a plan and
follow it. You need someone else to agree to keep an eye on you for a while. Do
not try to do this alone. What we cannot do alone, we can do together.
The Behavior Chain
All behavior occurs in a certain sequence. First there is the trigger. This is the
external event that starts the behavioral sequence. After the trigger, there comes
thinking. Much of this thinking is very fast, and you will not consciously pick it up
unless you stop and think about it. The thoughts trigger feeling, which gives you
energy and direction for action. Next comes the behavior or the action initiated by
the trigger. Lastly, there always is a consequence for any action.

Diagrammed, the behavior chain looks like this:

Trigger → Thinking → Feeling → Behavior → Consequence

Let’s go through a behavioral sequence and see how it works. On the way home
from work, Mark, a recovering gambler, passes a local casino. (This is the
trigger.) He thinks, “I have had a hard day. I would make a couple of bets to
unwind.” (The trigger initiates thinking.) Mark craves gambling. (The thinking
initiates feeling.) Mark turns into the bar and begins gambling. (The feeling
initiates behavior.) Mark loses all of his money, including his next month’s
mortgage payment. (The behavior has a consequence.)

Let us work through another example. It is 11:00 pm, and Mark is not asleep
(trigger). He thinks, “I would never get to sleep tonight unless I make a few bets
on the Internet” (thinking). He feels an increase in his anxiety about not sleeping
(feeling). He gets up and gambles online. He goes to sleep after going into debt on
all of his credit cards and wakes up unable to work the next morning
(consequence).

How to Cope With Triggers

At every point along the behavior chain, you can work on preventing relapse. First
you need to examine your triggers. What environmental events lead you to using
chemicals? We went over some of these when we examined high-risk situations.
Determine what people, places, or things make you vulnerable to relapse. Stay
away from these triggers as much as possible. If a trigger occurs, then use your
new coping skills.

Do not let the trigger initiate old behavior. Stop and think. Do not let your thinking
get out of control. Challenge your thinking, and get accurate about what is real. Let
us look at some common inaccurate thoughts.

1. One bet is not going to hurt.

2. No one is going to know.
3. I need to relax.
4. I am just going to have a couple.
5. I have had a hard day.
6. My friends want me to gamble; it is fun.
7. I never had a problem with poker.
8. It is the only way I can sleep.
9. I can do anything I want to.
10. I am lonely.

All of these inaccurate thoughts can be used to fuel the craving that leads to
relapse. You must stop and challenge your thinking until you are thinking
accurately. You must replace inaccurate thoughts with accurate ones. You are a
pathological gambler. If you gamble, you will lose everything. Think through the
first gambling episode. Get honest with yourself.

How to Cope With Craving

If you think inaccurately, then you will begin craving. This is the powerful feeling
that drives compulsive gambling. Craving is like an ocean wave; it will build and
then wash over you. Craving does not last long if you move away from your
addiction. If you move closer to the addiction, then the craving will increase until
you are compelled to gamble. Immediately on feeling a desire to gamble, think this
thought:

“Gambling is no longer an option for me.”

Now gambling is no longer an option. What are your options? You are in trouble.
You are craving. What are you going to do to prevent relapse? You must move
away from gambling thoughts and behaviors and choose what is accurate. Perhaps
you need to call your sponsor; go to a meeting; turn it over; call the GA hotline;
call the treatment center; call your counselor; go for a walk, run, or visit someone.
You must do something else other than thinking about chemicals. Do not sit there
and ponder gambling. You will lose that debate. This illness is called the great
debater. If you leave it unchecked, it will seduce you into gambling.

Remember that the illness must lie to work. You must uncover the lie as quickly as
possible and get back to the truth. You must take the appropriate action necessary
to maintain your recovery.
Develop a Daily Relapse Prevention Plan
If you work a daily program of recovery, then your chances of success increase
greatly. You need to evaluate your recovery daily and keep a log. This is your
daily inventory.

1. Assess all relapse warning signs.

1. What symptoms did I see in myself today?
2. What am I going to do about them?

2. Assess love of self.

1. What did I do to love myself today?
2. What am I going to do tomorrow?

3. Assess love of others.

1. What did I do to love others today?
2. What am I going to do tomorrow?

4. Assess love of God.

1. What did I do to love God today?
2. What am I going to do tomorrow?

5. Assess sleep pattern.

How am I sleeping?

6. Assess exercise.
Am I getting enough exercise?

7. Assess nutrition.
Am I eating right?

8. Review total recovery program.

1. How am I doing in recovery?
2. What is the next step in my recovery program?
9. Read GA material.

10. Make conscious contact with God.

1. Pray and meditate for a few minutes.
 2. Relax completely.

Social Support System

Every client needs to build a social support system. Positive social support is
highly predictive of long-term abstinence rates across many addictive behaviors.
You need to write down specifically who is going to be your advocate at home,
work, community, and school. This person needs to talk to your counselor and
understand exactly what being an advocate means. This person will have different
tasks depending upon whether or not he or she is a schoolteacher, parent, spouse,
pastor, sponsor, mentor, coach, community leader, school counselor, doctor, nurse,
counselor, etc. You need to make a list of all of these people and decide who is
going to do what. Someone needs to check up on you every day. You will need to
cancel all credit cards and give all of your extra money to someone you trust.
Limit your ability to write a check by having to have a cosigner to write checks.
Many gambling casinos have a self-exclusion program where you can sign a
contract that will allow them to prevent you from gambling in their establishment.
You will have to talk to security; they will take your picture and sign the no
gambling contract with you. The contract can last as long as you like, but 5 years
is a good length.
People Who Can Help You in Recovery
1. Case manager: _____________________ Phone: _____________________

The continuing care case manager makes sure everyone on the team is
working together to keep the client free from gambling. This person keeps a
record of all therapy meetings and 12-step groups. He or she has a contract
with the client that outlines exactly what is expected of the client and what
the consequences are if the client does not follow through with the recovery
program.

2. Parent or spouse: _____________________ Phone:

_____________________

The parent or spouse will be the person who knows what behavior is
adaptive and maladaptive. What friends are to be avoided? If an adolescent
develops the behavioral contract, he or she is responsible for rewards and
consequences.

3. The teacher: _____________________ Phone: _____________________ or

Employer: _____________________ Phone: _____________________

The teacher or employer knows about what behavior is to be expected and

what is not to be tolerated. Members of the team often call each other to
check up on the facts and make sure everyone is on the same team.

4. The sponsor/mentor/coach: _____________________ Phone:

_____________________

The sponsor/mentor/coach is the person who guides the client through

recovery. They are in a 12-step program themselves and take the client to
meetings and meet regularly to discuss the recovery process.

5. The physician: _____________________ Phone: _____________________

The physician orders the medication and does history and physical
examinations to maintain good health.
 6. The spiritual guide: _____________________ Phone:
_____________________

The spiritual guide helps the patient discuss and grow in his or her spiritual
journey. The client shares his or her spiritual journey and maybe keeps a spiritual
prayer journal.

Fill out this inventory every day following treatment, and keep a journal about
how you are doing. You will be amazed as you read back over your journal from
time to time. You will be surprised at how much you have grown.

Make a list of 10 reasons why you want to stop gambling.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Never forget these reasons. Read this list over and over to yourself. Carry a copy
with you and memorize them. If you are struggling in sobriety, then take it out and
read it to yourself. You are important. No one has to live a life of misery. You can
recover and live a clean and sober life.
Appendix 41: Adolescent Unit Point System

Adolescents will carry a report card with them during the day for the staff to add
and subtract points. Clients will count up their points each day and place the total
on a chart that they keep in their room or in the hallway. The most important part
of the program is that staff members need to catch the clients displaying
appropriate behavior and reward them. Clients can be rewarded for any behavior
that staff members want to see them increase such as being quiet in their room,
making a positive recovery statement, being cooperative with the staff, and getting
along with each other. The more points staff members hand out, the better and
more quickly the maladaptive behavior will come under control. Clients will
work for points if they can turn the points in for reinforcers that they want to earn.
Points need to be taken away by the staff, or by the group, only if the behavior is
bad enough to warrant a consequence. The best way in which to take away points
is by the group process or a trial. For the first few days that clients are in
treatment, all of the reinforcers need to be positive. Later, a staff member might
need to tell a client something like this: “I am going to fine you occasionally. That
does not mean I am mad at you, and you should not get mad at me. After all, these
are just points, and you can earn them back.” Clients need to be taught how to
receive criticism. After a consequence, the staff member might say, “That is good.
You looked me in the eye, did not mumble anything under your breath, and took the
points off your card. Good job.”

Points will be routinely given for the following behaviors:

Clients can turn in their points for the following rewards:

Clients can lose points for the following misbehaviors:

All large fines (more than 10,000 points), unless set, need to be adjudicated by the
community group. The group will vote by secret ballot as to the guilt or innocence
of the individual and set a consequence by a majority secret ballot. The person
accused and the staff will not vote, but the staff will retain the right to veto any
ruling.
Additional Guidelines
Phone Calls
1. Phone calls will cost 1,000 points for 5 minutes.
2. All phone calls will be dialed by the on-duty staff.
3. All phone calls will be placed on the hallway phone.
4. Outgoing phone calls will be allowed from 8:00 pm to 9:30 pm.
5. Incoming phone calls will be allowed from 4:30 pm to 9:30 pm.
Radios
1. No radios will be allowed in the hallway.
2. If radios are left on in a client’s room and no one is in the room, then the
radio will be taken away for 24 hours.
3. If a client is asked to turn down the volume of the radio and he or she refuses,
then the radio will be taken away for 24 hours.
Smoking
1. Clients on the adolescent unit who are 18 years old will be given two
cigarettes at a time by the on-duty staff.
2. If lighters and cigarettes are found on the adolescent unit, then these will be
taken away and destroyed.
Doors
1. Doors are to remain open at all times.
Point Card
Appendix 42: Results From the 2013 National
Survey on Drug Use and Health: Summary
of National Findings

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse

and Mental Health Services Administration Center for Behavioral Health
Statistics and Quality

Acknowledgments

This report was prepared by the Center for Behavioral Health Statistics and
Quality (CBHSQ), Substance Abuse and Mental Health Services Administration
(SAMHSA), U.S. Department of Health and Human Services (HHS), and by RTI
International (a trade name of Research Triangle Institute), Research Triangle
Park, North Carolina. Work by RTI was performed under Contract No.
HHSS283201000003C.

Public Domain Notice

All material appearing in this report is in the public domain and may be
reproduced or copied without permission from SAMHSA. However, this
publication may not be reproduced or distributed for a fee without the specific,
written authorization of the Office of Communications, SAMHSA, U.S.
Department of Health and Human Services. When using estimates and quotations
from this report, citation of the source is appreciated.

Recommended Citation

Substance Abuse and Mental Health Services Administration, Results from the
2013 National Survey on Drug Use and Health: Summary of National Findings,
NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD:
Substance Abuse and Mental Health Services Administration, 2014.

Electronic Access and Copies of Publication

This publication may be downloaded from [Link] Hard

copies may be obtained from SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727)
(English and Español).

Originating Office

Substance Abuse and Mental Health Services Administration

Center for Behavioral Health Statistics and Quality

1 Choke Cherry Road, Room 2-1067

Rockville, MD 20857

September 2014
Highlights
This report presents detailed results from the 2013 National Survey on Drug Use
and Health (NSDUH), an annual survey sponsored by the Substance Abuse and
Mental Health Services Administration (SAMHSA). The survey is the primary
source of information on the use of illicit drugs, alcohol, and tobacco in the
civilian, noninstitutionalized population of the United States aged 12 years old or
older. Approximately 67,500 persons are interviewed in NSDUH each year.
Unless otherwise noted, all comparisons in this report that are described using
terms such as “increased,” “decreased,” or “more than” are statistically
significant at the .05 level.
Illicit Drug Use
In 2013, an estimated 24.6 million Americans aged 12 or older were current
(past month) illicit drug users, meaning they had used an illicit drug during
the month prior to the survey interview. This estimate represents 9.4 percent
of the population aged 12 or older. Illicit drugs include marijuana/hashish,
cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-
type psychotherapeutics (pain relievers, tranquilizers, stimulants, and
sedatives) used nonmedically.
The rate of current illicit drug use among persons aged 12 or older in 2013
(9.4 percent) was similar to the rates in 2010 (8.9 percent) and 2012 (9.2
percent), but it was higher than the rates in 2002 to 2009 and in 2011
(ranging from 7.9 to 8.7 percent).
Marijuana was the most commonly used illicit drug in 2013. There were 19.8
million past month users in 2013 (7.5 percent of those aged 12 or older),
which was similar to the number and rate in 2012 (18.9 million or 7.3
percent). The 2013 rate was higher than the rates in 2002 to 2011 (ranging
from 5.8 to 7.0 percent). Marijuana was used by 80.6 percent of current
illicit drug users in 2013.
Daily or almost daily use of marijuana (used on 20 or more days in the past
month) increased from 5.1 million persons in 2005 to 2007 to 8.1 million
persons in 2013.
In 2013, there were 1.5 million current cocaine users aged 12 or older, or 0.6
percent of the population. These estimates were similar to the numbers and
rates in 2009 to 2012 (ranging from 1.4 million to 1.7 million or from 0.5 to
0.7 percent), but they were lower than those in 2002 to 2007 (ranging from
2.0 million to 2.4 million or from 0.8 to 1.0 percent).
The number of past year heroin users in 2013 (681,000) was similar to the
numbers in 2009 to 2012 (ranging from 582,000 to 669,000) and was higher
than the numbers in 2002 to 2005, 2007, and 2008 (ranging from 314,000 to
455,000).
An estimated 1.3 million persons aged 12 or older in 2013 (0.5 percent) used
hallucinogens in the past month. The number of users in 2013 was similar to
that in 2012 (1.1 million), but it was higher than in 2011 (1.0 million).
The percentage of persons aged 12 or older who used prescription-type
psychotherapeutic drugs nonmedically in the past month in 2013 (2.5 percent)
was similar to the percentages in 2010 to 2012 (ranging from 2.4 to 2.7
percent).
The number and percentage of past month methamphetamine users in 2013
(595,000 or 0.2 percent) were similar to those in 2012 (440,000 or 0.2
percent) and 2011 (439,000 or 0.2 percent), but they were higher than the
estimates in 2010 (353,000 or 0.1 percent).
Among youths aged 12 to 17, the rate of current illicit drug use was lower in
2013 (8.8 percent) than in 2002 to 2007 (ranging from 9.6 to 11.6 percent)
and in 2009 to 2012 (ranging from 9.5 to 10.1 percent).
The rate of current marijuana use among youths aged 12 to 17 in 2013 (7.1
percent) was similar to the 2012 rate (7.2 percent) and the rates in 2004 to
2010 (ranging from 6.7 to 7.6 percent); however, it was lower than the rates
in 2002, 2003, and 2011 (ranging from 7.9 to 8.2 percent).
Among youths aged 12 to 17, the rate of current nonmedical use of
prescription-type drugs declined from 4.0 percent in 2002 and 2003 to 2.2
percent in 2013. The rate of nonmedical pain reliever use among youths also
declined from 3.2 percent in 2002 and 2003 to 1.7 percent in 2013.
The rate of current use of illicit drugs among young adults aged 18 to 25 in
2013 (21.5 percent) was similar to the rates in 2009 to 2012 (ranging from
21.3 to 21.6 percent), which was consistent with the steady rate of current
marijuana use in this age group during this time (19.1 percent in 2013 and
ranging from 18.2 to 19.0 percent in 2009 to 2012).
Among young adults aged 18 to 25, the rate of current nonmedical use of
prescription-type drugs in 2013 was 4.8 percent, which was similar to the
rates in 2011 (5.0 percent) and 2012 (5.3 percent), but it was lower than the
rates in the years from 2002 to 2010 (ranging from 5.5 to 6.5 percent).
The rate of current cocaine use in 2013 among young adults aged 18 to 25
was 1.1 percent, which was similar to the rates in 2009, 2011, and 2012, but
it was lower than the rates from 2002 to 2008 and in 2010.
Among adults aged 26 or older, the rate of current illicit drug use in 2013
(7.3 percent) was similar to the rate in 2012 (7.0 percent), but it was higher
than the rates in 2002 to 2011 (ranging from 5.5 to 6.6 percent). This was
driven by rates of current marijuana use, which also remained steady
between 2013 and 2012 (5.6 and 5.3 percent, respectively). However, the
rate of current marijuana use in 2013 was higher than the rates in 2002 to
2011 (ranging from 3.9 to 4.8 percent).
Among adults aged 50 to 64, the rate of current illicit drug use increased
from 2.7 percent in 2002 to 6.0 percent in 2013. For adults aged 50 to 54, the
rate increased from 3.4 percent in 2002 to 7.9 percent in 2013. Among those
aged 55 to 59, the rate of current illicit drug use increased from 1.9 percent
in 2002 to 5.7 percent in 2013. Among those aged 60 to 64, the rate of
current illicit drug use increased from 1.1 percent in 2003 and 2004 to 3.9
percent in 2013.
Among unemployed adults aged 18 or older in 2013, 18.2 percent were
current illicit drug users, which was higher than the rates of 9.1 percent for
those who were employed full time and 13.7 percent for those who were
employed part time. However, most illicit drug users were employed. Of the
22.4 million current illicit drug users aged 18 or older in 2013, 15.4 million
(68.9 percent) were employed either full or part time.
In 2013, 9.9 million persons (3.8 percent of those aged 12 or older) reported
driving under the influence of illicit drugs during the past year, which was
similar to the rate in 2012 (3.9 percent). In 2013, the rate was highest among
young adults aged 18 to 25 (10.6 percent), although this rate was lower than
the rate in 2012 for this age group (11.9 percent).
Among persons aged 12 or older in 2012-2013 who used pain relievers
nonmedically in the past 12 months, 53.0 percent got the drug they used most
recently from a friend or relative for free, and 10.6 percent bought the drug
from a friend or relative. Another 21.2 percent reported that they got the drug
through a prescription from one doctor. An annual average of 4.3 percent got
pain relievers from a drug dealer or other stranger, and 0.1 percent bought
them on the Internet.
Alcohol Use
Slightly more than half (52.2 percent) of Americans aged 12 or older
reported being current drinkers of alcohol in the 2013 survey, which was
similar to the rate in 2012 (52.1 percent). This translates to an estimated
136.9 million current drinkers in 2013.
In 2013, nearly one quarter (22.9 percent) of persons aged 12 or older were
binge alcohol users in the past 30 days. This translates to about 60.1 million
people. The rate in 2013 was similar to the estimate in 2012 (23.0 percent).
Binge drinking is defined as having five or more drinks on the same occasion
on at least 1 day in the 30 days prior to the survey.
In 2013, heavy drinking was reported by 6.3 percent of the population aged
12 or older, or 16.5 million people. This rate was similar to the rate of heavy
drinking in 2012 (6.5 percent). Heavy drinking is defined as binge drinking
on at least 5 days in the past 30 days.
Among young adults aged 18 to 25 in 2013, the rate of binge drinking was
37.9 percent, and the rate of heavy drinking was 11.3 percent. These rates
were lower than the corresponding rates in 2012 (39.5 and 12.7 percent,
respectively).
The rate of current alcohol use among youths aged 12 to 17 was 11.6 percent
in 2013. Youth binge and heavy drinking rates in 2013 were 6.2 and 1.2
percent, respectively. The rates for current and binge alcohol use were lower
than those reported in 2012 (12.9 and 7.2 percent, respectively).
In 2013, an estimated 10.9 percent of persons aged 12 or older drove under
the influence of alcohol at least once in the past year. This percentage was
lower than in 2002 (14.2 percent), but it was similar to the rate in 2012 (11.2
percent). The rate was highest among persons aged 21 to 25 and persons
aged 26 to 29 (19.7 and 20.7 percent, respectively). Among persons aged 12
to 20 and those aged 21 to 25, the rates of driving under the influence of
alcohol were lower in 2013 (4.7 and 19.7 percent, respectively) than in 2012
(5.7 and 21.9 percent, respectively).
An estimated 8.7 million underage persons (aged 12 to 20) were current
drinkers in 2013, including 5.4 million binge drinkers and 1.4 million heavy
drinkers. Corresponding percentages of underage persons in 2013 were 22.7
percent for current alcohol use, 14.2 percent for binge alcohol use, and 3.7
percent for heavy use. All of these percentages were lower than those in
2012.
Past month, binge, and heavy drinking rates among underage persons
declined between 2002 and 2013. Past month alcohol use declined from 28.8
to 22.7 percent, binge drinking declined from 19.3 to 14.2 percent, and heavy
drinking declined from 6.2 to 3.7 percent.
In 2013, 52.2 percent of current underage drinkers reported that their last use
of alcohol occurred in someone else’s home, and 34.2 percent reported that it
had occurred in their own home. Most current drinkers aged 12 to 20 (77.6
percent) were with two or more other people the last time they drank
alcohol. The rate of drinking alone the last time that underage persons drank
alcohol was highest among youths aged 12 to 14 (14.5 percent).
Among current underage drinkers, 28.7 percent paid for the alcohol the last
time they drank, including 7.8 percent who purchased the alcohol themselves
and 20.5 percent who gave money to someone else to purchase it. Among
those who did not pay for the alcohol they last drank, 36.6 percent got it from
an unrelated person aged 21 or older; 24.5 percent got it from a parent,
guardian, or other adult family member; and 16.4 percent got it from another
person younger than 21 years old.
In 2013, underage current drinkers were more likely than current alcohol
users aged 21 or older to use illicit drugs within 2 hours of alcohol use on
their last reported drinking occasion (19.9 vs. 5.7 percent, respectively). The
most commonly reported illicit drug used by underage drinkers in
combination with alcohol was marijuana.
Tobacco Use
In 2013, an estimated 66.9 million Americans aged 12 or older were current
(past month) users of a tobacco product. This represents 25.5 percent of the
population in that age range. Also, 55.8 million persons (21.3 percent of the
population) were current cigarette smokers; 12.4 million (4.7 percent)
smoked cigars; 8.8 million (3.4 percent) used smokeless tobacco; and 2.3
million (0.9 percent) smoked tobacco in pipes.
Between 2002 and 2013, past month use of any tobacco product among
persons aged 12 or older decreased from 30.4 to 25.5 percent, and past
month cigarette use declined from 26.0 to 21.3 percent. Rates of past month
use of smokeless tobacco and pipe tobacco in 2013 were similar to
corresponding rates in 2002. However, past month cigar use decreased from
5.4 percent in 2002 to 4.7 percent in 2013.
The rate of past month tobacco use among 12 to 17 year olds declined from
15.2 percent in 2002 to 7.8 percent in 2013, including a decline from 2012
(8.6 percent) to 2013. The rate of past month cigarette use among 12 to 17
year olds also declined between 2002 and 2013, from 13.0 to 5.6 percent.
Among youths aged 12 to 17 who smoked cigarettes in the past month, 53.9
percent also used an illicit drug compared with only 6.1 percent of youths
who did not smoke cigarettes.
Initiation of Substance Use (Incidence, or First-Time
Use) Within the Past 12 Months
In 2013, an estimated 2.8 million persons aged 12 or older used an illicit
drug for the first time within the past 12 months. This averages to about 7,800
initiates per day and was similar to the estimate for 2012 (2.9 million). A
majority of these past year illicit drug initiates reported that their first drug
was marijuana (70.3 percent). About 1 in 5 initiated with nonmedical use of
prescription drugs (20.6 percent, including 12.5 percent with pain relievers,
5.2 percent with tranquilizers, 2.7 percent with stimulants, and 0.2 percent
with sedatives). In 2013, 6.3 percent of initiates reported inhalants as their
first illicit drug, and 2.6 percent used hallucinogens as their first drug.
In 2013, the illicit drug categories with the largest number of past year
initiates were marijuana use (2.4 million) and nonmedical use of pain
relievers (1.5 million). The marijuana estimate was similar to the numbers in
2008 to 2012; however, the estimate for nonmedical use of pain relievers
was lower in 2013 than in 2002 through 2012.
The number of past year initiates of methamphetamine was 144,000 in 2013,
which was similar to the estimates in 2007 to 2012.
The number of past year initiates of Ecstasy was 751,000 in 2013, which
was similar to the number in 2012 (869,000) but was lower than the numbers
in 2009, 2010, and 2011 (1.1 million, 949,000, and 922,000, respectively).
Most (69.4 percent) of the recent Ecstasy initiates in 2013 were aged 18 or
older at the time they first used Ecstasy.
The number of past year cocaine initiates was 601,000 in 2013, which was
similar to the numbers in 2008 to 2012 but was lower than the estimates from
2002 through 2007. The number of crack cocaine initiates was 58,000 in
2013, which was similar to the estimates in 2009 to 2012 but was lower than
the estimates from 2002 through 2008.
In 2013, there were 169,000 persons aged 12 or older who used heroin for
the first time within the past year, which was similar to the estimates in 2002
to 2005 and from 2007 to 2012.
Most (83.5 percent) of the 4.6 million past year alcohol initiates in 2013
were younger than age 21 at the time of initiation.
The number of persons aged 12 or older who smoked cigarettes for the first
time within the past 12 months was 2.1 million in 2013, which was lower
than the estimates from 2008 to 2012 (ranging from 2.3 million to 2.5
million). About half of new smokers in 2013 were younger than 18 when they
first smoked cigarettes (50.5 percent).
The number of persons aged 12 or older who used smokeless tobacco for the
first time within the past year was 1.1 million in 2013, which was similar to
the estimates in 2011 and 2012.
Youth Prevention-Related Measures
In 2013, 39.0 percent of youths aged 12 to 17 perceived great risk in having
five or more drinks once or twice a week. Similarly, 39.5 percent of youths
perceived great risk in smoking marijuana once or twice a week.
The percentage of youths aged 12 to 17 perceiving great risk in smoking
marijuana once or twice a week decreased from 54.6 percent in 2007 to 39.5
percent in 2013.
The percentage of youths who reported great risk in smoking one or more
packs of cigarettes per day was 64.3 percent in 2013. The 2013 rate was
lower than the rates between 2004 and 2009 (ranging from 65.5 to 69.5
percent) and was similar to the rates in 2002 (63.1 percent) and 2003 (64.2
percent).
About half (48.6 percent) of youths aged 12 to 17 reported in 2013 that it
would be “fairly easy” or “very easy” for them to obtain marijuana if they
wanted some. One in eleven reported it would be easy to get heroin (9.1
percent), 11.3 percent indicated that LSD would be easily available, and
14.4 percent reported easy availability for cocaine. In comparison with the
rates in 2002, the 2013 rates represent declines in perceived availability for
all four of these drugs.
About one in eight youths aged 12 to 17 (12.4 percent) indicated that they had
been approached by someone selling drugs in the past month, which was
similar to the rate in 2012 (13.2 percent).
A majority of youths aged 12 to 17 (88.4 percent) in 2013 reported that their
parents would strongly disapprove of their trying marijuana once or twice,
which was a decline from 2012 (89.3 percent). Current marijuana use was
much less prevalent among youths who perceived strong parental
disapproval for trying marijuana once or twice than for those who did not
(4.1 vs. 29.3 percent, respectively).
In 2013, 72.6 percent of youths aged 12 to 17 reported having seen or heard
drug or alcohol prevention messages from sources outside of school, which
was lower than in 2002 (83.2 percent) and in 2012 (75.9 percent). The
percentage of school-enrolled youths reporting that they had seen or heard
prevention messages at school also declined during this period, from 78.8
percent in 2002 to 73.5 percent. The prevalence of past month illicit drug use
in 2013 was lower among youths who reported having such exposure to
prevention messages compared with youths who did not have such exposure.
Substance Dependence, Abuse, and Treatment
In 2013, an estimated 21.6 million persons aged 12 or older (8.2 percent)
were classified with substance dependence or abuse in the past year based
on criteria specified in the Diagnostic and Statistical Manual of Mental
Disorders, 4th edition (DSM-IV). Of these, 2.6 million were classified with
dependence or abuse of both alcohol and illicit drugs, 4.3 million had
dependence or abuse of illicit drugs but not alcohol, and 14.7 million had
dependence or abuse of alcohol but not illicit drugs.
The annual number of persons with substance dependence or abuse in 2013
(21.6 million) was similar to the number in each year from 2002 through
2012 (ranging from 20.6 million to 22.7 million).
The specific illicit drugs with the largest numbers of persons with past year
dependence or abuse in 2013 were marijuana (4.2 million), pain relievers
(1.9 million), and cocaine (855,000). The number of persons with marijuana
dependence or abuse was similar between 2002 and 2013. The number with
pain reliever dependence or abuse in 2013 was similar to the numbers from
2006 to 2012. The number with cocaine dependence or abuse in 2013 was
similar to the numbers in 2010 to 2012.
The number of persons who had heroin dependence or abuse in 2013
(517,000) was similar to the numbers in 2009 to 2012 (ranging from 361,000
to 467,000), but it was higher than the numbers in 2002 to 2008 (ranging
from 189,000 to 324,000).
In 2013, adults aged 21 or older who had first used alcohol at age 14 or
younger were more likely to be classified with alcohol dependence or abuse
than adults who had their first drink at age 21 or older (14.8 vs. 2.3 percent).
Between 2002 and 2013, the percentage of youths aged 12 to 17 with
substance dependence or abuse declined from 8.9 to 5.2 percent. For young
adults aged 18 to 25, substance dependence or abuse also declined during
this period from 21.7 percent in 2002 to 17.3 percent in 2013.
Treatment need is defined as having substance dependence or abuse or
receiving substance use treatment at a specialty facility (hospital inpatient,
drug or alcohol rehabilitation, or mental health centers) within the past 12
months. In 2013, 22.7 million persons aged 12 or older needed treatment for
an illicit drug or alcohol use problem (8.6 percent of persons aged 12 or
older). Of these, 2.5 million (0.9 percent of persons aged 12 or older and
10.9 percent of those who needed treatment) received treatment at a specialty
facility. Thus, 20.2 million persons (7.7 percent of the population aged 12 or
older) needed treatment for an illicit drug or alcohol use problem but did not
receive treatment at a specialty facility in the past year.
Of the 20.2 million persons aged 12 or older in 2013 who were classified as
needing substance use treatment but did not receive treatment at a specialty
facility in the past year, 908,000 persons (4.5 percent) reported that they felt
they needed treatment for their illicit drug or alcohol use problem. Of these
908,000 persons who felt they needed treatment, 316,000 (34.8 percent)
reported that they made an effort to get treatment. Based on combined 2010-
2013 data, the most commonly reported reason for not receiving treatment
among this group of persons was a lack of insurance coverage and inability
to afford the cost (37.3 percent).
1. Introduction
This report presents a detailed look at results from the 2013 National Survey on Drug Use and
Health (NSDUH), an annual survey of the civilian, noninstitutionalized population of the United
States aged 12 years old or older. The report presents national estimates of rates of use, numbers
of users, and other measures related to illicit drugs, alcohol, and tobacco products.

The report focuses on trends between 2012 and 2013 and from 2002 to 2013 as well as differences
across population subgroups in 2013. A first glimpse of the NSDUH substance use and mental
health data was provided in September 2014 through a shorter report available on the Substance
Abuse and Mental Health Services Administration (SAMHSA) Web site
([Link] Detailed NSDUH national estimates related to mental health and
NSDUH state-level estimates related to both substance use and mental health will be published in
separate releases in the fall of 2014.
Summary of NSDUH
NSDUH is the primary source of statistical information on the use of illegal drugs, alcohol, and
tobacco by the U.S. civilian, noninstitutionalized population aged 12 or older. Conducted by the
Federal Government since 1971, the survey collects data through face-to-face interviews with a
representative sample of the population at the respondent’s place of residence. The survey is
sponsored by SAMHSA, U.S. Department of Health and Human Services, and is planned and
managed by SAMHSA’s Center for Behavioral Health Statistics and Quality (CBHSQ). Data
collection and analysis are conducted under contract with RTI International.1

This section briefly describes the survey methodology; a more complete description is provided in
Appendix A.

NSDUH collects information from residents of households and noninstitutional group quarters (e.g.,
shelters, rooming houses, dormitories) and from civilians living on military bases. The survey
excludes homeless persons who do not use shelters, military personnel on active duty, and residents
of institutional group quarters, such as jails and hospitals. Appendix C describes sources of data on
substance use and treatment, including those that include populations outside the NSDUH target
population.

From 1971 through 1998, the survey employed paper-and-pencil data collection. Since 1999, the
NSDUH interview has been carried out using computer-assisted interviewing (CAI). Most of the
questions are administered with audio computer-assisted self-interviewing (ACASI). ACASI is
designed to provide the respondent with a highly private and confidential mode for responding to
questions in order to increase the level of honest reporting of illicit drug use and other sensitive
behaviors. Less sensitive items are administered by interviewers using computer-assisted personal
interviewing.

The 2013 NSDUH continued to employ a state-based design with an independent, multistage area
probability sample within each state and the District of Columbia. The eight states with the largest
population (which together account for about half of the total U.S. population aged 12 or older) are
designated as large sample states (California, Florida, Illinois, Michigan, New York, Ohio,
Pennsylvania, and Texas) and have a sample size of about 3,600 each. For the remaining 42 states
and the District of Columbia, the sample size is about 900 per state. In all states and the District of
Columbia, the design oversampled youths and young adults; each state’s sample was approximately
equally distributed among three age groups: 12 to 17 years, 18 to 25 years, and 26 years or older.

Nationally, screening was completed at 160,325 addresses, and 67,838 completed interviews were
obtained. The survey was conducted from January through December 2013. Weighted response
rates for household screening and for interviewing were 83.9 and 71.7 percent, respectively. See
Appendix B for more information on NSDUH response rates.
Limitations on Trend Measurement
Trend analysis using NSDUH data is limited to 2002 to 2013, even though the survey has been
conducted since 1971. Because of the change in interviewing method in 1999, the estimates from
the pre-1999 surveys are not comparable with estimates from the current CAI-based surveys.
Although the design of the 2002 through 2012 NSDUHs is similar to the design of the 1999 through
2001 surveys, methodological differences affect the comparability of the 2002 to 2013 estimates
with estimates from prior surveys. The most important change was the addition of a $30 incentive
in 2002. Also, the name of the survey was changed in 2002, from the National Household Survey
on Drug Abuse (NHSDA) to the current name. Improved data collection quality control
procedures were introduced in the survey starting in 2001, and updated population data from the
2000 decennial census were incorporated into the sample weights starting with the 2002 estimates.
Analyses of the effects of these factors on NSDUH estimates have shown that 2002 and later
data should not be compared with 2001 and earlier data from the survey series to assess changes
over time. Appendix C of the 2004 NSDUH report on national findings discusses this in more detail
(Office of Applied Studies, 2005).

Because of changes in the questionnaire, estimates for methamphetamine, stimulants, and

psychotherapeutics in this report should not be compared with corresponding estimates presented
in previous reports for data years prior to 2007. Estimates for 2002 to 2006 for these drug
categories in this report, as well as in the 2007 and 2008 reports, incorporate statistical adjustments
that enable year-to-year comparisons to be made over the period from 2002 to 2013.

The calculation of NSDUH person-level weights includes a calibration step that results in weights
that are consistent with population control totals obtained from the U.S. Census Bureau (see
Section A.3.3 in Appendix A). These control totals are based on the most recently available
decennial census; the Census Bureau updates these control totals annually to account for
population changes after the census. For the analysis weights in the 2002 through 2010 NSDUHs,
the control totals were derived from the 2000 census data; starting with the 2011 NSDUH weights,
the control totals were based on data from the 2010 census. This shift to the 2010 census data
could affect comparisons between substance use estimates for 2011 onward and those from prior
years. Analyses of the impact of this change for the 2011 NSDUH weights show that estimates of
the number of substance users for some demographic groups were substantially affected, but
percentages of substance users within these groups (i.e., rates) were not. Details for this
investigation are provided in Section B.4.3 in Appendix B of the 2011 national findings report for
NSDUH (CBHSQ, 2012b). This change in control totals does not affect comparisons between
2012 and 2013 because the control totals for each of these years were based on the 2010 census.
However, some trends between 2013 and years prior to 2011 may need to be interpreted with
caution because of differences in how the control totals for each of these years were developed.
Format of Report and Data Presentation
This report has separate chapters that discuss findings on the use of illicit drugs; use of alcohol; use
of tobacco products; initiation of substance use; prevention-related issues; and substance
dependence, abuse, and treatment. A final chapter discusses key findings on trends in substance
use among youths and young adults, including comparisons with other survey results. The data and
findings described in this report are based on a comprehensive set of tables, referred to as
“detailed tables,” that include population estimates (e.g., numbers of drug users), rates (e.g.,
percentages of the population using drugs), and standard errors of estimates. These tables are
available separately at [Link] In addition, the tables are accompanied by a
glossary that covers key definitions used in this report and in the detailed tables. Appendices in this
report describe the survey (Appendix A), technical details on the statistical methods and
measurement (Appendix B), and other sources of related data (Appendix C). A list of references
cited in the report (Appendix D) and a list of contributors to this report (Appendix E) also are
provided.

Text, figures, and detailed tables present prevalence measures for the population in terms of both
the number of persons and the percentage of the population and by lifetime (i.e., ever used), past
year, and past month use. Analyses focus primarily on past month use, also referred to as “current
use.” Where applicable, footnotes are included in tables and figures to indicate whether the 2013
estimates are significantly different from 2012 or earlier estimates. In addition, some estimates are
based on data combined from two or more survey years to increase precision of the estimates;
those estimates are annual averages based on multiple years of data.

During regular data collection and processing checks for the 2011 NSDUH, data errors were
identified. These errors affected the data for Pennsylvania (2006 to 2010) and Maryland (2008 and
2009). Data and estimates for 2011 onward were not affected, including those for 2013. The errors
had minimal impact on the national estimates. The only 2008 to 2011 estimates appreciably
affected were estimates for the mid-Atlantic division and the Northeast region.

Cases with erroneous data were removed from data files, and the remaining cases were
reweighted to provide representative estimates. Therefore, some estimates for 2010 and other prior
years in the 2013 national findings report and the 2013 detailed tables will differ from
corresponding estimates found in some previous reports and tables. Further information is available
in Section B.3.5 in Appendix B of this report.

All estimates presented in the report have met the criteria for statistical reliability (see Section
B.2.2 in Appendix B). Estimates that do not meet these criteria are suppressed and do not appear
in tables, figures, or text. Statistical tests have been conducted for all statements appearing in the
text of the report that compare estimates between years or subgroups of the population.
Suppressed estimates are not included in statistical tests of comparisons. For example, a statement
that “whites had the highest prevalence” means that the rate among whites was higher than the
rate among all nonsuppressed racial/ethnic subgroups but not necessarily higher than the rate
among a subgroup for which the estimate was suppressed. Unless explicitly stated that a
difference is not statistically significant, all statements that describe differences are significant at
the .05 level. Statistically significant differences are described using terms such as “higher,”
“lower,” “increased,” and “decreased.” Statements that use terms such as “similar,” “no
difference,” “same,” or “remained steady” to describe the relationship between estimates denote
that a difference is not statistically significant. When a set of estimates for survey years or
population subgroups is presented without a statement of comparison, statistically significant
differences among these estimates are not implied and testing may not have been conducted.

Data are presented for racial/ethnic groups based on guidelines for collecting and reporting race
and ethnicity data (Office of Management and Budget [OMB], 1997). Because respondents could
choose more than one racial group, a “two or more races” category is included for persons who
reported more than one category (i.e., white, black or African American, American Indian or
Alaska Native, Native Hawaiian, Guamanian or Chamorro, Samoan,2 Other Pacific Islander,
Asian, Other). Respondents choosing more than one category from among Native Hawaiian,
Guamanian or Chamorro, Samoan, and Other Pacific Islander but no other categories are classified
as being in the “Native Hawaiian or Other Pacific Islander” category instead of the “two or more
races” category. Except for the “Hispanic or Latino” group, the racial/ethnic groups include only
non-Hispanics. The category “Hispanic or Latino” includes Hispanics of any race.

Data in this report also are presented for four U.S. geographic regions as defined by the U.S.
Census Bureau (Figure 1.1). Other geographic comparisons also are made based on county type, a
variable that reflects different levels of urbanicity and metropolitan area inclusion of counties. This
county classification was originally developed and subsequently updated by the U.S. Department of
Agriculture (Butler & Beale, 1994). All U.S. counties and county equivalents were grouped based
on revised definitions of metropolitan statistical areas (MSAs) and definitions of micropolitan
statistical areas as defined by the OMB in June 2003 (OMB, 2003). Large metropolitan areas have
a population of 1 million or more. Small metropolitan areas have a population of fewer than 1
million. Nonmetropolitan areas are outside of MSAs. Counties in nonmetropolitan areas are further
classified based on the number of people in the county who live in an urbanized area, as defined by
the Census Bureau at the subcounty level. “Urbanized” counties have a population of 20,000 or
more in urbanized areas, “less urbanized” counties have at least 2,500 but fewer than 20,000
population in urbanized areas, and “completely rural” counties have populations of fewer than 2,500
in urbanized areas. Additional details about this county type definition are included in the glossary
that accompanies the 2013 detailed tables.
Other NSDUH Reports and Data
Other reports using the 2013 NSDUH data and focusing on specific topics of interest will be made
available on SAMHSA’s Web site. In particular, detailed estimates on mental health will be
released later in 2014 in a separate report: Results From the 2013 National Survey on Drug Use
and Health: Mental Health Findings. State-level estimates for substance use and mental health
for 2012-2013 are scheduled to be released later this year as well.

Figure 1.1 U.S. Census Bureau Regions

The detailed tables, other descriptive reports and in-depth analytic reports focusing on specific
issues or populations, and methodological information on NSDUH are all available at
[Link] In addition, CBHSQ makes public use data files available through
the Substance Abuse and Mental Health Data Archive (SAMHDA) at
[Link] Currently, files are available from the 1979 to 2012 surveys. The
2013 NSDUH public use file will be available by the end of 2014. CBHSQ also makes confidential
restricted-use data available in two ways. Restricted-use data, including state codes and other
detailed variables, can be included in tables as part of the online restricted-use data analysis system
(R-DAS). In the R-DAS, data are not available for downloading, but estimates can be generated
by state and other restricted variables that are specified by the data user. Estimates that are
generated by the R-DAS do not require any further review for protection of respondent
confidentiality. CBHSQ also makes restricted-use microdata files available through a data portal on
the SAMHDA Web site. More details on both of these programs are available at
[Link]
2. Illicit Drug Use
The National Survey on Drug Use and Health (NSDUH) obtains information on nine categories of
illicit drug use: use of marijuana, cocaine, heroin, hallucinogens, and inhalants, as well as the
nonmedical use of prescription-type pain relievers, tranquilizers, stimulants, and sedatives. In these
categories, hashish is included with marijuana, and crack is considered a form of cocaine. Several
drugs are grouped under the hallucinogens category, including LSD, PCP, peyote, mescaline,
psilocybin mushrooms, and “Ecstasy” (MDMA). Inhalants include a variety of substances, such as
nitrous oxide, amyl nitrite, cleaning fluids, gasoline, spray paint, other aerosol sprays, and glue.
Respondents are asked to report use of inhalants to get high but not to report times when they
accidentally inhaled a substance.

The four categories of prescription-type drugs (pain relievers, tranquilizers, stimulants, and
sedatives) cover numerous medications that currently are or have been available by prescription.
They also include drugs within these groupings that originally were prescription medications but
currently may be manufactured and distributed illegally, such as methamphetamine, which is
included under stimulants. Respondents are asked to report only “nonmedical” use of these drugs,
defined as use without a prescription of the individual’s own or simply for the experience or feeling
the drugs caused. Use of over-the-counter drugs and legitimate use of prescription drugs are not
included. NSDUH reports combine the four prescription-type drug groups into a category referred
to as “psychotherapeutics.”

Estimates of “illicit drug use” reported from NSDUH reflect the use of any of the nine drug
categories listed above. Use of alcohol and tobacco products, while illegal for youths, is not
included in these estimates but is discussed in Chapters 3 and 4.

In 2013, an estimated 24.6 million Americans aged 12 or older were current (past month)
illicit drug users, meaning they had used an illicit drug during the month prior to the survey
interview (Figure 2.1). The estimate represents 9.4 percent of the population aged 12 or
older.
The overall rate of current illicit drug use among persons aged 12 or older in 2013 (9.4
percent) was similar to the rates in 2010 (8.9 percent) and 2012 (9.2 percent), but it was
higher than the rates in 2002 to 2009 and in 2011 (Figure 2.2).
In 2013, marijuana was the most commonly used illicit drug, with 19.8 million current (past
month) users. It was used by 80.6 percent of current illicit drug users. Nearly two thirds
(64.7 percent) of current illicit drug users used only marijuana in the past month. Also, in
2013, 8.7 million persons aged 12 or older were current users of illicit drugs other than
marijuana (or 35.3 percent of illicit drug users aged 12 or older). Current use of other drugs
but not marijuana was reported by 19.4 percent of illicit drug users, and 15.9 percent
reported using both marijuana and other drugs.
The number and percentage of persons aged 12 or older who were current users of
marijuana in 2013 (19.8 million or 7.5 percent) were similar to the estimates in 2012 (18.9
million or 7.3 percent) (Figure 2.2). The rate of current marijuana use in 2013 was higher
than the rates in 2002 to 2011. For example, during the period from 2002 to 2008, the rates
varied from 5.8 to 6.2 percent. By 2009, the rate increased to 6.7 percent then continued to
increase to the rate in 2013.

An estimated 8.7 million persons aged 12 or older (3.3 percent) were current users of illicit
drugs other than marijuana in 2013. The majority of these users (6.5 million persons or 2.5
percent of the population) were nonmedical users of psychotherapeutic drugs, including 4.5
million users of pain relievers (1.7 percent), 1.7 million users of tranquilizers (0.6 percent),
1.4 million users of stimulants (0.5 percent), and 251,000 users of sedatives (0.1 percent).

Figure 2.1 Past Month Illicit Drug Use Among Persons Aged 12 or Older: 2013

1 Illicit drugs include marijuana/hashish, cocaine (including crack), heroin,

hallucinogens, inhalants, or prescription- type psychotherapeutics used nonmedically.

Figure 2.2 Past Month Use of Selected Illicit Drugs Among Persons Aged 12 or Older:
2002-2013

+Difference between this estimate and the 2013 estimate is statistically significant at
 the .05 level.

The percentage of persons aged 12 or older who were current nonmedical users of
psychotherapeutic drugs in 2013 (2.5 percent) was lower than the percentages in 2006,
2007, and 2009 (ranging from 2.8 to 2.9 percent), but it was similar to the percentages in all
of the other years from 2002 to 2012 (ranging from 2.4 to 2.7 percent) (Figure 2.2). The
number of persons aged 12 or older who were current nonmedical users of
psychotherapeutic drugs in 2013 (6.5 million) was similar to the number of users in 2002 to
2012 (ranging from 6.1 million to 7.1 million).
The number and percentage of persons aged 12 or older who were current nonmedical
users of pain relievers in 2013 (4.5 million or 1.7 percent) were similar to those in 2011 and
2012 (4.5 million and 4.9 million, respectively, or 1.7 and 1.9 percent) (Figure 2.3).
The number and percentage of persons aged 12 or older who were current nonmedical
users of the pain reliever OxyContin® in 2013 (492,000 or 0.2 percent) were similar to the
numbers in 2007 to 2012 (ranging from 358,000 to 566,000 or 0.1 to 0.2 percent).
The number and percentage of current nonmedical users of tranquilizers in 2013 (1.7 million
or 0.6 percent) were lower than the estimates in 2012 (2.1 million or 0.8 percent).
The number and percentage of persons aged 12 or older who were current nonmedical
users of stimulants in 2013 (1.4 million or 0.5 percent) were similar to those in 2012 (1.2
million or 0.5 percent) but were higher than the estimates in 2011 (970,000 or 0.4 percent).
The number and percentage of persons aged 12 or older who were current users of
methamphetamine in 2013 (595,000 or 0.2 percent) were similar to those in 2012 (440,000 or
0.2 percent) and 2011 (439,000 or 0.2 percent). However, the estimates in 2013 were higher
than those in 2010 (353,000 or 0.1 percent).
The number and percentage of persons aged 12 or older who were current users of cocaine
in 2013 (1.5 million or 0.6 percent) were similar to those in 2009 to 2012 (ranging from 1.4
million to 1.7 million or from 0.5 to 0.7 percent), but were lower than those in 2002 to 2007
(ranging from 2.0 million to 2.4 million or from 0.8 to 1.0 percent) (Figure 2.2).
The number and percentage of persons aged 12 or older who were current heroin users in
2013 (289,000 or 0.1 percent) were similar to those in 2008 to 2012 (ranging from 193,000 to
335,000 or 0.1 percent for all 4 years) (Figure 2.4). The number of current heroin users in
2013 was higher than the number of users in 2002 to 2005 (ranging from 119,000 to 166,000)
and in 2007 (161,000). The number of persons aged 12 or older who were past year heroin
users in 2013 also was higher than the numbers in 2002 to 2005, 2007, and 2008 (ranging
from 314,000 to 455,000). (See Section B.2.3 in Appendix B for additional discussion of the
estimated numbers of past year and past month heroin users in 2006.)
The number and percentage of persons aged 12 or older who were current users of
hallucinogens in 2013 (1.3 million or 0.5 percent) were similar to those in 2012 (1.1 million or
0.4 percent) but were higher than in 2011 (1.0 million or 0.4 percent) (Figure 2.2).

Figure 2.3 Past Month Nonmedical Use of Types of Psychotherapeutic Drugs Among Persons
Aged 12 or Older: 2002-2013
+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.
Age
In 2013, the rate of current illicit drug use varied by age. Among youths aged 12 to 17 in
2013, the rate increased from 2.6 percent at ages 12 or 13 to 7.8 percent at ages 14 or 15 to
15.8 percent at ages 16 or 17 (Figure 2.5). The highest rate of current illicit drug use was
among 18 to 20 year olds (22.6 percent), with the next highest rate occurring among 21 to
25 year olds (20.9 percent). Thereafter, the rate generally declined with age, although not all
decreases between consecutive age groups were significant.
In 2013, the rate of current use of illicit drugs was highest among young adults aged 18 to 25
(21.5 percent), followed by youths aged 12 to 17 (8.8 percent), then by adults aged 26 or
older (7.3 percent) (Figure 2.6). The number and percentage of current illicit drug users
among youths aged 12 to 17 decreased from 2.4 million (9.5 percent) in 2012 to 2.2 million
(8.8 percent) in 2013.

Figure 2.4 Past Month and Past Year Heroin Use Among Persons Aged 12 or Older: 2002-2013

+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.

Figure 2.5 Past Month Illicit Drug Use Among Persons Aged 12 or Older, by Age: 2012 and 2013
 +Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.

Figure 2.6 Past Month Illicit Drug Use Among Persons Aged 12 or Older, by Age: 2002-2013

+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.
Youths Aged 12 to 17
In 2013, 8.8 percent of youths aged 12 to 17 were current illicit drug users (Figure 2.7). This
rate was lower than the rates of current illicit drug use among 12 to 17 year olds in 2002 to
2007 and in 2009 to 2012 but was similar to the rate in 2008 (9.3 percent).
In 2013, 7.1 percent of youths aged 12 to 17 were current users of marijuana, 2.2 percent
were current nonmedical users of psychotherapeutic drugs (including 1.7 percent who were
current nonmedical users of pain relievers), 0.6 percent were current users of hallucinogens,
0.5 percent were current users of inhalants, 0.2 percent were current users of cocaine, and
0.1 percent were current users of heroin. Current marijuana use among 12 to 17 year olds
declined from 8.2 percent in 2002 to 6.8 percent in 2005, remained similar through 2008,
then increased to 7.9 percent in 2011 before decreasing again to 7.2 percent in 2012 and 7.1
percent in 2013 (Figure 2.7). Current nonmedical use of psychotherapeutic drugs declined
from 4.0 percent in 2002 and 2003 to 2.2 percent in 2013. This includes a decrease in the
prevalence of current nonmedical use of pain relievers from 3.2 percent in 2002 and 2003 to
1.7 percent in 2013.
Among youths aged 12 to 17, the specific types of illicit drugs used in the past month varied
by age in 2013 (Figure 2.8). Among 12 or 13 year olds, 1.3 percent used psychotherapeutic
drugs nonmedically, including 0.9 percent using pain relievers nonmedically (which was a
decrease from 1.5 percent in 2012), 1.0 percent used marijuana, and 0.6 percent used
inhalants. Among 14 or 15 year olds, 5.8 percent used marijuana, 2.2 percent used
psychotherapeutic drugs nonmedically, including 1.8 percent using pain relievers
nonmedically, 0.6 percent used inhalants, and 0.4 percent used hallucinogens. Among 16 or
17 year olds, 14.2 percent used marijuana, 3.1 percent used psychotherapeutic drugs
nonmedically (which was a decrease from 4.0 percent in 2012), 1.3 percent used
hallucinogens (including an increase in the use of LSD from 0.2 percent in 2012 to 0.5
percent in 2013), 0.4 percent used cocaine, and 0.3 percent used inhalants (which was a
decrease from 0.7 percent in 2012). Rates of current nonmedical use of psychotherapeutic
drugs among youths aged 16 or 17 included 2.3 percent for pain relievers (which was a
decrease from 3.1 percent in 2012) and 0.5 percent for tranquilizers (which was a decrease
from 1.2 percent in 2012).

Figure 2.7 Past Month Use of Selected Illicit Drugs Among Youths Aged 12 to 17: 2002-2013
+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.
Young Adults Aged 18 to 25
Among young adults aged 18 to 25, the rate of current illicit drug use in 2013 (21.5 percent)
was similar to the rates in 2009 to 2012 (ranging from 21.3 to 21.6 percent) but was higher
than the rates in 2002 to 2008 (ranging from 19.4 to 20.3 percent) (Figure 2.9).
The rate of current marijuana use in 2013 among young adults aged 18 to 25 (19.1 percent)
was similar to the rates in 2009 to 2012 (ranging from 18.2 to 19.0 percent) but was higher
than the rates in 2002 to 2008 (ranging from 16.1 to 17.3 percent) (Figure 2.9).
Among young adults aged 18 to 25, the rate of current nonmedical use of psychotherapeutic
drugs in 2013 (4.8 percent) was similar to the rates in 2011 (5.0 percent) and 2012 (5.3
percent), but it was lower than the rates in 2002 to 2010 (ranging from 5.5 to 6.5 percent)
(Figure 2.9). The rate of current nonmedical use of pain relievers among young adults in
2013 (3.3 percent) was lower than the rates in 2012 (3.8 percent) and in 2002 to 2010
(ranging from 4.1 to 5.0 percent), but it was similar to the rate in 2011 (3.6 percent).
In 2013, the rate of current cocaine use among young adults aged 18 to 25 was 1.1 percent,
which was similar to the rates in 2009, 2011, and 2012, but it was lower than the rates from
2002 to 2008 and in 2010 (Figure 2.9).
Among 18 to 25 year olds in 2013, the rates of current use of hallucinogens (1.8 percent),
heroin (0.3 percent), and inhalants (0.3 percent) were similar to the rates in 2012.

Figure 2.8 Past Month Use of Selected Illicit Drugs Among Youths Aged 12 to 17: 2013

Note: The prevalence of past month cocaine use among youths aged 12 or 13 rounds to less
than 0.1 percent and is not shown.
Figure 2.9 Past Month Use of Selected Illicit Drugs Among Young Adults Aged 18 to 25: 2002-
2013

+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.
Adults Aged 26 or Older
In 2013, the rate of current illicit drug use among adults aged 26 or older was 7.3 percent,
including rates of 5.6 percent for current use of marijuana and 2.1 percent for current
nonmedical use of psychotherapeutic drugs. Less than 1 percent of adults in this age group
were current users of cocaine (0.5 percent), hallucinogens (0.3 percent), heroin (0.1
percent), and inhalants (0.1 percent). The rate of current illicit drug use in 2013 was similar
to the rate in 2012 (7.0 percent), but it was higher than the rates in 2002 to 2011 (ranging
from 5.5 to 6.6 percent). Also, the rate of current marijuana use in 2013 (5.6 percent) was
similar to the rate in 2012 (5.3 percent), but it was higher than the rates in 2002 to 2011
(ranging from 3.9 to 4.8 percent).
Among adults aged 50 to 64, the rate of current illicit drug use increased from 2.7 percent in
2002 to 6.0 percent in 2013. For adults aged 50 to 54, the rate increased from 3.4 percent in
2002 to 7.9 percent in 2013 (Figure 2.10). Among those aged 55 to 59, the rate of current
illicit drug use increased from 1.9 percent in 2002 to 5.7 percent in 2013. Among those aged
60 to 64, the rate of current illicit drug use increased from 1.1 percent in 2003 and 2004 to
3.9 percent in 2013.

Figure 2.10 Past Month Illicit Drug Use Among Adults Aged 50 to 64: 2002-2013

+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.
Gender
In 2013, as in prior years, the rate of current illicit drug use among persons aged 12 or older
was higher for males (11.5 percent) than for females (7.3 percent). Males were more likely
than females to be current users of several different illicit drugs, including marijuana (9.7 vs.
5.6 percent), cocaine (0.8 vs. 0.4 percent), and hallucinogens (0.7 vs. 0.3 percent).
In 2013, the rate of current illicit drug use was higher for males than females aged 12 to 17
(9.6 vs. 8.0 percent). This represents a change from 2012, when the rates of current illicit
drug use were similar among males and females aged 12 to 17 (9.6 and 9.5 percent,
respectively), and reflects a decrease in the rate of current illicit drug use among females
from 2012 to 2013. Likewise, in 2013, the rate of current marijuana use was higher for
males than females aged 12 to 17 (7.9 vs. 6.2 percent), which is a change from 2012 when
the rates of current marijuana use for males and females were similar (7.5 and 7.0 percent).
The rate of current marijuana use among males aged 12 to 17 declined from 9.1 percent in
2002 to 6.9 percent in 2006, then increased between 2006 and 2011 (9.0 percent) (Figure
2.11). The rate decreased from 2011 to 2012 (7.5 percent) and remained stable in 2013 (7.9
percent). Among females aged 12 to 17, the rate of current marijuana use decreased from
7.2 percent in 2002 and 2003 to 6.2 percent in 2013.
The rate of current nonmedical use of psychotherapeutic drugs among males aged 12 to 17
decreased from a high of 3.7 percent in 2003 to 2.0 percent in 2013. Among females aged
12 to 17, the rate of current nonmedical use of psychotherapeutic drugs decreased from a
high of 4.4 percent in 2002 to 2.4 percent in 2013, including a decrease from 3.2 percent in
2012.

Figure 2.11 Past Month Marijuana Use Among Youths Aged 12 to 17, by Gender: 2002-2013

+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.
Pregnant Women
Among pregnant women aged 15 to 44, 5.4 percent were current illicit drug users based on
data averaged across 2012 and 2013. This was lower than the rate among women in this
age group who were not pregnant (11.4 percent). Among pregnant women aged 15 to 44,
the average rate of current illicit drug use in 2012-2013 (5.4 percent) was not significantly
different from the rate averaged across 2010-2011 (5.0 percent). Current illicit drug use in
2012-2013 was lower among pregnant women aged 15 to 44 during the third trimester than
during the first and second trimesters (2.4 percent vs. 9.0 and 4.8 percent).
The rate of current illicit drug use in the combined 2012-2013 data was 14.6 percent among
pregnant women aged 15 to 17, 8.6 percent among women aged 18 to 25, and 3.2 percent
among women aged 26 to 44. These rates were not significantly different from those in the
combined 2010-2011 data (20.9 percent among pregnant women aged 15 to 17, 8.2 percent
among pregnant women aged 18 to 25, and 2.2 percent among pregnant women aged 26 to
44).
Race/Ethnicity
In 2013, among persons aged 12 or older, the rate of current illicit drug use was 3.1 percent
among Asians, 8.8 percent among Hispanics, 9.5 percent among whites, 10.5 percent
among blacks, 12.3 percent among American Indians or Alaska Natives, 14.0 percent
among Native Hawaiians or Other Pacific Islanders, and 17.4 percent among persons
reporting two or more races.
There were no statistically significant differences in the rates of current illicit drug use
between 2012 and 2013 for any of the racial/ethnic groups. Between 2002 and 2013, the
rate of current illicit drug use increased from 8.5 to 9.5 percent for whites. Among blacks,
the rate increased from 8.7 percent in 2003 and 2004 to 10.5 percent in 2013 (Figure 2.12).
Education
Illicit drug use in 2013 varied by the educational status of adults aged 18 or older. The rate
of current illicit drug use was lower among college graduates (6.7 percent) than those with
some college education but no degree (10.8 percent), high school graduates with no further
education (9.9 percent), and those who had not graduated from high school (11.8 percent).
College Students
In 2013, the rate of current illicit drug use was 22.3 percent among full-time college students
aged 18 to 22. This was similar to the rate among other persons aged 18 to 22 (23.0
percent), which included part-time college students, students in other grades or types of
institutions, and nonstudents.
In 2013, about one quarter of male full-time college students aged 18 to 22 were current
illicit drug users (26.0 percent). This rate was higher than the rate of current illicit drug use
among female full-time college students aged 18 to 22 (19.2 percent). Similarly, 23.6 percent
of male full-time college students aged 18 to 22 were current marijuana users compared
with 16.6 percent of female full-time college students aged 18 to 22.
Among full-time college students aged 18 to 22 in 2013, the rate of current illicit drug use
was 9.4 percent for Asians, 19.7 percent for blacks, 21.5 percent for Hispanics, and 25.1
percent for whites.

Figure 2.12 Past Month Illicit Drug Use Among Persons Aged 12 or Older, by Race/Ethnicity:
2002-2013

+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.

Note: Sample sizes for American Indians or Alaska Natives, Native Hawaiians or Other
Pacific Islanders, and persons of two or more races were too small for reliable trend
presentation for these groups.
Employment
Current illicit drug use differed by employment status in 2013. Among adults aged 18 or
older, the rate of current illicit drug use was higher for those who were unemployed (18.2
percent) than for those who were employed full time (9.1 percent), employed part time
(13.7 percent), or “other” (6.6 percent) (which includes students, persons keeping house or
caring for children full time, retired or disabled persons, or other persons not in the labor
force) (Figure 2.13). The percentage of adults employed full time who were current illicit
drug users in 2013 was similar to that in 2012 (8.9 percent).
Although the rate of current illicit drug use was higher among unemployed persons in 2013
than it was among those who were employed full time, employed part time, or in the “other”
employment category, most of these users were employed. Of the 22.4 million current illicit
drug users aged 18 or older in 2013, 15.4 million (68.9 percent) were employed either full or
part time.
Geographic Area
Among persons aged 12 or older, the rate of current illicit drug use in 2013 was 11.8 percent
in the West, 9.2 percent in the Northeast, 8.7 percent in the Midwest, and 8.3 percent in the
South.
In 2013, the rate of current illicit drug use among persons aged 12 or older was 9.6 percent
in large metropolitan areas, 9.8 percent in small metropolitan areas, and 7.8 percent in
nonmetropolitan areas (Figure 2.14). Within nonmetropolitan areas, the rate was 8.9 percent
in urbanized counties and 6.9 percent in both less urbanized counties and rural counties.

Figure 2.13 Past Month Illicit Drug Use Among Persons Aged 18 or Older, by Employment
Status: 2012 and 2013

+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.

1The Other Employment category includes students, persons keeping house or caring for
children full time, retired or disabled persons, or other persons not in the labor force.
Criminal Justice Populations
In 2013, an estimated 1.7 million adults aged 18 or older were on parole or other supervised
release from prison at some time during the past year. About one quarter (27.4 percent)
were current illicit drug users, with 20.4 percent reporting current use of marijuana and 12.1
percent reporting current nonmedical use of psychotherapeutic drugs. These rates were
higher than those reported by adults aged 18 or older who were not on parole or other
supervised release during the past year (9.3 percent for current illicit drug use, 7.5 percent
for current marijuana use, and 2.4 percent for current nonmedical use of psychotherapeutic
drugs).
In 2013, an estimated 4.5 million adults aged 18 or older were on probation at some time
during the past year. More than one quarter (31.4 percent) were current illicit drug users,
with 23.5 percent reporting current use of marijuana and 12.3 percent reporting current
nonmedical use of psychotherapeutic drugs. These rates were higher than those reported by
adults who were not on probation during the past year (9.0 percent for current illicit drug
use, 7.3 percent for current marijuana use, and 2.3 percent for current nonmedical use of
psychotherapeutic drugs).
Frequency of Marijuana Use
In 2013, 5.7 million persons aged 12 or older used marijuana on a daily or almost daily basis
in the past 12 months (i.e., on 300 or more days in that period), which was an increase from
the 3.1 million daily or almost daily users in 2006 (Figure 2.15). The number of daily or
almost daily users of marijuana in 2013 represented 17.4 percent of past year users.
In 2013, 8.1 million persons aged 12 or older used marijuana on 20 or more days in the past
month, which was an increase from the 5.1 million daily or almost daily past month users in
2005 to 2007 (Figure 2.15). The number of daily or almost daily users in 2013 represented
41.1 percent of past month marijuana users.

Figure 2.14 Past Month Illicit Drug Use Among Persons Aged 12 or Older, by County Type: 2013
Association With Cigarette and Alcohol Use
In 2013, the rate of current illicit drug use among youths aged 12 to 17 who smoked
cigarettes in the past month was approximately 9 times the rate among youths who did not
smoke cigarettes in the past month (53.9 vs. 6.1 percent). Also, the rate of current
marijuana use in 2013 among youths aged 12 to 17 who smoked cigarettes in the past month
was about 11 times the rate among youths who did not smoke cigarettes (49.5 vs. 4.6
percent).
In 2013, the rate of current illicit drug use was associated with the level of past month
alcohol use. Among youths aged 12 to 17 who were heavy drinkers (i.e., consumed five or
more drinks on the same occasion on each of 5 or more days in the past 30 days), 62.3
percent were current illicit drug users, and 57.9 percent were current marijuana users.
These rates were higher than the rates among youths who were not current alcohol users
(4.9 percent for current illicit drug use and 3.3 percent for current marijuana use).
Additionally, among youths aged 12 to 17 who were binge but not heavy alcohol users (i.e.,
consumed five or more drinks on the same occasion on 1 to 4 days in the past 30 days), 46.6
percent were current illicit drug users, and 43.2 percent were current marijuana users (with
the marijuana use rate being higher than the 2012 rate of 37.8 percent).
In 2013, the rate of current illicit drug use among youths aged 12 to 17 who both smoked
cigarettes and drank alcohol in the past month was approximately 16 times the rate among
those who neither smoked cigarettes nor drank alcohol in the past month (64.5 vs. 3.9
percent). Additionally, the rate of current marijuana use among youths aged 12 to 17 who
both smoked cigarettes and drank alcohol in the past month was about 25 times the rate
among those who neither smoked cigarettes nor drank alcohol in the past month (59.7 vs.
2.4 percent).

Figure 2.15 Daily or Almost Daily Marijuana Use in the Past Year and Past Month Among
Persons Aged 12 or Older: 2002-2013
+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.
Driving Under the Influence of Illicit Drugs
In 2013, 9.9 million persons, or 3.8 percent of the population aged 12 or older, reported
driving under the influence of illicit drugs during the past year. This rate was lower than the
rate in 2002 (4.7 percent) but was similar to the rate in 2012 (3.9 percent). Across age
groups, the rate of driving under the influence of illicit drugs in 2013 was highest among
young adults aged 18 to 25 (10.6 percent); this rate for young adults was lower than the rate
in 2012 (11.9 percent). Additionally, the rate of driving under the influence of illicit drugs
during the past year among youths aged 12 to 17 decreased from 2.3 percent in 2012 to 1.9
percent in 2013.

Figure 2.16 Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use
Among Past Year Users Aged 12 or Older: 2012-2013

1The Other category includes the sources “Wrote Fake Prescription,” “Stole from Doctor’s
Office/Clinic/Hospital/Pharmacy,” and “Some Other Way.”

Note: The percentages do not add to 100 percent due to rounding.

Source of Prescription Drugs
Past year nonmedical users of psychotherapeutic drugs are asked how they obtained the
drugs for their most recent nonmedical use. Rates averaged across 2012 and 2013 show
that more than half of the nonmedical users of pain relievers, tranquilizers, stimulants, and
sedatives aged 12 or older got the prescription drugs they most recently used “from a friend
or relative for free.” More than four in five of these nonmedical users who obtained
prescription drugs from a friend or relative for free indicated that their friend or relative had
obtained the drugs from one doctor.
Among persons aged 12 or older in 2012-2013 who used pain relievers nonmedically in the
past year, 53.0 percent got the pain relievers they most recently used from a friend or
relative for free (Figure 2.16). About one in five (21.2 percent) received them through a
prescription from one doctor (which was higher than the 18.1 percent in 2010-2011).
Another 10.6 percent of these nonmedical users in 2012-2013 bought pain relievers from a
friend or relative, and 4.0 percent took pain relievers from a friend or relative without
asking.
An annual average of 4.3 percent got the pain relievers from a drug dealer or other
stranger; 2.6 percent got pain relievers from more than one doctor; 0.1 percent bought pain
relievers on the Internet; and 4.3 percent got pain relievers in other ways, including 0.7
percent who stole pain relievers from a doctor’s office, clinic, hospital, or pharmacy.
Among persons aged 12 or older in 2012-2013 who used pain relievers nonmedically in the
past year and indicated that they most recently obtained the drugs from a friend or relative
for free in the past year, 83.8 percent reported that their friend or relative obtained the drugs
from just one doctor (Figure 2.16). About 1 in 20 (5.1 percent) of these past year
nonmedical users of pain relievers reported that the friend or relative got the pain relievers
from another friend or relative for free, 4.9 percent reported that the friend or relative
bought or took them from a friend or relative (including 3.7 percent who reported that the
friend or relative bought the pain relievers from a friend or relative and 1.2 percent who
reported that the friend or relative took the pain relievers from another friend or relative
without asking), 1.4 percent reported that the friend or relative bought the pain relievers
from a drug dealer or other stranger, and 0.3 percent reported that the friend or relative
bought the pain relievers on the Internet.
3. Alcohol Use
The National Survey on Drug Use and Health (NSDUH) includes questions about the recency and
frequency of consumption of alcoholic beverages, such as beer, wine, whiskey, brandy, and mixed
drinks. A “drink” is defined as a can or bottle of beer, a glass of wine or a wine cooler, a shot of
liquor, or a mixed drink with liquor in it. Times when the respondent only had a sip or two from a
drink are not considered to be consumption. For this report, estimates for the prevalence of alcohol
use are reported primarily at three levels defined for both males and females and for all ages as
follows:

Current (past month) use—At least one drink in the past 30 days.
Binge use—Five or more drinks on the same occasion (i.e., at the same time or within a
couple of hours of each other) on at least 1 day in the past 30 days.
Heavy use—Five or more drinks on the same occasion on each of 5 or more days in the
past 30 days.

These levels are not mutually exclusive categories of use; heavy use is included in estimates of
binge and current use, and binge use is included in estimates of current use.

This chapter is divided into two main sections. Section 3.1 describes trends and patterns of alcohol
use among the population aged 12 or older. Section 3.2 is concerned particularly with the use of
alcohol by persons aged 12 to 20. These persons are under the legal drinking age in all 50 states
and the District of Columbia.
3.1. Alcohol Use among Persons Aged 12 or
Older
Slightly more than half (52.2 percent) of Americans aged 12 or older reported being current
drinkers of alcohol in the 2013 survey, which was similar to the rate in 2012 (52.1 percent).
This translates to an estimated 136.9 million current drinkers in 2013.
Nearly one quarter (22.9 percent) of persons aged 12 or older in 2013 were binge alcohol
users in the 30 days prior to the survey. This translates to about 60.1 million people. The rate
in 2013 was similar to the rate in 2012 (23.0 percent).
In 2013, heavy drinking was reported by 6.3 percent of the population aged 12 or older, or
16.5 million people. This percentage was similar to the rate of heavy drinking in 2012 (6.5
percent).
Age
In 2013, rates of current alcohol use were 2.1 percent among persons aged 12 or 13, 9.5
percent for persons aged 14 or 15, 22.7 percent for 16 or 17 year olds, 43.8 percent for
those aged 18 to 20, and 69.3 percent for 21 to 25 year olds (Figure 3.1). The estimates for
persons aged 14 or 15 and those aged 16 or 17 were lower than those reported in 2012 (11.1
and 24.8 percent, respectively).

Rates of binge alcohol use in 2013 were 0.8 percent among 12 or 13 year olds, 4.5 percent
for 14 or 15 year olds, 13.1 percent for 16 or 17 year olds, 29.1 percent for persons aged 18
to 20, and peaked at 43.3 percent for those aged 21 to 25 (Figure 3.1). The estimates for
persons aged 14 or 15, 16 or 17, and 21 to 25 were lower than those reported in 2012 (5.4,
15.0, and 45.1 percent, respectively).

Figure 3.1 Current, Binge, and Heavy Alcohol Use Among Persons Aged 12 or Older, by
Age: 2013

Note: The past month binge alcohol use estimate for 12 or 13 year olds was 0.8
percent, and the past month heavy alcohol use estimate was 0.1 percent.

Rates of heavy alcohol use in 2013 were 0.1 percent among 12 or 13 year olds, 0.7 percent
for 14 or 15 year olds, 2.7 percent for 16 or 17 year olds, 8.5 percent for persons aged 18 to
20, and peaked at 13.1 percent for those aged 21 to 25 (Figure 3.1). The estimates for
persons aged 18 to 20 and 21 to 25 were lower than those reported in 2012 (10.0 and 14.4
percent, respectively).
The rate of current alcohol use among youths aged 12 to 17 was 11.6 percent in 2013.
Youth binge and heavy drinking rates were 6.2 and 1.2 percent, respectively. The rates for
current and binge youth alcohol use were lower than those in 2012 (12.9 and 7.2 percent,
respectively).
In 2013, the rate of current alcohol use was 59.6 percent among young adults aged 18 to 25,
which was similar to the rate in 2012 (60.2 percent). The rate of binge drinking in 2013 was
37.9 percent for young adults. Heavy alcohol use was reported by 11.3 percent of persons
in this age group. The binge and heavy drinking rates were lower than the rates in 2012
(39.5 and 12.7 percent, respectively).
The prevalence of current, binge, and heavy alcohol use in 2013 was lower among adults
aged 65 or older (41.7, 9.1, and 2.1 percent, respectively) than among all other adult age
groups (Figure 3.1). These rates among adults aged 65 or older were similar to the current,
binge, and heavy drinking rates in this age group in 2012 (41.2, 8.2, and 2.0 percent,
respectively).
Gender
In 2013, an estimated 57.1 percent of males aged 12 or older were current drinkers, which
was higher than the rate for females (47.5 percent). Among youths aged 12 to 17, however,
the percentage of males who were current drinkers (11.2 percent) was similar to the rate
for females (11.9 percent). The rates for male and female youths were lower than those
reported in 2012 (12.6 and 13.2 percent, respectively).
Among young adults aged 18 to 25, an estimated 62.3 percent of males and 56.9 percent of
females were current drinkers in 2013. In this age group, 44.4 percent of males and 31.4
percent of females reported binge drinking in 2013 (Figure 3.2). In 2013, the rate of binge
drinking among females aged 18 to 25 was lower than the rate reported in 2012 (33.2
percent). The rate of binge alcohol use in 2013 among males in this age group was similar to
the rate in 2012 (45.8 percent).
Among persons aged 26 or older, an estimated 62.2 percent of males and 50.1 percent of
females reported current drinking in 2013. In this age group, the rate of binge drinking for
males was approximately twice the rate for females (30.7 vs. 14.7 percent).
Pregnant Women
Among pregnant women aged 15 to 44 in 2012-2013, an annual average of 9.4 percent
reported current alcohol use, 2.3 percent reported binge drinking, and 0.4 percent reported
heavy drinking. These rates were lower than the rates for nonpregnant women in the same
age group (55.4, 24.6, and 5.3 percent, respectively). Current alcohol use in 2012-2013 was
lower among pregnant women aged 15 to 44 during the second and third trimesters than
during the first trimester (5.0 and 4.4 percent vs. 19.0 percent).
Race/Ethnicity
Among persons aged 12 or older, whites in 2013 were more likely than other racial/ethnic
groups to report current use of alcohol (57.7 percent) (Figure 3.3). The rates were 47.4
percent for persons reporting two or more races, 43.6 percent for blacks, 43.0 percent for
Hispanics, 38.4 percent for Native Hawaiians or Other Pacific Islanders, 37.3 percent for
American Indians or Alaska Natives, and 34.5 percent for Asians.
The rate of binge alcohol use in 2013 was lowest among Asians (12.4 percent) (Figure 3.3).
Rates for other racial/ethnic groups were 19.6 percent for persons reporting two or more
races, 20.1 percent for blacks, 23.5 percent for American Indians or Alaska Natives, 24.0
percent for whites, 24.1 percent for Hispanics, and 24.7 percent for Native Hawaiians or
Other Pacific Islanders.
Among youths aged 12 to 17 in 2013, rates of current alcohol use were 8.0 percent among
Asians, 8.2 percent for Native Hawaiians or Other Pacific Islanders, 9.0 percent for those
reporting two or more races, 9.3 percent for American Indians or Alaska Natives, 9.7
percent for blacks, 10.7 percent for Hispanics, and 12.9 percent for whites. The rates for
Hispanic and white youths were lower than those reported in 2012 (12.8 and 14.6 percent,
respectively).

Figure 3.2 Binge Alcohol Use Among Adults Aged 18 to 25, by Gender: 2002-2013

+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.
Education
Among adults aged 18 or older, the rate of past month alcohol use increased with increasing
levels of education. Among adults in 2013 with less than a high school education, 36.5
percent were current drinkers. In comparison, 69.2 percent of college graduates were
current drinkers.
Among adults aged 18 or older, rates of binge and heavy alcohol use varied by level of
education. Among adults in 2013, those who had graduated from college were less likely
than those with some college education but no degree to be binge drinkers (23.1 vs. 26.4
percent) or heavy drinkers (6.0 vs. 7.6 percent).
College Students
Young adults aged 18 to 22 who were enrolled full time in college were more likely than
their peers who were not enrolled full time (i.e., part-time college students and persons not
currently enrolled in college) to report current, binge, or heavy drinking. Among full-time
college students in 2013, 59.4 percent were current drinkers, 39.0 percent were binge
drinkers, and 12.7 percent were heavy drinkers. Among those not enrolled full time in
college, these rates were 50.6, 33.4, and 9.3 percent, respectively.
The pattern of higher rates of current alcohol use, binge alcohol use, and heavy alcohol use
among full-time college students compared with rates for others aged 18 to 22 has remained
consistent since 2002 (Figure 3.4).
Among young adults aged 18 to 22, the rate of binge drinking declined somewhat since
2002. In 2002, the binge drinking rate within this age group was 41.0 percent compared with
35.6 percent in 2013. Among full-time college students, the rate decreased over this period
from 44.4 to 39.0 percent (Figure 3.4). Among part-time college students and others not in
college, the rate decreased from 38.9 to 33.4 percent during the same time period. For both
full-time college students and others aged 18 to 22, the rates in 2013 were similar to those in
2012 (40.1 and 35.0 percent, respectively).
In 2013, male full-time college students aged 18 to 22 were more likely than their female
counterparts to be binge drinkers (44.8 vs. 33.9 percent) as well as heavy drinkers (16.5 vs.
9.3 percent). The rates for current drinking were similar for males and females who were
full-time college students (60.8 and 58.2 percent, respectively).

Figure 3.3 Current, Binge, and Heavy Alcohol Use Among Persons Aged 12 or Older, by
Race/Ethnicity: 2013
Employment
The rate of current alcohol use in 2013 was 65.8 percent for full-time employed adults aged
18 or older, which was higher than the rate for unemployed adults (53.8 percent). The rates
of binge drinking were similar for adults who were employed full time and those who were
unemployed (30.5 and 31.3 percent, respectively).
Among adults in 2013, most binge and heavy alcohol users were employed. Among the 8.5
million adults who were binge drinkers, 44.5 million (76.1 percent) were employed either full
or part time. Among the 16.2 million adults who were heavy drinkers, 12.4 million (76.0
percent) were employed.
Geographic Area
The rate of past month alcohol use for people aged 12 or older in 2013 was lowest in the
South (48.2 percent), followed by the West (50.7 percent), then the Midwest (55.7 percent),
then the Northeast (58.0 percent). Rates of binge drinking in these regions were 21.3, 22.2,
25.6, and 23.8 percent, respectively.
In 2013, the rates of past month alcohol use among persons aged 12 or older in large and
small metropolitan areas (54.3 and 51.6 percent, respectively) were higher than in
nonmetropolitan areas (46.3 percent). Rates of binge drinking were similar in large and
small metropolitan areas (23.3 and 23.1 percent, respectively). However, binge drinking
among persons aged 12 or older was less prevalent in nonmetropolitan areas (21.1 percent)
than in large metropolitan areas.
In 2013, roughly 1 in 9 youths aged 12 to 17 were current alcohol users, regardless of
whether they were in large metropolitan, small metropolitan, or nonmetropolitan areas (11.7,
11.4, and 11.3 percent, respectively). Among youths aged 12 to 17 in 2013, the rates of
binge alcohol use in large and small metropolitan areas (6.2 percent in both areas) were
similar to the rate for youths in nonmetropolitan areas (6.6 percent). Youths in
nonmetropolitan areas were less likely to be current alcohol drinkers and to be binge alcohol
users than they were in 2012 (14.2 and 9.2 percent, respectively).

Figure 3.4 Binge Alcohol Use Among Adults Aged 18 to 22, by College Enrollment: 2002-2013

+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.
Association With Illicit Drug and Tobacco Use
As was the case in prior years, the level of alcohol use was associated with illicit drug use in
2013. Among the 16.5 million heavy drinkers aged 12 or older, 33.7 percent were current
illicit drug users. Persons who were not current alcohol users were less likely to have used
illicit drugs in the past month (4.3 percent) than those who reported current use of alcohol
but no binge or heavy use (7.3 percent), binge use but no heavy use (18.5 percent), or heavy
use of alcohol (33.7 percent).
Alcohol consumption levels also were associated with tobacco use in 2013. Among heavy
alcohol users aged 12 or older, 53.1 percent smoked cigarettes in the past month compared
with 16.2 percent of non-binge current drinkers and 15.5 percent of persons who did not
drink alcohol in the past month. Smokeless tobacco use and cigar use also were more
prevalent among heavy drinkers (12.1 and 15.4 percent, respectively) than among non-binge
drinkers (2.0 and 3.9 percent) and persons who were not current alcohol users (2.0 and 1.8
percent).
Driving Under the Influence of Alcohol
In 2013, roughly 1 in 9 persons aged 12 or older (10.9 percent) drove under the influence of
alcohol at least once in the past year (Figure 3.5). This corresponds to 28.7 million persons.
The 2013 rate was lower than the rate in 2002 (14.2 percent), but was similar to the rate in
2012 (11.2 percent).
Driving under the influence of alcohol among persons aged 16 or older differed by age
group in 2013. The rate was highest among persons aged 21 to 25 and persons aged 26 to
29 (19.7 and 20.7 percent, respectively) (Figure 3.6). An estimated 3.8 percent of 16 or 17
year olds and 10.8 percent of 18 to 20 year olds reported driving under the influence of
alcohol in the past year.
Among persons aged 12 to 20 and those aged 21 to 25, the rates of driving under the
influence of alcohol in 2013 (4.7 and 19.7 percent, respectively) were lower than the rates in
2012 (5.7 and 21.9 percent, respectively). The rates of driving under the influence for those
26 or older were similar in 2012 and 2013 (11.1 and 11.2 percent, respectively).
Among persons aged 12 or older in 2013, males were more likely than females to drive
under the influence of alcohol in the past year (14.1 vs. 7.9 percent).
3.2. Underage Alcohol Use
In 2013, about 8.7 million persons aged 12 to 20 (22.7 percent of this age group) reported
drinking alcohol in the past month. Approximately 5.4 million (14.2 percent) were binge
drinkers, and 1.4 million (3.7 percent) were heavy drinkers. All three of these rates were
lower than those reported in 2012 (24.3, 15.3, and 4.3 percent, respectively).

Rates of current, binge, and heavy alcohol use among underage persons declined between
2002 and 2013. The rate of current alcohol use among 12 to 20 year olds decreased from
28.8 percent in 2002 to 22.7 percent in 2013. The binge drinking rate declined from 19.3 to
14.2 percent, and the rate of heavy drinking declined from 6.2 to 3.7 percent between 2002
and 2013.

Figure 3.5 Driving Under the Influence of Alcohol in the Past Year Among Persons Aged
12 or Older: 2002-2013

+Difference between this estimate and the 2013 estimate is statistically significant at
the .05 level.

Figure 3.6 Driving Under the Influence of Alcohol in the Past Year Among Persons Aged
16 or Older, by Age: 2013
Rates of current alcohol use increased with age among underage persons. In 2013, 2.1
percent of persons aged 12 or 13, 9.5 percent of persons aged 14 or 15, 22.7 percent of 16
or 17 year olds, and 43.8 percent of 18 to 20 year olds drank alcohol during the 30 days
before they were surveyed (Figure 3.7). This pattern by age has been observed since 2002.
The rates in 2013 for youths aged 14 or 15 and those aged 16 or 17 were lower than the
rates in 2012 (11.1 and 24.8 percent, respectively).
Males and females aged 12 to 20 in 2013 had similar rates of current alcohol use (23.0 and
22.5 percent) (Figure 3.8). However, underage males were more likely than underage
females to report binge (15.8 vs. 12.4 percent) or heavy alcohol use (4.6 vs. 2.7 percent).
Among persons aged 12 to 20, past month alcohol use rates in 2013 were 15.2 percent
among Asians, 17.8 percent for blacks, 17.8 percent for those reporting two or more races,
17.8 percent for American Indians or Alaska Natives, 20.6 percent for Hispanics, and 25.8
percent for whites. The rates of current alcohol use among Hispanics and whites were
lower than those reported in 2012 (23.2 and 27.4 percent, respectively).
In 2013, among persons aged 12 to 20, binge drinking was reported by 16.8 percent of
whites, 13.9 percent of American Indians or Alaska Natives, 13.5 percent of Hispanics,
12.1 percent of Native Hawaiians or Other Pacific Islanders, 11.1 percent of persons
reporting two or more races, 8.4 percent of blacks, and 7.6 percent of Asians.
Across geographic regions in 2013, the rate of current alcohol use among persons aged 12
to 20 was 25.9 percent in the Northeast, 24.5 percent in the Midwest, 22.5 percent in the
West, and 20.4 percent in the South. The rate of current alcohol use in the South in 2013
was lower than it was in 2012 (22.3 percent).

In 2013, the current alcohol use rates among underage persons were 22.7 percent in large
metropolitan areas, 23.1 percent in small metropolitan areas, and 21.9 percent in
nonmetropolitan areas. The underage current drinking rate in 2013 was lower in large
metropolitan areas than the rate reported in 2012 (24.7 percent).

Figure 3.7 Current Alcohol Use Among Persons Aged 12 to 20, by Age: 2002-2013
 +Difference between this estimate and the 2013 estimate is statistically significant at
the .05 level.

Figure 3.8 Current, Binge, and Heavy Alcohol Use Among Persons Aged 12 to 20, by
Gender: 2013

In 2013, 77.6 percent of current drinkers aged 12 to 20 were with two or more other people
the last time they drank alcohol, 16.3 percent were with one other person the last time they
drank, and 6.1 percent were alone. The rate of drinking alone the last time that underage
persons drank alcohol was highest among youths aged 12 to 14 (14.5 percent), followed by
youths aged 15 to 17 (7.8 percent), then by persons aged 18 to 20 (4.8 percent).
A majority of underage current drinkers in 2013 reported that their last use of alcohol in the
past month occurred in a home setting, either in someone else’s home (52.2 percent) or their
own home (34.2 percent). The rate for drinking at home was higher than it was in 2012
(31.4 percent). In 2013, underage females were more likely than males to have been in a
restaurant, bar, or club on their last drinking occasion (8.8 vs. 4.5 percent).
Among underage current drinkers in 2013, 28.7 percent paid for the alcohol the last time
they drank, including 7.8 percent who purchased the alcohol themselves and 20.5 percent
who gave money to someone else to purchase it. These rates were similar to those reported
in 2012 (28.2, 7.6, and 20.4 percent, respectively). Youths aged 12 to 14 were least likely to
report that they paid for the alcohol the last time they drank (6.3 percent), followed by
youths aged 15 to 17 (20.8 percent), then by persons aged 18 to 20 (33.6 percent).
In 2013, among underage current drinkers who did not pay for the alcohol the last time they
drank, the most common source was an unrelated person aged 21 or older (36.6 percent).
Parents, guardians, or other adult family members provided the last alcohol to 24.5 percent
of nonpaying underage drinkers. Other underage persons provided the alcohol on the last
occasion for 16.4 percent of nonpaying underage drinkers. Additional sources of alcohol for
underage drinkers who did not pay included (a) took the alcohol from home (7.8 percent),
(b) took it from someone else’s home (2.9 percent), and (c) got it some other way (6.0
percent).
In 2013, underage current drinkers were more likely than current alcohol users aged 21 or
older to use illicit drugs within 2 hours of alcohol use on their last reported drinking occasion
(19.9 vs. 5.7 percent). The most commonly reported illicit drug used by underage drinkers in
combination with alcohol was marijuana, which was used within 2 hours of alcohol use by
19.5 percent of current underage drinkers (1.6 million persons) on their last drinking
occasion.
4. Tobacco Use
The National Survey on Drug Use and Health (NSDUH) includes a series of questions about the
use of tobacco products, including cigarettes, chewing tobacco, snuff, cigars, and pipe tobacco.
Cigarette use is defined as smoking “part or all of a cigarette.” For analytic purposes, data for
chewing tobacco and snuff are combined and termed “smokeless tobacco.”

In 2013, an estimated 66.9 million Americans aged 12 or older were current (past month)
users of a tobacco product. This represents 25.5 percent of the population in that age range
(Figure 4.1). Also, 55.8 million persons (21.3 percent of the population) were current
cigarette smokers; 12.4 million (4.7 percent) smoked cigars; 8.8 million (3.4 percent) used
smokeless tobacco; and 2.3 million (0.9 percent) smoked tobacco in pipes.
Between 2002 and 2013, past month use of any tobacco product among persons aged 12 or
older decreased from 30.4 to 25.5 percent, and past month cigarette use declined from 26.0
to 21.3 percent (Figure 4.1). Past month cigar use decreased from 5.4 percent in 2002 to
4.7 percent in 2013. Rates of past month use of smokeless tobacco and pipe tobacco were
similar in 2002 and 2013.

Figure 4.1 Past Month Tobacco Use Among Persons Aged 12 or Older: 2002-2013

+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.
Age
In 2013, young adults aged 18 to 25 had the highest rate of current use of a tobacco product
(37.0 percent), followed by adults aged 26 or older (25.7 percent), then by youths aged 12 to
17 (7.8 percent). Young adults also had the highest rates of current use of the specific
tobacco products. Among young adults, the rates of past month use in 2013 were 30.6
percent for cigarettes, 10.0 percent for cigars, 5.8 percent for smokeless tobacco, and 2.2
percent for pipe tobacco.
The rate of current use of a tobacco product by young adults aged 18 to 25 declined from
45.3 percent in 2002 to 37.0 percent in 2013. The rate of current cigarette use among young
adults also declined from 40.8 percent in 2002 to 30.6 percent in 2013. However, the rates
of current use of smokeless tobacco and pipe tobacco by young adults increased from 4.8
percent in 2002 to 5.8 percent in 2013 for smokeless tobacco and from 1.1 percent in 2002
to 2.2 percent in 2013 for pipe tobacco. The rates in 2013 for current use of a tobacco
product, cigarettes, smokeless tobacco, and cigars among young adults were similar to the
rates in 2012 (38.1, 31.8, 5.5, and 10.7 percent, respectively). However, the rate of pipe
tobacco use among young adults in 2013 was higher than the rate in 2012 (1.8 percent).
The rate of past month tobacco use among 12 to 17 year olds declined from 15.2 percent in
2002 to 7.8 percent in 2013, including a decline from 8.6 percent in 2012 (Figure 4.2). The
rate of past month cigarette use among 12 to 17 year olds declined from 13.0 percent in
2002 to 5.6 percent in 2013. The rate of past month cigar use among this age group declined
from 4.5 percent in 2002 to 2.3 percent in 2013. The rate of past month smokeless tobacco
use among 12 to 17 year olds declined from 2.5 percent in 2007 to 2.0 percent in 2013,
which was the same as the rate in 2002.
Adults aged 21 to 34 had higher rates of current cigarette use than did persons in either
older or younger age groups (Figure 4.3). Rates of current cigarette use in 2013 were
similar among adults aged 30 to 34 (33.2 percent), those aged 21 to 25 (32.8 percent), and
those aged 26 to 29 (32.7 percent). Among adults aged 35 or older in 2013, 19.0 percent
smoked cigarettes in the past month.
Gender
In 2013, current use of a tobacco product among persons aged 12 or older was reported by
a higher percentage of males (31.1 percent) than females (20.2 percent). Males also had
higher rates of past month use than females of each specific tobacco product: cigarettes
(23.6 percent among males vs. 19.0 percent among females), cigars (7.7 vs. 2.0 percent),
smokeless tobacco (6.5 vs. 0.4 percent), and pipe tobacco (1.5 vs. 0.3 percent).
The rate of any tobacco use among males aged 12 or older declined from 37.0 percent in
2002 to 31.1 percent in 2013. The rate of any tobacco use for females aged 12 or older also
declined from 24.3 percent in 2002 to 20.2 percent in 2013. Rates of any tobacco use were
similar between 2012 and 2013 for females (20.9 and 20.2 percent, respectively) but
declined from 33.0 to 31.1 percent for males.
Among youths aged 12 to 17, the rates of current cigarette smoking in 2013 were 5.7
percent for males and 5.5 percent for females (Figure 4.4). From 2002 to 2013, the rate of
current cigarette smoking among youths decreased for both males (from 12.3 to 5.7
percent) and females (from 13.6 to 5.5 percent). In 2013, the rate for males was lower than
the rate in 2012 (6.8 percent), while the rate was similar to the rate in 2012 for females (6.3
percent).
The rate of current cigarette smoking among male young adults aged 18 to 25 declined from
44.4 percent in 2002 to 36.3 percent in 2013. Among female young adults, the rate declined
from 37.1 percent in 2002 to 24.9 percent in 2013. For females aged 18 to 25, the rate of
current cigarette smoking in 2013 was lower than the rate in 2012 (27.1 percent), while the
rate for males in 2013 was similar to the rate in 2012 (36.6 percent).

Figure 4.2 Past Month Tobacco Use Among Youths Aged 12 to 17: 2002-2013
 +Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.

Figure 4.3 Past Month Cigarette Use Among Persons Aged 12 or Older, by Age: 2013

Figure 4.4 Past Month Cigarette Use Among Youths Aged 12 to 17, by Gender: 2002-2013

+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.
Pregnant Women
The annual average rate of past month cigarette use in 2012 and 2013 among women aged
15 to 44 who were pregnant was 15.4 percent (Figure 4.5). The rate of current cigarette
use among women aged 15 to 44 who were pregnant was lower than that among women
who were not pregnant (24.0 percent). This pattern was also evident among women aged
18 to 25 (21.0 vs. 26.2 percent for pregnant and nonpregnant women, respectively) and
among women aged 26 to 44 (11.8 vs. 25.4 percent, respectively). Rates of current
cigarette use in 2012-2013 among pregnant women aged 15 to 44 were 19.9 percent in the
first trimester, 13.4 percent in the second trimester, and 12.8 percent in the third trimester.
The annual average rates of current cigarette use among women aged 15 to 44 who were
not pregnant decreased from 30.7 percent in 2002-2003 to 24.0 percent in 2012-2013
(Figure 4.5). However, the prevalence of cigarette use among pregnant women in this age
range did not change significantly during the same time period (18.0 percent in 2002-2003
and 15.4 percent in 2012-2013).
Race/Ethnicity
In 2013, the prevalence of current use of a tobacco product was 40.1 percent for American
Indians or Alaska Natives, 31.2 percent for persons reporting two or more races, 27.7
percent for whites, 27.1 percent for blacks, 25.8 percent for Native Hawaiians or Other
Pacific Islanders, 18.8 percent for Hispanics, and 10.1 percent for Asians. The rate of
current tobacco use among American Indians or Alaska Natives was higher than the rates
for all other groups except persons reporting two or more races. The rate of current
tobacco use among Asians was lower than the rates among other groups. The rate of
current tobacco use in 2013 for whites was lower than the rate in 2012 (29.2 percent).
Otherwise, there were no statistically significant changes in past month use of any tobacco
product between 2012 and 2013 across racial/ethnic groups.
The rate of past month cigarette use in 2013 was higher among American Indians or Alaska
Natives (36.5 percent) than among persons reporting two or more races (27.1 percent),
blacks (23.0 percent), whites (22.7 percent), Native Hawaiians or Other Pacific Islanders
(21.1 percent), Hispanics (16.8 percent), and Asians (8.5 percent). Rates of past month
cigarette use in 2013 were similar to rates in 2012 across racial/ethnic groups.
Rates of past month cigar use in 2013 were 6.9 percent for blacks, 6.1 percent for
American Indians or Alaska Natives, 5.5 percent for persons reporting two or more races,
4.8 percent for whites, 3.7 percent for Hispanics, 2.1 percent for Native Hawaiians or
Other Pacific Islanders, and 2.0 percent for Asians. There were no statistically significant
changes in past month cigar use between 2012 and 2013 across racial/ethnic groups, except
for whites (5.3 vs. 4.8 percent).
Rates of past month smokeless tobacco use in 2013 were 5.3 percent for American Indians
or Alaska Natives, 4.3 percent for whites, 3.9 percent for Native Hawaiians or Other
Pacific Islanders, 3.1 percent for persons reporting two or more races, 1.8 percent for
blacks, 1.3 percent for Hispanics, and 0.7 percent for Asians. Rates of past month
smokeless tobacco use in 2013 were similar to rates in 2012 across racial/ethnic groups.

Figure 4.5 Past Month Cigarette Use Among Women Aged 15 to 44, by Pregnancy Status:
Combined Years 2002-2003 to 2012-2013
+Difference between this estimate and the 2012-2013 estimate is statistically significant at the
.05 level.
Education
Since 2002, cigarette smoking in the past month has been less prevalent among adults who
were college graduates compared with those who completed less education. Among adults
aged 18 or older, current cigarette use in 2013 was reported by 33.6 percent of those who
had not completed high school, 27.7 percent of high school graduates with no further
education, 25.5 percent of persons with some college but no degree, and 11.2 percent of
college graduates. These rates by educational attainment were similar to the rates in 2012,
except for high school graduates who did not attend college (29.4 percent in 2012).
College Students
Among young adults aged 18 to 22, full-time college students were less likely to be current
cigarette smokers than their peers who were not enrolled full time in college. The same
pattern was found among both males and females in this age range.
The rate of past month cigarette use among full-time college students aged 18 to 22 declined
from 32.6 percent in 2002 to 21.0 percent in 2013. The rate among those who were not
enrolled full time declined from 45.8 percent in 2002 to 34.4 percent in 2013.
Among males aged 18 to 22 who were full-time college students, the rate of past month
cigarette use in 2013 (25.3 percent) was lower than the rate in 2002 (33.3 percent). Among
males aged 18 to 22 who were not enrolled full time in college, the rate of current cigarette
use in 2013 (39.5 percent) also was lower than the rate in 2002 (49.5 percent).
Among females aged 18 to 22 who were full-time college students, the rate of past month
cigarette use declined from 32.0 percent in 2002 to 17.2 percent in 2013. Among females
aged 18 to 22 who were not enrolled full time in college, the rate of current cigarette use in
2013 (28.6 percent) also was lower than the rate in 2002 (41.7 percent).
Employment
In 2013, current cigarette smoking was more common among unemployed adults aged 18 or
older (40.1 percent) than among adults who were working full time or part time (22.8 and
23.4 percent, respectively). Cigar smoking followed a similar pattern, with 10.9 percent of
unemployed adults reporting past month use compared with 5.6 percent of full-time workers
and 5.0 percent of part-time workers.
Current use of smokeless tobacco in 2013 was higher among adults aged 18 or older who
were employed full time (4.8 percent) and those who were unemployed (4.9 percent) than
among those who were employed part time (2.2 percent) and those in the “other”
employment category, which includes persons not in the labor force (1.9 percent).
Geographic Area
In 2013, current cigarette smoking among persons aged 12 or older was lowest in the West
(17.6 percent), followed by the Northeast (19.6 percent), then the South (22.4 percent), then
the Midwest (24.6 percent). Use of smokeless tobacco was lowest in the Northeast (2.0
percent), followed by the West (2.7 percent), then the Midwest and South (3.9 and 4.1
percent, respectively).
Consistent with the findings in previous years since 2002, the rates of use of any tobacco
product in 2013 were associated with county type among persons aged 12 or older. The rate
of current cigarette use was lowest in large metropolitan areas (19.0 percent), followed by
small metropolitan areas (22.4 percent), then by nonmetropolitan areas (26.6 percent). Use
of smokeless tobacco in the past month in 2013 among persons aged 12 or older was lowest
in large metropolitan areas (2.1 percent), followed by small metropolitan areas (3.7 percent),
then by nonmetropolitan areas (6.7 percent).
Association With Illicit Drug and Alcohol Use
Use of illicit drugs and alcohol was more common among current cigarette smokers than
among nonsmokers in 2013, as in previous years since 2002. Among persons aged 12 or
older, 24.1 percent of past month cigarette smokers reported current use of an illicit drug
compared with 5.4 percent of persons who were not current cigarette smokers. Among
youths aged 12 to 17 who smoked cigarettes in the past month, 53.9 percent also used an
illicit drug compared with 6.1 percent of youths who did not smoke cigarettes.
In 2013, past month alcohol use was reported by 65.2 percent of current cigarette smokers
compared with 48.7 percent of those who did not use cigarettes in the past month. This
association also was found for binge alcohol use (42.9 percent of current cigarette smokers
vs. 17.5 percent of current nonsmokers) and heavy alcohol use (15.7 vs. 3.8 percent,
respectively).3

Figure 4.6 Past Month Smokers of One or More Packs of Cigarettes per Day Among Daily
Smokers, by Age Group: 2002-2013

+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.
Frequency of Cigarette Use
Among the 55.8 million current cigarette smokers aged 12 or older in 2013, 33.2 million
(59.6 percent) used cigarettes daily. The percentage of daily cigarette smokers among past
month cigarette users increased with age (19.4 percent of past month cigarette users aged
12 to 17, 43.1 percent of those aged 18 to 25, and 64.9 percent of those aged 26 or older).
The percentage of current smokers aged 12 or older who used cigarettes daily decreased
from 63.4 percent in 2002 to 59.6 percent in 2013. During the same time period, daily
cigarette use declined among current smokers aged 12 to 17 (from 31.8 to 19.4 percent),
those aged 18 to 25 (from 51.8 to 43.1 percent), and those aged 26 or older (from 68.8 to
64.9 percent).
In 2013, 41.3 percent of daily smokers aged 12 or older reported smoking 16 or more
cigarettes per day (i.e., approximately one pack or more). The percentage of daily smokers
who smoked at least one pack of cigarettes per day increased with age, from 11.9 percent
among daily smokers aged 12 to 17, to 22.2 percent of those aged 18 to 25, then to 44.6
percent of those aged 26 or older (Figure 4.6).
The percentage of daily smokers aged 26 or older who smoked one or more packs of
cigarettes per day was lower in 2013 (44.6 percent) than in 2002 (56.9 percent). Declines
also were seen among daily smokers from 2002 to 2013 for youths aged 12 to 17 (from 21.7
to 11.9 percent) and for young adults aged 18 to 25 (from 39.0 to 22.2 percent).
5. Initiation of Substance Use
Estimates of substance use initiation (also known as incidence or first-time use) are often
considered leading indicators that can be used to assess the volume of new users by drug or drug
category, track emerging patterns of use, and forecast the associated treatment needs in various
population subgroups. These estimates can also be useful to target prevention efforts and evaluate
prevention programs.

With its large sample size and oversampling of youths aged 12 to 17 and young adults aged 18 to
25, the National Survey on Drug Use and Health (NSDUH) provides estimates of recent (i.e., past
year) initiation of use of illicit drugs, tobacco, and alcohol based on reported age and on year and
month at first use. Recent initiates are defined as those who reported use of a particular substance
for the first time within 12 months preceding the date of interview. There is a caveat to the past
year initiation measure worth mentioning. Because survey respondents are aged 12 or older, the
past year initiation estimates reflect only a portion of the initiation that occurred at age 11 and none
of the initiation that occurred at age 10 or younger. This underestimation primarily affects estimates
of initiation for cigarettes, alcohol, and inhalants because they tend to be initiated at a younger age
than other substances. See Section B.4.1 in Appendix B for further discussion of the methods and
bias in initiation estimates.

This chapter includes estimates of the number and rate of past year initiation of illicit drug, tobacco,
and alcohol use among the total population aged 12 or older and by selected age and gender
categories from the 2013 NSDUH, comparing with prior years. Also included are initiation
estimates that pertain to persons at risk for initiation. Persons at risk for initiation of use of a
particular substance are those who never used the substance in their lifetime plus those who used
that substance for the first time in the 12 months prior to the interview. In other words, persons at
risk are those who had never used as of 12 months prior to the interview date. Some analyses are
based on the age at the time of interview, and others focus on the age at the time of first substance
use. Readers need to be aware of these alternative estimation approaches when interpreting
NSDUH incidence estimates and pay close attention to the approach used in each situation. Titles
and notes on figures and associated detailed tables document which method applies.

For trend measurement, initiation estimates for each year (2002 to 2013) are produced
independently based on the data from the survey conducted that year. Estimates of trends in
incidence based on longer recall periods have not been considered because of concerns about their
validity (Gfroerer, Hughes, Chromy, Heller, & Packer, 2004).

Regarding the age at first use, estimates, means, as measures of central tendency, are heavily
influenced by the presence of extreme values in the data for persons aged 12 or older. To reduce
the effect of extreme values, the mean age at initiation was calculated for persons aged 12 to 49,
leaving out those few respondents who were past year initiates at age 50 or older. Including data
from initiates aged 26 to 49 in this broad age group also can cause instability of estimates of the
mean age at initiation among persons aged 12 to 49, but this effect is less than that of including
data from initiates aged 50 or older. Nevertheless, caution is needed in interpreting these trends for
persons aged 12 to 49. Section B.4.1 in Appendix B also discusses this issue. Note, however, that
this constraint affects only the estimates of mean age at initiation. Other estimates in this chapter,
including the numbers and percentages of past year initiates, are not affected by extreme ages at
initiation and therefore are reported for all persons aged 12 or older.
Another important consideration in examining incidence estimates across different drug categories
is that substance users typically initiate use of different substances at different times in their lives.
Thus, the estimates for past year initiation of each specific illicit drug cannot be added to obtain the
total number of overall illicit drug initiates because some of the initiates previously had used other
drugs. The initiation estimate for any illicit drug represents the past year initiation of use of a
specific drug that was not preceded by use of other illicit drugs. For example, a respondent who
reported initiating marijuana use in the past 12 months is counted as a marijuana initiate. The same
respondent also can be counted as an illicit drug initiate with marijuana as the first drug only if his
or her marijuana use initiation was not preceded by use of any other drug (cocaine, heroin,
hallucinogens, inhalants, pain relievers, tranquilizers, stimulants, or sedatives).4 In addition, past
year initiates of lysergic acid diethylamide (LSD), phencyclidine (PCP), or Ecstasy use are counted
as past year initiates of any hallucinogen use only if they had not previously used other
hallucinogens. Similarly, past year initiates of crack cocaine, OxyContin®, or methamphetamine
use are counted as past year initiates for the broader category (i.e., any cocaine, pain relievers, or
stimulants, respectively) only if they did not report previous use for the broader category.
Initiation of Illicit Drug Use
In 2013, an estimated 2.8 million persons aged 12 or older used an illicit drug for the first
time within the past 12 months; this averages to about 7,800 new users per day. This
estimate was similar to the 2012 estimate of 2.9 million. Over half of initiates (54.1 percent)
were younger than age 18 when they first used, and 58.3 percent of new users were
female.

The 2013 average age at initiation among persons aged 12 to 49 was 19.0 years, which was
similar to the 2012 estimate (18.7 years). See Section B.4.1 in Appendix B for a discussion
of the effects of older adult initiates on estimates of mean age at first use.
Of the estimated 2.8 million persons aged 12 or older in 2013 who used illicit drugs for the
first time within the past 12 months, a majority reported that their first drug was marijuana
(70.3 percent) (Figure 5.1). About 1 in 5 initiated with nonmedical use of psychotherapeutics
(20.6 percent, including 12.5 percent with pain relievers, 5.2 percent with tranquilizers, 2.7
percent with stimulants, and 0.2 percent with sedatives). A notable proportion reported
inhalants (6.3 percent) as their first illicit drug, and a small proportion used hallucinogens
(2.6 percent). The percentage of persons in 2013 reporting marijuana as the first illicit drug
in past year initiation was greater than the corresponding percentage in 2012 (70.3 vs. 65.6
percent). The percentage reporting nonmedical use of pain relievers as the first illicit drug
was lower in 2013 than in 2012 (12.5 vs. 17.0 percent).
Comparison, by Drug
In 2013, the specific illicit drug category with the largest number of recent initiates among
persons aged 12 or older was marijuana (2.4 million), followed by nonmedical use of pain
relievers (1.5 million), followed by nonmedical use of tranquilizers (1.2 million), followed by
Ecstasy (0.8 million), followed by stimulants, cocaine, and inhalants (0.6 million each)
(Figure 5.2).
Among past year initiates aged 12 to 49 in 2013, the average age at first use was 17.1 years
for PCP, 18.0 years for marijuana, 19.2 years for inhalants, 19.7 years for LSD, 20.4 years
for cocaine, 20.5 years for Ecstasy, 21.6 years for stimulants, 21.7 years for pain relievers,
24.5 years for heroin, 25.0 years for sedatives, and 25.4 years for tranquilizers (Figure 5.3).
Marijuana
In 2013, there were 2.4 million persons aged 12 or older who had used marijuana for the
first time within the past 12 months; this averages to about 6,600 new users each day. The
2013 estimate was similar to the estimates in 2008 through 2012 (ranging from 2.2 million to
2.6 million) but was higher than the estimates from 2002 through 2007 (ranging from 2.0
million to 2.2 million) (Figure 5.4).

Figure 5.1 First Specific Drug Associated With Initiation of Illicit Drug Use Among Past
Year Illicit Drug Initiates Aged 12 or Older: 2013

Note: The percentages do not add to 100 percent due to rounding or because a small
number of respondents initiated multiple drugs on the same day. The first specific drug
refers to the one that was used on the occasion of first-time use of any illicit drug.

Figure 5.2 Past Year Initiates of Specific Illicit Drugs Among Persons Aged 12 or Older:
2013
 Note: Numbers refer to persons who used a specific drug for the first time in the past
year, regardless of whether initiation of other drug use occurred prior to the past year.

Figure 5.3 Mean Age at First Use for Specific Illicit Drugs Among Past Year Initiates
Aged 12 to 49: 2013

In 2013, among persons aged 12 or older, an estimated 1.4 million first-time past year
marijuana users initiated prior to the age of 18. This estimate was similar to the
corresponding estimate in 2012. The estimated 1.4 million persons in 2013 who initiated prior
to the age of 18 represented the majority (56.6 percent) of the 2.4 million recent marijuana
initiates.
Among all youths aged 12 to 17, an estimated 4.8 percent had used marijuana for the first
time within the past year in 2013, which was similar to the rate in 2012 (5.0 percent). As a
percentage of those aged 12 to 17 who had not used marijuana prior to the past year (i.e.,
those at risk for initiation), the youth marijuana initiation rate in 2013 (5.5 percent) was
similar to the rate in 2012 (5.7 percent).
In 2013, the average age at first marijuana use among recent initiates aged 12 to 49 was
18.0 years, which was similar to the average ages in 2005 through 2008 and 2010 through
2012 but was higher than the average ages in 2002 through 2004 and in 2009 (Figure 5.4).
Section B.4.1 in Appendix B discusses the potential instability of estimates of older adult
initiation and the impact on estimates of mean age at first use.
In 2013, among recent initiates aged 12 or older who initiated marijuana use prior to the age
of 21, the mean age at first use was 16.2 years, which was similar to the 2012 estimate of
16.3 years.
Cocaine
In 2013, there were 601,000 persons aged 12 or older who had used cocaine for the first
time within the past 12 months; this averages to approximately 1,600 initiates per day. This
estimate was similar to the number in 2008 to 2012 (ranging from 623,000 to 724,000). The
annual number of cocaine initiates in 2013 was lower than the estimates from 2002 through
2007 (ranging from 0.9 million to 1.0 million).

Figure 5.4 Past Year Marijuana Initiates Among Persons Aged 12 or Older and Mean Age
at First Use of Marijuana Among Past Year Marijuana Initiates Aged 12 to 49: 2002-2013

+Difference between this estimate and the 2013 estimate is statistically significant at
the .05 level.

1Mean-age-at-first-use estimates are for past year initiates aged 12 to 49.

The number of initiates of crack cocaine ranged from 209,000 to 353,000 in 2002 to 2008
and declined to 95,000 in 2009. The number of initiates of crack cocaine has been similar
each year since 2009 (e.g., 58,000 in 2013).
In 2013, most (81.9 percent) of the 0.6 million recent cocaine initiates were aged 18 or older
when they first used. The average age at first use among recent initiates aged 12 to 49 was
20.4 years. The average age estimates have remained fairly stable since 2002.
Heroin
In 2013, there were 169,000 persons aged 12 or older who had used heroin for the first time
within the past 12 months. This estimated number in 2013 was similar to the numbers in
2002 to 2005 and from 2007 to 2012, but it was higher than the number in 2006 (90,000).
The average age at first use among recent heroin initiates aged 12 to 49 in 2013 was 24.5
years, which was similar to the 2012 estimate (23.0 years).
Hallucinogens
In 2013, there were 1.1 million persons aged 12 or older who had used hallucinogens for the
first time within the past 12 months (Figure 5.5). This estimate was similar to the estimates
for 2002, 2004 to 2008, and 2010 to 2012 (ranging from 0.9 million to 1.2 million). However,
this estimate for 2013 was higher than the 2003 estimate (886,000) and was lower than the
2009 estimate (1.3 million). The average age at first use among recent hallucinogen initiates
aged 12 to 49 in 2013 was 19.9 years, which was similar to the 2012 estimate (19.1 years).
The number of past year initiates of LSD aged 12 or older was 482,000 in 2013, which was
similar to the numbers in 2008, 2010, and 2012 (ranging from 381,000 to 421,000) but was
higher than the numbers in 2002 to 2007, 2009, and 2011 (ranging from 200,000 to 358,000)
(Figure 5.5). The average age at first use among recent LSD initiates aged 12 to 49 in 2013
was 19.7 years, which was similar to the 2012 estimate (19.0 years).
The number of past year initiates of PCP aged 12 or older was 32,000 in 2013. This number
was lower than the numbers from 2002 through 2006 and in 2012 (ranging from 70,000 to
123,000) but was similar to the numbers in 2007 to 2011 (ranging from 45,000 to 58,000).
The average age at first use among recent PCP initiates aged 12 to 49 in 2013 was 17.1
years, which was similar to the 2012 estimate (16.6 years). This average age at initiation of
PCP has remained fairly stable since 2002.
The number of past year initiates of Ecstasy was 751,000 in 2013, which was similar to the
number in 2012 (869,000) but was lower than the numbers in 2009, 2010, and 2011 (1.1
million, 949,000, and 922,000, respectively) (Figure 5.5). The 2002 estimate of 1.2 million
past year initiates declined to 642,000 in 2003, followed by an increase between 2004 and
2013.
Most (69.4 percent) of the recent Ecstasy initiates in 2013 were aged 18 or older at the time
they first used Ecstasy. The number of Ecstasy initiates who first used prior to the age of 18
was 230,000, which was similar to the estimate in 2012 (255,000).
Among past year initiates aged 12 to 49, the average age at initiation of Ecstasy in 2013 was
20.5 years. This average age at initiation of Ecstasy has remained fairly stable since 2002.
In 2013, among recent initiates aged 12 or older who initiated Ecstasy use prior to the age of
21, the mean age at first use was 17.4 years, which was similar to the 2012 estimate of 17.5
years.

Figure 5.5 Past Year Hallucinogen Initiates Among Persons Aged 12 or Older: 2002-2013
+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.
Inhalants
In 2013, there were 563,000 persons aged 12 or older who had used inhalants for the first
time within the past 12 months, which was similar to the 2012 estimate of 584,000 but was
lower than the numbers in 2002 to 2011 (ranging from 719,000 to 877,000). An estimated
46.8 percent of past year initiates of inhalants in 2013 were younger than age 18 when they
first used. The average age at first use among recent initiates aged 12 to 49 was 19.2 years,
which was higher than the 2012 estimate of 16.9 years.
Psychotherapeutics
Nonmedical use of psychotherapeutics includes nonmedical use of any prescription-type
pain relievers, tranquilizers, stimulants, or sedatives. Over-the-counter substances are not
included. In 2013, there were approximately 2.0 million persons aged 12 or older who used
psychotherapeutics nonmedically for the first time within the past year, which averages to
about 5,500 initiates per day. The number of new nonmedical users of psychotherapeutics in
2013 was lower than the estimates for prior years from 2002 through 2012 (ranging from
2.3 million to 2.8 million).
In 2013, the numbers of initiates were 1.5 million for pain relievers, 1.2 million for
tranquilizers, 603,000 for stimulants, and 128,000 for sedatives (Figure 5.6).

The number of new nonmedical users of pain relievers in 2013 (1.5 million) was lower than
the numbers in 2002 through 2012 (ranging from 1.9 million to 2.5 million) (Figure 5.6). The
number of past year initiates for nonmedical use of tranquilizers has been fairly stable from
2002 to 2013 (ranging from 1.1 million to 1.4 million). The number of initiates for nonmedical
use of stimulants in 2013 was similar to the numbers in 2003, 2005, and in 2007 to 2012
(ranging from 602,000 to 715,000), but was lower than the numbers in 2002, 2004, and 2006
(ranging from 783,000 to 846,000). The number of initiates for nonmedical use of sedatives
in 2013 was similar to the numbers in 2002, 2003, 2007 to 2009, 2011, and 2012 (ranging
from 159,000 to 209,000) but was lower than the numbers in 2004 to 2006 and in 2010
(ranging from 240,000 to 267,000).

Figure 5.6 Past Year Nonmedical Psychotherapeutic Initiates Among Persons Aged 12 or
Older: 2002-2013

+Difference between this estimate and the 2013 estimate is statistically significant at
the .05 level.
 In 2013, the average age at first nonmedical use of any psychotherapeutics among recent
initiates aged 12 to 49 was 22.4 years. Average ages at first nonmedical use were 21.6
years for stimulants, 21.7 years for pain relievers, 25.0 years for sedatives, and 25.4 years
for tranquilizers. All of these 2013 estimates were similar to the corresponding estimates in
2012.
In 2013, the number of new nonmedical users of OxyContin® aged 12 or older was 436,000,
which was similar to the estimates for prior years from 2004 through 2012. The average age
at first use of OxyContin® among past year initiates aged 12 to 49 was similar in 2012 and
2013 (22.0 and 23.6 years, respectively).
The number of recent new users of methamphetamine among persons aged 12 or older was
144,000 in 2013 (Figure 5.7), which was similar to the estimates in 2005 and from 2007
through 2012. However, the number of initiates in 2013 was lower than the estimates in
2002 to 2004 and in 2006 (ranging from 259,000 to 318,000). The average age at first use
among new methamphetamine users aged 12 to 49 in 2013 was 18.9 years, which was
similar to the corresponding estimates from 2002 to 2012 (ranging from 17.8 to 22.2 years).

Figure 5.7 Past Year Methamphetamine Initiates Among Persons Aged 12 or Older and Mean
Age at First Use of Methamphetamine Among Past Year Methamphetamine Initiates Aged 12 to
49: 2002-2013

+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.

1Mean-age-at-first-use estimates are for past year initiates aged 12 to 49.

Alcohol
In 2013, there were 4.6 million persons aged 12 or older who had used alcohol for the first
time within the past 12 months; this averages to approximately 12,500 initiates per day.
In 2013, most (83.5 percent) of the 4.6 million recent alcohol initiates were younger than age
21 at the time of initiation. An estimated 59.1 percent initiated prior to age 18.
In 2013, the average age at first alcohol use among recent initiates aged 12 to 49 was 17.3
years, which was similar to the 2008, 2010, 2011, and 2012 estimates but was higher than
the estimates in 2002 to 2007 and in 2009 (ranging from 16.4 to 16.9 years). In 2013, the
mean age at first use among recent initiates aged 12 or older who initiated use prior to the
age of 21 was 16.2 years, which was slightly higher than the 2012 estimate of 16.0 years.
Tobacco
The number of persons aged 12 or older who smoked cigarettes for the first time within the
past 12 months was approximately 2.1 million in 2013, which was lower than the estimates
for 2006 and from 2008 through 2012 (ranging from 2.3 million to 2.5 million) but was similar
to the estimates from 2002 to 2005 and 2007 (Figure 5.8). The 2013 estimate averages to
about 5,700 new cigarette smokers every day. About half of new cigarette smokers in 2013
(50.5 percent) initiated prior to age 18.5

Figure 5.8 Past Year Cigarette Initiates Among Persons Aged 12 or Older, by Age at First
Use: 2002-2013

+Difference between this estimate and the 2013 estimate is statistically significant at
the .05 level.

Figure 5.9 Past Year Cigarette Initiation Among Youths Aged 12 to 17 Who Had Never
Smoked Prior to the Past Year, by Gender: 2002-2013
 +Difference between this estimate and the 2013 estimate is statistically significant at
the .05 level.

The number of cigarette initiates who were younger than age 18 when they first used was
lower in 2013 than in 2002 (1.0 million vs. 1.3 million). However, the number of cigarette
initiates who began smoking at age 18 or older increased from 623,000 in 2002 to 1.0 million
in 2013.
In 2013, among recent initiates aged 12 to 49, the average age of first cigarette use was
17.8 years, which was the same as the corresponding average age in 2012.
Of persons aged 12 or older who had not smoked cigarettes prior to the past year (i.e.,
those at risk for initiation), the past year initiation rate for cigarettes was 2.0 percent in 2013,
which was lower than the rate in 2012 (2.3 percent).
Among youths aged 12 to 17 who had not smoked cigarettes prior to the past year (i.e.,
youths at risk for initiation), the first-time cigarette use rate in 2013 was 4.3 percent, which
was lower than the 2012 rate (4.8 percent). However, for each gender subgroup, this
incidence rate was similar in 2012 and 2013 (4.7 and 4.2 percent, respectively, for male
youths; 4.8 and 4.3 percent for female youths) (Figure 5.9). Past year initiation rates in 2013
among males and females aged 12 to 17 who were at risk for initiation of cigarette use were
lower than the rates in 2002 to 2011.
In 2013, the number of persons aged 12 or older who had started smoking cigarettes daily
within the past 12 months was 813,000 (Figure 5.10). This estimate was similar to the
estimates in 2005, 2008, and from 2010 through 2012 (ranging from 778,000 to 965,000), but
was lower than the estimates from 2002 through 2004 and in 2006, 2007, and 2009 (ranging
from 1.0 million to 1.1 million). Of the new daily smokers in 2013, 33.2 percent, or 270,000
persons, were younger than age 18 when they started smoking daily. This number is
equivalent to an average of approximately 700 persons per day under the age of 18 who
started smoking cigarettes on a daily basis.
In 2013, the average age of first daily cigarette smoking among new daily smokers aged 12
to 49 was similar in 2012 and 2013 (19.9 and 19.8 years, respectively). Among male initiates
of daily cigarette smoking in this age group, the average age at first daily use also was
 similar in 2012 and 2013 (19.1 and 19.0 years, respectively). Among female initiates, the
2013 estimate of 21.0 years was the same as the 2012 estimate.
In 2013, there were 2.8 million persons aged 12 or older who had used cigars for the first
time in the past 12 months, which was similar to the 2012 estimate (2.7 million) (Figure
5.10). However, the 2013 estimate was lower than the estimate in 2005 (3.3 million) and in
2009 (3.1 million). Among past year cigar initiates aged 12 to 49, the average age at first
use was 21.6 years in 2013, which was similar to the estimate in 2012 (20.5 years).
The number of persons aged 12 or older initiating use of smokeless tobacco in the past year
was 1.1 million in 2013, which was similar to the estimates in 2011 and 2012 (Figure 5.10).
The number of smokeless tobacco initiates in 2013 was higher than the estimates in 2002
and 2003 but was lower than the estimates from 2006 through 2010 (ranging from 1.3
million to 1.5 million). In 2013, about three quarters (73.8 percent) of new initiates were
male, and over two fifths (47.9 percent) were younger than age 18. In 2013, the average
age at first smokeless tobacco use among recent initiates aged 12 to 49 was 18.4 years,
which was similar to the estimate in 2012.

Figure 5.10 Past Year Specific Tobacco Product Initiates Among Persons Aged 12 or Older:
2002-2013

+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.
6. Youth Prevention-Related Measures
Research has shown that substance use by adolescents can often be prevented through
interventions involving risk and protective factors associated with the onset or escalation of use
(Catalano, Hawkins, Berglund, Pollard, & Arthur, 2002). Risk and protective factors include
variables that operate at different stages of development and reflect different domains of influence,
including the individual, family, peer, school, community, and societal levels (Hawkins, Catalano, &
Miller, 1992; Robertson, David, & Rao, 2003). Interventions to prevent substance use generally are
designed to ameliorate the influence of risk factors and enhance the effectiveness of protective
factors.

The National Survey on Drug Use and Health (NSDUH) includes questions for youths aged 12 to
17 to measure the risk and protective factors that may affect the likelihood that they will engage in
substance use. This chapter presents findings on youth prevention-related measures. Where
applicable, findings from 2013 are compared with estimates from prior years since 2002. Included
in this chapter are measures of the perceived risk of substance use (cigarettes, alcohol, and
specific illicit drugs), perceived availability of substances (including being approached by someone
selling drugs), perceived parental disapproval of youth substance use, attitudes about peer
substance use, involvement in fighting and delinquent behavior, religious involvement and beliefs,
exposure to substance use prevention messages and programs, and parental involvement. Also
presented are findings on the associations between selected measures of risk and protective
factors and substance use from NSDUH. However, the cross-sectional nature of these data
precludes making any causal connections between these risk and protective factors and substance
use.
Perceived Risk of Substance Use
One factor that can influence whether youths will use tobacco, alcohol, or illicit drugs is the extent
to which they believe these substances might cause them harm. NSDUH respondents were asked
how much they thought people risk harming themselves physically and in other ways when they
use various substances in certain amounts or frequencies. Response choices for these items were
“great risk,” “moderate risk,” “slight risk,” or “no risk.”

In 2013, 64.3 percent of youths aged 12 to 17 perceived great risk in smoking one or more
packs of cigarettes per day, 62.5 percent perceived great risk in having four or five drinks of
an alcoholic beverage nearly every day, and 39.0 percent perceived great risk in having five
or more drinks once or twice a week. For marijuana, 39.5 percent of youths perceived great
risk in smoking marijuana once or twice a week, and 24.2 percent perceived great risk in
smoking marijuana once a month. The percentages of youths who perceived great risk in
using other drugs once or twice a week were 79.8 percent for heroin, 78.4 percent for
cocaine, and 69.7 percent for LSD.
The percentages of youths reporting binge alcohol use and the use of cigarettes and
marijuana in the past month were lower among those who perceived great risk in using
these substances than among those who did not perceive great risk. For instance, in 2013,
past month binge drinking (consumption of five or more drinks of an alcoholic beverage on a
single occasion on at least 1 day in the past 30 days) was reported by 3.5 percent of youths
aged 12 to 17 who perceived great risk from “having five or more drinks of an alcoholic
beverage once or twice a week,” which was lower than the rate (8.1 percent) for youths
who saw moderate, slight, or no risk from having five or more drinks of an alcoholic
beverage once or twice a week (Figure 6.1). Past month marijuana use was reported by 0.6
percent of youths who saw great risk in smoking marijuana once a month compared with
9.3 percent of youths who saw moderate, slight, or no risk.
Trends in substance use often coincide with trends in perceived risk. Increases in perceived
risk typically precede or occur simultaneously with decreases in use and vice versa. For
example, the percentage of youths aged 12 to 17 indicating great risk in smoking marijuana
once a month decreased from 34.4 percent in 2007 to 24.2 percent in 2013 (Figure 6.2). The
rate of youths perceiving great risk in smoking marijuana once or twice a week also
decreased from 54.6 percent in 2007 to 39.5 percent in 2013. Consistent with these
decreasing trends in the perceived risk of marijuana use, the prevalence of past month
marijuana use among youths increased between 2007 (6.7 percent) and 2011 (7.9 percent).
Despite the perceived risk of marijuana use among youths continuing to decline between
2011 and 2013, however, the rate of past month marijuana use declined between 2011 and
2013 (7.1 percent). The rate of past month marijuana use among youths in 2013 was similar
to that in 2007.
The proportion of youths aged 12 to 17 who reported perceiving great risk from smoking
one or more packs of cigarettes per day increased from 63.1 percent in 2002 to 69.5
percent in 2008 (Figure 6.3). This rate declined between 2009 (65.5 percent) and 2013 (64.3
percent). Consequently, the 2013 rate was similar to the 2002 rate. Although rates of use
often increase as perceptions of risk decrease, the rate of past month adolescent cigarette
use decreased from 9.0 percent in 2009 to 5.6 percent in 2013. Also, the rate of past month
cigarette use among youths in 2013 was lower than that in 2002 (13.0 percent), despite
similar percentages of youths perceiving great risk from smoking one or more packs of
cigarettes in both of these years.
The percentage of youths aged 12 to 17 indicating great risk in having four or five drinks of
an alcoholic beverage nearly every day increased from 62.2 percent in 2002 to 65.6 percent
in 2008 (Figure 6.3). This rate declined between 2009 (64.1 percent) and 2013 (62.5
percent), such that the 2013 rate was similar to the 2002 rate. The percentage of youths
perceiving great risk in having five or more drinks of an alcoholic beverage once or twice a
week increased from 38.2 percent in 2002 to 40.7 percent in 2011. This rate declined
between 2011 and 2013 (39.0 percent). Consistent with the increases in perceived risk of
alcohol use among youths aged 12 to 17 between 2002 and 2008, there were decreases
during this period in the rate of binge alcohol use (from 10.7 to 8.9 percent) and heavy
alcohol use (from 2.5 to 2.0 percent). Although perceived risk of alcohol use peaked in 2008
for both measures of perceived risk, the rate of adolescent alcohol use continued to decline
between 2008 and 2013 for both binge alcohol use (to 6.2 percent in 2013) and heavy
alcohol use (to 1.2 percent in 2013).

Figure 6.1 Past Month Binge Drinking and Marijuana Use Among Youths Aged 12 to 17,
by Perceptions of Risk: 2013

Figure 6.2 Perceived Great Risk of Marijuana Use Among Youths Aged 12 to 17: 2002-
2013
 +Difference between this estimate and the 2013 estimate is statistically significant at
the .05 level.

Figure 6.3 Perceived Great Risk of Cigarette and Alcohol Use Among Youths Aged 12 to
17: 2002-2013

+Difference between this estimate and the 2013 estimate is statistically significant at
the .05 level.
Between 2002 and 2013, the percentage of youths aged 12 to 17 perceiving great risk from
using an illicit drug once or twice a week declined for the following substances: heroin (from
82.5 to 79.8 percent), cocaine (from 79.8 to 78.4 percent), LSD (from 76.2 to 69.7 percent),
and marijuana (from 51.5 to 39.5 percent) (Figure 6.4). The rates remained unchanged
between 2011 and 2013 for heroin, cocaine, and LSD. For marijuana, the rate in 2013 was
lower than the rate in 2011 (44.8 percent). Youths were less likely to perceive great risk for
smoking marijuana once or twice a week than for corresponding use of the other listed illicit
drugs.
Perceived Availability
In 2013, about half (48.6 percent) of youths aged 12 to 17 reported that it would be “fairly
easy” or “very easy” for them to obtain marijuana if they wanted some (Figure 6.5). About
1 in 11 (9.1 percent) indicated that heroin would be fairly or very easily available, and 11.3
percent reported so for LSD. Between 2002 and 2013, there were decreases in the
perceived easy availability of marijuana (from 55.0 to 48.6 percent), cocaine (from 25.0 to
14.4 percent), crack (from 26.5 to 14.9 percent), LSD (from 19.4 to 11.3 percent), and
heroin (from 15.8 to 9.1 percent). There was no change between 2012 and 2013 in the
perceived easy availability for marijuana, heroin, or LSD. However, the percentage of
youths who perceived that cocaine would be fairly easy or very easy to obtain was lower in
2013 than in 2012 (16.0 percent).

Figure 6.4 Perceived Great Risk of Use of Selected Illicit Drugs Once or Twice a Week
Among Youths Aged 12 to 17: 2002-2013

+Difference between this estimate and the 2013 estimate is statistically significant at
the .05 level.

Youths aged 12 to 17 in 2013 who perceived that it was easy to obtain specific illicit drugs
were more likely to be past month users of those illicit drugs than were youths who
perceived that obtaining specific illicit drugs would be fairly difficult, very difficult, or
probably impossible. For example, 15.8 percent of youths who reported that marijuana
would be easy to obtain were past month illicit drug users, but only 2.7 percent of those who
thought marijuana would be more difficult to obtain were past month users. Similarly, 13.9
percent of youths who reported that marijuana would be easy to obtain were past month
 marijuana users, but only 1.1 percent of those who thought marijuana would be more
difficult to obtain were past month users.
The percentage of youths who reported that marijuana, cocaine, crack, heroin, and LSD
would be easy to obtain generally increased with age in 2013. For instance, 20.5 percent of
youths aged 12 or 13 reported it would be fairly or very easy to obtain marijuana compared
with 51.2 percent of those aged 14 or 15 and 71.5 percent of those aged 16 or 17. However,
the differences in perceived availability between youths aged 14 or 15 and those aged 16 or
17 were not significant for crack and heroin.
In 2013, about one in eight youths aged 12 to 17 (12.4 percent) indicated that they had been
approached by someone selling drugs in the past month. This rate declined between 2002
(16.7 percent) and 2013, although the 2013 rate was similar to the 2012 rate (13.2 percent).

Figure 6.5 Perceived Availability of Selected Illicit Drugs Among Youths Aged 12 to 17: 2002-
2013

+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.
Perceived Parental Disapproval of Substance
Use
Most youths aged 12 to 17 believed their parents would “strongly disapprove” of them using
substances. In 2013, 88.4 percent of youths reported that their parents would strongly
disapprove of them trying marijuana or hashish once or twice, which was lower than the
rates in 2012 (89.3 percent) and 2002 (89.1 percent). Most youths in 2013 (90.7 percent)
reported that their parents would strongly disapprove of them having one or two drinks of an
alcoholic beverage nearly every day, which was similar to the rate in 2012 (90.5 percent)
but was higher than the rate in 2002 (89.0 percent). In 2013, 93.5 percent of youths reported
that their parents would strongly disapprove of them smoking one or more packs of
cigarettes per day, which was similar to the rate reported in 2012 (93.1 percent) but was
higher than the 89.5 percent reported in 2002.
Youths aged 12 to 17 who believed their parents would strongly disapprove of them using
specific substances were less likely to use these substances than were youths who believed
their parents would somewhat disapprove or neither approve nor disapprove. For instance,
in 2013, past month cigarette use was reported by 4.0 percent of youths who perceived
strong parental disapproval if they were to smoke one or more packs of cigarettes per day
compared with 27.8 percent of youths who believed their parents would not strongly
disapprove. Also, past month marijuana use was much less prevalent among youths who
perceived strong parental disapproval for trying marijuana or hashish once or twice than
among those who did not perceive this level of disapproval (4.1 vs. 29.3 percent,
respectively).
Attitudes Toward Peer Substance Use
A majority of youths aged 12 to 17 reported that they disapproved of their peers using
substances. In 2013, 91.4 percent of youths “strongly” or “somewhat” disapproved of their
peers smoking one or more packs of cigarettes per day, which was also the rate in 2012 but
was higher than the 87.1 percent in 2002. Also in 2013, 79.2 percent strongly or somewhat
disapproved of peers using marijuana or hashish once a month or more, which was lower
than the rates reported in 2012 (80.3 percent) and in 2002 (80.4 percent). In addition, 88.7
percent of youths strongly or somewhat disapproved of peers having one or two drinks of an
alcoholic beverage nearly every day in 2013, which was also the rate in 2012 but was higher
than the 84.7 percent reported in 2002.
The percentage of youths who reported that they disapproved of their peers using
substances decreased with age in 2013. For instance, 92.4 percent of those aged 12 or 13
reported that they strongly or somewhat disapproved of peers using marijuana once a month
or more compared with 80.6 percent of those aged 14 or 15 and 65.6 percent of those aged
16 or 17.
In 2013, youths aged 12 to 17 who strongly or somewhat disapproved of their peers using
marijuana once a month or more were less likely to be past month marijuana users than
those who neither approved nor disapproved of this behavior from their peers (2.0 vs. 26.2
percent).
Fighting and Delinquent Behavior
NSDUH includes questions for youths aged 12 to 17 about the number of times they had
engaged in fighting or other delinquent behavior in the 12 months prior to the interview. In
2013, 17.7 percent of youths aged 12 to 17 reported that they had gotten into a serious fight
at school or at work in the past year; 11.0 percent had taken part in a group-against-group
fight; 5.1 percent attacked others in at least one instance with the intent to harm or seriously
hurt them; 3.4 percent had carried a handgun at least once; 2.8 percent had, at least once,
stolen or tried to steal something worth more than $50; and 2.4 percent sold illegal drugs in
the past year. The 2013 rates for taking part in a group-against-group fight and for stealing
or trying to steal something worth more than $50 among youths aged 12 to 17 were lower
than the 2012 rates.
Rates of the following behaviors in the past year among youths aged 12 to 17 were lower in
2013 than in 2002: getting into a serious fight at school or work (17.7 vs. 20.6 percent);
taking part in a group-against-group fight (11.0 vs. 15.9 percent); attacking others with the
intent to harm or seriously hurt them (5.1 vs. 7.8 percent); stealing or trying to steal
something worth more than $50 (2.8 vs. 4.9 percent); and selling illegal drugs (2.4 vs. 4.4
percent). Percentages of youths who had carried a handgun in the past year were similar in
2013 and 2002 (3.4 and 3.3 percent).
Youths aged 12 to 17 who had engaged in fighting or other delinquent behaviors were more
likely than other youths to have used illicit drugs in the past month. In 2013, past month illicit
drug use was reported by 17.0 percent of youths who had gotten into a serious fight at
school or work in the past year compared with 7.1 percent of those who had not engaged in
fighting at school or work. An estimated 34.6 percent of youths who had stolen or tried to
steal something worth over $50 in the past year used illicit drugs in the past month compared
with 8.0 percent of those who had not attempted or had engaged in such theft.
Religious Involvement and Beliefs
In 2013, 29.8 percent of youths aged 12 to 17 reported that they had attended religious
services 25 or more times in the past year; 73.3 percent agreed or strongly agreed with the
statement that religious beliefs are a very important part of their lives; and 66.2 percent
agreed or strongly agreed with the statement that religious beliefs influence their decision
making in life. These rates were lower than the corresponding rates in 2002 but were similar
to corresponding rates in 2012. In 2013, 32.0 percent of youths agreed or strongly agreed
with the statement that it is important for their friends to share their religious beliefs, which
was lower than the 2002 rate (35.8 percent) and the 2012 rate (33.7 percent).
The rates of past month use of illicit drugs and cigarettes and binge alcohol use were lower
among youths aged 12 to 17 who agreed with statements about the importance of religious
beliefs than among those who disagreed. In 2013, past month illicit drug use was reported by
6.6 percent of those who agreed or strongly agreed that religious beliefs are a very
important part of their lives compared with 14.9 percent of those who disagreed with that
statement. Similar differences were found between those two subgroups for the past month
use of cigarettes (4.1 vs. 9.8 percent) and past month binge alcohol use (4.8 vs. 10.3
percent).
Exposure to Substance Use Prevention Messages
and Programs
In 2013, approximately one in nine youths aged 12 to 17 (11.5 percent) reported that they
had participated in drug, tobacco, or alcohol prevention programs outside of school in the
past year. This rate was similar to the 11.9 percent reported in 2012 but was lower than the
rate reported in 2002 (12.7 percent). In 2013, youths who did or did not participate in these
programs had similar rates of past month use for illicit drugs (8.9 and 8.7 percent),
marijuana (7.0 percent for both groups), cigarettes (6.5 and 5.4 percent), and binge alcohol
use (5.2 and 6.3 percent).

In 2013, 72.6 percent of youths aged 12 to 17 reported having seen or heard drug or alcohol
prevention messages in the past year from sources outside of school, such as from posters
or pamphlets, on the radio, or on television (Figure 6.6). This rate in 2013 was lower than
the 75.9 percent reported in 2012 and the 83.2 percent reported in 2002. In 2013, the
prevalence of past month use of illicit drugs among those who reported having such
exposure (8.4 percent) was lower than the prevalence among those who reported having no
such exposure (10.0 percent).

Figure 6.6 Exposure to Substance Use Prevention Messages and Programs Among
Youths Aged 12 to 17: 2002-2013

+Difference between this estimate and the 2013 estimate is statistically significant at
the .05 level.

1Estimates are from youths aged 12 to 17 who were enrolled in school in the past year.
 Youths who were enrolled in school in the past year included those who were home
schooled.

In 2013, 73.5 percent of youths aged 12 to 17 who were enrolled in school in the past year
reported having seen or heard drug or alcohol prevention messages at school, which was
lower than the 75.0 percent reported in 2012 and the 78.8 percent reported in 2002 (Figure
6.6). In 2013, the prevalence of past month use of illicit drugs or marijuana was lower
among those who reported having such exposure in school (8.4 and 6.7 percent for illicit
drugs and marijuana, respectively) than among youths who were enrolled in school but
reported having no such exposure (10.2 and 8.7 percent).
Parental Involvement
Youths aged 12 to 17 were asked several questions related to the extent of support,
oversight, and control that they perceived their parents provided or exercised over them in
the year prior to the survey interview. In 2013, among youths aged 12 to 17 who were
enrolled in school in the past year, 68.4 percent reported that their parents limited the
amount of time that they spent out with friends on school nights. This rate in 2013 was
lower than the rate reported in 2012 (70.3 percent) and in 2002 (70.7 percent). In 2013, 83.0
percent reported that in the past year their parents always or sometimes checked on
whether or not they had completed their homework, and 79.4 percent reported that their
parents always or sometimes provided help with their homework. The rate in 2013 for
parents checking on whether youths had completed their homework was higher than in 2012
(81.3 percent) and in 2002 (78.4 percent). However, the rate for parents providing help with
homework in 2013 was lower than the rate in 2012 (80.6 percent) and the rate in 2002 (81.4
percent).
In 2013, 88.5 percent of youths aged 12 to 17 reported that their parents always or
sometimes made them do chores around the house in the past year, which was also the rate
in 2012 but was slightly higher than the rate in 2002 (87.4 percent). In 2013, 85.7 percent of
youths reported that their parents always or sometimes let them know that they had done a
good job, and 85.7 percent reported that their parents always or sometimes let them know
they were proud of something they had done. These percentages in 2013 were similar to
those reported in 2012 and 2002. In 2013, 40.8 percent of youths reported that their parents
limited the amount of time that they watched television, which was similar to the rate in
2012 (41.0 percent) but was higher than the 36.9 percent reported in 2002.
In 2013, past month use of illicit drugs and cigarettes and binge alcohol use were lower
among youths aged 12 to 17 who reported that their parents always or sometimes engaged
in supportive or monitoring behaviors than among youths whose parents seldom or never
engaged in such behaviors. For instance, the rate of past month use of any illicit drug in
2013 was 7.3 percent for youths whose parents always or sometimes helped with
homework compared with 14.7 percent among youths who indicated that their parents
seldom or never helped. Rates of current cigarette smoking and past month binge alcohol
use also were lower among youths whose parents always or sometimes helped with
homework (4.5 and 5.1 percent, respectively) than among youths whose parents seldom or
never helped (10.3 and 11.4 percent).
7. Substance Dependence, Abuse, and Treatment
The National Survey on Drug Use and Health (NSDUH) includes a series of questions to assess
the prevalence of substance use disorders (substance dependence or abuse) in the past 12 months.
Substances include alcohol and illicit drugs, such as marijuana, cocaine, heroin, hallucinogens,
inhalants, and the nonmedical use of prescription-type psychotherapeutic drugs. These questions
are used to classify persons as dependent on or abusing specific substances based on criteria
specified in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV)
(American Psychiatric Association [APA], 1994).

The questions related to dependence ask about health and emotional problems associated with
substance use, unsuccessful attempts to cut down on use, tolerance, withdrawal, reducing other
activities to use substances, spending a lot of time engaging in activities related to substance use, or
using the substance in greater quantities or for a longer time than intended. The questions on abuse
ask about problems at work, home, and school; problems with family or friends; physical danger;
and trouble with the law due to substance use. Dependence is considered to be a more severe
substance use problem than abuse because it involves the psychological and physiological effects
of tolerance and withdrawal.

This chapter provides estimates from the 2013 NSDUH of the prevalence and patterns of
substance use disorders occurring in the past year and compares these estimates against the
results from the 2002 through 2012 surveys. It also provides estimates of the prevalence and
patterns of the receipt of treatment in the past year for problems related to substance use. This
chapter concludes with a discussion of the need for and the receipt of treatment at specialty
facilities for problems associated with substance use. Note that the terms “substance use
disorders,” “substance dependence or abuse,” and “alcohol or illicit drug dependence or abuse” are
used interchangeably.
7.1 Substance Dependence or Abuse
In 2013, an estimated 21.6 million persons aged 12 or older were classified with substance
dependence or abuse in the past year (8.2 percent of the population aged 12 or older)
(Figure 7.1). Of these, 2.6 million were classified with dependence or abuse of both alcohol
and illicit drugs, 4.3 million had dependence or abuse of illicit drugs but not alcohol, and 14.7
million had dependence or abuse of alcohol but not illicit drugs. Overall, 17.3 million had
alcohol dependence or abuse, and 6.9 million had illicit drug dependence or abuse.
The annual number of persons with substance dependence or abuse in 2013 (21.6 million)
was similar to the number in each year from 2002 through 2012 (ranging from 20.6 million to
22.7 million) (Figure 7.1).
The rate of persons aged 12 or older who had substance dependence or abuse in 2013 (8.2
percent) was similar to the rates in 2011 (8.0 percent) and 2012 (8.5 percent), but it was
lower than the rate in each year from 2002 through 2010 (ranging from 8.8 to 9.4 percent).
In 2013, 6.6 percent of the population aged 12 or older had alcohol dependence or abuse,
which was similar to the rates in 2011 (6.5 percent) and 2012 (6.8 percent), but it was lower
than the rate in each year from 2002 through 2010 (ranging from 7.1 to 7.8 percent).

The rate of persons aged 12 or older who had illicit drug dependence or abuse in 2013 (2.6
percent) was similar to the rate in 2012 (2.8 percent) and in each year since 2005 (ranging
from 2.5 to 2.9 percent), but it was lower than the rates in 2002 to 2004 (ranging from 2.9 to
3.0 percent).

Figure 7.1 Substance Dependence or Abuse in the Past Year Among Persons Aged 12 or
Older: 2002-2013

+Difference between this estimate and the 2013 estimate is statistically significant at
the .05 level.
 Note: Due to rounding, the stacked bar totals may not add to the overall total.

Marijuana was the illicit drug with the largest number of persons with past year dependence
or abuse in 2013, followed by pain relievers, then by cocaine. Of the 6.9 million persons
aged 12 or older who were classified with illicit drug dependence or abuse in 2013, 4.2
million persons had marijuana dependence or abuse (representing 1.6 percent of the total
population aged 12 or older and 61.4 percent of all those classified with illicit drug
dependence or abuse), 1.9 million persons had pain reliever dependence or abuse, and
855,000 persons had cocaine dependence or abuse (Figure 7.2).
The number of persons who had marijuana dependence or abuse in 2013 (4.2 million) was
similar to the number in 2012 (4.3 million) and in each year from 2002 through 2011 (ranging
from 3.9 million to 4.5 million) (Figure 7.3). The rate of marijuana dependence or abuse in
2013 (1.6 percent) was lower than the rates in 2002 (1.8 percent) and 2004 (1.9 percent).
Otherwise, the rate in 2013 was similar to the rates in prior years (ranging from 1.6 to 1.8
percent).
The number of persons who had pain reliever dependence or abuse in 2013 (1.9 million)
was similar to the number in 2012 (2.1 million) and in each year from 2006 through 2011
(ranging from 1.6 million to 1.9 million) (Figure 7.3). However, the number in 2013 was
higher than the numbers in 2002 to 2005 (ranging from 1.4 million to 1.5 million).
The rate of pain reliever dependence or abuse in 2013 (0.7 percent) was higher than the
rate in 2004 (0.6 percent). However, the rate in 2013 was similar to the rates in 2012 (0.8
percent), 2002, 2003, and from 2005 through 2011 (ranging from 0.6 to 0.8 percent).
The rate and the number of persons who had cocaine dependence or abuse in 2013 (0.3
percent and 855,000) were similar to those in 2010 to 2012 (ranging from 0.3 to 0.4 percent
and from 821,000 to 1.1 million). However, the rate and the number in 2013 were lower than
those in 2002 to 2009 (ranging from 0.4 to 0.7 percent and from 1.1 million to 1.7 million).
The number of persons who had heroin dependence or abuse in 2013 (517,000) was similar
to the numbers in 2009 to 2012 (ranging from 361,000 to 467,000), but it was higher than the
numbers in 2002 to 2008 (ranging from 189,000 to 324,000). The rate of persons who had
heroin dependence or abuse in 2013 (0.2 percent) was similar to the rate in 2006 and in
2009 to 2012 (ranging from 0.1 to 0.2 percent), but it was higher than the rate of 0.1 percent
in 2002 through 2005, 2007, and 2008.

Figure 7.2 Specific Illicit Drug Dependence or Abuse in the Past Year Among Persons Aged 12
or Older: 2013
Figure 7.3 Illicit Drug Dependence or Abuse in the Past Year Among Persons Aged 12 or Older:
2002-2013

+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.
Age at First Use
In 2013, among adults aged 18 or older, age at first use of marijuana was associated with
illicit drug dependence or abuse. Among those who first tried marijuana at age 14 or
younger, 11.5 percent were classified with illicit drug dependence or abuse, which was
higher than the 2.6 percent of adults who had first used marijuana at age 18 or older.
Among adults, age at first use of alcohol was associated with alcohol dependence or abuse.
In 2013, among adults aged 18 or older who first tried alcohol at age 14 or younger, 15.4
percent were classified with alcohol dependence or abuse, which was higher than the 3.8
percent of adults who had first used alcohol at age 18 or older.
Adults aged 21 or older who had first used alcohol before age 21 were more likely than
adults who had their first drink at age 21 or older to be classified with alcohol dependence or
abuse. In particular, adults aged 21 or older who had first used alcohol at age 14 or younger
were more likely to be classified with alcohol dependence or abuse than adults who had
their first drink at age 21 or older (14.8 vs. 2.3 percent) (Figure 7.4).
Age
Rates of substance dependence or abuse were associated with age. In 2013, the rate of
substance dependence or abuse among adults aged 18 to 25 (17.3 percent) was higher than
that among adults aged 26 or older (7.0 percent), followed by youths aged 12 to 17 (5.2
percent). From 2002 to 2013, the rate decreased for youths aged 12 to 17 (from 8.9 to 5.2
percent) (Figure 7.5) and for young adults aged 18 to 25 (from 21.7 to 17.3 percent).

Figure 7.4 Alcohol Dependence or Abuse in the Past Year Among Adults Aged 21 or
Older, by Age at First Use of Alcohol: 2013

The rate of alcohol dependence or abuse among youths aged 12 to 17 was 2.8 percent in
2013, which was lower than the rates of 3.4 percent in 2012 and 5.9 percent in 2002 (Figure
7.5). Among young adults aged 18 to 25, the rate of alcohol dependence or abuse was 13.0
percent in 2013, which also was lower than the rates of 14.3 percent in 2012 and 17.7
percent in 2002. Among adults aged 26 or older, the rates were not significantly different
between 2012 (5.9 percent) and 2013 (6.0 percent) and between 2002 (6.2 percent) and
2013.
The rate of illicit drug dependence or abuse among youths aged 12 to 17 was 3.5 percent in
2013, which was lower than the rates in 2012 (4.0 percent), 2011 (4.6 percent), 2010 (4.7
percent), and 2002 (5.6 percent) (Figure 7.5). Among young adults aged 18 to 25, the rate
of illicit drug dependence or abuse was 7.4 percent in 2013, which was similar to the rates in
2012 (7.8 percent), 2011 (7.5 percent), and 2010 (7.9 percent). Among adults aged 26 or
older, the rate of illicit drug dependence or abuse remained stable between 2012 (1.8
percent) and 2013 (1.7 percent) and between 2002 (1.8 percent) and 2013.
Gender
As was the case from 2002 through 2012, the rate of substance dependence or abuse for
males aged 12 or older in 2013 was greater than the rate for females (10.8 vs. 5.8 percent)
(Figure 7.6). Among youths aged 12 to 17, however, the rate of substance dependence or
abuse among males in 2013 (5.3 percent) was similar to the rate among their female
counterparts (5.2 percent).

Figure 7.5 Alcohol and Illicit Drug Dependence or Abuse Among Youths Aged 12 to 17: 2002-
2013

+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.

Figure 7.6 Substance Dependence or Abuse in the Past Year, by Age and Gender: 2013
Race/Ethnicity
In 2013, among persons aged 12 or older, the rate of substance dependence or abuse was
4.6 percent among Asians, 7.4 percent among blacks, 8.4 percent among whites, 8.6
percent among Hispanics, 10.9 percent among persons reporting two or more races, 11.3
percent among Native Hawaiians or Other Pacific Islanders, and 14.9 percent among
American Indians or Alaska Natives. Except for Native Hawaiians or Other Pacific
Islanders, the rate for Asians was lower than the rates for the other racial/ethnic groups.
Education
In 2013, rates of illicit drug or alcohol dependence or abuse among adults aged 26 or older
were not associated with levels of educational attainment.6 Among this group, rates of illicit
drug or alcohol dependence or abuse were 6.4 percent for those who graduated from high
school but had no further education, 7.2 percent for college graduates, 7.3 percent for those
who did not graduate from high school, and 7.4 percent for those with some college
education but no degree.
Among adults aged 26 or older in 2013, rates of alcohol dependence or abuse also were not
associated with levels of educational attainment. Rates of alcohol dependence or abuse for
this age group were 5.4 percent for those who graduated from high school but had no
further education, 5.7 percent for those who did not graduate from high school, 5.9 percent
for those with some college education but no degree, and 6.6 percent for college graduates.
However, rates of illicit drug dependence or abuse were associated with levels of
educational attainment among adults aged 26 or older in 2013. Adults aged 26 or older who
were college graduates had a lower rate of illicit drug dependence or abuse (0.9 percent)
than those who did not graduate from high school (2.5 percent), those with some college
education but no degree (2.1 percent), and those who graduated from high school but had no
further education (1.9 percent).
Employment
Rates of substance dependence or abuse were associated with current employment status
in 2013. A higher percentage of unemployed adults aged 18 or older were classified with
dependence or abuse (15.2 percent) than were full-time employed adults (9.5 percent) or
part-time employed adults (9.3 percent).
Over half of the adults aged 18 or older with substance dependence or abuse were
employed full time in 2013. Of the 20.3 million adults who were classified with dependence
or abuse, 11.3 million (55.7 percent) were employed full time.
Criminal Justice Populations
In 2013, adults aged 18 or older who were on parole or a supervised release from jail during
the past year had a higher rate of illicit drug or alcohol dependence or abuse (34.3 percent)
than their counterparts who were not on parole or supervised release during the past year
(8.4 percent).
In 2013, probation status was associated with substance dependence or abuse. The rate of
substance dependence or abuse was 35.0 percent among adults who were on probation
during the past year, which was higher than the rate among adults who were not on
probation during the past year (8.0 percent).
Geographic Area
In 2013, rates of illicit drug or alcohol dependence or abuse among persons aged 12 or older
were 8.9 percent in the West, 8.3 percent in the Northeast, 8.2 percent in the Midwest, and
7.8 percent in the South.
Rates for illicit drug or alcohol dependence or abuse among persons aged 12 or older in
2013 were similar in large metropolitan areas (8.6 percent) and small metropolitan areas
(8.4 percent) but were higher than in nonmetropolitan areas (6.6 percent).
7.2 Past Year Treatment for a Substance Use
Problem
Estimates described in this section refer to treatment received for illicit drug or alcohol use or for
medical problems associated with the use of illicit drugs or alcohol. This includes treatment
received in the past year at any location, such as a hospital (inpatient), rehabilitation facility
(outpatient or inpatient), mental health center, emergency room, private doctor’s office, prison or
jail, or a self-help group, such as Alcoholics Anonymous or Narcotics Anonymous. Persons could
report receiving treatment at more than one location. Note that the definition of treatment in this
section is different from the definition of specialty treatment described in Section 7.3. Specialty
treatment includes treatment only at a hospital (inpatient), a rehabilitation facility (inpatient or
outpatient), or a mental health center.

Individuals who reported receiving substance use treatment but were missing information on
whether the treatment was specifically for alcohol use or illicit drug use were not counted in
estimates of either illicit drug use treatment or alcohol use treatment; however, they were counted
in estimates for “drug or alcohol use” treatment.

In 2013, 4.1 million persons aged 12 or older (1.5 percent of the population) received
treatment for a problem related to the use of alcohol or illicit drugs. Of these, 1.3 million
received treatment for the use of both alcohol and illicit drugs, 0.9 million received treatment
for the use of illicit drugs but not alcohol, and 1.4 million received treatment for the use of
alcohol but not illicit drugs. (Note that estimates by substance do not sum to the total number
of persons receiving treatment because the total includes persons who reported receiving
treatment but did not report for which substance the treatment was received.)
The rate and the number of persons in the population aged 12 or older receiving any
substance use treatment within the past year remained stable between 2012 (1.5 percent
and 4.0 million) and 2013 (1.5 percent and 4.1 million). The rate and number of persons
receiving any substance use treatment within the past year in 2002 were 1.5 percent and 3.5
million. The rate in 2002 was similar to that in 2013, but the number of persons who
received substance use treatment in 2002 was lower than that in 2013.
In 2013, among the 4.1 million persons aged 12 or older who received treatment for alcohol
or illicit drug use in the past year, 2.3 million persons received treatment at a self-help group,
and 1.8 million received treatment at a rehabilitation facility as an outpatient (Figure 7.7).
The numbers of persons who received treatment at other locations were 1.2 million at a
mental health center as an outpatient, 1.0 million at a rehabilitation facility as an inpatient,
879,000 at a hospital as an inpatient, 770,000 at a private doctor’s office, 603,000 at an
emergency room, and 263,000 at a prison or jail. None of these estimates changed
significantly between 2012 and 2013. The number of persons receiving treatment at a
private doctor’s office was lower in 2002 (523,000) than in 2013.

In 2013, 2.5 million persons aged 12 or older reported receiving treatment for alcohol use
during their most recent treatment in the past year, 845,000 persons received treatment for
marijuana use, and 746,000 persons received treatment for pain relievers (Figure 7.8).
Estimates for receiving treatment for the use of other drugs were 584,000 for cocaine,
526,000 for heroin, 461,000 for stimulants, 376,000 for tranquilizers, and 303,000 for
hallucinogens. None of these estimates changed significantly between 2012 and 2013.
Figure 7.7 Locations Where Past Year Substance Use Treatment Was Received Among
Persons Aged 12 or Older: 2013

The numbers of persons aged 12 or older who received their most recent treatment in the
past year for alcohol, marijuana, cocaine, hallucinogens, inhalants, and sedatives were
similar in 2002 and 2013. However, the number of persons who received treatment for
tranquilizers increased from 2002 (197,000 persons) to 2013 (376,000 persons). The number
who received treatment for heroin increased from 277,000 persons in 2002 to 526,000
persons in 2013. The number who received treatment for nonmedical use of prescription
pain relievers increased from 2002 (360,000 persons) to 2013 (746,000 persons) (Figure
7.9). The number who received treatment for stimulants increased from 268,000 persons in
2002 to 461,000 persons in 2013. (Note that respondents could indicate that they received
treatment for more than one substance during their most recent treatment.)
7.3 Need for and Receipt of Specialty Treatment
This section discusses the need for and receipt of treatment for a substance use problem at a
“specialty” treatment facility. Specialty treatment is defined as treatment received at any of the
following types of facilities: hospitals (inpatient only), drug or alcohol rehabilitation facilities
(inpatient or outpatient), or mental health centers. It does not include treatment at an emergency
room, private doctor’s office, self-help group, prison or jail, or hospital as an outpatient. An
individual is defined as needing treatment for an alcohol or drug use problem if he or she met the
DSM-IV (APA, 1994) diagnostic criteria for alcohol or illicit drug dependence or abuse in the past
12 months or if he or she received specialty treatment for alcohol use or illicit drug use in the past
12 months.

Figure 7.8 Substances for Which Most Recent Treatment Was Received in the Past Year Among
Persons Aged 12 or Older: 2013

Figure 7.9 Received Most Recent Treatment in the Past Year for the Use of Pain Relievers
Among Persons Aged 12 or Older: 2002-2013
 +Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.

In this section, an individual needing treatment for an illicit drug use problem is defined as receiving
treatment for his or her drug use problem only if he or she reported receiving specialty treatment
for illicit drug use in the past year. Thus, an individual who needed treatment for illicit drug use but
received specialty treatment only for alcohol use in the past year or who received treatment for
illicit drug use only at a facility not classified as a specialty facility was not counted as receiving
treatment for illicit drug use. Similarly, an individual who needed treatment for an alcohol use
problem was counted as receiving alcohol use treatment only if the treatment was received for
alcohol use at a specialty treatment facility. Individuals who reported receiving specialty substance
use treatment but were missing information on whether the treatment was specifically for alcohol
use or drug use were not counted in estimates of specialty drug use treatment or in estimates of
specialty alcohol use treatment; however, they were counted in estimates for “drug or alcohol use”
treatment.

In addition to questions about symptoms of substance use problems that are used to classify
respondents’ need for treatment based on DSM-IV criteria, NSDUH includes questions asking
respondents about their perceived need for treatment (i.e., whether they felt they needed treatment
or counseling for illicit drug use or alcohol use). In this report, estimates for perceived need for
treatment are discussed only for persons who were classified as needing treatment (based on
DSM-IV criteria) but did not receive treatment at a specialty facility. Similarly, estimates for
whether a person made an effort to get treatment are discussed only for persons who felt the need
for treatment and did not receive it.
Illicit Drug or Alcohol Use Treatment and
Treatment Need
In 2013, 22.7 million persons aged 12 or older needed treatment for an illicit drug or alcohol
use problem (8.6 percent of persons aged 12 or older). The number in 2013 was similar to
the numbers in 2002 to 2012 (ranging from 21.6 million to 23.6 million). The rate in 2013
was similar to the rates in 2011 (8.4 percent) and 2012 (8.9 percent), but it was lower than
the rates in 2002 to 2010 (ranging from 9.2 to 9.8 percent).
In 2013, 2.5 million persons (0.9 percent of persons aged 12 or older and 10.9 percent of
those who needed treatment) received treatment at a specialty facility for an illicit drug or
alcohol problem. The number in 2013 was similar to the numbers in 2002 (2.3 million) and in
2004 through 2012 (ranging from 2.3 million to 2.6 million), and it was higher than the
number in 2003 (1.9 million). The rate in 2013 was not different from the rates in 2002 to
2012 (ranging from 0.8 to 1.0 percent).
In 2013, 20.2 million persons (7.7 percent of the population aged 12 or older) needed
treatment for an illicit drug or alcohol use problem but did not receive treatment at a
specialty facility in the past year. The number in 2013 was similar to the numbers in 2002 to
2012 (ranging from 19.3 million to 21.1 million). The rate in 2013 was similar to the rates in
2010 to 2012 (ranging from 7.5 to 8.1 percent), but it was lower than the rates in 2002 to
2009 (ranging from 8.3 to 8.8 percent).
Of the 2.5 million persons aged 12 or older who received specialty substance use treatment
in 2013, 875,000 received treatment for alcohol use only, 936,000 received treatment for
illicit drug use only, and 547,000 received treatment for both alcohol and illicit drug use.
These estimates in 2013 were similar to the estimates in 2012 and 2002.
Among persons in 2013 who received their most recent substance use treatment at a
specialty facility in the past year, 41.7 percent reported using private health insurance as a
source of payment for their most recent specialty treatment, 40.6 percent reported using
their “own savings or earnings,” 29.0 percent reported using Medicaid, 29.0 percent
reported using public assistance other than Medicaid, 26.8 percent reported using Medicare,
and 23.0 percent reported using funds from family members. None of these estimates
changed significantly between 2012 and 2013.
In 2013, among the 20.2 million persons aged 12 or older who were classified as needing
substance use treatment but not receiving treatment at a specialty facility in the past year,
908,000 persons (4.5 percent) reported that they perceived a need for treatment for their
illicit drug or alcohol use problem (Figure 7.10). Of these 908,000 persons who felt they
needed treatment but did not receive treatment in 2013, 316,000 (34.8 percent) reported that
they made an effort to get treatment, and 592,000 (65.2 percent) reported making no effort
to get treatment. These estimates were stable between 2012 and 2013.

The rate and the number of youths aged 12 to 17 who needed treatment for an illicit drug or
alcohol use problem in 2013 (5.4 percent and 1.3 million) were lower than those in 2012 (6.3
percent and 1.6 million), 2011 (7.0 percent and 1.7 million), 2010 (7.5 percent and 1.8
million), and 2002 (9.1 percent and 2.3 million). Of the 1.3 million youths who needed
treatment in 2013, 122,000 received treatment at a specialty facility (about 9.1 percent of
the youths who needed treatment), leaving about 1.2 million who needed treatment for a
substance use problem but did not receive it at a specialty facility.

Figure 7.10 Past Year Perceived Need for and Effort Made to Receive Specialty
Treatment Among Persons Aged 12 or Older Needing But Not Receiving Treatment for
Illicit Drug or Alcohol Use: 2013

Based on 2010-2013 combined data, commonly reported reasons for not receiving illicit drug
or alcohol use treatment among persons aged 12 or older who needed and perceived a need
for treatment but did not receive treatment at a specialty facility were (a) not ready to stop
using (40.3 percent), (b) no health coverage and could not afford cost (31.4 percent), (c)
possible negative effect on job (10.7 percent), (d) concern that receiving treatment might
cause neighbors/community to have a negative opinion (10.1 percent), (e) not knowing
where to go for treatment (9.2 percent), and (f) no program having type of treatment (8.0
percent).
Based on 2010-2013 combined data, among persons aged 12 or older who needed but did
not receive illicit drug or alcohol use treatment, felt a need for treatment, and made an effort
to receive treatment, commonly reported reasons for not receiving treatment were (a) no
health coverage and could not afford cost (37.3 percent), (b) not ready to stop using (24.5
percent), (c) did not know where to go for treatment (9.0 percent), (d) had health coverage
but did not cover treatment or did not cover cost (8.2 percent), and (e) no transportation or
inconvenient (8.0 percent) (Figure 7.11).
Illicit Drug Use Treatment and Treatment Need
In 2013, the number of persons aged 12 or older needing treatment for an illicit drug use
problem was 7.6 million (2.9 percent of the total population). The number in 2013 was
similar to the number in each year from 2002 through 2012 (ranging from 7.2 million to 8.1
million). The rate of persons needing treatment for an illicit drug use problem in 2013 was
lower than the rates in 2002 (3.3 percent) and 2004 (3.3 percent), but it was similar to the
rates in 2012 and 2003 (3.1 percent in each year) and in 2005 to 2011 (ranging from 2.8 to
3.2 percent).

Figure 7.11 Reasons for Not Receiving Substance Use Treatment Among Persons Aged
12 or Older Who Needed and Made an Effort to Get Treatment But Did Not Receive
Treatment and Felt They Needed Treatment: 2010-2013 Combined

Of the 7.6 million persons aged 12 or older who needed treatment for an illicit drug use
problem in 2013, 1.5 million (0.6 percent of the total population and 19.5 percent of persons
who needed treatment) received treatment at a specialty facility for an illicit drug use
problem in the past year. The number in 2013 was similar to the numbers in 2012 (1.5
million), 2002 (1.4 million), and in 2004 to 2011 (ranging from 1.2 million to 1.6 million), but it
was higher than the number in 2003 (1.1 million). The rate in 2013 was similar to the rates in
2002 to 2012 (ranging from 0.5 to 0.6 percent).
There were 6.1 million persons (2.3 percent of the total population) who needed but did not
receive treatment at a specialty facility for an illicit drug use problem in 2013. The number in
2013 was similar to the numbers in 2002 to 2012 (ranging from 5.8 million to 6.6 million).
The rate in 2013 was similar to the rates in 2006 to 2012 (ranging from 2.3 to 2.5 percent),
but it was lower than the rates in 2002 to 2005 (ranging from 2.6 to 2.8 percent).
Of the 6.1 million persons aged 12 or older who needed but did not receive specialty
treatment for illicit drug use in 2013, 395,000 (6.4 percent) reported that they perceived a
need for treatment for their illicit drug use problem, and 5.7 million did not perceive a need
for treatment. The number of persons in 2013 who needed treatment for an illicit drug use
problem but did not perceive a need for treatment was similar to the number in 2012 (5.9
million). However, the number of persons who needed treatment and perceived a need for
treatment for an illicit drug problem in 2013 was lower than the number in 2012 (588,000
persons).
Of the 395,000 persons aged 12 or older in 2013 who felt a need for treatment for use of
illicit drugs, 148,000 reported that they made an effort to get treatment, and 247,000 reported
making no effort to get treatment. These estimates in 2013 for making or not making an
effort to get treatment were similar to those in 2012.
In 2013, among youths aged 12 to 17, 908,000 persons (3.6 percent) needed treatment for
an illicit drug use problem, but only 90,000 received treatment at a specialty facility (10.0
percent of youths aged 12 to 17 who needed treatment), leaving 817,000 youths who needed
treatment but did not receive it at a specialty facility. These estimates in 2013 were similar
to those in 2012, except that the number and the rate of youths who needed treatment for an
illicit drug use problem in 2013 were lower than those in 2012 (1.0 million and 4.2 percent).
Among persons aged 12 or older who needed but did not receive illicit drug use treatment
and felt they needed treatment (based on 2010-2013 combined data), the commonly
reported reasons for not receiving treatment were (a) no health coverage and could not
afford cost (42.1 percent), (b) not ready to stop using (27.5 percent), (c) concern that
receiving treatment might cause neighbors/community to have negative opinion (15.9
percent), (d) possible negative effect on job (15.2 percent), (e) not knowing where to go for
treatment (12.8 percent), and (f) having health coverage that did not cover treatment or did
not cover the cost (9.6 percent).
Alcohol Use Treatment and Treatment Need
In 2013, the number of persons aged 12 or older needing treatment for an alcohol use
problem was 18.0 million (6.9 percent of the population aged 12 or older). The number in
2013 was similar to the numbers in 2010 to 2012 (ranging from 17.4 million to 18.6 million)
and in 2002, 2003, and 2008 (ranging from 18.2 million to 19.1 million). However, the
number in 2013 was lower than the numbers in 2004 to 2007 and in 2009 (ranging from 19.4
million to 19.6 million). The rate in 2013 (6.9 percent) was similar to the rates in 2011 (6.8
percent) and 2012 (7.0 percent), but it was lower than the rates in 2002 to 2010 (ranging
from 7.3 to 8.0 percent).
Among the 18.0 million persons aged 12 or older who needed treatment for an alcohol use
problem in 2013, 1.4 million (0.5 percent of the total population and 7.9 percent of the
persons who needed treatment for an alcohol use problem) received alcohol use treatment
at a specialty facility. The number and the rate of the need and receipt of treatment at a
specialty facility for an alcohol use problem in 2013 did not change significantly since 2002
(ranging from 1.3 million to 1.7 million and from 0.5 to 0.7 percent).
The number of persons aged 12 or older who needed but did not receive treatment at a
specialty facility for an alcohol use problem in 2013 (16.6 million) was similar to the numbers
in 2002 (17.1 million), 2003 (16.9 million), and from 2008 to 2012 (ranging from 15.9 million
to 17.7 million), but it was lower than the numbers from 2004 to 2007 (ranging from 17.8
million to 18.0 million). The rate in 2013 (6.3 percent of the population aged 12 or older) was
similar to the rates in 2010 to 2012 (ranging from 6.2 to 6.7 percent), but it was lower than
the rates in 2002 to 2009 (ranging from 7.0 to 7.4 percent).
Among the 16.6 million persons aged 12 or older who needed but did not receive specialty
treatment for an alcohol use problem in 2013, 554,000 persons (3.3 percent) felt they needed
treatment for their alcohol use problem. The number and rate in 2013 were similar to those
in 2012 (665,000 persons and 4.0 percent) and 2002 (761,000 persons and 4.5 percent). Of
the 554,000 persons in 2013 who perceived a need for treatment for an alcohol use problem
but did not receive specialty treatment, 353,000 did not make an effort to get treatment, and
201,000 made an effort but were unable to get treatment.
The number and the rate of youths aged 12 to 17 who needed treatment for an alcohol use
problem in 2013 (735,000 and 3.0 percent) were lower than those in 2012 (889,000 and 3.6
percent). Of the youths in 2013 who needed treatment for an alcohol use problem, only
73,000 received treatment at a specialty facility (0.3 percent of all youths and 10.0 percent
of youths who needed treatment). These estimates were similar to those in 2012. The
number and the rate of youths who needed but did not receive treatment for an alcohol use
problem in 2013 (662,000 and 2.7 percent) were lower than those in 2012 (814,000 and 3.3
percent).
Among persons aged 12 or older who needed but did not receive alcohol use treatment and
felt they needed treatment (based on 2010-2013 combined data), commonly reported
reasons for not receiving treatment were (a) not ready to stop using (50.5 percent), (b) no
health coverage and could not afford cost (26.4 percent), (c) not finding a program that
offered the type of treatment (7.6 percent), (d) not knowing where to go for treatment (7.3
percent), (e) possible negative effect on job (7.1 percent), (f) no transportation or
inconvenient (7.0 percent), (g) could handle the problem without treatment (6.8 percent),
and (h) having health coverage that did not cover treatment or did not cover cost (6.7
percent).
8. Comparison of Trends in Substance Use
Among Youths and Young Adults
Previous chapters in this report presented findings from the 2013 National Survey on Drug Use
and Health (NSDUH) that describe trends and demographic differences for the incidence and
prevalence of use for a variety of substances. In this chapter, comparisons are presented of
NSDUH trend results with substance use results from other surveys of youths and young adults.
Description of NSDUH and Other Data Sources
Conducted since 1971 and previously named the National Household Survey on Drug Abuse
(NHSDA), the survey underwent several methodological improvements in 2002 that have affected
prevalence estimates (see Chapter 1). As a result, the 2002 through 2013 estimates are not
comparable with estimates from 2001 and earlier surveys. Therefore, the primary focus of this
report is on comparisons of measures of substance use across subgroups of the U.S. population in
2013, changes between 2012 and 2013, and changes between 2002 and 2013. An important step in
the analysis and interpretation of NSDUH or any other survey data is to compare the results with
those from other data sources. This can be difficult because the other surveys typically have
different purposes, definitions, and designs. Research has established that surveys of substance use
and other sensitive topics often produce inconsistent results because of different methods that are
used. Thus, it is important to understand that conflicting results often reflect differing
methodologies, not incorrect results. Despite this limitation, comparisons can be very useful.
Consistency across surveys can confirm or support conclusions about trends and patterns of use,
and inconsistent results can point to areas for further study. Further discussion of this issue is
included in Appendix C, along with descriptions of methods and results from other sources of
substance use data.

Unfortunately, few additional data sources are available to compare with NSDUH results. One
established source is Monitoring the Future (MTF), a study sponsored by the National Institute on
Drug Abuse (NIDA). MTF surveys students in the 8th, 10th, and 12th grades in classrooms during
the spring of each year. MTF also collects data by mail from a subsample of adults who had
participated earlier in the study as 12th graders. Further details about MTF are available on the
MTF Web site at [Link] Historically, NSDUH rates of youth
substance use have been lower than those of MTF. Although the two surveys occasionally have
shown different trends in youth substance use over a short time period, these two sources of youth
behavior have shown very similar long-term trends in prevalence. NSDUH and MTF rates of
substance use generally have been similar among young adults, and the two sources also have
shown similar trends for this age group.

Another source of data on trends in the use of drugs among youths is the Youth Risk Behavior
Survey (YRBS), sponsored by the Centers for Disease Control and Prevention (CDC). The YRBS
interviews students in the 9th through 12th grades in classrooms every other year during February
through May (Brener et al., 2013). The most recent survey was completed in 2013 (Kann et al.,
2014). Generally, the YRBS has shown higher prevalence rates but similar trends when compared
with NSDUH and MTF. However, trend comparisons between the YRBS and NSDUH or MTF
can be less straightforward because of the different periodicity (i.e., biennially instead of annually)
and ages covered, the limited number of drug use questions, and smaller sample size in the YRBS.
Comparison of NSDUH, MTF, and YRBS
Trends for Youths
A comparison of NSDUH and MTF estimates among youths for 2002 to 2013 is shown in Tables
8.1 through 8.3 at the end of this chapter for several substances that are defined similarly in the
two surveys. For comparison purposes, MTF data on 8th and 10th graders are combined to give an
age range close to 12 to 17 years, the standard youth age group for NSDUH. Table C.1 in
Appendix C provides comparisons according to the MTF definitions for youths who are in school.
The NSDUH results in Tables 8.1 through 8.3 are remarkably consistent with MTF trends for
youths, as discussed in the following paragraphs.

Both surveys showed decreases between 2002 and 2013 in the percentages of youths who used
cocaine, Ecstasy, inhalants, alcohol, and cigarettes in the past month (Table 8.3). For youth alcohol
and cigarette use in the past month, both surveys showed lower rates in 2013 compared with all
other years from 2002 to 2012. Although the MTF rate has been consistently higher than the
NSDUH rate because of methodological differences between the surveys, the relative changes
over time have been similar. For example, NSDUH data for past month alcohol use showed a 15
percent decline between 2010 and 2013 (from 13.6 to 11.6 percent), and the MTF data showed a
16 percent decrease during those years (from 21.4 to 18.0 percent) (Figure 8.1).

There have been instances where the two surveys showed differing trends from 1 year to the next,
but these discrepancies usually “correct” themselves with 1 or 2 more years of data, pointing to the
need to use caution in the interpretation of 1-year shifts in prevalence levels. For example, 2010
MTF data indicated a leveling or possible increase in current cigarette use among youths, in
contrast to the 2010 NSDUH data, which showed a lower rate in 2010 compared with rates in
2002 to 2008. The 2012 and 2013 MTF estimates, however, showed a continuing decline,
consistent with the NSDUH trend in youth smoking. Over the long term, the two surveys showed
consistent decreases in the prevalence of smoking among youths (Figure 8.2). During the 4-year
period from 2010 to 2013, NSDUH showed a 33 percent decline (from 8.4 to 5.6 percent), and
MTF showed a 35 percent decline (from 10.4 to 6.8 percent) in current cigarette use.

Figure 8.1 Past Month Alcohol Use Among Youths in NSDUH and MTF: 2002-2013
 MTF = Monitoring the Future; NSDUH = National Survey on Drug Use and Health.

+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.

Figure 8.2 Past Month Cigarette Use Among Youths in NSDUH and MTF: 2002-2013

MTF = Monitoring the Future; NSDUH = National Survey on Drug Use and Health.
 +Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.

Figure 8.3 Past Month Marijuana Use Among Youths in NSDUH and MTF: 2002-2013

MTF = Monitoring the Future; NSDUH = National Survey on Drug Use and Health.

+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level.

For current marijuana use, both surveys showed declines from 2002 to 2006 and increases from
2008 to 2011 (Figure 8.3). The estimate of current marijuana use was lower in NSDUH in 2012
than in 2011, but the MTF change was not statistically significant over that period. However, rates
of current marijuana use remained similar between 2012 and 2013 in both NSDUH and MTF.

NSDUH and MTF data showed generally consistent trends for past month use of Ecstasy, with
decreases in use from 2002 to the middle of the decade, then increases in use from 2007 to 2010,
declines between 2010 and 2012, and no change between 2012 and 2013. For past month use of
cocaine, both surveys showed declines between 2013 and 2002 to 2008. Rates of past month use
of inhalants also were lower in both surveys in 2013 than in 2002 to 2011, although NSDUH
showed a continued decline from 2012 to 2013 that was not shown in MTF. For LSD, most rates
of current use in 2002 to 2012 were similar to the rates in 2013 for both surveys.

NSDUH and MTF also collect data on perceived risk of harm. The extent to which youths believe
that substances might cause them harm can influence whether or not they will use these
substances. Declining levels of perceived risk among youths historically have been associated with
subsequent increases in rates of use. Among youths aged 12 to 17, the percentage reporting in
NSDUH that they thought there was a great risk of harm in smoking marijuana once or twice a
week declined from 43.6 percent in 2012 to 39.5 percent in 2013. MTF data for combined 8th and
10th graders showed a similar decline in perceived great risk of harm of regular marijuana use over
this time period, from 58.9 to 53.8 percent.

For the substances for which information on current use was collected in the YRBS, including
alcohol, cigarettes, marijuana, and cocaine, the YRBS trend results between 2001 and 2013 were
consistent with NSDUH and MTF (see the link for the Youth Online interactive data tables at
[Link] Grunbaum et al., 2002). YRBS data for the combined
grades 9 through 12 showed decreases in past month alcohol use (47.1 percent in 20017 and 34.9
percent in 2013) and cigarette use (28.5 percent in 2001 and 15.7 percent in 2013). YRBS showed
a decline in past month marijuana use between 2001 (23.9 percent) and 2007 (19.7 percent) and an
increase between 2007 and 2013 (23.4 percent). This increase between 2007 and 2013 was
consistent with the increase in MTF across that same period. The prevalence of current marijuana
use also increased between 2007 and 2011 both for NSDUH (from 6.7 to 7.9 percent) and YRBS
(from 19.7 to 23.1 percent). However, the prevalence in NSDUH among youths declined between
2011 and 2013, such that the rates in 2007 and 2013 were similar for NSDUH. All three surveys
showed no significant change in rates of current marijuana use between their most recent pair of
survey years (2012 and 2013 for NSDUH and MTF; 2011 and 2013 for YRBS).

Although changes in NSDUH survey methodology preclude direct comparisons of recent estimates
with estimates before 2002, it is important to put the recent trends in context by reviewing longer
term trends in use. NSDUH data (prior to the design changes in 1999 and 2002) on youths aged 12
to 17 and MTF data on high school seniors showed substantial increases in youth illicit drug use
during the 1970s, reaching a peak in the late 1970s. Both surveys then showed declines throughout
the 1980s until about 1992, when rates reached a low point. These trends were driven by the trend
in marijuana use (Figure 8.4). With the start of annual data collection in NSDUH in 1991, along
with the biennial YRBS and the annual 8th and 10th grade samples in MTF, trends among youths
are well documented since the low point that occurred in the early 1990s. Although they employ
different survey designs and cover different age groups, the three surveys are consistent in
showing increasing rates of marijuana use during the early to mid-1990s, reaching a peak in the late
1990s (but lower than in the late 1970s). This peak in the late 1990s was followed by declines in
use after the turn of the 21st century and fairly stable rates in the most recent years.

As noted in Chapter 2 of this report, NSDUH data indicated that nonmedical use of prescription
drugs among youths aged 12 to 17 in 2013 was the second most prevalent illicit drug use category,
with marijuana being first. The most prevalent category of misused prescription drugs among
youths in 2013 was pain relievers.

NSDUH and MTF both collect data on misuse of prescription drugs, but they use somewhat
different definitions and questioning strategies. For example, NSDUH defines misuse as use of
prescription drugs that were not prescribed for the respondent or use of these drugs only for the
experience or feeling they caused; MTF defines misuse as use not under a doctor’s orders. MTF
also does not estimate overall prescription drug misuse. However, MTF asks questions about
“narcotics other than heroin,” a category that is similar in coverage to the pain reliever category in
NSDUH. Also, MTF data on misuse of narcotics other than heroin are reported only for 12th
graders because of concerns about the validity of estimates for 8th and 10th graders (Johnston,
O’Malley, Bachman, Schulenberg, & Miech, 2014).

In addition, as has been the case with NSDUH trends, methodological changes in MTF have
sometimes resulted in discontinuities. For the data on narcotics other than heroin, there was a
questionnaire change in the 2002 MTF that resulted in increased reporting of misuse of narcotics
other than heroin, such that estimates prior to 2002 are not strictly comparable with estimates for
2002 and beyond.

Figure 8.5 shows NSDUH data for past year misuse of pain relievers from 2002 to 2013 for youths
aged 12 to 17 and MTF data for 12th graders. Both surveys showed lower rates of nonmedical use
in 2013 compared with rates in 2002 to 2011. The rate of nonmedical use of pain relievers in 2013
in the past year among 12 to 17 year olds in NSDUH was 4.6 percent and ranged from 5.9 to 7.7
percent in 2002 to 2011. The rate in 2012 among 12 to 17 year olds in NSDUH also was lower
than the rate in 2013. In MTF, the rate for nonmedical use of narcotics other than heroin in the past
year was 7.1 percent in 2013 and ranged from 8.7 to 9.5 percent in 2002 to 2011. The rates among
12th graders did not differ from 2011 to 2012 and from 2012 to 2013; see Johnston, O’Malley,
Bachman, and Schulenberg (2013) for a comparison of rates between 2011 and 2012.

Figure 8.4 Past Month Marijuana Use Among Youths in NSDUH, MTF, and YRBS: 1971-2013

MTF = Monitoring the Future; NSDUH = National Survey on Drug Use and Health; YRBS =
Youth Risk Behavior Survey.

Note: NSDUH data for youths aged 12 to 17 are not presented for 1999 to 2001 because of
design changes in the survey. These design changes preclude direct comparisons of estimates
from 2002 to 2013 with estimates prior to 1999.

Figure 8.5 Past Year Nonmedical Pain Reliever Use Among Youths in NSDUH and MTF: 2002-
2013
MTF = Monitoring the Future; NSDUH = National Survey on Drug Use and Health.

+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level. Note: Data for MTF are for “narcotics other than heroin.”
Comparison of NSDUH and MTF Trends for
Young Adults
MTF follow-up data on persons aged 19 to 24 provide the closest match on age to estimates for
NSDUH young adults aged 18 to 25. As shown in Tables 8.4 to 8.6, data for young adults showed
similar trends in NSDUH and MTF, although not as consistent as for the youth data. Potential
reasons for differences from the data for youths are the relatively smaller MTF sample size for
young adults and possible bias in the MTF sample due to noncoverage of school dropouts and a
low overall response rate; the MTF response rate for young adults is affected by nonresponse by
schools, by students in the 12th grade survey, and by young adults in the follow-up mail survey.

Both surveys showed an increase in past month marijuana use among young adults from 2008 to
2013 (from 16.6 to 19.1 percent in NSDUH; from 17.3 to 21.6 percent in MTF) (Table 8.6). Both
surveys showed declines in past month cigarette use between 2002 and 2013, with NSDUH
showing a decline from 40.8 to 30.6 percent and MTF showing a decline from 31.4 to 20.2
percent. Both surveys showed no significant change in rates of past month cigarette use among
young adults between 2012 and 2013. There also was no significant change between 2012 and
2013 in the rate of current alcohol use among young adults in either survey. Both surveys showed
declines in past year and past month cocaine use from 2002 to 2013, with no significant changes in
rates between 2012 and 2013 (Tables 8.5 and 8.6, respectively). Similarly, past year Ecstasy use
among young adults increased between 2007 and 2010 and remained steady in 2011 through 2013,
according to both NSDUH and MTF.

As was the case for youths aged 12 to 17, NSDUH data indicated that nonmedical use of
prescription drugs among young adults aged 18 to 25 in 2013 was the second most prevalent illicit
drug use category (see Chapter 2). Both NSDUH and MTF indicated lower rates of past year
nonmedical use of pain relievers in 2013 than in 2003 to 2010 among young adults (Figure 8.6). The
rate of past year nonmedical use among young adults aged 18 to 25 in NSDUH for 2013 (8.8
percent) also was lower than the rate in 2002 and showed continued declines since 2010. Trend
data for adults aged 19 to 24 in MTF showed similar rates in 2011 to 2013.

Figure 8.6 Past Year Nonmedical Pain Reliever Use Among Young Adults in NSDUH and MTF:
2002-2013
MTF = Monitoring the Future; NSDUH = National Survey on Drug Use and Health.

+Difference between this estimate and the 2013 estimate is statistically significant at the .05
level. Note: Data for MTF are for “narcotics other than heroin.”
Sources: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on
Drug Use and Health, 2002-2013.
National Institute on Drug Abuse, Monitoring the Future Study, University of Michigan, 2002-
2013.
Centers for Disease Control and Prevention, Youth Risk Behavior Survey, 2003, 2005, 2007,
2009, 2011, and 2013.
Note: NSDUH data are for youths aged 12 to 17. Some 2006 to 2010 NSDUH estimates
may differ from previously published estimates due to updates (see Section B.3 in Appendix
B of this report).
MTF data are simple averages of estimates for 8th and 10th graders. MTF data for 8th and
10th graders are reported in Johnston et al. (2014), as are the MTF design effects used for
variance estimation.
Statistical tests for the YRBS were conducted using the “Youth Online” tool at
[Link]
Results of testing for statistical significance in this table may differ from published YRBS
reports of change.
MTF = Monitoring the Future; NSDUH = National Survey on Drug Use and Health; YRBS =
Youth Risk Behavior Survey.
– Not available.

a Difference between this estimate and 2013 estimate is statistically significant at the .05
level.
Sources: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on
Drug Use and Health, 2002-2013.
National Institute on Drug Abuse, Monitoring the Future Study, University of Michigan, 2002-
2013.
Centers for Disease Control and Prevention, Youth Risk Behavior Survey, 2003, 2005, 2007,
2009, 2011, and 2013.
Note: NSDUH data are for youths aged 12 to 17. Some 2006 to 2010 NSDUH estimates
may differ from previously published estimates due to updates (see Section B.3 in Appendix
B of this report).
MTF data are simple averages of estimates for 8th and 10th graders. MTF data for 8th and
10th graders are reported in Johnston et al. (2014), as are the MTF design effects used for
variance estimation.
Statistical tests for the YRBS were conducted using the “Youth Online” tool at
[Link]
Results of testing for statistical significance in this table may differ from published YRBS
reports of change.
MTF = Monitoring the Future; NSDUH = National Survey on Drug Use and Health; YRBS =
Youth Risk Behavior Survey.
– Not available.

a Difference between this estimate and 2013 estimate is statistically significant at the .05
level.
Sources: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on
Drug Use and Health, 2002-2013.
National Institute on Drug Abuse, Monitoring the Future Study, University of Michigan, 2002-
2013.
Centers for Disease Control and Prevention, Youth Risk Behavior Survey, 2003, 2005, 2007,
2009, 2011, and 2013.
Note: NSDUH data are for youths aged 12 to 17. Some 2006 to 2010 NSDUH estimates
may differ from previously published estimates due to updates (see Section B.3 in Appendix
B of this report).
MTF data are simple averages of estimates for 8th and 10th graders. MTF data for 8th and
10th graders are reported in Johnston et al. (2014), as are the MTF design effects used for
variance estimation.
Statistical tests for the YRBS were conducted using the “Youth Online” tool at
[Link]
Results of testing for statistical significance in this table may differ from published YRBS
reports of change.
MTF = Monitoring the Future; NSDUH = National Survey on Drug Use and Health; YRBS =
Youth Risk Behavior Survey.
– Not available.

a Difference between this estimate and 2013 estimate is statistically significant at the .05
level.
Sources: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on
Drug Use and Health, 2002-2013.
National Institute on Drug Abuse, Monitoring the Future Study, University of Michigan, 2002-
2013.
Note: NSDUH data are for persons aged 18 to 25. Some 2006 to 2010 NSDUH estimates
may differ from previously published estimates due to updates (see Section B.3 in Appendix
B of this report).
NSDUH = National Survey on Drug Use and Health; MTF = Monitoring the Future.
– Not available.
MTF data were calculated for persons aged 19 to 24 using simple averages of modal age
groups 19-20, 21-22, and 23-24 (source data at
[Link] Estimates may differ from those published
previously due to rounding. For the 19 to 24 age group in the MTF data, significance tests
were performed assuming independent samples between years an odd number of years apart
because two distinct cohorts a year apart were monitored longitudinally at 2-year intervals.
Although appropriate for comparisons of 2002, 2004, 2006, 2008, 2010, and 2012 estimates
with 2013 estimates, this assumption results in conservative tests for comparisons of 2003,
2005, 2007, 2009, and 2011 data with 2013 estimates because it does not take into account
covariances that are associated with repeated observations from the longitudinal samples.
Estimates of covariances were not available.

a Difference between this estimate and 2013 estimate is statistically significant at the .05
level.

1 MTF data are for “narcotics other than heroin.”

Sources: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on
Drug Use and Health, 2002-2013.
National Institute on Drug Abuse, Monitoring the Future Study, University of Michigan, 2002-
2013.
Note: NSDUH data are for persons aged 18 to 25. Some 2006 to 2010 NSDUH estimates
may differ from previously published estimates due to updates (see Section B.3 in Appendix
B of this report).
NSDUH = National Survey on Drug Use and Health; MTF = Monitoring the Future.
MTF data were calculated for persons aged 19 to 24 using simple averages of modal age
groups 19-20, 21-22, and 23-24 (source data at
[Link] Estimates may differ from those published
previously due to rounding. For the 19 to 24 age group in the MTF data, significance tests
were performed assuming independent samples between years an odd number of years apart
because two distinct cohorts a year apart were monitored longitudinally at 2-year intervals.
Although appropriate for comparisons of 2002, 2004, 2006, 2008, 2010, and 2012 estimates
with 2013 estimates, this assumption results in conservative tests for comparisons of 2003,
2005, 2007, 2009, and 2011 data with 2013 estimates because it does not take into account
covariances that are associated with repeated observations from the longitudinal samples.
Estimates of covariances were not available.

a Difference between this estimate and 2013 estimate is statistically significant at the .05
level.

1 MTF data are for “narcotics other than heroin.” In 2002, MTF question text was changed in
half of the sample by updating the example list of narcotics other than heroin. To be consistent
with MTF data for 2003 and later years, MTF data for 2002 past year use of narcotics other
than heroin are based on the half sample that received the new question text.
Sources: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on
Drug Use and Health, 2002-2013.
National Institute on Drug Abuse, Monitoring the Future Study, University of Michigan, 2002-
2013.
Note: NSDUH data are for persons aged 18 to 25. Some 2006 to 2010 NSDUH estimates
may differ from previously published estimates due to updates (see Section B.3 in Appendix
B of this report).
NSDUH = National Survey on Drug Use and Health; MTF = Monitoring the Future.
– Not available.
MTF data were calculated for persons aged 19 to 24 using simple averages of modal age
groups 19-20, 21-22, and 23-24 (source data at
[Link] Estimates may differ from those published
previously due to rounding. For the 19 to 24 age group in the MTF data, significance tests
were performed assuming independent samples between years an odd number of years apart
because two distinct cohorts a year apart were monitored longitudinally at 2-year intervals.
Although appropriate for comparisons of 2002, 2004, 2006, 2008, 2010, and 2012 estimates
with 2013 estimates, this assumption results in conservative tests for comparisons of 2003,
2005, 2007, 2009, and 2011 data with 2013 estimates because it does not take into account
covariances that are associated with repeated observations from the longitudinal samples.
Estimates of covariances were not available.

a Difference between this estimate and 2013 estimate is statistically significant at the .05
level.

1 MTF data are for “narcotics other than heroin.”

Appendix A: Description of the Survey
A.1 Sample Design
The sample design for the 2013 National Survey on Drug Use and Health (NSDUH)8 was an
extension of a coordinated 5-year design providing estimates for all 50 states plus the District of
Columbia initially for the years 2005 through 2009, then continuing through 2013. The respondent
universe for NSDUH is the civilian, noninstitutionalized population aged 12 years old or older
residing within the United States. The survey covers residents of households (persons living in
houses/townhouses, apartments, condominiums; civilians living in housing on military bases, etc.)
and persons in noninstitutional group quarters (e.g., shelters, rooming/boarding houses, college
dormitories, migratory workers’ camps, halfway houses). Excluded from the survey are persons
with no fixed household address (e.g., homeless and/or transient persons not in shelters), active-
duty military personnel, and residents of institutional group quarters, such as correctional facilities,
nursing homes, mental institutions, and long-term hospitals.

The coordinated design for 2005 through 2009 included a 50 percent overlap in second-stage units
(area segments) within each successive 2-year period from 2005 through 2009. The 2010 through
2013 NSDUHs continued the 50 percent overlap by retaining half of the second-stage units from
the previous survey. Because the coordinated design enabled estimates to be developed by state in
all 50 states plus the District of Columbia, states may be viewed as the first level of stratification
and as a variable for reporting estimates.

For the 50-state design, 8 states were designated as large sample states (California, Florida, Illinois,
Michigan, New York, Ohio, Pennsylvania, and Texas) with target sample sizes of 3,600. In 2013,
the actual sample sizes in these states ranged from 3,503 to 3,729. For the remaining 42 states and
the District of Columbia, the target sample size was 900. Sample sizes in these states ranged from
852 to 953 in 2013. This approach ensured there was sufficient sample in every state to support
state estimation by either direct methods or small area estimation (SAE)9 while at the same time
providing adequate precision for national estimates.

States were first stratified into a total of 900 state sampling regions (SSRs) (48 regions in each
large sample state and 12 regions in each small sample state). These regions were contiguous
geographic areas designed to yield approximately the same number of interviews.10 Unlike the
1999 through 2001 NHSDAs and the 2002 through 2004 NSDUHs in which the first-stage
sampling units were clusters of census blocks called area segments, the first stage of selection for
the 2005 through 2013 NSDUHs was census tracts.11 This stage was included to contain sample
segments within a single census tract to the extent possible.12

Within each SSR, 48 census tracts were selected with probability proportional to population size.
Within sampled census tracts, adjacent census blocks were combined to form the second-stage
sampling units or area segments. One area segment was selected within each sampled census
tract with probability proportional to population size. Although only 24 segments were needed to
support the coordinated 2005 through 2009 5-year sample, an additional 24 segments were selected
to support any supplemental studies that the Substance Abuse and Mental Health Services
Administration (SAMHSA) may have chosen to field. These 24 segments constituted the reserve
sample and were available for use in 2010, 2011, 2012, and 2013. Eight reserve sample segments
per SSR were fielded during the 2013 survey year. Four of these segments were retained from the
2012 survey, and four were selected for use in the 2013 survey.
These sampled segments were allocated equally into four separate samples, one for each 3-month
period (calendar quarter) during the year. That is, a sample of addresses was selected from two
segments in each calendar quarter so that the survey was relatively continuous in the field. In each
of the area segments, a listing of all addresses was made, from which a national sample of 227,075
addresses was selected. Of the selected addresses, 190,067 were determined to be eligible sample
units. In these sample units (which can be either households or units within group quarters), sample
persons were randomly selected using an automated screening procedure programmed in a
handheld computer carried by the interviewers. The number of sample units completing the
screening was 160,325. Youths aged 12 to 17 years and young adults aged 18 to 25 years were
oversampled at this stage, with 12 to 17 year olds sampled at an actual rate of 87.5 percent and 18
to 25 year olds at a rate of 68.5 percent on average, when they were present in the sampled
households or group quarters. Similarly, persons in age groups 26 or older were sampled at rates of
23.4 percent or less, with persons in the eldest age group (50 years or older) sampled at a rate of
8.3 percent on average. The overall population sampling rates were 0.090 percent for 12 to 17 year
olds, 0.064 percent for 18 to 25 year olds, 0.017 percent for 26 to 34 year olds, 0.015 percent for
35 to 49 year olds, and 0.007 percent for those 50 or older. Nationwide, 88,742 persons were
selected. Consistent with previous surveys in this series, the final respondent sample of 67,838
persons was representative of the U.S. general population (since 1991, the civilian,
noninstitutionalized population) aged 12 or older. In addition, state samples were representative of
their respective state populations. More detailed information on the disposition of the national
screening and interview sample can be found in Appendix B. More information about the sample
design can be found in the 2013 NSDUH sample design report (Center for Behavioral Health
Statistics and Quality [CBHSQ], 2014b).
A.2 Data Collection Methodology
The data collection method used in NSDUH involves in-person interviews with sample persons,
incorporating procedures to increase respondents’ cooperation and willingness to report honestly
about their illicit drug use behavior. Confidentiality is stressed in all written and oral
communications with potential respondents. Respondents’ names are not collected with the data,
and computer-assisted interviewing (CAI) methods are used to provide a private and confidential
setting to complete the interview.

Introductory letters are sent to sampled addresses, followed by an interviewer visit. When
contacting a dwelling unit (DU), the field interviewer (FI) asks to speak with an adult resident
(aged 18 or older) of the household who can serve as the screening respondent. Using a handheld
computer, the FI completes a 5-minute procedure with the screening respondent that involves
listing all household members along with their basic demographic data. The computer uses the
demographic data in a preprogrammed selection algorithm to select zero to two sample persons,
depending on the composition of the household. This selection process is designed to provide the
necessary sample sizes for the specified population age groupings. In areas where a third or more
of the households contain Spanish-speaking residents, the initial introductory letters written in
English are mailed with a Spanish version on the back. All interviewers carry copies of this letter in
Spanish. If the interviewer is not certified bilingual, he or she will use preprinted Spanish cards to
attempt to find someone in the household who speaks English and who can serve as the screening
respondent or who can translate for the screening respondent. If no one is available, the
interviewer will schedule a time when a Spanish-speaking interviewer can come to the address. In
households where a language other than Spanish is encountered, another language card is used to
attempt to find someone who speaks English to complete the screening.

The NSDUH interview can be completed in English or Spanish, and both versions have the same
content. If the sample person prefers to complete the interview in Spanish, a certified bilingual
interviewer is sent to the address to conduct the interview. Because the interview is not translated
into any other language, if a sample person does not speak English or Spanish, the interview is not
conducted.

Immediately after the completion of the screener, interviewers attempt to conduct the NSDUH
interview with each sample person in the household. The interviewer requests that the sampled
respondent identify a private area in the home to conduct the interview away from other household
members. The interview averages about an hour and includes a combination of CAPI (computer-
assisted personal interviewing, in which the interviewer reads the questions) and ACASI (audio
computer-assisted self-interviewing).

The NSDUH interview consists of core and noncore (i.e., supplemental) sections. A core set of
questions critical for basic trend measurement of prevalence estimates remains in the survey every
year and comprises the first part of the interview. Noncore questions, or modules, that can be
revised, dropped, or added from year to year make up the remainder of the interview. The core
consists of initial demographic items (which are interviewer-administered) and self-administered
questions pertaining to the use of tobacco, alcohol, marijuana, cocaine, crack cocaine, heroin,
hallucinogens, inhalants, pain relievers, tranquilizers, stimulants, and sedatives. Topics in the
remaining noncore self-administered sections include (but are not limited to) injection drug use,
perceived risks of substance use, substance dependence or abuse, arrests, treatment for substance
use problems, pregnancy and health care issues, and mental health issues. Noncore demographic
questions (which are interviewer-administered and follow the ACASI questions) address such
topics as immigration, current school enrollment, employment and workplace issues, health
insurance coverage, and income. In practice, some of the noncore portions of the interview have
remained in the survey, relatively unchanged, from year to year (e.g., current health insurance
coverage, employment).

Thus, the interview begins in CAPI mode with the FI reading the questions from the computer
screen and entering the respondent’s replies into the computer. The interview then transitions to the
ACASI mode for the sensitive questions. In this mode, the respondent can read the questions
silently on the computer screen and/or listen to the questions read through headphones and enter
his or her responses directly into the computer. At the conclusion of the ACASI section, the
interview returns to the CAPI mode with the FI completing the questionnaire. Each respondent
who completes a full interview is given a $30 cash incentive as a token of appreciation for his or
her time.

No personal identifying information about the respondent is captured in the CAI record. FIs
transmit the completed interview data to RTI in Research Triangle Park, North Carolina. Screening
and interview data are encrypted while they reside on laptops and mobile computers. Data are
transmitted back to RTI on a regular basis using either a direct dial-up connection or the Internet.
All data are encrypted while in transit across dial-up or Internet connections. In addition, the
screening and interview data are transmitted back to RTI in separate data streams and are kept
physically separate (on different devices) before transmission occurs.

After the data are transmitted to RTI, certain cases are selected for verification. The respondents
are contacted by RTI to verify the quality of an FI’s work based on information that respondents
provide at the end of screening (if no one is selected for an interview at the DU or the entire DU is
ineligible for the study) or at the end of the interview. For the screening, the adult DU member who
served as the screening respondent provides his or her first name and telephone number to the FI,
who enters the information into a handheld computer and transmits the data to RTI. For completed
interviews, respondents write their home telephone number and mailing address on a quality control
form and seal the form in a preaddressed envelope that FIs mail back to RTI. All contact
information is kept completely separate from the answers provided during the screening or
interview.

Samples of respondents who completed screenings or interviews are randomly selected for
verification. These cases are called by telephone interviewers who ask scripted questions designed
to determine the accuracy and quality of the data collected. Any cases discovered to have a
problem or discrepancy are flagged and routed to a small specialized team of telephone
interviewers who recontact respondents for further investigation of the issue(s). Depending on the
amount of an FI’s work that cannot be verified through telephone verification, including bad
telephone numbers (e.g., incorrect number, disconnected, not in service), a field verification may be
conducted. Field verification involves another FI returning to the sampled DU to verify the
accuracy and quality of the data in person. If the verification procedures identify situations in
which an FI has falsified data, the FI is terminated. All cases completed that quarter by the
falsifying FI are verified and reworked by the FI conducting the field verification. Any cases
completed by the falsifying FI in earlier quarters of the same year are also verified. All cases from
earlier quarters identified as falsified or unresolvable are removed and not reworked. Examples of
unresolvable cases include those for which verifiers were never able to make contact with a
resident of the DU, residents who refused to verify their data, previous residents who had moved,
or residents who reported accurate roster data for the DU but did not recall speaking to an FI.
A.3 Data Processing
Data that FIs transmit to RTI are processed to create a raw data file in which no logical editing of
the data has been done. The raw data file consists of one record for each transmitted interview.
Cases are eligible to be treated as final respondents only if they provided data on lifetime use of
cigarettes and at least 9 out of 13 of the other substances in the core section of the questionnaire.
Even though editing and consistency checks are done by the CAI program during the interview,
additional, more complex edits and consistency checks are completed at RTI. Additionally,
statistical imputation is used to replace missing or ambiguous values after editing for some key
variables. Analysis weights are created so that estimates will be representative of the target
population. Details of the editing, imputation, and weighting procedures for 2013 will appear in the
2013 NSDUH Methodological Resource Book, which is in process. Until that volume becomes
available, refer to the 2012 NSDUH Methodological Resource Book (CBHSQ, 2014a).
A.3.1 Data Coding and Logical Editing
With the exception of industry and occupation data, coding of written answers that respondents or
interviewers typed was performed at RTI for the 2013 NSDUH. These written answers include
mentions of drugs that respondents had used or other responses that did not fit a previous response
option (subsequently referred to as “OTHER, Specify” data). Written responses in “OTHER,
Specify” data were assigned numeric codes through computer-assisted survey procedures and the
use of a secure Web site that allowed for coding and review of the data. The computer-assisted
procedures entailed a database check for a given “OTHER, Specify” variable that contained typed
entries and the associated numeric codes. If an exact match was found between the typed
response and an entry in the system, the computer-assisted procedures assigned the appropriate
numeric code. Typed responses that did not match an existing entry were coded through the Web-
based coding system. Data on the industries in which respondents worked and respondents’
occupations were assigned numeric industry and occupation codes by staff at the U.S. Census
Bureau.

As noted above, the CAI program included checks that alerted respondents or interviewers when
an entered answer was inconsistent with a previous answer in a given module. In this way, the
inconsistency could be resolved while the interview was in progress. However, not every
inconsistency was resolved during the interview, and the CAI program did not include checks for
every possible inconsistency that might have occurred in the data.

Therefore, the first step in processing the raw NSDUH data was logical editing of the data.
Logical editing involved using data from within a respondent’s record to (a) reduce the amount of
item nonresponse (i.e., missing data) in interview records, including identification of items that were
legitimately skipped; (b) make related data elements consistent with each other; and (c) identify
ambiguities or inconsistencies to be resolved through statistical imputation procedures (see Section
A.3.2).

For example, if respondents reported that they never used a given drug, the CAI logic skipped
them out of all remaining questions about use of that drug. In the editing procedures, the skipped
variables were assigned codes to indicate that the respondents were lifetime nonusers. Similarly,
respondents were instructed in the prescription psychotherapeutics modules (i.e., pain relievers,
tranquilizers, stimulants, and sedatives) not to report the use of over-the-counter (OTC) drugs.
Therefore, if a respondent’s only report of lifetime use of a particular type of “prescription”
psychotherapeutic drug was for an OTC drug, the respondent was logically inferred never to have
been a nonmedical user of the prescription drugs in that psychotherapeutic category.

In addition, respondents could report that they were lifetime users of a drug but not provide specific
information on when they last used it. In this situation, a temporary “indefinite” value for the most
recent period of use was assigned to the edited recency-of-use variable (e.g., “Used at some point
in the lifetime LOGICALLY ASSIGNED”), and a final, specific value was statistically imputed.
The editing procedures for key drug use variables also involved identifying inconsistencies between
related variables so that these inconsistencies could be resolved through statistical imputation. For
example, if a respondent reported last using a drug more than 12 months ago and also reported first
using it at his or her current age, both of those responses could not be true. In this example, the
inconsistent period of most recent use was replaced with an “indefinite” value, and the inconsistent
age at first use was replaced with a missing data code. These indefinite or missing values were
subsequently imputed through statistical procedures to yield consistent data for the related
measures, as discussed in the next section.
A.3.2 Statistical Imputation
For some key variables that still had missing or ambiguous values after editing, statistical imputation
was used to replace these values with appropriate response codes. For example, a response is
ambiguous if the editing procedures assigned a respondent’s most recent use of a drug to “Used at
some point in the lifetime,” with no definite period within the lifetime. In this case, the imputation
procedure assigns a value for when the respondent last used the drug (e.g., in the past 30 days,
more than 30 days ago but within the past 12 months, more than 12 months ago). Similarly, if a
response is completely missing, the imputation procedures replace missing values with nonmissing
ones.

For most variables, missing or ambiguous values are imputed in NSDUH using a methodology
called predictive mean neighborhoods (PMN), which was developed specifically for the 1999
survey and has been used in all subsequent survey years. PMN allows for the following: (1) the
ability to use covariates to determine donors is greater than that offered in the hot-deck imputation
procedure, (2) the relative importance of covariates can be determined by standard modeling
techniques, (3) the correlations across response variables can be accounted for by making the
imputation multivariate, and (4) sampling weights can be easily incorporated in the models. The
PMN method has some similarity with the predictive mean matching method of Rubin (1986)
except that, for the donor records, Rubin used the observed variable value (not the predictive
mean) to compute the distance function. Also, the well-known method of nearest neighbor
imputation is similar to PMN, except that the distance function is in terms of the original predictor
variables and often requires somewhat arbitrary scaling of discrete variables. PMN is a
combination of a model-assisted imputation methodology and a random nearest neighbor hot-deck
procedure. The hot-deck procedure within the PMN method ensures that missing values are
imputed to be consistent with nonmissing values for other variables. Whenever feasible, the
imputation of variables using PMN is multivariate, in which imputation is accomplished on several
response variables at once. Variables imputed using PMN are the core demographic variables,
core drug use variables (recency of use, frequency of use, and age at first use), income, health
insurance, and noncore demographic variables for work status, immigrant status, and the household
roster. Table A.1 at the end of this appendix summarizes the distribution of weighted statistical
imputation rates of these variables by interview section.

In the modeling stage of PMN, the model chosen depends on the nature of the response variable.
In the 2013 NSDUH, the models included binomial logistic regression, multinomial logistic
regression, Poisson regression, time-to-event (survival) regression, and ordinary linear regression,
where the models incorporated the sampling design weights.

In general, hot-deck imputation replaces an item nonresponse (missing or ambiguous value) with a
recorded response that is donated from a “similar” respondent who has nonmissing data. For
random nearest neighbor hot-deck imputation, the missing or ambiguous value is replaced by a
responding value from a donor randomly selected from a set of potential donors. Potential donors
are those defined to be “close” to the unit with the missing or ambiguous value according to a
predefined function called a distance metric. In the hot-deck procedure of PMN, the set of
candidate donors (the “neighborhood”) consists of respondents with complete data who have a
predicted mean close to that of the item nonrespondent. The predicted means are computed both
for respondents with and without missing data, which differs from Rubin’s method where predicted
means are not computed for the donor respondent (Rubin, 1986). In particular, the neighborhood
consists of either the set of the closest 30 respondents or the set of respondents with a predicted
mean (or means) within 5 percent of the predicted mean(s) of the item nonrespondent, whichever
set is smaller. If no respondents are available who have a predicted mean (or means) within 5
percent of the item nonrespondent, the respondent with the predicted mean(s) closest to that of the
item nonrespondent is selected as the donor.

In the univariate case (where only one variable is imputed using PMN), the neighborhood of
potential donors is determined by calculating the relative distance between the predicted mean for
an item nonrespondent and the predicted mean for each potential donor, then choosing those means
defined by the distance metric. The pool of donors is restricted further to satisfy logical constraints
whenever necessary (e.g., age at first crack use must not be less than age at first cocaine use).

Whenever possible, missing or ambiguous values for more than one response variable are
considered together. In this (multivariate) case, the distance metric is a Mahalanobis distance,
which takes into account the correlation between variables (Manly, 1986), rather than a Euclidean
distance. The Euclidean distance is the square root of the sum of squared differences between
each element of the predictive mean vector for the respondent and the predictive mean vector for
the nonrespondent. The Mahalanobis distance standardizes the Euclidean distance by the variance-
covariance matrix, which is appropriate for random variables that are correlated or have
heterogeneous variances. Whether the imputation is univariate or multivariate, only missing or
ambiguous values are replaced, and donors are restricted to be logically consistent with the
response variables that are not missing. Furthermore, donors are restricted to satisfy “likeness
constraints” whenever possible. That is, donors are required to have the same values for variables
highly correlated with the response. For example, donors for the age at first use variable are
required to be of the same age as recipients, if at all possible. If no donors are available who meet
these conditions, these likeness constraints can be loosened. Further details on the PMN
methodology are provided by Singh, Grau, and Folsom (2002).

Although statistical imputation could not proceed separately within each state due to insufficient
pools of donors, information about each respondent’s state of residence was incorporated in the
modeling and hot-deck steps. For most drugs, respondents were separated into three “State usage”
categories as follows: respondents from states with high usage of a given drug were placed in one
category, respondents from states with medium usage into another, and the remainder into a third
category. This categorical “State rank” variable was used as one set of covariates in the imputation
models. In addition, eligible donors for each item nonrespondent were restricted to be of the same
state usage category (i.e., the same “State rank”) as the nonrespondent.

In the 2013 NSDUH, the majority of variables that underwent statistical imputation required less
than 5 percent of their records to be logically assigned or statistically imputed. Variables for
measures that are highly sensitive or that may not be known to younger respondents (e.g., family
income) often have higher rates of item nonresponse. In addition, certain variables that are subject
to a greater number of skip patterns and consistency checks (e.g., frequency of use in the past 12
months and past 30 days) often require greater amounts of imputation.
A.3.3 Development of Analysis Weights
The general approach to developing and calibrating analysis weights involved developing design-
based weights as the product of the inverse of the selection probabilities at each selection stage.
Since 2005, NSDUH has used a four-stage sample selection scheme in which an extra selection
stage of census tracts was added before the selection of a segment. Thus, the design-based
weights, d k , incorporate an extra layer of sampling selection to reflect the sample design change.
Adjustment factors, a k (λ) , then were applied to the design-based weights to adjust for
nonresponse, to poststratify to known population control totals, and to control for extreme weights
when necessary. In view of the importance of state-level estimates with the 50-state design, it was
necessary to control for a much larger number of known population totals. Several other
modifications to the general weight adjustment strategy that had been used in past surveys also
were implemented for the first time beginning with the 1999 CAI sample.

Weight adjustments were based on a generalization of Deville and Särndal’s (1992) logit model.
This generalized exponential model (GEM) (Folsom & Singh, 2000) incorporates unit-specific
bounds (lk , u k ), k ∈ s, for the adjustment factor ak (λ) as follows:
a k ( λ ) = l k ( u k − c k ) + u k ( c k − l k ) exp ( A k x / k λ ) ( u k − c k ) + ( c k − l k ) e x p ( A
kx/kλ)

where ck are prespecified centering constants, such that lk <ck<u k and A k = ( u k − l k ) / ( u k

−c k) ( c k−lk) The
variables lk , ck , and u k are user-specified bounds, and λ is the column vector of p model
parameters corresponding to the p covariates x.

The λ parameters are estimated by solving

Σsxkdkak(λ)−Τ~x=0,

where T ~ x denotes control totals that could be either nonrandom, as is generally the case
with poststratification, or random, as is generally the case for nonresponse adjustment.

The final weights wk = d k a k (λ) minimize the distance function ∆ (w, d) defined as
Δ ( w , d ) = Σ k ∈ s d k A k { ( a k − l k ) log a k − l k c k − l k + ( u k − a k ) log u k − a k u k −
ck}
This general approach was used at several stages of the weight adjustment process, including (1)
adjustment of household weights for nonresponse at the screener level, (2) poststratification of
household weights to meet population controls for various household-level demographics by state,
(3) adjustment of household weights for extremes, (4) poststratification of selected person weights,
(5) adjustment of responding person weights for nonresponse at the questionnaire level, (6)
poststratification of responding person weights, and (7) adjustment of responding person weights
for extremes.

Every effort was made to include as many relevant state-specific covariates (typically defined by
demographic domains within states) as possible in the multivariate models used to calibrate the
weights (nonresponse adjustment and poststratification steps). Because further subdivision of state
samples by demographic covariates often produced small cell sample sizes, it was not possible to
retain all state-specific covariates (even after meaningful collapsing of covariate categories) and
still estimate the necessary model parameters with reasonable precision. Therefore, a hierarchical
structure was used in grouping states with covariates defined at the national level, at the census
division level within the nation, at the state group within the census division, and whenever possible,
at the state level. In every case, the controls for the total population within a state and the five age
groups (12 to 17, 18 to 25, 26 to 34, 35 to 49, 50 or older) within a State were maintained except
that, in the last step of poststratification of person weights, six age groups (12 to 17, 18 to 25, 26 to
34, 35 to 49, 50 to 64, 65 or older) were used. Census control totals by age, race, gender, and
Hispanic origin were required for the civilian, noninstitutionalized population of each state.
Beginning with the 2002 NSDUH, the Population Estimates Branch of the U.S. Census Bureau
has produced the necessary population estimates for the same year as each NSDUH survey in
response to a special request.

Census control totals for the 2013 NSDUH weights were based on population estimates from the
2010 decennial census as for the 2011 and 2012 NSDUHs, whereas the control totals for the 2010
NSDUH weights were still based on the 2000 census. This shift to the 2010 census data for the
2011 NSDUH could have affected comparisons between substance use estimates in 2011 and
onward and those from prior years. Section B.4.3 in Appendix B of the 2011 NSDUH national
findings report (CBHSQ, 2012b) discusses the results of an investigation using data from 2010 and
2011 that assessed the effects of using control totals based on the 2010 census instead of the 2000
census for estimating substance use in 2010.

Consistent with the surveys from 1999 onward, control of extreme weights through separate
bounds for adjustment factors was incorporated into the GEM calibration processes for both
nonresponse and poststratification. This is unlike the traditional method of winsorization in which
extreme weights are truncated at prespecified levels and the trimmed portions of weights are
distributed to the nontruncated cases. In GEM, it is possible to set bounds around the prespecified
levels for extreme weights. Then the calibration process provides an objective way of deciding the
extent of adjustment (or truncation) within the specified bounds. A step was included to poststratify
the household-level weights to obtain census-consistent estimates based on the household rosters
from all screened households. An additional step poststratified the selected person sample to
conform to the adjusted roster estimates. This additional step takes advantage of the inherent two-
phase nature of the NSDUH design. The respondent poststratification step poststratified the
respondent person sample to external census data (defined within the state whenever possible, as
discussed above).

For certain populations of interest, 2 years of NSDUH data were combined to obtain annual
averages. The person-level weights for estimates based on the annual averages were obtained by
dividing the analysis weights for the 2 specific years by a factor of 2.
1 Core drug use variables do not include initiation variables beyond age at first use because
these additional questions are asked only if respondents first used within 1 year of their
current age.

2 Other noncore demographic variables include work status, immigrant status, and household
roster variables. Source: SAMHSA, Center for Behavioral Health Statistics and Quality,
National Survey on Drug Use and Health, 2013.
Appendix B: Statistical Methods and
Measurement
B.1 Target Population
The estimates of drug use prevalence from the National Survey on Drug Use and Health
(NSDUH) are designed to describe the target population of the survey—the civilian,
noninstitutionalized population aged 12 or older living in the United States. This population includes
almost 98 percent of the total U.S. population aged 12 or older. However, it excludes some small
subpopulations that may have very different drug use patterns. For example, the survey excludes
active military personnel, who have been shown to have significantly lower rates of illicit drug use.
The survey also excludes two groups that have been shown to have higher rates of illicit drug use:
persons living in institutional group quarters, such as prisons and residential drug use treatment
centers, and homeless persons not living in a shelter. Readers are reminded to consider the
exclusion of these subpopulations when interpreting results. Appendix C describes other surveys
that provide data for some of these populations.
B.2 Sampling Error and Statistical Significance
This report includes national estimates that were drawn from a set of tables referred to as
“detailed tables” that are available at [Link] The national estimates, along
with the associated standard errors (SEs, which are the square roots of the variances), were
computed for all detailed tables using a multiprocedure package, SUDAAN® Software for
Statistical Analysis of Correlated Data. This software accounts for the complex survey design of
NSDUH in estimating the SEs (RTI International, 2012). The final, nonresponse-adjusted, and
poststratified analysis weights were used in SUDAAN to compute unbiased, design-based drug
use estimates.

The sampling error of an estimate is the error caused by the selection of a sample instead of
conducting a census of the population. The sampling error may be reduced by selecting a large
sample and/or by using efficient sample design and estimation strategies, such as stratification,
optimal allocation, and ratio estimation. The use of probability sampling methods in NSDUH allows
estimation of sampling error from the survey data. SEs have been calculated using SUDAAN for
all estimates presented in this report using a Taylor series linearization approach that takes into
account the effects of NSDUH’s complex design features. The SEs are used to identify unreliable
estimates and to test for the statistical significance of differences between estimates.
B.2.1 Variance Estimation for Totals
The variances and SEs of estimates of means and proportions can be calculated reasonably well in
SUDAAN using a Taylor series linearization approach. Estimates of means or proportions, p ^ d

, such as drug use prevalence estimates for a domain d, can be expressed as a ratio estimate:
p^d=Y ^dN ^d,

where Y ^ d is a linear statistic estimating the number of substance users in the domain d

and N ^ d is a linear statistic estimating the total number of persons in domain d (including
both users and nonusers). The SUDAAN software package is used to calculate direct estimates of

Y ^d and N ^ d (and, therefore, p ^ d )and also can be used to estimate their

respective SEs. A Taylor series approximation method implemented in SUDAAN provides the

estimate for the SE of p ^ d .

When the domain size, N ^ d , is free of sampling error, an estimate of the SE for the total
number of substance users is
SE( Y ^d) =N ^dSE( p^d)

This approach is theoretically correct when the domain size estimates, N ^ d , are among
those forced to match their respective U.S. Census Bureau population estimates through the

weight calibration process. In these cases, N ^ d is not subject to a sampling error induced
by the NSDUH design. Section A.3.3 in Appendix A contains further information about the weight
calibration process. In addition, more detailed information about the weighting procedures for 2013
will appear in the 2013 NSDUH Methodological Resource Book, which is in process. Until that
volume becomes available, refer to the 2012 NSDUH Methodological Resource Book (Center
for Behavioral Health Statistics and Quality [CBHSQ], 2014a).

For estimated domain totals, Y ^ d , where N ^ d is not fixed (i.e., where domain size
estimates are not forced to match the U.S. Census Bureau population estimates), this formulation
still may provide a good approximation if it can be assumed that the sampling variation in N ^ d

is negligible relative to the sampling variation in p ^ d . This is a reasonable assumption

for many cases in this study.

For some subsets of domain estimates, the above approach can yield an underestimate of the SE of

the total when N ^ d was subject to considerable variation. Because of this underestimation,
alternatives for estimating SEs of totals were implemented. Since the 2005 NSDUH report, a
“mixed” method approach has been implemented for all detailed tables to improve the accuracy of
SEs and to better reflect the effects of poststratification on the variance of total estimates. This
approach assigns the methods of SE calculation to domains (i.e., subgroups for which the estimates
were calculated) within tables so that all estimates among a select set of domains with fixed N ^ d

were calculated using the formula above, and all other estimates were calculated directly in
SUDAAN, regardless of what the other estimates are within the same table. The set of domains

considered controlled (i.e., those with a fixed N ^ d ) was restricted to main effects and
two-way interactions in order to maintain continuity between years. Domains consisting of three-
way interactions may be controlled in a single year but not necessarily in preceding or subsequent
years. The use of such SEs did not affect the SE estimates for the corresponding proportions
presented in the same sets of tables because all SEs for means and proportions are calculated
directly in SUDAAN. As a result of the use of this mixed-method approach, the SEs for the total
estimates within many detailed tables were calculated differently from those in NSDUH reports
prior to the 2005 report.

Table B.1 at the end of this appendix contains only a partial list of domains with a fixed N ^ d

that were used in the weight calibration process. However, the list does include all of the
domains that were used in computing SEs for estimates produced in this report and in the 2013
detailed tables. This table includes both the main effects and two-way interactions and may be
used to identify the method of SE calculation employed for estimates of totals. For example, Table
1.23 in the 2013 detailed tables presents estimates of illicit drug use among persons aged 18 or
older within the domains of gender, Hispanic origin and race, education, and current employment.
Estimates among the total population (age main effect), males and females (age by gender
interaction), and Hispanics and non-Hispanics (age by Hispanic origin interaction) were treated as
controlled in this table, and the formula above was used to calculate the SEs. The SEs for all other
estimates, including white and black or African American (age by Hispanic origin by race
interaction) were calculated directly from SUDAAN. Estimates presented in this report for racial
groups are for non-Hispanics. Thus, the domain for whites by age group in the weight calibration
process in Table B.1 is a two-way interaction. However, published estimates for whites by age
group in this report and in the 2013 detailed tables actually represent a three-way interaction: white
by Hispanic origin (i.e., not Hispanic) by age group.
B.2.2 Suppression Criteria for Unreliable
Estimates
As has been done in past NSDUH reports, direct estimates from NSDUH that are designated as
unreliable are not shown in this report and are noted by asterisks (*) in figures containing such
estimates. The criteria used to define unreliability of direct estimates from NSDUH are based on
the prevalence (for proportion estimates), relative standard error (RSE) (defined as the ratio of the
SE over the estimate), nominal (actual) sample size, and effective sample size for each estimate.
These suppression criteria for various NSDUH estimates are summarized in Table B.2 at the end
of this appendix.

Proportion estimates p ^ d , or rates, within the range [0 < p ^ d < 1] , and the
corresponding estimated numbers of users were suppressed if
RSE [ − 1n ( p ^ ) ] > .175 when p ^ ≤ .5

Or
RSE [ − 1n ( 1 − p ^ ) ] > . 1 7 5 when p ^ > . 5

Using a first-order Taylor series approximation to estimate RSE[-1n( p ^ d )] and RSE[-1n(1 -

p^d )], the following equation was derived and used for computational purposes when
applying a suppression rule dependent on effective sample size:
SE ( p ^ ) / p ^ − ln ( p ^ ) > .175 when p ^ ≤ .5

Or
SE ( p ^ ) / ( 1 − p ^ ) − ln ( 1 − p ^ ) > . 1 7 5 when p ^ > . 5

The separate formulas for p ^ ≤ .5 and p ^ > .5 produce a symmetric suppression rule; that
is, if p ^ is suppressed, 1 − p ^ d will be suppressed as well (see Figure B.1

following Table B.2). When .05 < p ^ d <ss .95, the symmetric properties of the rule produce

a local minimum effective sample size of 50 at p ^ d = .2 and at p ^ = .8. Using the

minimum effective sample size for the suppression rule would mean that estimates of p ^
between .05 and .95 would be suppressed if their corresponding effective sample sizes were less

than 50. Within this same interval, a local maximum effective sample size of 68 is found at p ^ =

.5. To simplify requirements and maintain a conservative suppression rule, estimates of p ^

between .05 and .95 were suppressed if they had an effective sample size below 68.

In addition, a minimum nominal sample size suppression criterion (n = 100) that protects against
unreliable estimates caused by small design effects and small nominal sample sizes was employed;
Table B.2 shows a formula for calculating design effects. Prevalence estimates also were

suppressed if they were close to 0 or 100 percent (i.e., if p ^ < .00005 or if p ^ ≥ .99995).

Beginning with the 1991 survey, the suppression rule for proportions based on RSE[-1n( p ^ )]

described previously replaced a rule in which data were suppressed whenever RSE( p ^ ) > .5.
This rule was changed because the rule prior to 1991 imposed a very stringent application for

suppressing estimates when p ^ is small but imposed a very lax application for large p ^ .

The new rule ensured a more uniformly stringent application across the whole range of p ^ (i.e.,
from 0 to 1). The previous rule also was asymmetric in the sense that suppression only occurred in

terms of p ^ . That is, there was no complementary rule for ( 1 − p ^ d ) , which

the current NSDUH suppression criteria for proportions take into account.

Estimates of totals were suppressed if the corresponding prevalence rates were suppressed.
Estimates of means that are not bounded between 0 and 1 (e.g., mean of age at first use) were
suppressed if the RSEs of the estimates were larger than .5 or if the nominal sample size was
smaller than 10 respondents. This rule was based on an empirical examination of the estimates of
mean age of first use and their SEs for various empirical sample sizes. Although arbitrary, a sample
size of 10 appeared to provide sufficient precision and still allow reporting by year of first use for
many substances.
B.2.3 Statistical Significance of Differences
This section describes the methods used to compare prevalence estimates in this report.
Customarily, the observed difference between estimates is evaluated in terms of its statistical
significance. Statistical significance is based on the p value of the test statistic and refers to the
probability that a difference as large as that observed would occur because of random variability in
the estimates if there were no difference in the prevalence estimates for the population groups
being compared. The significance of observed differences in this report is reported at the .05 level.
When comparing prevalence estimates, the null hypothesis (no difference between prevalence
estimates) was tested against the alternative hypothesis (there is a difference in prevalence
estimates) using the standard difference in proportions test expressed as
z = p ^ 1 − p ^ 2 var ( p ^ 1 ) + var ( p ^ 2 ) − 2 cov ( p ^ 1 − p ^ 2 )

where p ^ 1 = first prevalence estimate, p ^ 2 = second prevalence estimate, var( p ^ 1

) = variance of first prevalence estimate, var( p ^ 2 ) = variance of second prevalence

estimate, and cov ( p ^ 1 , p ^ 2 ) = covariance between p ^ 1 and p ^ 2 .

In cases where significance tests between years were performed, the prevalence estimate from
the earlier year becomes the first estimate, and the prevalence estimate from the later year
becomes the second estimate (e.g., 2012 is the first estimate and 2013 the second).

Under the null hypothesis, Z is asymptotically distributed as a standard normal random variable.
Therefore, calculated values of Z can be referred to the unit normal distribution to determine the
corresponding probability level (i.e., p value). Because the covariance term between the two
estimates is not necessarily zero, SUDAAN was used to compute estimates of Z along with the
associated p values using the analysis weights and accounting for the sample design as described
in Appendix A. A similar procedure and formula for Z were used for estimated totals. Whenever it
was necessary to calculate the SE outside of SUDAAN (i.e., when domains were forced by the
weighting process to match their respective U.S. Census Bureau population estimates), the
corresponding test statistics also were computed outside of SUDAAN.

When comparing population subgroups across three or more levels of a categorical variable, log-
linear chi-square tests of independence of the subgroups and the prevalence variables were
conducted using SUDAAN in order to first control the error level for multiple comparisons. If
Shah’s Wald F test (transformed from the standard Wald chi-square) indicated overall significant
differences, the significance of each particular pairwise comparison of interest was tested using
SUDAAN analytic procedures to properly account for the sample design (RTI International, 2012).
Using the published estimates and SEs to perform independent t tests for the difference of
proportions usually will provide the same results as tests performed in SUDAAN. However, where
the significance level is borderline, results may differ for two reasons: (1) the covariance term is
included in SUDAAN tests, whereas it is not included in independent t tests; and (2) the reduced
number of significant digits shown in the published estimates may cause rounding errors in the
independent t tests.

A caution in interpreting trends in totals (e.g., estimated numbers of users) is that respondents with
large analysis weights can greatly influence the estimated total in a given year when the number of
persons in the population with the characteristic of interest is relatively small. As discussed in
Chapter 2, for example, the number of persons aged 12 or older who were past year heroin users
in 2013 (681,000) was higher than the numbers in most years from 2002 to 2008, but it was not
significantly different from the number in 2006 (580,000). The estimate for 2006 was determined to
be affected by large analysis weights for a small number of heroin users and suggests that the
estimated numbers of past year and past month heroin users in 2006 were statistical anomalies.
This finding also underscores the importance of reviewing trends across a larger range of years
especially for outcome measures that correspond to a relatively small proportion of the total
population (e.g., 681,000 past year heroin users from a population of more than 260 million people
aged 12 or older in 2013).

As part of a comparative analysis discussed in Chapter 8, prevalence estimates from the

Monitoring the Future (MTF) study, sponsored by the National Institute on Drug Abuse (NIDA),
were presented for recency measures of selected substances (see Tables 8.1 to 8.6). The analyses
focused on prevalence estimates for 8th and 10th graders and prevalence estimates for young
adults aged 19 to 24 for 2002 through 2013. Estimates for the 8th and 10th grade students were
calculated using MTF data as the simple average of the 8th and 10th grade estimates. Estimates
for young adults aged 19 to 24 were calculated using MTF data as the simple average of three
modal age groups: 19 and 20 years, 21 and 22 years, and 23 and 24 years. Published results were
not available from NIDA for significant differences in prevalence estimates between years for
these subgroups, so testing was performed using information that was available.

For the 8th and 10th grade average estimates, tests of differences were performed between 2013
and the 11 prior years. Estimates for persons in grade 8 and grade 10 were considered
independent, simplifying the calculation of variances for the combined grades. Across years, the
estimates for 2013 involved samples independent of those in 2002 to 2011. For 2012 and 2013,
however, the sample of schools overlapped 50 percent, creating a covariance in the estimates.
Design effects published in Johnston et al. (2013) for adjacent and nonadjacent year testing were
used.

For the 19- to 24-year-old age group, tests of differences were done assuming independent
samples between years an odd number of years apart because two distinct cohorts a year apart
were monitored longitudinally at 2-year intervals. This is appropriate for comparisons of 2002,
2004, 2006, 2008, 2010, and 2012 data with 2013 data. However, this assumption results in
conservative tests for comparisons of 2003, 2005, 2007, 2009, and 2011 data with 2013 data
because testing did not take into account covariances associated with repeated observations from
the longitudinal samples. Estimates of covariances were not available.

Complete details on testing between NSDUH and MTF can be found in Section B.2.3 in Appendix
B of the 2010 national findings report (CBHSQ, 2011). This discussion also includes variance
estimation in the MTF data for testing between adjacent survey years.
B.3 Other Information on Data Accuracy
The accuracy of survey estimates can be affected by nonresponse, coding errors, computer
processing errors, errors in the sampling frame, reporting errors, and other errors not due to
sampling. These types of “nonsampling errors” and their impact are reduced through data editing,
statistical adjustments for nonresponse, close monitoring and periodic retraining of interviewers,
and improvement in quality control procedures.

Although these types of errors often can be much larger than sampling errors, measurement of
most of these errors is difficult. However, some indication of the effects of some types of these
errors can be obtained through proxy measures, such as response rates, and from other research
studies.
B.3.1 Screening and Interview Response Rate
Patterns
In 2013, respondents continued to receive a $30 incentive in an effort to maximize response rates.
The weighted screening response rate (SRR) is defined as the weighted number of successfully
screened households13 divided by the weighted number of eligible households (as defined in Table
B.3), or
SR R =Σ w hhc omple t e hhΣ w hhe ligible hh,

where whh is the inverse of the unconditional probability of selection for the household and
excludes all adjustments for nonresponse and poststratification defined in Section A.3.3 of
Appendix A. Of the 190,067 eligible households sampled for the 2013 NSDUH, 160,325 were
screened successfully, for a weighted screening response rate of 83.9 percent (Table B.3). At the
person level, the weighted interview response rate (IRR) is defined as the weighted number of
respondents divided by the weighted number of selected persons (see Table B.4), or
I R R =Σ w ic omple t e iΣ w is e le c t e di,

where w i is the inverse of the probability of selection for the person and includes household-
level nonresponse and poststratification adjustments (adjustments 1, 2, and 3 in Section A.3.3 of
Appendix A). To be considered a completed interview, a respondent must provide enough data to
pass the usable case rule.14 In the 160,325 screened households, a total of 88,742 sample persons
were selected, and completed interviews were obtained from 67,838 of these sample persons, for a
weighted IRR of 71.7 percent (Table B.4). A total of 15,717 sample persons (20.9 percent) were
classified as refusals or parental refusals, 2,622 (3.0 percent) were not available or never at home,
and 2,565 (4.4 percent) did not participate for various other reasons, such as physical or mental
incompetence or language barrier (see Table B.4, which also shows the distribution of the selected
sample by interview code and age group). Among demographic subgroups, the weighted IRR was
higher among 12 to 17 year olds (82.0 percent), females (73.3 percent), blacks (78.8 percent),
persons in the South (73.3 percent), and residents of small metropolitan areas (73.4 percent) than
among other related groups (Table B.5).

The overall weighted response rate, defined as the product of the weighted screening response
rate and weighted interview response rate or
ORR=SRR×IRR

was 60.2 percent in 2013s. Nonresponse bias can be expressed as the product of the nonresponse
rate (1 – R) and the difference between the characteristic of interest between respondents and
nonrespondents in the population (Pr – Pnr). By maximizing NSDUH response rates, it is hoped
that the bias due to the difference between the estimates from respondents and nonrespondents is
minimized. Drug use surveys are particularly vulnerable to nonresponse because of the difficult
nature of accessing heavy drug users. However, in a study that matched 1990 census data to 1990
NHSDA nonrespondents,15 it was found that populations with low response rates did not always
have high drug use rates. For example, although some populations were found to have low
response rates and high drug use rates (e.g., residents of large metropolitan areas and males),
other populations had low response rates and low drug use rates (e.g., older adults and high-income
populations). Therefore, many of the potential sources of bias tend to cancel each other in
estimates of overall prevalence (Gfroerer, Lessler, & Parsley, 1997a).
B.3.2 Inconsistent Responses and Item
Nonresponse
Among survey participants, item response rates were generally very high for most drug use items.
However, respondents could give inconclusive or inconsistent information about whether they ever
used a given drug (i.e., “yes” or “no”) and, if they had used a drug, when they last used it; the
latter information is needed to identify those lifetime users of a drug who used it in the past year or
past month. In addition, respondents could give inconsistent responses to items such as when they
first used a drug compared with their most recent use of a drug. These missing or inconsistent
responses first are resolved where possible through a logical editing process. Additionally, missing
or inconsistent responses are imputed using statistical methodology. These imputation procedures in
NSDUH are based on responses to multiple questions, so that the maximum amount of information
is used in determining whether a respondent is classified as a user or nonuser, and if the respondent
is classified as a user, whether the respondent is classified as having used in the past year or the
past month. For example, ambiguous data on the most recent use of cocaine are statistically
imputed based on a respondent’s data for use (or most recent use) of tobacco products, alcohol,
inhalants, marijuana, hallucinogens, and nonmedical use of prescription psychotherapeutic drugs.
Nevertheless, editing and imputation of missing responses are potential sources of measurement
error. For more information on editing and statistical imputation, see Sections A.3.1 and A.3.2 of
Appendix A. Details of the editing and imputation procedures for 2013 also will appear in the 2013
NSDUH Methodological Resource Book, which is in process. Until that volume becomes
available, refer to the 2012 NSDUH Methodological Resource Book (CBHSQ, 2014a).
B.3.3 Data Reliability
A reliability study was conducted as part of the 2006 NSDUH to assess the reliability of responses
to the NSDUH questionnaire. An interview/reinterview method was employed in which 3,136
individuals were interviewed on two occasions during 2006 generally 5 to 15 days apart; the initial
interviews in the reliability study were a subset of the main study interviews. The reliability of the
responses was assessed by comparing the responses of the first interview with the responses from
the reinterview. Responses from the first interview and reinterview that were analyzed for
response consistency were raw data that had been only minimally edited for ease of analysis and
had not been imputed (see Sections A.3.1 and A.3.2 in this report).

This section summarizes the results for the reliability of selected variables related to substance use
and demographic characteristics. Reliability is expressed by estimates of Cohen’s kappa (κ)
(Cohen, 1960), which can be interpreted according to benchmarks proposed by Landis and Koch
(1977, p. 165): (a) poor agreement for kappas less than 0.00, (b) slight agreement for kappas of
0.00 to 0.20, (c) fair agreement for kappas of 0.21 to 0.40, (d) moderate agreement for kappas of
0.41 to 0.60, (e) substantial agreement for kappas of 0.61 to 0.80, and (f) almost perfect
agreement for kappas of 0.81 to 1.00.

The kappa values for the lifetime and past year substance use variables (marijuana use, alcohol
use, and cigarette use) all showed almost perfect response consistency, ranging from 0.82 for past
year marijuana use to 0.93 for lifetime marijuana use and past year cigarette use. The value
obtained for the substance dependence or abuse measure in the past year showed substantial
agreement (0.67), while the substance abuse treatment variable showed almost perfect consistency
in both the lifetime (0.89) and past year (0.87). The variables for age at first use of marijuana and
perceived great risk of smoking marijuana once a month showed substantial agreement (0.74 and
0.68, respectively). The demographic variables showed almost perfect agreement, ranging from
0.95 for current enrollment in school to 1.00 for gender. For further information on the reliability of
a wide range of measures contained in NSDUH, see the complete methodology report (Chromy et
al., 2010).
B.3.4 Validity of Self-Reported Substance Use
Most substance use prevalence estimates, including those produced for NSDUH, are based on
self-reports of use. Although studies generally have supported the validity of self-report data, it is
well documented that these data may be biased (underreported or overreported). The bias varies
by several factors, including the mode of administration, the setting, the population under
investigation, and the type of drug (Aquilino, 1994; Brener et al., 2006; Harrison & Hughes, 1997;
Tourangeau & Smith, 1996; Turner, Lessler, & Gfroerer, 1992). NSDUH utilizes widely accepted
methodological practices for increasing the accuracy of self-reports, such as encouraging privacy
through audio computer-assisted self-interviewing (ACASI) and providing assurances that
individual responses will remain confidential. Comparisons using these methods within NSDUH
have shown that they reduce reporting bias (Gfroerer, Eyerman, & Chromy, 2002). Various
procedures have been used to validate self-report data, such as biological specimens (e.g., urine,
hair, saliva), proxy reports (e.g., family member, peer), and repeated measures (e.g., recanting)
(Fendrich, Johnson, Sudman, Wislar, & Spiehler, 1999). However, these procedures often are
impractical or too costly for general population epidemiological studies (SRNT Subcommittee on
Biochemical Verification, 2002).

A study cosponsored by the Substance Abuse and Mental Health Services Administration
(SAMHSA) and the National Institute on Drug Abuse (NIDA) examined the validity of NSDUH
self-report data on drug use among persons aged 12 to 25. The study found that it is possible to
collect urine and hair specimens with a relatively high response rate in a general population survey,
and that most youths and young adults reported their recent drug use accurately in self-reports
(Harrison, Martin, Enev, & Harrington, 2007). However, there were some reporting differences in
either direction, with some respondents not reporting use but testing positive, and some reporting
use but testing negative. Technical and statistical problems related to the hair tests precluded
presenting comparisons of self-reports and hair test results, while small sample sizes for self-
reports and positive urine test results for opiates and stimulants precluded drawing conclusions
about the validity of self-reports of these drugs. Further, inexactness in the window of detection for
drugs in biological specimens and biological factors affecting the window of detection could
account for some inconsistency between self-reports and urine test results.
B.3.5 Revised Estimates for 2006 to 2010
During regular data collection and processing checks for the 2011 NSDUH, data errors were
identified. These errors resulted from fraudulent cases submitted by field interviewers and affected
the data for Pennsylvania (2006 to 2010) and Maryland (2008 and 2009). Although all fraudulent
interview cases were removed from the data files, the affected screening cases were not removed
because they were part of the assigned sample. Instead, these screening cases were assigned a
final screening code of 39 (“Fraudulent Case”) and treated as incomplete with unknown eligibility.
The screening eligibility status for these cases then was imputed. Those cases that were imputed
to be eligible were treated as unit nonrespondents for weighting purposes; however, these cases
were not treated differently from other unit nonrespondents in the weighting process in 2006 to
2010 (see Section A.3.3 in Appendix A).

Table B.3 in Appendix B of the 2011 national findings report (CBHSQ, 2012b) presents screening
results for 2010, the last year that was affected by these errors. Cases that were imputed to be
eligible are classified with a final code of 39 (“Fraudulent Case”; see Table B.3 in this report). The
cases that were imputed to be ineligible did not contribute to the weights and were reported as
“Other, Ineligible” in the affected years. Because any cases with falsified data were treated either
as ineligible or as unit nonrespondents at the screening level, they were excluded from the
interview data (see Table B.4). However, some estimates for 2006 to 2010 in the 2013 national
findings report and the 2013 detailed tables, as well as other new reports, may differ from
corresponding estimates found in some previous reports or tables.

These errors had minimal impact on the national estimates and no effect on direct estimates for the
other 48 states and the District of Columbia. In reports where model-based small area estimation
techniques are used, estimates for all states may be affected, even though the errors were
concentrated in only two states. In reports that do not use model-based estimates, the only
estimates appreciably affected are estimates for Pennsylvania, Maryland, the mid-Atlantic division,
and the Northeast region.

The 2013 national findings report and detailed tables do not include state-level or model-based
estimates. However, they do include estimates for the mid-Atlantic division and the Northeast
region. Single-year estimates based on 2006 to 2010 data and estimates based on pooled data
including any of these years may differ from previously published estimates. Tables and estimates
based only on data since 2011 are unaffected by these data errors.

Caution is advised when comparing data from older reports with data from more recent reports
that are based on corrected data files. As discussed previously, comparisons of estimates for
Pennsylvania, Maryland, the mid-Atlantic division, and the Northeast region are of most concern,
while comparisons of national data or data for other states and regions are essentially still valid.
CBHSQ within SAMHSA has produced a selected set of corrected versions of reports and tables.
In particular, CBHSQ has released a set of modified detailed tables that include revised 2006 to
2010 estimates for the mid-Atlantic division and the Northeast region for certain key measures.
CBHSQ does not recommend making comparisons between unrevised 2006 to 2010 estimates and
estimates based on data for 2011 and subsequent years for the geographic areas of greatest
concern.
B.4 Measurement Issues
B.4.1 Incidence
In epidemiological studies, incidence is defined as the number of new cases of a disease occurring
within a specific period of time. Similarly, in substance use studies, incidence refers to the first use
of a particular substance.

In the 2004 NSDUH national findings report (Office of Applied Studies [OAS], 2005), a new
measure related to incidence was introduced and since then has become the primary focus of
Chapter 5 in this national findings report series. The incidence measure is termed as “past year
initiation” and refers to respondents whose date of first use of a substance was within the 12
months prior to their interview date. This measure is determined by self-reported past year use,
age at first use, year and month of recent new use, and the interview date.

Since 1999, the survey questionnaire has allowed for collection of year and month of first use for
recent initiates (i.e., persons who used a particular substance for the first time in a given survey
year). Month, day, and year of birth also are obtained directly or are imputed for item
nonrespondents as part of the data postprocessing. Additionally, the computer-assisted interviewing
(CAI) instrument records and provides the date of the interview. By imputing a day of first use
within the year and month of first use, a specific date of first use can be used for estimation
purposes.

Past year initiation among persons using a substance in the past year can be viewed as an indicator
variable defined as follows:

I(Past Year Initiate) if [(MM/DD/YYYY)Interview – (MM/DD/YYYY)First Use of Substance ]

≤ 365,

where (MM/DD/YYYY)Interview denotes the month, day, and year of the interview, and
(MM/DD/YYYY)First Use of Substance denotes the date of first use. The total number of past
year initiates can be used in the estimation of different percentages. Denominators for these
percentages vary according to whether rates are being estimated for (a) all persons in the
population (or all persons in a subgroup of the population, such as persons in a given age group);
(b) persons who are at risk for initiation because they have not used the substance of interest prior
to the past 12 months; or (c) past year users of the substance. The detailed tables show all three of
these percentages. Chapter 5 in this report includes additional information on these percentages
that are reported for NSDUH.

Calculation of estimates of past year initiation do not take into account whether a respondent
initiated substance use while a resident of the United States. This method of calculation allows for
direct comparability with other standard measures of substance use because the populations of
interest for the measures will be the same (i.e., both measures examine all possible respondents
and are not restricted to those initiating substance use only in the United States).

One important note for incidence estimates is the relationship between main categories and
subcategories of substances (e.g., illicit drugs would be a main category, and inhalants and
marijuana would be subcategories in relation to illicit drugs). For most measures of substance use,
any member of a subcategory is by necessity a member of the main category (e.g., if a respondent
is a past month user of a particular drug, then he or she is also a past month user of illicit drugs in
general). However, this is not the case with regard to incidence statistics. Because an individual
can only be an initiate of a particular substance category (main or sub) a single time, a respondent
with lifetime use of multiple substances may not, by necessity, be included as a past year initiate of
a main category, even if he or she were a past year initiate for a particular subcategory because
his or her first initiation of other substances within the main category could have occurred earlier.

In addition to estimates of the number of persons initiating use of a substance in the past year,
estimates of the mean age of past year initiates of these substances are computed. Unless
specified otherwise, estimates of the mean age at initiation in the past 12 months have been
restricted to persons aged 12 to 49 so that the mean age estimates reported are not influenced by
those few respondents who were past year initiates and were aged 50 or older. As a measure of
central tendency, means are influenced heavily by the presence of extreme values in the data, and
this constraint should increase the utility of these results to health researchers and analysts by
providing a better picture of the substance use initiation behaviors among the civilian,
noninstitutionalized population in the United States. This constraint was applied only to estimates of
mean age at first use and does not affect estimates of the numbers of new users or the incidence
rates.

Although past year initiates aged 26 to 49 are assumed not to be as likely as past year initiates
aged 50 or older to influence mean ages at first use, caution still is advised in interpreting trends in
these means. Sampling error in initiation estimates for persons aged 26 to 49 can affect year-to-
year interpretation of trends (see Section B.2). Consequently, review of substance initiation trends
across a larger range of years is especially advised for this age group.

For example, the estimated number of persons aged 26 to 49 who were past year initiates of
marijuana increased from 49,000 in 2009 to 210,000 in 2010, or an apparent fourfold increase in the
space of a single year (Table B.6). The estimated number of past year marijuana initiates aged 26
to 49 in 2010 was not significantly different from the numbers in 2011 to 2013. Except for 2009, the
estimated numbers of past year marijuana initiates in this age group since 2004 were not
significantly different from the number in 2013.

In addition, the mean age at first use of marijuana among past year marijuana initiates aged 26 to
49 was higher in 2010 than in 2013, but the means in 2011 and 2012 were not significantly different
from the mean in 2013 (Table B.7). Since 2002, only the mean age at first use of marijuana in 2010
(36.3 years) was significantly different from the mean in 2013 (31.2 years) for past year marijuana
initiates in this age group. The mean age at first use for any illicit drug among past year initiates
aged 26 to 49 in 2013 (35.4 years) was greater than the means in 2004 and 2009 (31.6 and 31.7
years, respectively), but it was not significantly different from the means in other years. Again,
these findings indicate the importance of examining substance initiation trends across a larger
range of years for this age group. Except for the differences that were indicated, trends in the
mean age at initiation for marijuana and any illicit drug among initiates aged 26 to 49 have been
fairly stable since 2002.

Similarly, the mean age at first use of inhalants among past year initiates aged 12 to 49 was higher
in 2013 than in 2012 (19.2 vs. 16.9 years) (see Chapter 5). In comparison, the median ages at first
use for inhalants, which are less susceptible to the influence of extreme values, were 18 years for
past year initiates aged 12 to 49 in 2013 and 16 years for those in 2012. Thus, the higher mean in
2013 could be explained by the effect of extreme values on the age at first use in 2013. This
finding also underscores the importance of reviewing mean ages at first use across a larger range
of years. Anomalous 1-year shifts in the mean age at first use typically “correct” themselves with
1 or 2 additional years of data.

Because NSDUH is a survey of persons aged 12 years old or older at the time of the interview,
younger individuals in the sample dwelling units are not eligible for selection into the NSDUH
sample. Some of these younger persons may have initiated substance use during the past year. As
a result, past year initiate estimates suffer from undercoverage if a reader assumes that these
estimates reflect all initial users instead of reflecting only those above the age of 11. For earlier
years, data can be obtained retrospectively based on the age at and date of first use. As an
example, persons who were 12 years old on the date of their interview in the 2013 survey may
report having initiated use of cigarettes between 1 and 2 years ago; these persons would have been
past year initiates reported in the 2012 survey had persons who were 11 years old on the date of
the 2012 interview been allowed to participate in the survey. Similarly, estimates of past year use
by younger persons (age 10 or younger) can be derived from the current survey, but they apply to
initiation in prior years and not the survey year.

To get an impression of the potential undercoverage in the current year, reports of substance use
initiation reported by persons aged 12 or older were estimated for the years in which these persons
would have been 1 to 11 years younger. These estimates do not necessarily reflect behavior by
persons 1 to 11 years younger in the current survey. Instead, the data for the 11 year olds reflect
initiation in the year prior to the current survey, the data for the 10 year olds reflect behavior
between the 12th and 23rd months prior to this year’s survey, and so on. A very rough way to
adjust for the difference in the years that the estimate pertains to without considering changes in
the population is to apply an adjustment factor to each age-based estimate of past year initiates.
This adjustment factor can be based on a ratio of lifetime users aged 12 to 17 in the current survey
year to the same estimate for the prior applicable survey year. To illustrate the calculation, consider
past year use of alcohol. In the 2013 survey, 101,441 persons who were 12 years old were
estimated to have initiated use of alcohol between 1 and 2 years earlier. These persons would have
been past year initiates in the 2012 survey conducted on the same dates had the 2012 survey
covered younger persons. The estimated number of lifetime users currently aged 12 to 17 was
7,669,220 for 2013 and 8,067,487 for 2012, indicating fewer overall initiates of alcohol use among
persons aged 17 or younger in 2013. Thus, an adjusted estimate of initiation of alcohol use by
persons who were 11 years old in 2013 is given by
( E s t ima t e dP a s t Y e a r I nit a t e s A ge d11) 2012×( E s t ima t e dL if e t im
e U s e r s A ge d12t o17) 2013( E s t ima t e dL if e t ime U s e r s A ge d12t o17
)2012

This yielded an adjusted estimate of 96,433 persons 11 years old on a 2013 survey date and
initiating use of alcohol in the past year:
101,441×7,669,2208,067,487=96,433.

A similar procedure was used to adjust the estimated number of past year initiates among persons
who would have been 10 years old on the date of the interview in 2011 and for younger persons in
earlier years. The overall adjusted estimate for past year initiates of alcohol use by persons 11
years of age or younger on the date of the interview was 161,183, or about 3.5 percent of the
estimate based on past year initiation only by persons aged 12 or older (161,183 ÷ 4,558,527 =
0.0354). Based on similar analyses, the estimated undercoverage of past year initiates was 2.3
percent for cigarettes, 1.1 percent for marijuana, and 13.4 percent for inhalants.

The undercoverage of past year initiates aged 11 or younger also affects the mean age at first use
estimate. An adjusted estimate of the mean age at first use was calculated using a weighted
estimate of the mean age at first use based on the current survey and the numbers of persons aged
11 or younger in the past year obtained in the aforementioned analysis for estimating
undercoverage of past year initiates. Analysis results showed that the mean age at first use was
changed from 17.3 to 17.0 for alcohol, from 17.8 to 17.6 for cigarettes, from 18.0 to 17.9 for
marijuana, and from 19.2 to 17.7 for inhalants. The decreases reported above are comparable with
results generated in prior survey years.
B.4.2 Illicit Drug and Alcohol Dependence and
Abuse
The 2013 NSDUH CAI instrumentation included questions that were designed to measure alcohol
and illicit drug dependence and abuse. For these substances,16 dependence and abuse questions
were based on the criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th
edition (DSM-IV) (American Psychiatric Association [APA], 1994). Specifically, for marijuana,
hallucinogens, inhalants, and tranquilizers, a respondent was defined as having dependence if he or
she met three or more of the following six dependence criteria:

1. Spent a great deal of time over a period of a month getting, using, or getting over the effects
of the substance.
2. Used the substance more often than intended or was unable to keep set limits on the
substance use.
3. Needed to use the substance more than before to get desired effects or noticed that the
same amount of substance use had less effect than before.
4. Inability to cut down or stop using the substance every time tried or wanted to.
5. Continued to use the substance even though it was causing problems with emotions, nerves,
mental health, or physical problems.
6. The substance use reduced or eliminated involvement or participation in important activities.

For alcohol, cocaine, heroin, pain relievers, sedatives, and stimulants, a seventh withdrawal criterion
was added. The seventh withdrawal criterion is defined by a respondent reporting having
experienced a certain number of withdrawal symptoms that vary by substance (e.g., having trouble
sleeping, cramps, hands tremble). A respondent was defined as having dependence if he or she
met three or more of seven dependence criteria for these substances.

For each illicit drug and alcohol, a respondent was defined as having abused that substance if he or
she met one or more of the following four abuse criteria and was determined not to be dependent
on the respective substance in the past year:

1. Serious problems at home, work, or school caused by the substance, such as neglecting your
children, missing work or school, doing a poor job at work or school, or losing a job or
dropping out of school.
2. Used the substance regularly and then did something that might have put you in physical
danger.
3. Use of the substance caused you to do things that repeatedly got you in trouble with the law.
4. Had problems with family or friends that were probably caused by using the substance and
continued to use the substance even though you thought the substance use caused these
problems.

Criteria used to determine whether a respondent was asked about the dependence and abuse
questions during the interview included the core substance use questions, the frequency of
substance use questions (for alcohol and marijuana only), and the noncore substance use questions
(for cocaine, heroin, and stimulants, including methamphetamine). Missing or incomplete responses
in the core substance use and frequency of substance use questions were imputed. However, the
imputation process did not take into account reported data in the noncore (i.e., substance
dependence and abuse) CAI modules because of the complexity of doing this and to avoid
disrupting trends for imputed variables as a result of any changes to the noncore questions. Very
infrequently, this may result in responses to the dependence and abuse questions that are
inconsistent with the imputed substance use or frequency of substance use.

For alcohol and marijuana, respondents were asked the dependence and abuse questions if they
reported substance use on more than 5 days in the past year or if they reported any substance use
in the past year but did not report their frequency of past year use (i.e., they had missing frequency
data). These missing frequency data were subsequently imputed after data collection processing.
Therefore, inconsistencies could have occurred where the imputed frequency of use response
indicated less frequent use than required for respondents to be asked the dependence and abuse
questions originally (i.e., the imputed frequency value was 5 or fewer days). For alcohol, for
example, about 40,000 respondents were past year alcohol users in 2013. Of these, fewer than 100
respondents were missing their frequency data, but were still asked the alcohol dependence and
abuse questions; however, their final imputed frequency of use indicated that they used alcohol on
5 or fewer days in the past year.

For cocaine, heroin, and stimulants, respondents were asked the dependence and abuse questions if
they reported past year use in a core drug module or past year use in the noncore special drugs
module. Thus, the CAI logic allowed some respondents to be asked the dependence and abuse
questions for these drugs even if they did not report past year use in the corresponding core
module. For cocaine, for example, fewer than 1,400 respondents in 2013 were asked the questions
about cocaine dependence and abuse because they reported past year use of cocaine or crack in
the core section of the interview. Fewer than 10 additional respondents were asked these questions
because they reported past year use of cocaine with a needle in the special drugs module despite
not having previously reported past year use of cocaine or crack.

In 2005, two new questions were added to the noncore special drugs module about past year
methamphetamine use: “Have you ever, even once, used methamphetamine?” and “Have you ever,
even once, used a needle to inject methamphetamine?” In 2006, an additional follow-up question
was added to the noncore special drugs module confirming prior responses about
methamphetamine use: “Earlier, the computer recorded that you have never used
methamphetamine. Which answer is correct?” The responses to these new questions were used in
the skip logic for the stimulant dependence and abuse questions. Based on the decisions made
during the methamphetamine analysis,17 respondents who indicated past year methamphetamine
use solely from these new special drug use questions (i.e., did not indicate methamphetamine use
from the core drug module or other questions in the special drugs module) were categorized as
NOT having past year stimulant dependence or abuse regardless of how they answered the
dependence and abuse questions. Furthermore, if these same respondents were categorized as not
having past year dependence or abuse of any other psychotherapeutic drug (e.g., pain relievers,
tranquilizers, or sedatives), then they were categorized as NOT having past year dependence or
abuse of psychotherapeutics. Also, if these respondents were not classified as having dependence
or abuse for other substances (e.g., alcohol, marijuana, other illicit drugs), then they were
categorized as not having dependence or abuse for illicit drugs, illicit drugs or alcohol, or illicit drugs
and alcohol.

In 2008, questionnaire logic for determining hallucinogen, stimulant, and sedative dependence or
abuse was modified. The revised skip logic used information collected in the noncore special drugs
module in addition to that collected in questions from the core drug modules. Respondents were
asked about hallucinogen dependence and abuse if they additionally reported in the special drugs
module using ketamine, dimethyltryptamine (DMT), alpha-methyltryptamine (AMT), Foxy, or
Salvia divinorum; stimulant dependence and abuse if they additionally reported nonmedical use of
Adderall®; and sedative dependence and abuse if they additionally reported nonmedical use of
Ambien.® Complying with the previous decision to exclude respondents whose methamphetamine
use was based solely on responses to noncore questions from being classified as having stimulant
dependence or abuse, respondents who indicated past year use or nonmedical use of hallucinogens,
stimulants, or sedatives based solely on these special drug questions were categorized as NOT
having past year dependence or abuse of the relevant substance regardless of how they answered
the dependence and abuse questions.

Respondents might have provided ambiguous information about past year use of any individual
substance, in which case these respondents were not asked the dependence and abuse questions
for that substance. Subsequently, these respondents could have been imputed to be past year users
of the respective substance. In this situation, the dependence and abuse data were unknown; thus,
these respondents were classified as not having dependence or abuse of the respective substance.
However, such a respondent never actually was asked the dependence and abuse questions.
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on
Drug Use and Health, 2013.

1 Combinations of the age groups (including but not limited to 12 or older, 18 or older, 26 or
older, 35 or older, and 50 or older) also were forced to match their respective U.S. Census
Bureau population estimates through the weight calibration process.

2 Unlike racial and ethnic groups discussed elsewhere in this report, race domains in this table
include Hispanics in addition to persons who were not Hispanic.
 Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on
Drug Use and Health, 2013.
deff = design effect; RSE = relative standard error; SE = standard error.

Figure B.1 Required Effective Sample in the 2013 NSDUH as a Function of the Proportion
Estimated
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on
Drug Use and Health, 2012 and 2013.

1 Examples of “Other, Ineligible” cases are those in which all residents lived in the dwelling
unit for less than half of the calendar quarter and dwelling units that were listed in error.
2 “Other, Access Denied” includes all dwelling units to which the field interviewer was denied
access, including locked or guarded buildings, gated communities, and other controlled access
situations.
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on
Drug Use and Health, 2012 and 2013.

1 “Other” includes eligible person moved, data not received from field, too dangerous to
interview, access to building denied, computer problem, and interviewed wrong household
member.
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on
Drug Use and Health, 2012 and 2013.
Note: Estimates are based on demographic information obtained from screener data and are
not consistent with estimates on demographic characteristics presented in the 2012 and 2013
sets of detailed tables.
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on
Drug Use and Health, 2002-2013.
* Low precision; no estimate reported.

a Difference between estimate and 2013 estimate is statistically significant at the .05 level.

b Difference between estimate and 2013 estimate is statistically significant at the .01 level.

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on
Drug Use and Health, 2002-2013.
* Low precision; no estimate reported.

a Difference between estimate and 2013 estimate is statistically significant at the .05 level.
b
Difference between estimate and 2013 estimate is statistically significant at the .01 level.
Appendix C: Other Sources of Data
There are sources of substance use data other than the National Survey on Drug Use and Health
(NSDUH). It is useful to consider the results of these other studies when discussing NSDUH data
because no single source of data can fully cover all issues associated with substance use in the
United States. Each data source can contribute to a broader understanding of substance use and
the relationships of substance use to other issues of interest. This appendix briefly describes
several of these other data systems and presents selected comparisons with NSDUH results. In
addition, this appendix describes other sources of data specifically for receipt of substance abuse
treatment services. Populations covered by other sources of data for substance abuse treatment
may overlap with the population covered by NSDUH but also may include populations not covered
by NSDUH (e.g., persons receiving treatment in facilities as an inpatient or resident for an
extended period, persons entering treatment as an inpatient after having been incarcerated). Some
of the surveys on substance use included in this appendix also include populations not covered by
NSDUH.

When evaluating the information presented here, it is important to consider and understand the
methodological differences between the different surveys and the impact that these differences
could have on estimates of the presence of substance use. Several studies have compared
NSDUH estimates with estimates from other studies and have evaluated how differences may
have been affected by differences in survey methodology (Batts et al., 2014; Center for Behavioral
Health Statistics and Quality [CBHSQ], 2012a; Gfroerer, Wright, & Kopstein, 1997b; Grucza,
Abbacchi, Przybeck, & Gfroerer, 2007; Hennessy & Ginsberg, 2001; Miller et al., 2004;
Pemberton et al., 2013). These comparisons suggest that the goals and approaches of surveys are
often different, making comparisons between them difficult. Some methodological differences that
have been identified as affecting comparisons include populations covered, sampling methods,
modes of data collection, questionnaires, and estimation methods.
C.1 Other National Surveys of Substance Use
Behavioral Risk Factor Surveillance System
(BRFSS)
The Behavioral Risk Factor Surveillance System (BRFSS)—a state-based system of health
surveys—collects information on health risk behaviors, preventive health practices, and health care
access primarily related to chronic disease and injury. The BRFSS surveys are cross-sectional
telephone surveys conducted by state health departments with technical and methodological
assistance from the Centers for Disease Control and Prevention (CDC). Every year, states
conduct monthly telephone surveys of adults (aged 18 or older) in households using random-digit-
dialing (RDD) methods; unlike NSDUH, BRFSS excludes persons living in group quarters (e.g.,
dormitories).

Currently, the questionnaire has three parts: (1) a core questionnaire, (2) optional modules, and (3)
state-added questions. The core questionnaire consists of a standard set of questions asked by all
states every year and includes questions on demographic characteristics, alcohol use, and tobacco
use. Questions about lifetime depression have been included in the core since 2011. Optional
modules consist of questions on specific topics that states can elect to include. Although the
modules are optional, CDC standards require that states use them without modification. Optional
modules include mental health topics, such as anxiety, depression, or psychological distress.
However, the number of states administering optional modules can vary from year to year, and the
content of these modules can vary over time. For example, 12 states and Puerto Rico administered
the anxiety and depression module in 2010, but only 2 states did so in 2011. States also may include
state-added questions at their own expense. However, these questions are not part of the official
BRFSS questionnaire. Development of these questions and analysis of data from them are not
supported by the CDC.

Since 1994, BRFSS has collected data from all 50 states, the District of Columbia, Puerto Rico,
and the U.S. Virgin Islands using a computer-assisted telephone interviewing (CATI) design. More
than 400,000 adults are interviewed each year. Prior to 2011, the sample included only households
with landline telephones, and the weighting methodology included a poststratification step.
Beginning with the 2011 BRFSS, the sample was expanded to include households with only cellular
telephones in addition to those that were covered by landline phones, and the weighting
methodology replaced the poststratification step with ranking in order to incorporate more
demographic variables (e.g., education level, home ownership) as well as telephone source
(landline or cellular telephone). These changes were recognized as having the potential to produce
shifts in prevalence estimates in 2011 and subsequent years relative to estimates in prior years that
were based on the previous methodology (CDC, 2012). The CDC has since concluded that the
BRFSS 2011 prevalence data should be considered a baseline year because of these
methodological changes.

National estimates obtained through the BRFSS online analysis tool or in publications that cite
BRFSS data typically are presented as medians.18 BRFSS includes questions on alcohol
consumption and tobacco use. However, definitions of binge alcohol use and current cigarette use
differ between NSDUH and BRFSS. Since 2006, BRFSS has used a lower threshold for binge
alcohol use for females (four or more drinks on an occasion) than for males (five or more drinks on
an occasion), whereas NSDUH uses the same criterion for males and females (i.e., consumption
of five or more drinks on an occasion). Current cigarette users in BRFSS are defined as adults
who have smoked 100 or more cigarettes in their lifetime and who report that they currently smoke
cigarettes. In NSDUH, current cigarette use is defined as any cigarette use in the 30 days prior to
the interview.

These differences in definitions and methodological differences can affect the comparability of
estimates between BRFSS and NSDUH. For example, the prevalence of current cigarette use
among adults in NSDUH in 2012 was 23.8 percent, and the median BRFSS prevalence for the 50
states and the District of Columbia was 19.6 percent. Although BRFSS data are presented as
medians and NSDUH estimates are not, BRFSS rates of binge drinking were somewhat lower
than the NSDUH estimates among adults aged 18 or older in 2012, despite the lower threshold for
women (e.g., for females: 11.4 percent for BRFSS and 16.8 percent for NSDUH). The use of
audio computer-assisted self-interviewing (ACASI) in NSDUH, which is considered to be more
anonymous than CATI in BRFSS and yields higher reporting of sensitive behaviors, may explain
lower binge alcohol use rates in combined 1999 and 2000 BRFSS data than in corresponding
NSDUH data (Miller et al., 2004).19 Response rates also have been higher in NSDUH than
BRFSS, which could result in differential nonresponse bias patterns in the two surveys.

For further details, see the CDC Web site at [Link]

Monitoring the Future (MTF)
The Monitoring the Future (MTF) study is an ongoing study of substance use trends and related
attitudes among America’s secondary school students, college students, and adults through age 50.
The MTF provides information on the use of alcohol, illicit drugs, and tobacco. The study is
conducted annually by the Institute for Social Research at the University of Michigan through
grants awarded by the National Institute on Drug Abuse (NIDA). The MTF and NSDUH are the
federal government’s largest and primary tools for tracking youth substance use. The MTF is
composed of three substudies: (a) an annual survey of high school seniors that was initiated in
1975; (b) ongoing panel studies of representative samples from each graduating class (i.e., 12th
graders) that have been conducted by mail since 1976; and (c) annual surveys of 8th and 10th
graders that were initiated in 1991. Each spring, students in the 8th, 10th, and 12th grades complete
a self-administered, machine-readable questionnaire during a regular class period. Approximately
50,000 students in about 420 public and private secondary schools are surveyed annually for the
cross-sectional study, and approximately 2,400 persons who participated in the survey of 12th
graders are followed longitudinally. The latest MTF was conducted in 2013.

Comparisons between the MTF estimates and estimates based on students sampled in NSDUH
generally have shown NSDUH substance use prevalence levels to be lower than MTF estimates
(see Table C.1 at the end of this appendix and CBHSQ, 2012a).20 The lower prevalences in
NSDUH may be due to more underreporting in the household setting as compared with the MTF
school setting and some overreporting in the school settings. However, findings presented in
Chapter 8 of this report generally show parallel trends in the prevalence of substance use in
NSDUH and MTF for both the annual cross-sectional data for youths and the longitudinal data for
young adults.

The population of inference for the MTF school-based data collection is adolescents who were in
the 8th, 10th, and 12th grades; therefore, the MTF does not survey dropouts. The MTF also does
not include students who were absent from school on the day of the survey, although they are part
of the population of inference. NSDUH has shown that dropouts and adolescents who frequently
were absent from school have higher rates of illicit drug use (CBHSQ, 2012a; Gfroerer et al.,
1997b). In October 2012, the percentages of persons who were not currently enrolled in school and
had not graduated from high school were 1.7 percent for adolescents aged 14 or 15, 2.9 percent
for those aged 16 or 17, 7.1 percent for persons aged 18 or 19, and 6.6 percent for those aged 20
or 21.21 Depending on the effects of the exclusion of dropouts and frequent absentees, data from
MTF may not generalize to the population of adolescents as a whole, especially for older
adolescents.

For further details, see the MTF Web site at [Link]

National Comorbidity Survey (NCS)
The National Comorbidity Survey (NCS) was sponsored by the National Institute of Mental Health
(NIMH), NIDA, and the W. T. Grant Foundation. It was designed to measure in the general
population the prevalence of the illnesses described in the Diagnostic and Statistical Manual of
Mental Disorders, 3rd edition revised (DSM-III-R) (American Psychiatric Association [APA],
1987). The first wave of the NCS, conducted from 1990 to 1992, was a household survey of
persons in the continental United States (i.e., excluding Alaska and Hawaii) that collected data
from 8,098 respondents aged 15 to 54 in a face-to-face interview using paper-and-pencil
interviewing (PAPI). These responses were weighted to produce nationally representative
estimates. A random sample of 4,414 respondents also was administered an additional module that
captured information on nicotine dependence. The interviews took place between 1990 and 1992.
The NCS used a modified version of the Composite International Diagnostic Interview (the
University of Michigan-CIDI) to generate DSM-III-R diagnoses.

There have been several follow-ups to and replications of the original NCS, including a 10-year
follow-up of the baseline sample (NCS-2), a replication study conducted in 2001 to 2003 with a
newly recruited nationally representative sample of 9,282 respondents aged 18 or older (NCS-R)
(Kessler et al., 2004) and an adolescent sample of adolescents aged 13 to 17 (NCS-A) in 2001 to
2004 that included 904 adolescents from households that participated in the NCS-R and 9,244
respondents from a nationally representative sample of 320 schools (Kessler et al., 2009). As for
the NCS, the samples for the NCS-2, NCS-R, and NCS-A excluded Alaska and Hawaii.

The NCS provides information on the use of alcohol, illicit drugs, and tobacco and on substance
dependence or abuse. The NCS-R used an updated version of the CIDI that was designed to
capture diagnoses of substance abuse or dependence using DSM-IV criteria (APA, 1994).
Interviews were conducted using computer-assisted personal interviewing (CAPI). It should be
noted that in several NCS-R studies (e.g., Kessler, Chiu, Demler, Merikangas, & Walters, 2005),
the diagnosis for abuse also includes those who meet the diagnosis for dependence. In contrast,
NSDUH follows DSM-IV guidelines and limits the definition of abuse to persons who do not meet
the criteria for dependence. To make the NCS definition of abuse comparable with that of
NSDUH, the rate for dependence must be subtracted from the rate for abuse. Rates of alcohol
dependence or abuse and rates of illicit drug dependence or abuse were generally lower in NCS-R
than in NSDUH (Kessler et al., 2005).

For further details, see the NCS Web site at [Link]

National Health and Nutrition Examination
Survey (NHANES)
The National Health and Nutrition Examination Survey (NHANES) has assessed the health and
nutritional status of children and adults in the United States since the 1960s through the use of both
survey and physical examination components. It is sponsored by the National Center for Health
Statistics (NCHS) and began as a series of periodic surveys in which several years of data were
combined into a single data release. Since 1999, it has been a continuous survey, with interview
data collected each year for approximately 5,000 persons of all ages. The target population for
NHANES is the civilian, noninstitutionalized population from birth onward. Data for 2011-2012 are
the most currently available for public use; 2 years of data are combined to protect respondent
confidentiality.

NHANES interviews are conducted in respondents’ homes. NHANES also collects physical health
measurements and data on sensitive topics through ACASI in mobile examination centers (MECs),
which travel to locations throughout the United States. The NHANES MEC interview includes
questions on alcohol, illicit drug, and tobacco use.

Both NSDUH and NHANES use complex cluster sample designs that affect the precision of
estimates. In addition, the smaller sample sizes for NHANES (i.e., 5,000 per year vs. 67,500 per
year for NSDUH) are likely to yield estimates that are less precise than those in NSDUH. The
sources of nonresponse and coverage bias also differ for the two surveys. For example, NHANES
respondents have to travel to a MEC to respond to the substance use items, which may eliminate
homebound respondents or affect the participation of respondents with limited access to
transportation.

The most recently available substance use estimates from NHANES were based on combined
data from 1999 to 2004 and indicated that 13.0 percent of youths aged 12 to 17 had smoked
cigarettes in the past 30 days, 21.1 percent had used alcohol in the past 30 days, and 10.4 percent
were past month binge alcohol users. An estimated 21.1 percent of youths had ever tried
marijuana, and 2.4 percent had ever used cocaine (Fryar, Merino, Hirsch, & Porter, 2009).
NSDUH estimates for youths aged 12 to 17 in 2002 to 2004 ranged from 11.9 to 13.0 percent for
past month use of cigarettes, from 17.6 to 17.7 percent for past month alcohol use, and from 10.6
to 11.1 percent for past month binge alcohol use. Lifetime use of marijuana in 2002 to 2004 among
youths ranged from 19.0 to 20.6 percent, and lifetime use of cocaine ranged from 2.4 to 2.7
percent.

For further details, see the NHANES Web site at [Link]

National Health Interview Survey (NHIS)
The National Health Interview Survey (NHIS) is a continuous, nationally representative sample
survey that collects data using personal household interviews through CAPI. The survey is
sponsored by the NCHS and provides national estimates of the health status, access to care and
insurance, health service utilization, and health behaviors of the civilian, noninstitutionalized
population, including cigarette smoking and alcohol use among persons aged 18 or older. NHIS data
have been collected since 1957. In 2012, there were three core components of the survey: the
Family Core, which collects information from all family members aged 18 or older in each
household; the Sample Adult Core, which collects information from one adult aged 18 or older in
each family; and the Sample Child Core, which collects information on youths under age 18 from a
knowledgeable family member, usually a parent, in households with a child. In 2012, NHIS sample
sizes were 108,131 persons for the Family Core, 34,525 adults for the Sample Adult Core, and
13,275 children for the Sample Child Core (NCHS, Office of Information Services, 2013).

The NHIS estimates of substance use for adults are not strictly comparable with NSDUH
estimates. For example, in the NHIS, consumption of five or more drinks on at least 1 day is
measured for the past year, whereas the reference period for NSDUH is the past 30 days. As for
BRFSS, adults in the NHIS are defined as current cigarette users if they smoked at least 100
cigarettes in their lifetime and also reported that they currently smoke (Schoenborn, Adams, &
Peregoy, 2013).

For further details, see the NCHS Web site at [Link]

National Longitudinal Alcohol Epidemiologic
Survey (NLAES) and National Epidemiologic
Survey on Alcohol and Related Conditions
(NESARC)
The National Longitudinal Alcohol Epidemiologic Survey (NLAES) was conducted in 1991 and
1992 by the U.S. Bureau of the Census for the National Institute on Alcohol Abuse and
Alcoholism (NIAAA). Face-to-face, interviewer-administered interviews using paper-and-pencil
questionnaires were conducted with 42,862 respondents aged 18 or older in households in the
contiguous United States. Despite the survey name, the design was cross-sectional.

The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) was a
longitudinal study conducted in 2001 and 2002, also by the U.S. Bureau of the Census for NIAAA,
using CAPI. The NESARC sample was designed to make inferences for persons aged 18 or older
in the civilian, noninstitutionalized population of the United States, including Alaska, Hawaii, and the
District of Columbia, and including persons living in noninstitutional group quarters. The first wave
was conducted in 2001 and 2002, with a final sample size of 43,093 respondents aged 18 or older.
The second wave was conducted in 2004 and 2005, in which 34,653 Wave 1 respondents were
reinterviewed (Grant & Dawson, 2006; NIAAA, 2010). A 1-year data collection period for
NESARC-III began in 2012 with a new cohort of approximately 46,500 adults.

NESARC contains assessments of drug use, dependence, and abuse and associated mental
disorders. NESARC included an extensive set of questions, based on DSM-IV criteria (APA,
1994), designed to assess the presence of symptoms of alcohol and drug dependence and abuse in
persons’ lifetimes and during the prior 12 months. In addition, DSM-IV diagnoses of major mental
disorders were generated using the Alcohol Use Disorder and Associated Disabilities Interview
Schedule-version 4 (AUDADIS-IV), which is a structured diagnostic interview that captures major
DSM-IV axis I and axis II disorders.

Research indicates that (a) prevalence estimates for substance use were generally higher in
NSDUH than in NESARC; (b) rates of past year substance use disorder (SUD) for cocaine and
heroin use were higher in NSDUH than in NESARC; (c) rates of past year SUD for use of
alcohol, marijuana, and hallucinogens were similar between NSDUH and NESARC; and (d)
prevalence estimates for past year SUD conditional on past year use were substantially lower in
NSDUH for the use of marijuana, hallucinogens, and cocaine (Grucza et al., 2007). A number of
methodological factors might have contributed to such discrepancies, including privacy and
anonymity. Questions about sensitive topics in NSDUH are self-administered, while similar
questions are interviewer administered in NESARC, which may have resulted in higher use
estimates in NSDUH. In addition, differences in SUD diagnostic instrumentation may have
resulted in higher SUD prevalence among past year substance users in NESARC.

For further details about NLAES, see Stinson et al. (1998). For an overview of NESARC findings,
see Caetano (2006).
National Longitudinal Study of Adolescent
Health (Add Health)
The National Longitudinal Study of Adolescent Health (Add Health) was conducted to measure
the effects of family, peer group, school, neighborhood, religious institution, and community
influences on health risks, such as tobacco, drug, and alcohol use. Add Health was initiated in 1994
and supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and
Human Development (NICHD) with cofunding from 23 other federal agencies and foundations.

The study began in 1994-1995 (Wave I) with an in-school questionnaire administered to a nationally
representative sample of 90,000 students in grades 7 to 12 in 144 schools and followed up with an
in-home interview. In Wave I, the students were administered brief, machine-readable
questionnaires during a regular class period. Interviews also were conducted with about 20,000
students and their parents in the students’ homes using a combined CAPI and ACASI design. In
Wave II, conducted in 1996, about 15,000 students in grades 8 to 12 were interviewed a second
time in their homes. In Wave III in 2001-2002, about 15,000 of the original Add Health
respondents, then aged 18 to 26, were reinterviewed to investigate how adolescent experiences
and behaviors are related to outcomes during the transition to adulthood. Wave IV was conducted
in 2007-2008 when the approximately 15,000 respondents were aged 24 to 32. The study provides
information on the use of alcohol, illicit drugs, and tobacco.

For further details, see the Add Health Web site at [Link]
Partnership Attitude Tracking Study (PATS)
The Partnership Attitude Tracking Study (PATS), an annual national research study that tracks
attitudes about illegal drugs, is sponsored by the Partnership at [Link] and the MetLife
Foundation. PATS consists of two nationally representative samples—a teenage sample for
students in grades 9 through 12 and a parent sample. Adolescents complete self-administered,
machine-readable questionnaires during a regular class period. The latest PATS surveys of
teenagers and parents were conducted in 2012. The 2012 survey of adolescents included questions
about use of cigarettes, alcohol, and illicit drugs. In 2012, 3,884 teenagers were surveyed
nationwide in the 24th wave of the survey conducted since 1987, and 817 parents or caregivers of
children in grades 9 to 12 were surveyed (Partnership at [Link] & MetLife Foundation,
2013).

In general, NSDUH estimates of substance use prevalence for adolescents are lower than PATS
estimates for youths in that age group. In 2012, for example, PATS estimates of marijuana use
among adolescents in grades 9 through 12 were 45 percent for lifetime use and 24 percent for use
in the past month (Partnership at [Link] & MetLife Foundation, 2013). In 2012,
corresponding estimates of lifetime marijuana use in NSDUH were 23.8 percent for 10th graders
and 38.5 percent for 12th graders (Table C.1). Rates of past month marijuana use in NSDUH
were 10.9 percent for 10th graders and 15.5 percent for 12th graders. The differences in
prevalence estimates may be due to the different study designs. The youth portion of PATS is a
school-based survey, which, similar to other school-based surveys (e.g., MTF), may elicit more
reporting of illicit drug use than the home-based NSDUH.

For further details, see the Partnership at [Link] Web site at [Link]
Youth Risk Behavior Survey (YRBS)
Since 1991, the Youth Risk Behavior Survey (YRBS) has been a component of the CDC’s Youth
Risk Behavior Surveillance System (YRBSS), which measures the prevalence of six priority health
risk behavior categories: (a) behaviors that contribute to unintentional injuries and violence; (b)
tobacco use; (c) alcohol and other drug use; (d) sexual behaviors that contribute to unintended
pregnancy and sexually transmitted diseases, including human immunodeficiency virus infection;
(e) unhealthy dietary behaviors; and (f) physical inactivity. The YRBSS includes national, state,
territorial, tribal, and local school-based surveys of high school students conducted every 2 years.
The national school-based survey uses a three-stage cluster sample design to produce a nationally
representative sample of students in grades 9 through 12 who attend public and private schools.
The State and local surveys use a two-stage cluster sample design to produce representative
samples of public school students in grades 9 through 12 in their jurisdictions. The YRBS is
conducted during the spring, with students completing a self-administered, machine-readable
questionnaire during a regular class period. For the 2013 national YRBS (the latest that has been
conducted), 13,583 usable questionnaires were obtained in 148 schools.

In general, the YRBS school-based survey has found higher rates of substance use for youths than
those found in NSDUH (Table C.2).22 The lower prevalence rates in NSDUH are likely due to
the differences in study design. As in the case of comparisons with estimates from the MTF, the
lower prevalences in NSDUH may be due to more underreporting in the household setting, as
compared with the YRBS school setting, and some overreporting in the school settings.

Similar to other school-based surveys, the population of inference for the YRBS is the population
of adolescents who are in school, specifically those in the 9th through 12th grades. Consequently,
the YRBS does not include data from dropouts. The YRBS makes follow-up attempts to obtain
data from youths who were absent on the day of survey administration but nevertheless does not
obtain complete coverage of these youths. For these reasons, YRBS data are not intended to be
used for making inferences about the adolescent population of the United States as a whole.

For further details, see the CDC Web site at [Link]

C.2 Substance Abuse Treatment Data Sources
The Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Behavioral
Health Services Information System (BHSIS, formerly the Drug and Alcohol Services Information
System, or DASIS) includes three components that provide national- and state-level information on
the numbers and characteristics of individuals admitted to substance abuse treatment programs and
that describe the facilities that deliver care to those individuals. The core of BHSIS is the Inventory
of Behavioral Health Services (I-BHS), a continually updated, comprehensive listing of all known
substance abuse and mental health treatment facilities; further details about I-BHS are not included
in this section. The two other components of BHSIS are described in this section: the National
Survey of Substance Abuse Treatment Services (N-SSATS) and the Treatment Episode Data Set
(TEDS).
National Survey of Substance Abuse Treatment
Services (N-SSATS)
The National Survey of Substance Abuse Treatment Services (N-SSATS) started in 2000 and is an
annual survey of all known drug and alcohol abuse treatment facilities in the United States and
U.S. jurisdictions. The 2012 N-SSATS facility universe totaled 19,316 facilities. About 17 percent
of the facilities in 2012 were found to be ineligible because they had closed or did not provide
substance abuse treatment or detoxification. Of the remaining eligible facilities, more than 14,000
(93 percent) completed the survey. The 2012 N-SSATS employed three sequential data collection
modes: a secure Web-based questionnaire, a paper questionnaire sent by mail upon request to
facilities that had not responded to the Web-based questionnaire, and a telephone interview for
facilities that had not responded to the Web or paper questionnaire. The percentage of facilities
responding via the Web increased from 44 percent in 2007 to 81 percent in 2012 (CBHSQ, 2013).

In N-SSATS, facilities provide information on the characteristics of the treatment facility, including
(but not limited to) client payment sources, services provided, and hospital and residential capacity.
N-SSATS also collects data from facilities on the number of clients in treatment on the survey
reference date (i.e., the last working day of March in the survey year, such as March 30, 2012)
and the percentages of clients in treatment on the reference date for abuse of alcohol and other
drugs, alcohol abuse only, other substance abuse only, and co-occurring substance abuse and
mental health disorders. Average counts of the number of persons in treatment for alcohol or illicit
drug abuse on a single day were about 1.2 million based on N-SSATS data from 2007 to 2009.
Corresponding average single-day counts from NSDUH were about 1.4 million based on the
questionnaire item asking about treatment on October 1st and 1.2 million based on the item about
currently being in treatment at the time of the interview.23 Compared with data reported by
facilities in N-SSATS, NSDUH respondents were more likely to report treatment only for alcohol
and were less likely to report treatment only for illicit drugs (Batts et al., 2014).

As noted previously, N-SSATS collects data on substance abuse treatment utilization from
facilities. In contrast, NSDUH estimates of treatment utilization are based on self-reports of
treatment from respondents in the general population. The validity of N-SSATS data on treatment
utilization depends on the accuracy of the reports provided by the person(s) responding on behalf
of the facility just as the validity of NSDUH estimates on the receipt of substance abuse treatment
depends on accurate respondent self-reports. Also, N-SSATS counts of clients who received
treatment cover clients who may be outside of the NSDUH target population (e.g., homeless
persons not living in shelters, active-duty military personnel). In addition, N-SSATS percentages of
clients receiving treatment both for alcohol and other drugs, only alcohol, and only other drugs are
based on responses to a single question that asks a facility staff member to assign these
percentages to each category. In contrast, NSDUH respondents who reported receiving treatment
at a specialty facility are asked about the substances for which they received treatment.

For further details, see the SAMHSA Web site at [Link]

Treatment Episode Data Set (TEDS)
The Treatment Episode Data Set (TEDS) is a compilation of data on the demographic
characteristics and substance abuse problems of those aged 12 or older who are admitted for
substance abuse treatment, based on administrative data that are routinely collected by state
substance abuse agencies (SSAs) for substance abuse treatment. SSAs report data to TEDS for
approximately 2 million annual admissions to treatment in the United States and Puerto Rico
primarily from facilities that receive some public funding. The TEDS system consists of two major
components—the Admissions Data Set and the Discharge Data Set. The TEDS Admissions Data
Set includes annual client-level data on substance abuse treatment admissions since 1992. The
TEDS Discharge Data Set can be linked at the record level to admissions and includes information
from clients discharged in 2000 and later. The most current TEDS data at the time this report was
written were the 2012 admissions data and the 2011 discharge data.

The TEDS Admissions Data Set consists of a Minimum Data Set collected by all states and a
Supplemental Data Set collected by some States. The Minimum Data Set consists of 19 items that
include demographic information; primary, secondary, and tertiary substance problems at
admission; source of referral; number of prior treatment episodes; and service type at admission.
Supplemental Data Set items consist of 17 items that include psychiatric, social, and economic
measures. The TEDS Discharge Data Set consists of items on service type at discharge, reason
for discharge (e.g., completed treatment, transferred to another program or facility, dropped out),
and length of stay (LOS). LOS is calculated by subtracting the admission date from the discharge
date (or date of last contact). Based on linked admissions and discharge data, the average number
of persons who received treatment in the past year based on TEDS data from 2007 to 2009 was
about 22 percent lower than the average from 2005 to 2010 in NSDUH for treatment in a specialty
facility (1.9 million vs. 2.4 million). The single-day count of persons in treatment from TEDS was
about 0.5 million, which was lower than the single-day counts for N-SSATS (1.2 million) and
NSDUH (1.2 million to 1.4 million, depending on the questions that were used; see the N-SSATS
section in this appendix).24 Thus, TEDS may underestimate the number of persons in treatment on
a single day (Batts et al., 2014).

Although TEDS includes data for a sizable proportion of admissions to substance abuse treatment,
it does not include all admissions. Because TEDS is a compilation of data from state administrative
systems, the scope of facilities included in TEDS is affected by differences in state reporting
requirements, licensure, certification, and accreditation practices, as well as disbursement of public
funds. Many SSAs require facilities that receive public funding (including federal block grant
funds) for substance abuse treatment services to report data to the SSA, whereas others require all
facilities that are licensed or certified by the state to report TEDS data. States also vary in terms of
the specific admissions that are reported to TEDS (e.g., all admissions to eligible facilities that
report to TEDS versus admissions financed by public funds).

For further details, see the SAMHSA Web site at [Link]

C.3 Surveys of Populations Not Covered by
NSDUH
Department of Defense Health Related
Behaviors Survey of Active Duty Military
Personnel
The 2011 Department of Defense Health Related Behaviors Survey of Active Duty Military
Personnel (HRB survey) was updated extensively since the last iteration of the survey in 2008. For
the first time, the survey was administered using a Web-based individual self-administered
questionnaire rather than through an onsite group administration of paper-and-pencil questionnaires.
Because of this change in survey administration, the 2011 sample was no longer clustered
geographically. The questionnaire also was revised to allow use of skip logic to reduce respondent
burden and additional alignment with questions in national surveys of civilian populations, such as
the NHIS. For example, current cigarette use was defined in the 2011 HRB survey based on the
NHIS definition of persons having smoked 100 or more cigarettes in their lifetime and now
smoking on some days or every day; the NSDUH definition of current cigarette use is any use of
cigarettes in the past 30 days. The 2011 HRB survey sample consisted of 39,877 active-duty,
nondeployed service members in the Army, Navy, Marine Corps, Air Force, and Coast Guard
(Barlas, Higgins, Pflieger, & Diecker, 2013). The survey provides information about the use of
alcohol, illicit drugs, and tobacco. Because of changes to procedures for sampling, data collection
(including questionnaire changes), weighting, data processing, and analysis, estimates from the 2011
HRB survey are not directly comparable with estimates from prior HRB survey administrations.
Consequently, the 2011 HRB survey represents a new baseline.

In administrations of this survey prior to 2011, comparisons with NSDUH data have consistently
shown that, even after accounting for demographic differences between the military and civilian
populations, the military personnel had higher rates of heavy alcohol use than their civilian
counterparts, similar rates of cigarette use, and lower rates of illicit drug use (Bray et al., 2009).
Published comparisons of rates of heavy alcohol use, binge alcohol use, and cigarette use between
military personnel and civilians based on 2011 HRB survey data were not adjusted for demographic
differences between the populations other than to limit the civilian data to persons aged 18 to 65,
thus affecting the conclusions that can be drawn from comparisons between the HRB and civilian
data sources.
National Inmate Survey (NIS)
The National Inmate Surveys were conducted in 2007 (NIS-1) and in 2008-2009 (NIS-2). They
fulfill the requirements of the Prison Rape Elimination Act of 2003 (P.L. 108-79) for the Bureau of
Justice Statistics (BJS) to provide a list of prisons and jails according to the prevalence of sexual
victimization. BJS added a companion survey on drug and alcohol use and treatment to both the
NIS-1 and NIS-2. Inclusion of the companion survey on substance use and treatment was
designed to prevent facility staff from knowing whether inmates were selected to receive the
survey on sexual victimization or the companion survey and also was intended to provide more
recent information on substance use and related issues among correctional populations in the
United States compared with the Surveys of Inmates in State and Federal Correctional Facilities
(see below).

The NIS used a two-stage probability sample design first to select state and federal correctional
facilities, then to select inmates within sampled facilities. This resulted in a sample representing
approximately 10 percent of the 1,260 state and 192 federal adult confinement facilities identified in
the 2005 Census of State and Federal Adult Correctional Facilities. At least one facility in every
state was selected; federal facilities were grouped together and treated like a state for sampling
purposes. The sample design also ensured a sufficient number of women in the sample. Samples
were restricted to confinement facilities (i.e., institutions in which fewer than 50 percent of the
inmates were regularly permitted to leave for work, study, or treatment without being accompanied
by facility staff). The NIS samples also excluded community-based facilities, such as halfway
houses, group homes, and work release centers. Inmates aged 18 or older within sampled facilities
were randomly selected for the interview.

The NIS-1 was conducted in 146 state and federal prisons and in 282 local jails between April and
August 2007. Overall NIS-1 response rates for both survey forms were 72 percent for prison
inmates and 67 percent for jail inmates. A total of 7,754 prison or jail inmates completed the drug
and alcohol survey for the NIS-1. The NIS-2 was conducted in 167 state and federal prisons and
286 jails between October 2008 and August 2009. NIS-2 response rates were 71 percent for
prison inmates and 68 percent for jail inmates. A total of 5,015 prison or jail inmates completed the
drug and alcohol survey for the NIS-2.

The interviews used CAPI for general background information at the beginning of the interview
and ACASI for the remainder. Respondents completed the ACASI portion of the interview in
private, with the interviewer either leaving the room or moving away from the computer. Sampled
inmates were randomly assigned to receive the sexual victimization survey or the companion
survey on substance use and treatment. Substance use questions were based on items from past
inmate surveys conducted by BJS, such as the 2004 Survey of Inmates in State Correctional
Facilities (SISCF), and included questions about lifetime and first use of drugs or alcohol, being
under the influence of drugs or alcohol at the time of their current offense, substance use prior to
being admitted to the facility, problems associated with substance use, and treatment for use of
drugs or alcohol.

For further details about the NIS, see BJS’s “All Data Collections” Web page at
[Link] Results from the drug and alcohol use and treatment
surveys are expected in 2015. Upon release of the findings, data will be made available at the
National Archive of Criminal Justice Data ([Link]
Surveys of Inmates in State and Federal
Correctional Facilities (SISCF, SIFCF)
The Survey of Inmates in State Correctional Facilities (SISCF) and the Survey of Inmates in
Federal Correctional Facilities (SIFCF) have provided nationally representative data on state prison
inmates and sentenced federal inmates held in federally owned and operated facilities. The Survey
of State Inmates was conducted in 1974, 1979, 1986, 1991, 1997, and 2004 and the Survey of
Federal Inmates in 1991, 1997, and 2004. The U.S. Census Bureau conducted the 2004 SISCF for
the BJS and the SIFCF for BJS and the Federal Bureau of Prisons. Both surveys provide
information about current offense and criminal history; family background and personal
characteristics; prior drug and alcohol use and treatment; gun possession; and prison treatment,
programs, and services. The surveys are the only national source of detailed information on
criminal offenders, particularly special populations such as drug and alcohol users and offenders
who have mental health problems. Systematic random sampling was used to select the inmates,
and the SISCF and SIFCF in 2004 were administered through CAPI. In 2004, 14,499 state
prisoners in 287 state prisons and 3,686 federal prisoners in 39 federal prisons were interviewed.

Prior drug use among state prisoners remained stable on all measures between 1997 and 2004,
while the percentage of federal inmates who reported prior drug use rose on most measures
(Mumola & Karberg, 2006). For the first time, half of federal inmates reported drug use in the
month before their offense. In 2004, measures of drug dependence and abuse based on criteria in
DSM-IV (APA, 1994) were introduced, and 53 percent of the state and 45 percent of federal
prisoners met the DSM-IV criteria for substance abuse or dependence. The survey results indicate
substantially higher rates of drug use among state and federal prisoners as compared with
NSDUH’s rates for the general household population.

For further details, see BJS’s “All Data Collections” Web page at
[Link]
Sources: National Institute on Drug Abuse, Monitoring the Future Study, University of
Michigan, 2012 and 2013. SAMHSA, Center for Behavioral Health Statistics and Quality,
National Survey on Drug Use and Health, 2012 and 2013 (January-June).
Note: NSDUH data have been drawn from January to June of each survey year and subset
to persons aged 12 to 20 to be more comparable with MTF data.

a Difference between this estimate and the 2013 estimate within the same survey is
statistically significant at the .05 level.
b Difference between this estimate and the 2013 estimate within the same survey is
statistically significant at the .01 level.
MTF = Monitoring the Future; NSDUH = National Survey on Drug Use and Health.
– Not available.
Sources: Centers for Disease Control and Prevention, Youth Risk Behavior Survey, 2005,
2007, 2009, 2011, and 2013. SAMHSA, Center for Behavioral Health Statistics and Quality,
National Survey on Drug Use and Health, January-June for 2005, 2007, 2009, 2011, and 2013.
Note: NSDUH data have been drawn from January to June of each survey year and subset
to persons aged 12 to 20 to be more comparable with YRBS data. Some 2007 and 2009
NSDUH estimates may differ from previously published estimates due to updates (see
Section B.3 in Appendix B of this report).
Statistical tests for the YRBS were conducted using the “Youth Online” tool at
[Link]
Results of testing for statistical significance in this table may differ from published YRBS
reports of change.

a Difference between this estimate and the 2013 estimate within the same survey is
statistically significant at the .05 level.

b Difference between this estimate and the 2013 estimate within the same survey is
statistically significant at the .01 level.
NSDUH = National Survey on Drug Use and Health; YRBS = Youth Risk Behavior Survey.
– Not available.
Appendix D: References
American Psychiatric Association. (1987). Diagnostic and statistical manual of mental
disorders (DSM-III-R) (3rd rev. ed.). Washington, DC: Author.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental

disorders (DSM-IV) (4th ed.). Washington, DC: Author.

Aquilino, W. S. (1994). Interview mode effects in surveys of drug and alcohol use: A field
experiment. Public Opinion Quarterly, 58, 210-240.

Barlas, F. M., Higgins, W. B., Pflieger, J. C., & Diecker, K. (2013, February). 2011 Department
of Defense Health Related Behaviors Survey of Active Duty Military Personnel (prepared
under Contract No. GS-23F-8182H, Task Order No. W81XWH-10-F-0608 for the Assistant
Secretary of Defense – Health Affairs and Task Order No. HSCG23-11-F-PMD008 for the U.S.
Coast Guard). Fairfax, VA: ICF International.

Batts, K., Pemberton, M., Bose, J., Weimer, B., Henderson, L., Penne, M., Gfroerer, J., Trunzo, D.,
& Strashny, A. (2014). CBHSQ Data Review: Comparing and evaluating substance use
treatment utilization estimates from the National Survey on Drug Use and Health and other
data sources. Rockville, MD: Substance Abuse and Mental Health Services Administration,
Center for Behavioral Health Statistics and Quality.

Bray, R. M., Pemberton, M. R., Hourani, L. L., Witt, M., Rae Olmsted, K. L., Brown, J. M.,
Weimer, B. J., Lane, M. E., Marsden, M. E., Scheffler, S. A., Vandermaas-Peeler, R., Aspinwall,
K. R., Anderson, E. M., Spagnola, K., Close, K. L., Gratton, J. L., Calvin, S. L., & Bradshaw, M.
R. (2009, September). 2008 Department of Defense Survey of Health Related Behaviors
Among Active Duty Military Personnel: A component of the Defense Lifestyle Assessment
Program (DLAP) (RTI/10940-FR, prepared under Contract No. GS-10F-0097L, Task Order No.
W81XWH-07-F-0538, for the Assistant Secretary of Defense (Health Affairs) and Task Order
No. HSCG23-07-F-PMD047 for the U.S. Coast Guard). Research Triangle Park, NC: RTI
International.

Brener, N. D., Eaton, D. K., Kann, L., Grunbaum, J. A., Gross, L. A., Kyle, T. M., & Ross, J. G.
(2006). The association of survey setting and mode with self-reported health risk behaviors among
high school students. Public Opinion Quarterly, 70, 354-374.

Brener, N. D., Kann, L., Shanklin, S., Kinchen, S., Eaton, D. K., Hawkins, J., & Flint, K. H. (2013,
March 1). Methodology of the Youth Risk Behavior Surveillance System—2013. Morbidity and
Mortality Weekly Report Recommendations and Reports, 62(RR-1), 1-20.

Butler, M. A., & Beale, C. L. (1994, September). Rural–urban continuum codes for metro and
non-metro counties, 1993 (Staff Report No. AGES 9425). Washington, DC: U.S. Department of
Agriculture, Economic Research Service.

Caetano, R. (2006). NESARC findings on alcohol abuse and dependence. Alcohol Research &
Health, 29, 152-155.

Catalano, R. F., Hawkins, J. D., Berglund, M. L., Pollard, J. A., & Arthur, M. W. (2002).
Prevention science and positive youth development: Competitive or cooperative frameworks?
Journal of Adolescent Health, 31(6 Suppl.), 230-239.

Center for Behavioral Health Statistics and Quality. (2011). Results from the 2010 National
Survey on Drug Use and Health: Summary of national findings (HHS Publication No. SMA
11-4658, NSDUH Series H-41). Rockville, MD: Substance Abuse and Mental Health Services
Administration.

Center for Behavioral Health Statistics and Quality. (2012a). Comparing and evaluating youth
substance use estimates from the National Survey on Drug Use and Health and other
surveys (HHS Publication No. SMA 12-4727, Methodology Series M-9). Rockville, MD:
Substance Abuse and Mental Health Services Administration.

Center for Behavioral Health Statistics and Quality. (2012b). Results from the 2011 National
Survey on Drug Use and Health: Summary of national findings (HHS Publication No. SMA
12-4713, NSDUH Series H-44). Rockville, MD: Substance Abuse and Mental Health Services
Administration.

Center for Behavioral Health Statistics and Quality. (2013). National Survey of Substance Abuse
Treatment Services (N-SSATS): 2012. Data on substance abuse treatment facilities (HHS
Publication No. SMA 14-4809, Behavioral Health Services Information System Series S-66).
Rockville, MD: Substance Abuse and Mental Health Services Administration.

Center for Behavioral Health Statistics and Quality. (2014a). 2012 National Survey on Drug Use
and Health: Methodological resource book. Rockville, MD: Substance Abuse and Mental
Health Services Administration.

Center for Behavioral Health Statistics and Quality. (2014b). 2013 National Survey on Drug Use
and Health: Methodological resource book (Section 2, Sample design report). Rockville, MD:
Substance Abuse and Mental Health Services Administration.

Centers for Disease Control and Prevention. (2012, June 8). Methodologic changes in the
Behavioral Risk Factor Surveillance System in 2011 and potential effects on prevalence estimates.
Morbidity and Mortality Weekly Report, 61, 410-413.

Chromy, J. R., Feder, M., Gfroerer, J., Hirsch, E., Kennet, J., Morton, K. B., Piper, L., Riggsbee,
B. H., Snodgrass, J. A., Virag, T. G., & Yu, F. (2010). Reliability of key measures in the
National Survey on Drug Use and Health (HHS Publication No. SMA 09-4425, Methodology
Series M-8). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office
of Applied Studies.

Cohen, J. (1960). A coefficient of agreement for nominal scales. Educational and Psychological
Measurement, 20, 37-46.

Deville, J. C., & Särndal, C. E. (1992). Calibration estimators in survey sampling. Journal of the
American Statistical Association, 87, 376-382.

Fendrich, M., Johnson, T. P., Sudman, S., Wislar, J. S., & Spiehler, V. (1999). Validity of drug use
reporting in a high-risk community sample: A comparison of cocaine and heroin survey reports with
hair tests. American Journal of Epidemiology, 149, 955-962.

Folsom, R. E., & Singh, A. C. (2000). The generalized exponential model for sampling weight
calibration for extreme values, nonresponse, and poststratification. In Proceedings of the 2000
Joint Statistical Meetings, American Statistical Association, Survey Research Methods
Section, Indianapolis, IN (pp. 598-603). Alexandria, VA: American Statistical Association.
Fryar, C. D., Merino, M. C., Hirsch, R., & Porter, K. S. (2009, May 20). Smoking, alcohol use, and
illicit drug use reported by adolescents aged 12-17 years: United States, 1999-2004. National
Health Statistics Reports, No. 15, 1-23.

Gfroerer, J., Eyerman, J., & Chromy, J. (Eds.). (2002). Redesigning an ongoing national
household survey: Methodological issues (HHS Publication No. SMA 03-3768). Rockville, MD:
Substance Abuse and Mental Health Services Administration, Office of Applied Studies.

Gfroerer, J., Hughes, A., Chromy, J., Heller, D., & Packer, L. (2004, July). Estimating trends in
substance use based on reports of prior use in a cross-sectional survey. In S. B. Cohen & J. M.
Lepkowski (Eds.), Eighth Conference on Health Survey Research Methods: Conference
proceedings [Peachtree City, GA] (HHS Publication No. PHS 04-1013, pp. 29-34). Hyattsville,
MD: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease
Control and Prevention, National Center for Health Statistics.

Gfroerer, J., Lessler, J., & Parsley, T. (1997a). Studies of nonresponse and measurement error in
the National Household Survey on Drug Abuse. In L. Harrison & A. Hughes (Eds.), The validity
of self-reported drug use: Improving the accuracy of survey estimates (NIH Publication No.
97-4147, NIDA Research Monograph 167, pp. 273-295). Rockville, MD: National Institute on Drug
Abuse.

Gfroerer, J., Wright, D., & Kopstein, A. (1997b). Prevalence of youth substance use: The impact
of methodological differences between two national surveys. Drug and Alcohol Dependence,
47, 19-30.

Grant, B. F., & Dawson, D. A. (2006). Introduction to the National Epidemiologic Survey on
Alcohol and Related Conditions. Alcohol Research & Health, 29, 74-78.

Grucza, R. A., Abbacchi, A. M., Przybeck, T. R., & Gfroerer, J. C. (2007). Discrepancies in
estimates of prevalence and correlates of substance use and disorders between two national
surveys. Addiction, 102, 623-629.

Grunbaum, J. A., Kann, L., Kinchen, S. A., Williams, B., Ross, J. G., Lowry, R., & Kolbe, L.
(2002, June 28). Youth risk behavior surveillance—United States, 2001. Morbidity and Mortality
Weekly Report CDC Surveillance Summaries, 51(4), 1-62.

Harrison, L., & Hughes, A. (Eds.). (1997). The validity of self-reported drug use: Improving
the accuracy of survey estimates (NIH Publication No. 97-4147, NIDA Research Monograph
167). Rockville, MD: National Institute on Drug Abuse.

Harrison, L. D., Martin, S. S., Enev, T., & Harrington, D. (2007). Comparing drug testing and
self-report of drug use among youths and young adults in the general population (HHS
Publication No. SMA 07-4249, Methodology Series M-7). Rockville, MD: Substance Abuse and
Mental Health Services Administration, Office of Applied Studies.

Hawkins, J. D., Catalano, R. F., & Miller, J. Y. (1992). Risk and protective factors for alcohol and
other drug problems in adolescence and early adulthood: Implications for substance abuse
prevention. Psychological Bulletin, 112(1), 64-105.

Hennessy, K. H., & Ginsberg, C. (Eds.). (2001). Substance use survey data collection
methodologies and selected papers [Special issue]. Journal of Drug Issues, 31(3), 595-808.

Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2013). Monitoring the
Future national survey results on drug use, 1975-2012: Volume I, Secondary school
students. Ann Arbor, MI: University of Michigan, Institute for Social Research.

Johnston, L. D., O’Malley, P. M., Bachman, J. G., Schulenberg, J. E., & Miech, R. A. (2014).
Monitoring the Future national survey results on drug use, 1975-2013: Volume I, Secondary
school students. Ann Arbor, MI: University of Michigan, Institute for Social Research.

Kann, L., Kinchen, S., Shanklin, S. L., Flint, K. H., Hawkins, J., Harris, W. A., Lowry, R., Olsen,
E. O., McManus, T., Chyen, D., Whittle, L., Taylor, E., Demissie, Z., Brener, N., Thornton, J.,
Moore, J., & Zaza, S. (2014, June 13). Youth risk behavior surveillance—United States, 2013.
Morbidity and Mortality Weekly Report CDC Surveillance Summaries, 63(Suppl. 4), 1-168.

Kessler, R. C., Avenevoli, S., Costello, J., Green, J. G., Gruber, M. J., Heeringa, S., Merikangas, K.
R., Pennell, B. E., Sampson, N. A., & Zaslavsky, A. M. (2009). Design and field procedures in the
US National Comorbidity Survey Replication Adolescent Supplement (NCS-A). International
Journal of Methods in Psychiatric Research, 18(2), 69-83.

Kessler, R. C., Berglund, P., Chiu, W. T., Demler, O., Heeringa, S., Hiripi, E., Jin, R., Pennell, B.
E., Walters, E. E., Zaslavsky, A., & Zheng, H. (2004). The US National Comorbidity Survey
Replication (NCS-R): Design and field procedures. International Journal of Methods in
Psychiatric Research, 13(2), 69-92.

Kessler, R. C., Chiu, W. T., Demler, O., Merikangas, K. R., & Walters, E. E. (2005). Prevalence,
severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey
Replication. Archives of General Psychiatry, 62, 617-627.

Landis, J. R., & Koch, G. G. (1977). The measurement of observer agreement for categorical
data. Biometrics, 33, 159-174.

Manly, B. F. J. (1986). Multivariate statistical methods: A primer. London, England: Chapman

and Hall.

Miller, J. W., Gfroerer, J. C., Brewer, R. D., Naimi, T. S., Mokdad, A., & Giles, W. H. (2004).
Prevalence of adult binge drinking: A comparison of two national surveys. American Journal of
Preventive Medicine, 27, 197-204.

Mumola, C. J., & Karberg, J. C. (2006, October [revised January 19, 2007]). Drug use and
dependence, State and Federal prisoners, 2004 (NCJ 213530, BJS Special Report).
Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice
Statistics.

National Center for Health Statistics, Office of Information Services. (2013, August). National
Health Interview Survey (NHIS): 2012 data release. Retrieved from
[Link]

National Institute on Alcohol Abuse and Alcoholism. (2010, September). Alcohol use and alcohol
use disorders in the United States, a 3-year follow-up: Main findings from the 2004-2005
Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (U.S.
Alcohol Epidemiologic Data Reference Manual, Vol. 8, No. 2, NIH Publication No. 10-7677).
Bethesda, MD: National Institutes of Health.

Office of Applied Studies. (2005). Results from the 2004 National Survey on Drug Use and
Health: National findings (HHS Publication No. SMA 05-4062, NSDUH Series H-28).
Rockville, MD: Substance Abuse and Mental Health Services Administration.
Office of Applied Studies. (2009). Results from the 2008 National Survey on Drug Use and
Health: National findings (HHS Publication No. SMA 09-4434, NSDUH Series H-36).
Rockville, MD: Substance Abuse and Mental Health Services Administration.

Office of Management and Budget. (1997). Revisions to the standards for the classification of
federal data on race and ethnicity. Federal Register, 62(210), 58781-58790.

Office of Management and Budget. (2003, June 6). Revised definitions of metropolitan
statistical areas, new definitions of micropolitan statistical areas and combined statistical
areas, and guidance on uses of the statistical definitions of these areas (OMB Bulletin No.
03-04). Washington, DC: The White House.

Partnership at [Link] & MetLife Foundation. (2013, April 23). 2012 Partnership Attitude
Tracking Study: Teens and parents. New York, NY: Author.

Pemberton, M., Bose, J., Kilmer, G., Kroutil, L., Forman-Hoffman, V., & Gfroerer, J. (2013).
CBHSQ Data Review: Comparison of NSDUH health and health care utilization estimates to
other national data sources. Rockville, MD: U.S. Department of Health and Human Services,
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health
Statistics and Quality.

Robertson, E. B., David, S. L., & Rao, S. A. (2003, October). Preventing drug use among
children and adolescents: A research-based guide for parents, educators, and community
leaders (NIH Publication No. 04-4212(A), 2nd ed.). Bethesda, MD: National Institute on Drug
Abuse.

RTI International. (2012). SUDAAN®, Release 11.0 [computer software]. Research Triangle
Park, NC: Author.

Rubin, D. B. (1986). Statistical matching using file concatenation with adjusted weights and
multiple imputations. Journal of Business and Economic Statistics, 4(1), 87-94.

Schoenborn, C. A., Adams, P. F., & Peregoy, J. A. (2013, May). Health behaviors of adults:
United States, 2008-2010. Data from the National Health Interview Survey. Vital and Health
Statistics, Series 10(257), 1-184.

Singh, A., Grau, E., & Folsom, R., Jr. (2002). Predictive mean neighborhood imputation for
NHSDA substance use data. In J. Gfroerer, J. Eyerman, & J. Chromy (Eds.), Redesigning an
ongoing national household survey: Methodological issues (HHS Publication No. SMA 03-
3768, pp. 111-133). Rockville, MD: Substance Abuse and Mental Health Services Administration,
Office of Applied Studies.

SRNT Subcommittee on Biochemical Verification. (2002). Biochemical verification of tobacco use

and cessation. Nicotine & Tobacco Research, 4, 149-159.

Stinson, F. S., Yi, H.-Y., Grant, B. F., Chou, P., Dawson, D. A., & Pickering, R. (1998, November).
Drinking in the United States: Main findings from the 1992 National Longitudinal Alcohol
Epidemiologic Survey (NLAES) (NIH Publication No. 99-3519, U.S. Alcohol Epidemiologic Data
Reference Manual, Vol. 6, 1st ed.). Bethesda, MD: National Institutes of Health, National Institute
on Alcohol Abuse and Alcoholism.

Tourangeau, R., & Smith, T. W. (1996). Asking sensitive questions: The impact of data collection
mode, question format, and question context. Public Opinion Quarterly, 60, 275-304.
Turner, C. F., Lessler, J. T., & Gfroerer, J. C. (Eds.). (1992). Survey measurement of drug use:
Methodological studies (HHS Publication No. ADM 92-1929). Rockville, MD: National Institute
on Drug Abuse.
 Appendix E: List of Contributors
This National Survey on Drug Use and Health (NSDUH) report was prepared by the Center for
Behavioral Health Statistics and Quality (CBHSQ), Substance Abuse and Mental Health Services
Administration (SAMHSA), U.S. Department of Health and Human Services (HHS), and by RTI
International (a trade name of Research Triangle Institute), Research Triangle Park, North
Carolina. Work by RTI was performed under Contract No. HHSS283201000003C.

Contributors at SAMHSA listed alphabetically, with chapter authorship noted, include Jonaki Bose
(Chapter 1), Kathy Downey, Beth Han (Chapter 7), Sarra L. Hedden, Art Hughes (Chapter 8),
Joel Kennet (Chapter 3), Rachel Lipari (Chapter 6), Pradip Muhuri (Chapter 5), Grace O’Neill
(Chapter 4), Dicy Painter, and Peter Tice (Project Officer) (Chapter 2).

Contributors and reviewers at RTI listed alphabetically include Jeremy Aldworth, Katherine J.
Asman, Stephanie N. Barnett, Kathryn R. Batts, Ellen Bishop, Pinliang (Patrick) Chen, James R.
Chromy, Elizabeth A. P. Copello, Devon S. Cribb, Christine Davies, Teresa R. Davis, Ralph E.
Folsom, Misty S. Foster, Peter Frechtel, Julia M. Gable, Rebecca A. Granger, Kristen Gulledge,
Wafa Handley, Erica L. Hirsch, David Hunter (Project Director), Ilona S. Johnson, Greta A.
Kilmer, Phillip S. Kott, Larry A. Kroutil, Jeffrey S. Laufenberg, Dan Liao, Philip Kam Lee, Martin
D. Meyer, Andrew S. Moore, Katherine B. Morton, Lisa E. Packer, Michael R. Pemberton,
Jeremy Porter, Harley F. Rohloff, Jessica Roycroft, Neeraja S. Sathe, Kathryn Spagnola, Jiantong
(Jean) Wang, Lauren Klein Warren, and Cherie J. Winder.

Also at RTI, report and Web production staff listed alphabetically include Teresa F. Bass, Debbie
F. Bond, Kimberly H. Cone, Valerie Garner, Melissa H. Hargraves, Laura James, E. Andrew
Jessup, Shari B. Lambert, Farrah Bullock Mann, Brenda K. Porter, Pamela Couch Prevatt,
Margaret A. Smith, Roxanne Snaauw, Richard S. Straw, Pamela Tuck, and Cheryl L. Velez.

1 RTI International is a trade name of Research Triangle Institute.

2 Since 2013, the question about race has included categories for Guamanian or
Chamorro and for Samoan. Prior to 2013, these groups were reported in the
interview as Other Pacific Islander.

3 Definitions for binge alcohol use and heavy alcohol use are given in the
introduction to Chapter 3 in this report.

4 Initiation for pain relievers, tranquilizers, stimulants, or sedatives refers to first

nonmedical use.

5 Due to rounding, percentages of past year initiates who initiated prior to age 18
that are calculated from the estimated numbers in Figure 5.8 may differ from the
actual percentages.
6 Unlike other sections that present estimates among adults aged 18 or older, this
section focuses on the associations between educational attainment and substance
use disorders among adults aged 26 or older. Age is associated with both
educational attainment and substance use disorders among adults aged 18 to 25.
Many 18 year olds are still in high school. Many 18 to 22 year olds have some
college education but have not yet received a college degree. College graduates
generally are aged 22 or older. Moreover, in the United States, it is illegal to drink
alcohol before age 21. The prevalence of alcohol use disorders among adults
under the age of 21 often is lower than that among adults aged 21 to 25. Focusing
on adults aged 26 or older minimizes the potential confounding effect of age on the
associations between educational attainment and substance use disorders.

7 Estimates for the 2001 YRBS are not shown in Tables 8.1 and 8.3 for
consistency with the new NSDUH baseline in 2002.

8 Prior to 2002, the survey was known as the National Household Survey on Drug
Abuse (NHSDA).

9 SAE is a hierarchical Bayes modeling technique used to make state-level

estimates for 25 measures related to substance use and mental health. For more
details, see “2011-2012 NSDUH: Model-Based Prevalence Estimates (50 States
and the District of Columbia)” (Tables 1 to 26, by Age Group) at
[Link]

10 Sampling areas were defined using 2000 census geography. Counts of dwelling
units (DUs) and population totals were obtained from the 2000 decennial census
data supplemented with revised population projections from Nielsen Claritas.

11 Census tracts are relatively permanent statistical subdivisions of counties and

parishes and provide a stable set of geographic units across decennial census
periods.

12 Some census tracts had to be aggregated in order to meet the minimum DU

requirement of 150 DUs in urban areas and 100 DUs in rural areas.

13 A successfully screened household is one in which all screening questionnaire

items were answered by an adult resident of the household and either zero, one, or
two household members were selected for the NSDUH interview.

14 The usable case rule requires that a respondent answer “yes” or “no” to the
question on lifetime use of cigarettes and “yes” or “no” to at least nine additional
lifetime use questions.

15 Prior to 2002, NSDUH was known as the National Household Survey on Drug
Abuse (NHSDA).

16 Substances include alcohol, marijuana, cocaine, heroin, hallucinogens,

inhalants, pain relievers, tranquilizers, stimulants, and sedatives.

17 See Section B.4.8 in the Results from the 2008 National Survey on Drug Use
and Health: National Findings (OAS, 2009) for the methamphetamine analysis
decisions.

18 The BRFSS online analysis tool is available by clicking on the “Prevalence

Data and Data Analysis Tools” link at [Link]

19 NSDUH and BRFSS in 1999 and 2000 used a threshold of five or more drinks
for both males and females; see the BRFSS online analysis tool at
[Link]

20 To examine estimates that are comparable with MTF data, NSDUH estimates
presented in Table C.1 are based on data collected in the first 6 months of the
survey year and are subset to ages 12 to 20.

21 These data were taken from the U.S. Census Bureau’s Current Population
Survey (CPS) and were available (at the time of publication) at
[Link] by clicking on the “People” heading, selecting “School
Enrollment,” then selecting the detailed tables for “School Enrollment in the
United States: 2012.” Rates cited in this appendix are from the Census Bureau’s
Table 1 for all races and for both males and females.

22 To examine estimates that are comparable with YRBS data, NSDUH estimates
presented in Table C.2 are based on data collected in the first 6 months of the
survey year and are subset to ages 12 to 20.

23 Counts of the number of persons in treatment on a single day in N-SSATS were

based on reports of the number of persons in treatment on the last working day of
March. Corresponding NSDUH estimates were based on data from respondents
from the 2008 to 2010 NSDUHs who reported that they were enrolled in a
specialty substance use treatment program on October 1st of the year prior to the
interview or those from the 2007 to 2009 NSDUHs who were in specialty
substance use treatment at the time of the interview (Batts et al., 2014).

24 The numbers of persons in TEDS who received treatment were derived from
linked admissions and discharge data or from adjusted admissions data for states
that did not submit discharge data. Multiple admissions that were linked by a
single unique identifier represented one person. Three states (Alabama, Alaska,
and Georgia) and the District of Columbia were not included in the TEDS data
because they did not report TEDS data or reported incomplete data. For
comparison purposes, data from these states were excluded from NSDUH data on
average numbers who received treatment in the past year. However, single-day
counts for persons in treatment from N-SSATS and NSDUH included data from
these States (Batts et al., 2014).
Appendix 43: Drug Categories for Substances
of Abuse

To assist you in locating substances in this appendix, the following cross-

reference by category is provided.

Narcotics
Alfentanil
Cocainea
Codeine
Crack cocainea
Fentanyl
Heroin
Hydromorphone
Ice
Meperidine
Methadone
Morphine
Nalorphine
Opium
Oxycodone
Propoxyphene
Depressants
Amobarbital
Benzodiazepine
Chloral hydrate
Chlordiazepoxide
Diazepam
Glutethimide
Meprobamate
Methaqualone
Nitrous Oxide
Pentobarbital
Phenobarbital
Secobarbital
Stimulants
Amphetamine
Benzedrine
Benzphetamine
Butyl nitrite
Dextroamphetamine
Methamphetamine
Methylphenidate
Phenmetrazine
Hallucinogens
Bufotenine
LSD
MDA
MDEA
MDMA
Mescaline
MMDA
Phencyclidine
Psilocybin
Cannabis
Marijuana
Tetrahydrocannabinol
Alcohol
Ethyl alcohol
Steroids
Dianabol
Nandrolone
Drug Category Profiles
Narcotics
Depressants
Stimulants

aCocaine, although classified under the Controlled Substances Act as a narcotic, also is discussed as a
stimulant.
Substances of Abuse: Brief Profiles
Cocaine
Also known as:

Coke, dust, snow, flake, blow, girl

You probably know why cocaine is abused:

Carefree feeling
Euphoria
Relaxation
In control

But did you know that:

A cocaine high lasts only about 5 to 20 minutes.

Cocaine use may cause severe “mood swings” and irritability.
You need more and more cocaine each time you want a high.
Cocaine increases your blood pressure and heart rate, and this is particularly
dangerous if you have a heart condition.
One use can cause death.
Possession and use are illegal and can result in fines and arrest.
Crack
Also known as:

Crack, crack cocaine, freebase rocks, rock

You probably know why crack is abused:

Quick high
Power
Euphoria

But did you know that:

Crack is almost instantly addictive.

One use could cause a fatal heart attack.
Repeated use may cause insomnia, hallucinations, seizures, and paranoia.
The euphoric effects of crack last for only a few minutes.
Possession and use are illegal in all 50 states.
There are more hospitalizations per year resulting from crack and cocaine
use than from the use of any other illicit substance.
Ice
Also known as:

Meth, crystal, crank, methamphetamine

You probably know why ice is abused:

Temporary mood elevation

Exhilaration (high)
Increased mental alertness
Upper—increase wakefulness

But did you know that:

Ice is extremely addictive, sometimes with just one use.

Ice can cause convulsions, heart irregularities, high blood pressure,
depression, restlessness, tremors, and severe fatigue.
An overdose can cause coma and death.
When one stops using ice, one may experience a deep depression.
Ice causes a very jittery high along with anxiety, insomnia, and sometimes
paranoia.
Inhalants
Some of the substances that are abused:

Butyl nitrite
Amyl nitrite (gas in aerosol cans)
Gasoline and toluene vapors (typewriter correction fluid, glue, marking
pens)

You probably know why inhalants are abused:

Cheap high
Quick buzz
Fun

But did you know that inhalants may cause:

Loss of muscle control

Slurred speech
Drowsiness or loss of consciousness
Excessive secretions from the nose and watery eyes
Brain damage and damage to lung cells
Drug Category Profile
Hallucinogens

aPhencyclidine analogs, amphetamine variants

Substances of Abuse: Brief Profile
Hallucinogens
Types:

LSD (acid, red/green dragon)

Ecstacy (designer drug)
PCP (angel dust, loveboat)
PCP and cocaine (“Beam me up, Scottie”)
Mescaline
Psilocybin

You probably know why hallucinogens are abused:

Fun
Stimulation or depression
Behavioral changes

But did you know that:

One use of LSD or PCP may cause multiple and dramatic behavioral
changes.
Large doses of hallucinogens may cause convulsions, ruptured blood vessels
in the brain, and irreversible brain damage.
Many hallucinogens cause unpleasant and potentially dangerous flashbacks
long after the drug was used.
Most hallucinogens cause hallucinations—changes in perception of time,
smell, touch, and so on.
Drug Category Profile
Cannabis
Substances of Abuse: Brief Profile
Marijuana
Also known as:

Pot, grass, joints, roaches, reefer, weed, Mary Jane

You probably know why marijuana is abused:

Relaxation
Euphoria

But did you know that:

Marijuana may cause impaired short-term memory, a shortened attention

span, and delayed reflexes.
During pregnancy, marijuana may cause birth defects.
Marijuana may cause a fast heart rate and pulse.
Repeated use of marijuana may cause breathing problems.
Possession of marijuana is illegal in all 50 states.
Marijuana may cause relaxed inhibitions and disoriented behavior.
Drug Category Profile
Alcohol
Substances of Abuse: Brief Profile
Alcohol
Also known as:

Booze, juice, brew, vino, sauce

You probably know why alcohol is abused:

Relaxation
Sociability
Cheap high

But did you know that:

Alcohol is a depressant that decreases the responses of the central nervous

system.
Excessive drinking can cause liver damage and psychotic behavior.
As little as two beers or drinks can impair coordination and thinking.
Alcohol often is used by substance abusers to enhance the effects of other
drugs.
Alcohol continues to be the most frequently abused substance among young
adults.
Drug Category Profile
Steroids
Substances of Abuse: Brief Profile
Steroids
Types:

Anabolic (male hormone, steroids most frequently abused), cortical, estrogenic

(female hormone)

You probably know why steroids are abused:

Increased strength
Increased muscle size
Helps muscles to recover

But did you know that abuse of steroids may cause:

Severe acne, rashes, stunted growth

Sexual function problems
Women to take on masculine traits, develop hairiness
Behavioral changes, aggressiveness (“paranoid rages”)
Long-term effects such as cholesterol increases, heart disease, liver tumors,
cancer, cataracts, death

Source: U.S. Department of Labor. (1994). America in jeopardy: The young

employee and drugs in the workplace. Washington, DC: U.S. Department of
Labor, Office of the Assistant Secretary for Policy.
aCocaine, although classified under the Controlled Substances Act as a narcotic,
also is discussed as a stimulant.
Appendix 44: Adult Inpatient Program
Schedule
Appendix 45: Adolescent Inpatient Program
Schedule
Appendix 46: Adult Outpatient Program
Schedule

WEEK 1

Monday

6:00 pm–6:30 pm Open—Serenity Prayer

Commitments
Open discussion
Group rules
6:30–7:15 Interpersonal relationship group
7:15–7:30 Break
7:30–9:00 Continue interpersonal group
9:00 Close—Lord’s Prayer

Tuesday

6:00 pm–6:30 pm Open—Serenity Prayer

Commitments
6:30–7:15 Spirituality group
7:15–7:30 Break

7:30–9:00 Continue spirituality group

Family interpersonal group
9:00 Close—Lord’s Prayer

Wednesday

6:00 pm–6:30 pm Open—Serenity Prayer

Commitments
Open discussion
Hamilton Depression Rating Scale (HAM-D)
6:30–7:15 Recovery skills group
7:15–7:30 Break
7:30–9:00 Continue recovery skills group
9:00 Close—Lord’s Prayer
Each week, the schedule stays the same on Mondays and Wednesdays. The
following schedules are rotating schedules on Tuesdays for each additional week.

WEEK 2

Tuesday

6:00 pm–6:30 pm Open—Serenity Prayer

Commitments
6:30–7:15 Disease concept video and discussion
7:15–7:30 Break

7:30–9:00 Lecture and discussion on progression/Jellinek chart

Family interpersonal group
9:00 Close—Lord’s Prayer

WEEK 3

Tuesday

6:00 pm–6:30 pm Open—Serenity Prayer

Commitments
6:30–7:15 Recovery and the Family video and discussion
7:15–7:30 Break

7:30–9:00 Lecture and discussion on family dynamics

Family interpersonal group
9:00 Close—Lord’s Prayer

WEEK 4

Tuesday

6:00 pm–6:30 pm Open—Serenity Prayer

Commitments
6:30–7:15 Chalk Talk video and discussion
7:15–7:30 Break

7:30–9:00 Lecture and discussion on Steps One, Two, and Three

Family interpersonal group
 9:00 Close—Lord’s Prayer

WEEK 5

Tuesday

6:00 pm–6:30 pm Open—Serenity Prayer

Commitments
6:30–7:15 Feelings video and discussion
7:15–7:30 Break

7:30–9:00 Lecture and discussion on Steps Four, Five, Six, and Seven
Family interpersonal group
9:00 Close—Lord’s Prayer

WEEK 6

Tuesday

6:00 pm–6:30 pm Open—Serenity Prayer

Commitments
6:30–7:15 Medical Aspects video and discussion
7:15–7:30 Break

7:30–9:00 Lecture and discussion on Steps Eight and Nine

Family interpersonal group
9:00 Close—Lord’s Prayer

WEEK 7

Tuesday

6:00 pm–6:30 pm Open—Serenity Prayer

Commitments
6:30–7:15 HIV video and discussion
7:15–7:30 Break

7:30–9:00 Lecture and discussion on Steps Ten, Eleven, and Twelve

Family interpersonal group
9:00 Close—Lord’s Prayer
WEEK 8

Tuesday

6:00 pm–6:30 pm Open—Serenity Prayer

Commitments
6:30–9:00 Social and recreational activities
9:00 Close—Lord’s Prayer
Appendix 47: Adolescent Outpatient Program
Schedule

WEEK 1

Monday

4:30 pm Open—Serenity Prayer

Highs and lows
Open discussion
4:45 Interpersonal relationship group
5:20 Break
5:30 Continue interpersonal relationship group
6:30 Close—Lord’s Prayer

Wednesday

4:30 pm Open—Serenity Prayer

Highs and lows
Open discussion
4:45 Recovery skills group
5:20 Break
5:30 Continue recovery skills group
6:30 Close—Lord’s Prayer

Thursday

4:30 pm Open—Serenity Prayer

Highs and lows
Open discussion
4:45 Pot video
5:20 Break
5:30 Read, complete, and discuss Pot handout
6:30 Close—Lord’s Prayer

Each week, the schedule stays the same on Mondays and Wednesdays. The
following schedules are rotating schedules on Thursdays for each additional
week.

WEEK 2

Thursday

4:30 pm Open—Serenity Prayer

Highs and lows
Open discussion
4:45 Three-Headed Dragon video
5:20 Break
5:30 Discuss video and handout
6:30 Close—Lord’s Prayer

WEEK 3

Thursday

4:30 pm Open—Serenity Prayer

Highs and lows
Open discussion
4:45 Step One video
5:20 Break
5:30 Facts about alcohol test and discussion
6:30 Close—Lord’s Prayer

WEEK 4

Thursday

4:30 pm Open—Serenity Prayer

Highs and lows
Open discussion
4:45 Teens and AA video and discussion
5:20 Break
5:30 Sponsorship role-playing
6:30 Close—Lord’s Prayer

WEEK 5
Thursday

4:30 pm Open—Serenity Prayer

Highs and lows
Open discussion
4:45 Soft Is the Heart of a Child video
5:20 Break
5:30 Discuss systems dynamics roles
6:30 Close—Lord’s Prayer

WEEK 6

Thursday

4:30 pm Open—Serenity Prayer

Highs and lows
Open discussion
4:45 What Is Wrong With This Picture video
5:20 Break
5:30 Values exercise and discussion
6:30 Close—Lord’s Prayer

WEEK 7

Thursday

4:30 pm Open—Serenity Prayer

Highs and lows
Open discussion
4:45 Epitaph for a Drug User video
5:20 Break
5:30 Lecture and discussion on HIV and AIDS
6:30 Close—Lord’s Prayer

WEEK 8

Thursday

4:30 pm Open—Serenity Prayer

Highs and lows
 Open discussion
4:45 Fetal Alcohol Syndrome video
5:20 Break
5:30 Discussion regarding fetal alcohol syndrome and fetal alcohol effects
6:30 Close—Lord’s Prayer
Appendix 48: Gambling Inpatient Program
Schedule
Note: Individual sessions are to include assessments, evaluations, individual financial responsibility, and
continuing care plans. Family conjoints are to be done during the week of the family program, or more
as needed, and are to be assessed on an individual basis.

Aspects of the gambling program are combined with all addiction-based

disorders.
Family dynamics: Family program scheduled for the first Monday and
Tuesday following admission
Problem solving: Daily interpersonal groups
Relapse prevention: Weekly in a 4-week cycle (triggers, thoughts, feelings,
and slips)
Cross-addiction: Lecture
Spirituality: Weekly sessions with clergy
Appendix 49: Gambling Outpatient Program
Schedule
Appendix 50: Day Treatment Program
Schedule
Appendix 51: Pressure Relief Group Meeting
and Budget Form
To the Gamblers Anonymous Group:
When a member attends his or her first meeting, it is important that a pressure
relief meeting be explained to him or her and that a member will contact him or
her within 30 days to arrange a pressure relief meeting.

The member should be told to contact all creditors and tell them that he or she
will be back to them in 30 days. It should be emphasized that no payments should
be made and also that no commitment of dollar amounts should be promised. Each
member should be told to choose someone to take care of his or her money
(spouse, if married). It is suggested that the member’s name be removed from all
items of value (e.g., house, cars, stocks, bonds, bank books, credit cards, checking
accounts). The member should be told not to carry more money than he or she
needs for daily essentials.

The pressure relief meeting should be given only by a Gamblers Anonymous (GA)
member experienced in pressure relief procedures. There should be at least one
other GA member and a Gam-Anon member present. The pressure relief meeting
should not take place at a member’s home; there could be too many distractions.
Do not plan a pressure relief meeting at a GA meeting room prior to a regularly
scheduled meeting.

One week prior to the pressure relief meeting, the member should be given copies
of the budget forms.

The pressure relief committee should schedule a reevaluation date approximately

6 months after the pressure relief meeting.
Dear Gamblers Anonymous Member:
According to the standards set forth by your local GA chapter, you are now
eligible for a pressure group.

An integral part of your recovery is that of making financial restitution.

Considering the fact that your debts usually are much greater than those of the
average individual, it is vitally important that great care be taken when planning a
manageable budget. The key word is manageable. It is very difficult for anyone to
live a normal life while being overburdened with financial pressures, especially
for a compulsive gambler.

The main concepts behind a compulsive gambler’s pressure relief meeting are to
allow the gambler and his or her family to be able to lead a normal life and, at the
same time, make financial restitution to his or her creditors.

The first step in planning a budget requires total honesty. If you have withheld any
information pertaining to your debts, now is the time to become totally honest.
Hopefully, by now you have followed the advice of your fellow GA members and
have done the following:

1. Contact all creditors and ask for a 30- to 45-day moratorium on payments. Be
sure not to pay anyone, and do not make any financial commitments.
2. Choose someone to handle your money (spouse, if married).
3. Turn all ownership of properties (e.g., home, car) over to someone else.
4. Remove your name from all bank books, checking accounts, and credit cards.
5. Turn over all paychecks uncashed with stubs attached to the individual who
will manage your money.
The Choice Is Yours
The choice between paying over a long period of time, while functioning and
living as a human being, or complete collapse due to immense financial pressures
that cannot be met is, in reality, not a choice at all but rather the only avenue that
will return you back to sanity and solvency. You have to be honest, forthright, and
humble in regard to the debts that you owe and in your determination to repay
them. GA experience has shown that our creditors, in a very human and helpful
way, will respond to sincerity, honesty, and courage but will rightfully reject
arrogance and self-pity. Everyone is willing to help a person who is down (and
who wants to get back up), but much more important is the willingness to help
yourself. This is the key. This is the quest. This is the never-ending endeavor.

Have faith in the GA program and follow the budget that will be set up for you. If
you adhere to the budget and refrain from gambling, your financial pressures will
soon be relieved, and this will greatly improve your chances for recovery.
Remember that you have a gambling problem, not a financial problem. Go slow;
take it one day at a time.

DIRECTIONS: Please complete these pages with the most accurate and up-to-date
information that you have available. Do not leave anything out.
To the Creditor
Dear Creditor:
The attached budget has been prepared for , who is a member of GA. He/she has
admitted that he/she is a compulsive gambler and that his/her life has become
unmanageable. An integral part of the compulsive gambler’s recovery is to make
restitution to all of his/her creditors. Due to the fact that the compulsive gambler
has accumulated a large debt, it may be necessary to repay you over a long period
of time. If a previous repayment schedule already exists, the compulsive gambler
may have to give you smaller payments and, therefore, take longer to repay his/her
debt.

As you can see by the prepared budget, the compulsive gambler must provide for
all living expenses for himself/herself and his/her family before paying his/her
debts. The repayment schedule has been prepared by experienced members of
GA. The amount suggested for repayment of each debt was based on the amount
originally borrowed, the balance due, and the original monthly payment.

The compulsive gambler is not claiming bankruptcy and is not running away.
He/she wants to repay his/her debts. Your cooperation is greatly appreciated.

GA is not responsible for the information listed on this form, nor does it
guarantee the compliance of the proposed financial arrangement on this form.

Signed:

Pressure Relief Chairperson

Name Spouse’s name Date

GA group

Budget committee chairperson Others

Member’s phone Chairperson’s phone

Reevaluation date
Budget
a4.33 weeks per month.
List of Creditors
Please list, in the following order, (1) bad checks or debts for which you may be
prosecuted, (2) court-ordered judgments, (3) credit unions, (4) bank or finance
company loans, (5) back taxes, (6) credit cards, (7) bookmakers and loan sharks,
(8) family and friends, and (9) others.
Repayment Schedule
Financial Summary

TOTAL INCOME:

SUBTRACT TOTAL EXPENSES:

AMOUNT AVAILABLE FOR REPAYMENT:

Note: GA is not responsible for the information listed on this form, nor does it
guarantee the compliance of the proposed financial arrangement on this form.
Appendix 52: Heroin
What Are the Treatments for Heroin Addiction?
A variety of effective treatments are available for heroin addiction. Treatment
tends to be more effective when heroin abuse is identified early. The treatments
that follow vary depending on the individual, but methadone, a synthetic opiate
that blocks the effects of heroin and eliminates withdrawal symptoms, has a
proven record of success for people addicted to heroin. Other pharmaceutical
approaches (e.g., LAAM [levo-alpha-acetyl-methadol], buprenorphine), as well
as many behavioral therapies, also are used for treating heroin addiction.
Detoxification
The primary objective of detoxification is to relieve withdrawal symptoms while
clients adjust to a drug-free state. Not in itself a treatment for addiction,
detoxification is a useful step only when it leads to long-term treatment that either
is drug free (residential or outpatient) or uses medications as part of the treatment.
The best-documented drug-free treatments are the therapeutic community
residential programs lasting at least 3 to 6 months.
Methadone Programs
Methadone treatment has been used effectively and safely to treat opioid addiction
for more than 30 years. Properly prescribed methadone is not intoxicating or
sedating, and its effects do not interfere with ordinary activities such as driving a
car. The medication is taken orally, and it suppresses narcotic withdrawal for 24
to 36 hours. Clients are able to perceive pain and have emotional reactions. Most
important, methadone relieves the craving associated with heroin addiction
(craving is a major reason for relapse). Among methadone clients, it has been
found that normal street doses of heroin are ineffective at producing euphoria,
thereby making the use of heroin more easily extinguishable.

Methadone’s effects last for about 24 hours—four to six times as long as those of
heroin—so people in treatment need to take it only once a day. Also, methadone is
medically safe even when used continuously for 10 years or more. Combined with
behavioral therapies or counseling and other supportive services, methadone
enables clients to stop using heroin (and other opiates) and return to more stable
and productive lives.

Methadone doses must be monitored carefully in clients who are receiving

antiviral therapy for HIV infection so as to avoid potential medication
interactions.
LAAM and Other Medications
LAAM, like methadone, is a synthetic opiate that can be used to treat heroin
addiction. LAAM can block the effects of heroin for up to 72 hours with minimal
side effects when taken orally. In 1993, the Food and Drug Administration
approved the use of LAAM for treating clients addicted to heroin. Its long
duration of action permits dosing just three times per week, thereby eliminating
the need for daily dosing and take-home doses for weekends. LAAM will be
increasingly available in clinics that already dispense methadone. Naloxone and
naltrexone are medications that also block the effects of morphine, heroin, and
other opiates. As antagonists, they are especially useful as antidotes. Naltrexone
has long-lasting effects, ranging from 1 to 3 days depending on the dose.
Naltrexone blocks the pleasurable effects of heroin and is useful in treating some
highly motivated individuals. Naltrexone also has been found to be successful in
preventing relapse by former opiate addicts released from prison on probation.

Another medication to treat heroin addiction, buprenorphine, is a particularly

attractive treatment because, compared to other medications such as methadone, it
causes weaker opiate effects and is less likely to cause overdose problems.
Buprenorphine also produces a lower level of physical dependence, so clients
who discontinue the medication generally have fewer withdrawal symptoms than
do those who stop taking methadone. Because of these advantages, buprenorphine
may be appropriate for use in a wider variety of treatment settings than is the case
with the currently available medications. Several other medications with potential
for treating heroin overdose or addiction currently are under investigation by the
National Institute on Drug Abuse.
Behavioral Therapies
Although behavioral and pharmacological treatments can be extremely useful
when employed alone, science has taught us that integrating both types of
treatments ultimately will be the most effective approach. There are many
effective behavioral treatments available for heroin addiction. These can include
residential and outpatient approaches. An important task is to match the best
treatment approach to meet the particular needs of the client. Moreover, several
new behavioral therapies, such as contingency management therapy and cognitive-
behavioral interventions, show particular promise as treatments for heroin
addiction. Contingency management therapy uses a voucher-based system, where
the client earns points based on negative drug tests that the client can exchange for
items that encourage healthy living. Cognitive-behavioral interventions are
designed to help modify the client’s thinking, expectancies, and behaviors and to
increase skills in coping with various life stressors. Both behavioral and
pharmacological treatments help to restore a degree of normalcy to brain function
and behavior, with increased employment rates and lower risk of HIV and other
diseases and criminal behavior.
What Are the Opioid Analogs and Their Dangers?
Drug analogs are chemical compounds that are similar to other drugs in their
effects but differ slightly in their chemical structure. Some analogs are produced
by pharmaceutical companies for legitimate medical reasons. Other analogs,
sometimes referred to as “designer” drugs, can be produced in illegal laboratories
and often are more dangerous and potent than the original drugs. Two of the most
commonly known opioid analogs are fentanyl and meperidine (e.g., marketed
under the brand name Demerol).

Fentanyl was introduced in 1968 by a Belgian pharmaceutical company as a

synthetic narcotic to be used as an analgesic in surgical procedures because of its
minimal effects on the heart. Fentanyl is particularly dangerous because it is 50
times more potent than heroin and can rapidly stop respiration. This is not a
problem during surgical procedures because machines are used to help clients
breathe. On the street, however, users have been found dead with the needles used
to inject the drug still in their arms.
Methadone Programs
There are approximately 980,000 heroin addicts in the United States, and 20%
receive methadone or LAAM. A client who comes into a methadone clinic first
receives a complete physical, biopsychosocial, and treatment plan. The client is
stabilized on liquid methadone (up to 100 milligrams per day). Then the counselor
begins to talk to the client about treatment. Does the client want to be on
methadone forever, or does the client want to work toward abstinence? All clients
need to be encouraged to move toward abstinence as the ultimate goal.

The client needs to be stabilized on enough methadone to get his or her life back
from abusing drugs on the street. Methadone levels are taken to verify compliance.
When the time is right, methadone is tapered very slowly, as little as 2 milligrams
per month or as much as the client can comfortably tolerate. At any point, the
client may reach a level where he or she cannot decrease any further without going
into uncomfortable withdrawal symptoms. The client is maintained at the lowest
level until another decrease can be attempted.

All clients have a monthly drug screen, and if their urine is found to be positive
for substances of abuse, then they discuss this with their counselors and make
plans for abstaining. Clients should not be discharged from treatment just because
they use. Recovery is a program of progress, not perfection.

Clients can earn take-home doses of methadone by having clean urine samples for
a required period, usually one take-home dose for each month clean. They can get
guest doses from another clinic if they travel.

Clients should get individual, group, or family therapy each month as needed. The
extent of this counseling is negotiated between the clients and their counselors. All
methadone clients need to be examined for chronic pain syndromes to meet the
needs of this population. A pain management team is used to help these clients
manage the pain and the addiction simultaneously. Clients need to be educated
about pregnancy, parenting, reproductive health, and HIV/AIDS as they go through
treatment.

More information on methadone can be obtained from the National Association of

Methadone Advocates ([Link]) and the National Institute on Drug
Abuse ([Link]).
Source: With the exception of the LAAM and Other Medications and Methadone
Programs sections, all information is taken from National Institute on Drug Abuse.
(2005, May). Heroin abuse and addiction (Rev. ed.). Bethesda, MD: Author.
Appendix 53: South Oaks Gambling Screen
Appendix 54: Barriers in Thinking
Blueprint for Change
Source: Spon, A. R. (1999). Blueprint for change: Corrective thinking
facilitator’s guide. Roscoe, IL: Truthought, LLC.

More information can be obtained by contacting Truthought Corrective Thinking

Process, PO Box 22, Roscoe, IL 61073. 815-389-0127. Copyright © 2001. Used
with permission.
Appendix 55: Psychotherapeutic Medications
2011

What Every Counselor Should Know

About this Publication
Originally developed as a companion piece to the Mid-America ATTC systems
change curriculum, A Collaborative Response: Addressing the Needs of
Consumers With Co-Occurring Substance Use and Mental Health Disorders,
this edition includes adaptations made for inclusion in CSAT’s TIP 42: Substance
Abuse Treatment for Persons with Co-Occurring Disorders. The language has
been modified to increase readability for a larger audience and, in keeping with
the goal of updating the publication biannually, several new medications are
included.
Counselors’ Use of This Publication
A list of generic and brand names is included for the following medications:
Antipsychotics/Neuroleptics
Antiparkinsonian Medications
Antimanic Medications
Antidepressant Medications
Antianxiety Medications
Stimulant Medications
Narcotic and Opioid Analgesics
Hypnotics (Sleep Aids)

Addiction Treatment Medications

Alcohol
Opioids
Tobacco
Others

Each section includes the following topics for the different medication types:

Purpose: Describes typical uses of medications, including specific

symptoms treated and positive treatment response expected.
Usual dose, frequency, and side effects: Discusses when and how
medications are administered, typical side effects, and methods for
monitoring side effects.
Potential side effects: Lists common side effects.
Potential for abuse or dependence: Elaborates upon those medications
with potential for abuse and/or physical dependence. Discusses withdrawal
reactions and management of withdrawal.
Emergency Conditions: Includes risks associated with overdose,
withdrawal or other drug reactions.
Cautions: Describes risks associated with use of additional medications
(i.e., over the counter), increasing or discontinuing use of medications,
adverse consequences with concurrent use of alcohol and/or street drugs.
Special Considerations for Pregnant Women: Describes risks for pregnant
women prescribed psychotherapeutic medications. References to research
are included. The special role of the substance abuse counselor in
encouraging discussion between clients and the prescribing physician is
emphasized.
Important Notes Across Medication Types
Name brand medications have a limited patent. When the patent expires, the
medication may be made as a generic. The generic name of a medication is the
actual name of the medication and never changes. A generic medication may be
made by many different manufacturers. Additionally, manufacturers can make
several forms of a single medication with only slight variations. For instance, they
may vary the color, size, or shape of the medication. If a person says his or her
medication “looks different” AND he or she is experiencing new side effects,
contact the prescriber immediately.

For ease of reading, some technical terms are defined in accompanying footnotes.
All medications are listed in the index along with page numbers for quick
reference. When specific brands are discussed in the accompanying text, the name
of the medication is bolded to assist the reader in finding the reference.

This publication is available for free download via the Mid-America ATTC Web
site at [Link].
Limitations of the Publication
This publication is designed as a quick “desk reference” for substance abuse and
mental health treatment providers. It is not intended to be used as a complete
reference for psychotherapeutic medications. The section, “Tips for
Communicating with Physicians,” is meant to be just that: tips for communicating.
The publication assumes providers are knowledgeable about the Health Insurance
Portability and Accountability Act (HIPAA) regulations, including issues related
to privacy and confidentiality and will use these communication tips in
accordance with those regulations. For more information about HIPAA, refer to
the SAMHSA Web site “HIPAA: What It Means for Mental Health and Substance
Abuse Services” at [Link]

The section, “Talking with Clients about their Medication,” is a prompt designed
to help the provider initiate conversation about medication management and
adherence with clients who have co-occurring mental health and substance use
disorders. It is not intended as a complete guide to client education. For a more
thorough discussion of these co-occurring issues, see the current edition of the
American Society of Addiction Medicine’s (ASAM’s) Principles of Addiction
Medicine, Third Edition (ASAM 2003).

For physicians desiring a more in-depth discussion regarding the challenges of

treating specific population groups with substance use disorders (e.g., homeless,
older adults, people with HIV/AIDS or hepatitis, pregnant or nursing women,
etc.), which include medication compliance, adverse drug interactions, and
relapse with the use of potentially addictive medications, refer to the current
edition of the American Society of Addiction Medicine’s (ASAM’s) Principles of
Addiction Medicine, Third Edition (ASAM 2003), and CSAT’s TIP 42:
Substance Abuse Treatment for Persons with Co-Occurring Disorders (CSAT
2005).
Antipsychotics/Neuroleptics
Generic Brand

Traditional antipsychotics
chlorpromazine Thorazine, Largactil
fluphenazine Prolixin, Permitil, Anatensol
haloperidol Haldol
loxapine Loxitane, Daxolin
mesoridazine Serentil
molindone Moban, Lidone
perphenazine Trilafon, Etrafon
pimozide Orap
thioridazine Mellaril
thiothixene Navane
trifluoperazine Stelazine

Novel or atypical antipsychotics

aripiprazole Abilify
clozapine Clozaril
olanzapine Zyprexa, Zyprexa Zydis
paliperidone Invega
quetiapine fumarate Seroquel
risperidone Risperdal
risperidone long-acting injection Risperdal Consta
ziprasidone Geodon
Purpose
Antipsychotics (neuroleptics) are most frequently used for persons who
experience psychotic symptoms as a result of having some form of schizophrenia,
severe depression or bipolar disorder. They may be used to treat brief psychotic
episodes caused by drugs of abuse. Psychotic symptoms may include being out of
touch with reality, “hearing voices,” and having false perceptions (e.g., thinking
you are a famous person, thinking someone is out to hurt you). Antipsychotic
medications can be effective in either minimizing or stopping these symptoms
altogether. In some cases, these medications can shorten the course of the illness
or prevent it from happening again.

Positive treatment response to antipsychotic medications allows many with severe

and disabling mental disorders to live and function in the community, often
relatively normally. This positive response may include thoughts that are more
rational, decreased psychosis1, paranoia and delusions, behavior that is more
appropriate, and the ability to have relationships and work.

All of the older and newer antipsychotic medications are approved by the Food
and Drug Administration (FDA) and are thus evidence-based treatments (EBT) for
schizophrenia. The newest antipsychotic medications—Risperdal, Zyprexa,
Seroquel, Geodon, and Abilify—are showing positive effects across a range of
disorders. These medications stabilize mood and are also used to treat bipolar
disorder. They are being added to antidepressants to treat severe depressions.
Some have been shown to be effective at relieving anxiety in low doses, but the
FDA does not approve this use. A growing number of the atypical antipsychotic
medications have received FDA approval for treatment of manic episodes, and
some for extended treatment of bipolar disorder.
Usual Dose, Frequency & Side Effects
All medications have specific doses and frequencies. The physician will specify
the exact amount of medication and when it should be taken. This information is on
the prescription bottle. Many medications are taken once a day, some at bedtime to
take advantage of the drowsiness side effect of some antipsychotic medications.
Several medications are taken in pill form or liquid form. Others are given by
injection once or twice per month to ensure that the medication is taken reliably. It
is important to take medications on schedule. It is also important that people talk
to their doctor so they know about potential side effects and steps they need to
take to monitor their health.

Novel or atypical antipsychotics are different from traditional antipsychotics.

These medications are more powerful with treatment-resistant schizophrenia but
may also be used with severe depression or other psychiatric illness. Because the
atypical antipsychotics work in a slightly different way than traditional
antipsychotics, they are less likely to produce serious side effects, such as tardive
dyskinesia2 or neuroleptic malignant syndrome3. The most common mild side
effects are either sedation4 or agitation, especially when starting the medications.
The most worrisome side effects are weight gain and elevated blood sugar and
lipids5. There is also some evidence that the use of atypical antipsychotics may
lead to the development of diabetes mellitus6 (Sernyak et al. 2002). Because
diabetes is associated with obesity, it is unclear whether the diabetes is actually
caused by certain atypical antipsychotic medications or obesity. These issues can
be medically worrisome and can lead to medication noncompliance. Since
effectiveness and side effects vary across medications and people, matching the
right medication to the right person is the key.

Clozapine (Clozaril) can very rarely cause serious abnormalities or irregularities

in the blood cells (blood dyscrasias7). Approximately 1 to 2 percent of people
who take Clozaril develop a condition in which their white blood cell count
drops drastically (agranulocytosis8). As a result, they are at high risk for
infections due to a compromised immune system, and this could be fatal.
However, most cases of agranulocytosis can be treated successfully by stopping
Clozaril treatment. To maintain safety, white blood cell counts must be checked
each week for 6 months and every 2 weeks thereafter. The results must be sent to
the person’s pharmacy before he or she can pick up the next supply of medication.
Risperidone (Risperdal) and olanzapine (Zyprexa) came soon after clozapine.
Both are strong and predictable antipsychotics. Risperidone may cause
involuntary movements, tremors, muscular rigidity, and immobility without
paralysis, and at higher doses and is moderately sedative. Olanzapine is highly
sedative and has more tendency to cause weight gain and other metabolic changes.

Risperidone long-acting injections (Risperdal Consta) also a newly approved

antipsychotic, is an injection of microencapsulated9 medication that releases into
the body at a constant level. An injection is usually given every 2 weeks. Side
effects are similar to those for Risperdal.

Quetiapine (Seroquel) is antipsychotic only in higher doses, but is most used for
non-psychotic conditions such as bipolar disorder, depression, and PTSD
conditions. It is very sedative and calming at moderate to high doses. In some
prison settings, there have been reports of “abuse” of both quetiapine and
olanzapine, by prisoners feigning psychotic symptoms in order to obtain heavy
sedation.

Ziprasidone (Geodon) and aripiprazole (Abilify) are newer agents and have only
moderate sedative and few weight, diabetes, or lipid effects, but their
antipsychotic response seems to be less predictable.

Paliperidone (Invega) is the newest of the antipsychotics and is related to

risperidone but contained in a capsule which distributes the medicine over 24
hours.

Traditional antipsychotics are cheap, and the newer ones are expensive. In
general, the newer antipsychotics, when taken in proper dosage, have fewer
clinical side effects and a broader treatment response than traditional
antipsychotics.
Potential Side Effects

Tardive Dyskinesia
Involuntary movements of the tongue or mouth
Jerky, purposeless movements of legs, arms or entire body
More often seen in women
Risk increases with age and length of time on medication
Usually seen with long-term treatment using traditional antipsychotic
medications; rarely seen with atypical antipsychotic medications

Symptoms of diabetes mellitus (associated with

obesity)
Excessive thirst and hunger
Fatigue
Frequent urination
Headaches
Slow healing cuts and/or blemishes
Weight loss

Neuroleptic Malignant Syndrome (very rare)

Blood pressure up and down
Dazed and confused
Difficulty breathing
Muscle stiffness
Rapid heart rate
Sweating and shakiness
Temperature above normal

Other
Blurred vision
 Changes in sexual functioning
Constipation
Diminished enthusiasm
Dizziness
Drowsiness
Dry mouth
Lowered blood pressure
Muscle rigidity
Nasal congestion
Restlessness
Sensitivity to bright light
Slowed heart rate
Slurred speech
Upset stomach
Weight gain

Note: Any side effects that bother a person need to be reported and discussed
with the prescribing physician. Anticholinergic/antiparkinsonian medications like
Cogentin or Artane may be prescribed to control movement difficulties
associated with the use of antipsychotic medications.
Emergency Conditions
Contact a physician and/or seek emergency medical assistance if the person
experiences involuntary muscle movements, painful muscle spasms, difficulty
urinating, eye pain, skin rash or any of the symptoms listed above under tardive
dyskinesia, and neuroleptic malignant syndrome. An overdose is always
considered an emergency and treatment should be sought immediately.
Cautions
Doctors and pharmacists should be told about all medications being taken
and dosage, including over the counter preparations, vitamins, minerals, and
herbal supplements (i.e., St. John’s wort, Echinacea, ginkgo, and ginseng).
People taking antipsychotic medications should not increase their dose unless
this has been checked with their physician and a change is ordered.
Special Considerations for Pregnant Women
For women of childbearing age who may be or think they may be pregnant, the
physician should discuss the safety of this medication before starting, continuing,
or discontinuing medication treatment. Substance abuse counselors may have a
role in encouraging this discussion by suggesting their clients talk with the
prescribing physician.

Generally, the use of antipsychotic medications should be avoided in the first

trimester unless the mother poses a danger to herself, to others, or to the unborn
child, or if the mother shows signs of profound psychosis (Cohen 1989). Tapering
and discontinuation of antipsychotic medication 10 days to 2 weeks before
delivery is generally advised, though the way this is done varies by medication
(Mortola 1989).
Antiparkinsonian Medications
Generic Brand
amantadine hydrochloride Symmetrel, Symadine
benztropine mesylate Cogentin
diphenhydramine hydrochloride Benadryl
trihexyphenidyl hydrochloride Artane
Purpose
Antiparkinsonian (anticholinergic) medications are used to control the side effects
associated with antipsychotic medications. They are called antiparkinsonian
because the neurological side effects of antipsychotic medications are similar to
the symptoms of Parkinson’s disease (i.e., tremors, stiff or rigid muscles, poor
balance, and a distinctive unsteady walk).
Usual Dose & Frequency
All medications have specific doses and frequencies. The physician will specify
the exact amount of medication and when it should be taken. This information is on
the prescription bottle. These medications have very specific doses and taking too
much can be harmful. A doctor must be consulted in order to safely change the
dose in response to side effects of the antipsychotic medications.
Potential Side Effects
Constipation
Dizziness
Dry mouth
Heart failure
Irritability
Light headedness
Stomach upset
Tiredness
Emergency Conditions
Report immediately any overdose or changes in heart rate and/or rhythm to the
doctor.
Potential for Abuse or Dependence
Despite their utility, these medications can be abused by some persons with
severe mental illness who require neuroleptics. Survey research has found that
many abusers of antiparkinsonians used these medications “to get high, to increase
pleasure, to decrease depression, to increase energy and to relax” (Buhrich et al.
2000, p. 929). The survey also found that the misuse of other drugs accompanied
the misuse of antiparkinsonian medications. Consequently, in the context of co-
occurring mental health and substance use disorders, providers and consumers
need to be aware of and openly communicate about the abuse potential of these
medications.
Cautions
Doctors and pharmacists should be told about all medications being taken
and dosage, including over-the-counter preparations, vitamins, minerals, and
herbal supplements (i.e., St. John’s wort, Echinacea, ginkgo, ginseng).
People taking antiparkinsonian medications should not increase their dose
unless this has been checked with their physician and a change is ordered.
Special Considerations for Pregnant Women
The risk of birth defects associated with Cogentin, Artane, and Benadryl is not
clear, although there is some evidence to suggest that amantadine (Symmetrel,
Symadine) may produce a deformed baby (Mortola 1989). For all women of
childbearing age who may be or think they may be pregnant, the physician should
discuss the safety of this medication before starting, continuing, or discontinuing
medication treatment. Substance abuse counselors may have a role in encouraging
this discussion by suggesting their clients talk with the prescribing physician.
Antimanic Medications
Generic Brand

Lithium products
lithium carbonate Eskalith, Eskalith CR, Lithane, Lithobid, Lithonate,
Lithotabs
lithium citrate Cibalith

Anticonvulsant products
carbamazepine Tegretol
divalproex sodium Depakote, Depakote Sprinkle, Depakote ER
lamotrigine Lamictal

Atypical antipsychotics

(see Antipsychotics/Neuroleptics, p. 668 for side

effects)
aripiprazole Abilify
olanzapine Zyprexa, Zyprexa Zydis
olanzapine plus fluoxetine Symbyax
quetiapine fumarate Seroquel
risperidone Risperdal
ziprasidone Geodon

Other anticonvulsant products (not FDA approved for

the treatment of mania)
gabapentin Neurontin
levetiracetam Keppra
oxcarbazepine Trileptal
tiagabine hydrochloride Gabitril
topiramate Topamax, Topamax Sprinkle
valproate sodium Depakene, Depacon
valproic acid Depakene
Purpose
Antimanic medications are used to control the mood swings of bipolar (manic–
depressive) illness. Bipolar illness is characterized by cycling mood changes
from severe highs (mania) to severe lows (depression). The “highs” and “lows”
vary in intensity, frequency, and severity. Bipolar I conditions include full manic
episodes. Bipolar II conditions, by definition do not include full mania, but are
characterized more as depression plus a low level of mania (hypomania). Bipolar
cycles that occur more often than 3 times a year are considered “rapid cycling,” a
condition often found in people with higher rates of substance abuse.

Positive treatment responses to antimanic medications include less hyperactivity,

pressured speech and/or illogical thought. They improve the clients’ ability to
sleep, concentrate and allow the person to function more normally.

If bipolar disorder is left untreated, the associated mania may worsen into a
psychotic state and depression may result in thoughts of suicide. By leveling mood
swings with antimanic medications, some of the suicidal and other self-harming
behaviors can be decreased. Additionally, appropriate treatment with antimanic
medications can reduce a person’s violent outbursts toward others or property.

All of the lithium products, Tegretol, Depakote, and those products listed under
atypical antipsychotics qualify as evidence-based treatments (EBT) for Bipolar I
disorder. Lamictal qualifies as an EBT for Bipolar II disorder.
Usual Dose, Frequency & Side Effects
All medications have specific doses and frequencies. The physician will specify
the exact amount of medication and when it should be taken. This information is
provided on the prescription bottle. Most medications in this class are given 2 to
4 times per day. Some extended release formulations10 may be given every 12
hours. Dosage is determined by the active amount of medication found in the
person’s blood after taking the medication, and by his or her response to the
medication. Expect a check of monthly blood levels until the person is at his or
her optimal dose.

Lithium products: Most common side effects are tremor, acne, and weight gain.
People taking these products may require more fluids than they did before taking
the medication. However, too much fluid in a person’s diet can “wash” the lithium
out of his or her system, and too little fluid can allow the lithium to concentrate in
the system. Additionally, anything that can decrease sodium in the body (i.e.,
decreased table salt intake, a low-salt diet, excessive sweating during strenuous
exercise, diarrhea, vomiting) could result in lithium toxicity11. People taking any
antimanic medications should have blood levels tested regularly to check the
concentration level of the medication in their bodies. Specifically, people taking
lithium products, Tegretol, Depakote, and Depakene need their blood levels
monitored.

Anticonvulsant products:12 Most common side effects are sedation and weight
gain. Keppra is noted for causing mood changes, primarily depression and anger
in some people. This may limit its use as a mood stabilizer.

For the most common side effects of atypical antipsychotics, refer to

Antipsychotics/Neuroleptics, p. 6. It is likely that all of the newer atypical
antipsychotics mentioned in the previous section will soon be FDA approved for
treatment of mania.
Potential Side Effects
Blurred vision
Coma*
Diarrhea*
Drowsiness
Fatigue
Hand tremor*
Increased thirst and urination*
Inflammation of the pancreas
Irregular heart beats
Kidney damage*
Liver inflammation, hepatitis
Nausea or vomiting
Problems with the blood, both red and white cells
Rash and skin changes
Seizures
Under or overactive thyroid*
Weakness
Weight gain

*These side effects are associated with lithium, anticonvulsants, and atypical
antipsychotics only. Effects vary greatly between persons.
Emergency Conditions
Lithium overdose is a life-threatening emergency. Signs of lithium toxicity may
include nausea, vomiting, diarrhea, drowsiness, mental dullness, slurred speech,
confusion, dizziness, muscle twitching, irregular heartbeat and blurred vision. An
overdose of any of the other antimanic medications is always considered an
emergency and treatment should be sought immediately.
Cautions
Doctors and pharmacists should be told about all medications being taken
and dosage, including over-the-counter preparations, vitamins, minerals, and
herbal supplements (i.e., St. John’s wort, Echinacea, ginkgo, ginseng).
People taking antimanic medications should not increase their dose unless
this has been checked with their physician and a change is ordered.
Persons taking antimanic medications are particularly vulnerable to adverse
medical consequences if they concurrently use alcohol and/or street drugs.
Lithium can cause birth defects in the first 3 months of pregnancy.
Thyroid function must be monitored if a person takes lithium.
Heavy sweating or use of products that cause excessive urination (i.e.,
coffee, tea, some high caffeine sodas, use of diuretics) can lower the level of
lithium in the blood.
Blood tests for medication levels need to be checked every 1 to 2 months.
Use of these medications will lower the effectiveness of birth control
medications.
Special Considerations for Pregnant Women
Some antimanic medications, such as Depakene (valproic acid), are associated
with several birth defects if taken during pregnancy. If this type of medication must
be used during pregnancy, the woman must be told that there is substantial risk of
malformations (Robert et al. 2001). Lithium is also a medication that may be
harmful to an unborn child. Those exposed to lithium before week 12 of gestation
are at increased risk of heart abnormalities. For women taking lithium, blood
levels of the medication should be monitored every 2 weeks. Ultrasound
examinations should be performed on the fetus to rule out the development of an
enlarged thyroid (goiter) in the unborn child (Mortola 1989).

Generally, the use of antipsychotic medications should be avoided in the first

trimester unless the mother poses a danger to herself, to others, or to the unborn
child, or if the mother shows signs of profound psychosis (Cohen 1989). Tapering
and discontinuation of antipsychotic medication 10 days to 2 weeks before
delivery is generally advised, though the way this is done varies by medication
(Mortola 1989).

For women of childbearing age who may be or think they may be pregnant, the
physician should discuss the safety of these medications before starting,
continuing, or discontinuing medication treatment. Substance abuse counselors
may have a role in encouraging this discussion by suggesting their clients talk with
the prescribing physician.
Antidepressant Medications
Generic Brand

SSRIs — Selective Serotonin Reuptake Inhibitors

citalopram Celexa
escitalopram oxalate Lexapro
fluoxetine Prozac, Prozac Weekly, Sarafem
fluvoxamine Luvox
paroxetine Paxil, Paxil CR
sertraline Zoloft

Other new antidepressants

bupropion Wellbutrin, Wellbutrin SR
duloxetine Cymbalta
mirtazapine Remeron, Remeron SolTab
nefazodone Serzone
trazodone Desyrel
venlafaxine Effexor, Effexor ER

Tricyclics & Quatracyclics

Amitriptyline Elavil
Amoxapine Asendin
Clomipramine Anafranil
Desipramine Nopramin, Pertofrane
Doxepin Sinequan
Imipramine Tofranil
Maprotiline Ludiomil
Nortriptyline Pamelor
Protriptyline Vivactil

Monoamine Oxidase (MAO) Inhibitors

Isocarboxazid Marplan
Phenelzine Nardil
Tranylcypromine Parnate
Purpose
Antidepressant medications are used for moderate to serious depressions, but they
can also be very helpful for milder depressions such as dysthymia. Most
antidepressants must be taken for a period of 3 to 4 weeks to begin to reduce or
take away the symptoms of depression but a full therapeutic effect may not be
present for several months. Antidepressants are also the first line medications for
certain anxiety disorders such as panic disorder, social phobia, and obsessive-
compulsive disorders.

Positive early treatment responses to antidepressant medications include

improved energy, concentration, and sleep. Later positive treatment responses
include improved mood, attitude, and statements of “feeling better.”

Treatment for a single episode of major depression should be continued for 2

years before discontinuing. Since major depression is a chronic recurrent illness
for many people, long-term use of antidepressants is often indicated (much as one
would take medication for high blood pressure or diabetes for a long period of
time). Discontinuing antidepressant therapy before the depression is completely
resolved may result in the person decompensating13 and possibly becoming
medication resistant. Untreated depression may result in suicide, especially with
co-occurring substance use disorders. Therefore, treatment for depression must be
taken as seriously as treatment for any other major life-threatening illness.
Types of Antidepressants
SSRIs are the most frequently prescribed class of antidepressants because of their
broad effectiveness, low side effects, and safety. They are thought to affect the
serotonin14 system to reduce symptoms of depression. The extended release
formula of fluoxetine (Prozac Weekly) can be dosed once per week. Sarafem is
fluoxetine under another label used for treatment of Premenstrual Dysphoric
Disorder. SSRIs include both less expensive generic medications (fluoxetine,
citalopram, and paroxetine) and more expensive brand name only versions.

Other new antidepressants, such as venlafaxine (Effexor) work on both the

serotonin and norepinephrine15 levels. Bupropion (Wellbutrin) is an
antidepressant unrelated to other antidepressants. It has more effect on
norepinephrine and dopamine levels than on serotonin levels in the brain. In
addition, bupropion (Wellbutrin) can be “activating” (as opposed to sedating). It
is not associated with weight gain or sexual dysfunction like many other
antidepressant medications. Bupropion (Wellbutrin) should, however, be avoided
by people who are at risk for or who currently have a seizure disorder.

The MAO inhibitors and the tricyclic and quatracyclic antidepressants (named for
their chemical structures) are older and less commonly used due to safety and side
effects. MAOs are used for “atypical depressions,” which produce symptoms like
oversleeping, anxiety or panic attacks, and phobias. Also, they may be used when
a person does not respond to other antidepressants. The older tricyclics may be
preferred in spite of their common side effects because they are inexpensive.
Usual Dose, Frequency & Side Effects
All medications have specific doses and frequencies. The physician will specify
the exact amount of medication and when it should be taken. This information is
provided on the prescription bottle. Several factors are considered before an
antidepressant is prescribed: the type of medication, the person’s individual body
chemistry, weight, and age. Generally, people are started on a low dose, and the
dosage is slowly raised until the optimal effects are reached without troublesome
side effects.

Both mild sedation and mild agitation sometimes occur with SSRI use. The most
troubling SSRI side effect is decreased sexual performance, which may be
difficult for many persons to discuss. Common side effects specific to both
bupropion (Wellbutrin) and venlafaxine (Effexor) include sleeplessness and
agitation. For the older tricyclics, side effects include dry mouth and sedation.
Potential Side Effects

SSRIs
Anxiety, agitation or nervousness
Change in appetite (lack of or increase)
Change in sexual desire
Confusion
Decrease in sexual ability
Diarrhea or loose stools
Dizziness
Dry mouth
Headache
Heart rhythm changes
Increased sweating
Insomnia or sleepiness
Lack or increase of appetite
Shakiness
Stomach upset
Taste disturbances (Wellbutrin)
Weight loss or gain

Tricyclics & Quatracyclics

Allergic reactions
Blood cell problems (both white and red cells)
Blurred vision
Change in sexual desire
Changes in heartbeat and rhythm
Constipation
Decrease in sexual ability
Difficulty with urination
Dizziness when changing position
Dry mouth
Fatigue
Heart block16
 Increased sweating
Kidney failure (Asendin)
Muscle twitches
Neuroleptic Malignant Syndrome (Asendin)
Seizures
Stroke
Weakness
Weight gain

MAO Inhibitors
Blood cell problems (both white and red cells)
Dizziness when changing position
Fluid retention (swollen ankles, feet, legs or hands)
Headache
High blood pressure crisis17
Insomnia
Lack of appetite
Rapid heart beat
Emergency Conditions
An overdose of any of the MAO inhibitors, tricyclics, quatracyclics, or other
antidepressants is serious and potentially life threatening and must be reported to
a physician immediately. Symptoms of tricyclic and quatracyclic overdose may
include rapid heartbeat, dilated pupils, flushed face, agitation, loss of
consciousness, seizures, irregular heart rhythm, heart and breathing stopping, and
death.

The potential for a fatal outcome from an overdose with the SSRIs is much less.
However, the possibility that a person has attempted suicide should be dealt with
as an emergency situation that needs immediate intervention.
Cautions
Doctors and pharmacists should be told about all medications being taken
and dosage, including over-the-counter preparations, vitamins, minerals, and
herbal supplements (i.e., St. John’s wort, Echinacea, ginkgo, ginseng).
People taking antidepressant medications should not increase their dose
unless this has been checked with their physician and a change is ordered.
Withdrawal from SSRIs and other new antidepressants can cause flu-like
symptoms. Discontinuing antidepressant therapy should be done gradually
under a physician’s care.
People taking MAO inhibitors must avoid all foods with high levels of
tryptophan or tyramine (e.g., aged cheese, wine, beer, chicken liver,
chocolate, bananas, soy sauce, meat tenderizers, salami, bologna, and
pickled fish). High levels of caffeine must also be avoided. If eaten, these
foods may react with the MAO inhibitors to raise blood pressure to
dangerous levels.
Many medications interact with the MAO inhibitors. It is largely for this
reason that they are rarely used. Other medications should not be taken unless
the treating physician approves them. Even a simple over-the-counter cold
medication can cause life-threatening side effects.
People using MAO inhibitors should check all new medications with a
physician or pharmacist before taking them.
People taking antidepressant medications are particularly vulnerable to
adverse medical consequences if they concurrently use alcohol and/or street
drugs.
If there is little to no change in symptoms after 3 to 4 weeks, talk to the
doctor about raising the dose or changing the antidepressant.
Treatment with antidepressants usually lasts a minimum of 9 to 12 months.
Many patients are on long-term antidepressant therapy to avoid the frequency
and severity of depressive episodes.
Special Considerations for Pregnant Women
Using SSRIs is safer for the mother and fetus than using tricyclic antidepressants.
Fluoxetine (Prozac) is the most studied SSRI in pregnancy and no increased
incidence in birth defects has been noted, nor were developmental abnormalities
of the nervous system observed in preschool-age children (Garbis and McElhatton
2001). However, possible withdrawal signs have been observed in the newborn.
Fluoxetine (Prozac) is the recommended SSRI for use during pregnancy (Garbis
and McElhatton 2001). MAO Inhibitor use is not advised in pregnancy, and its use
should be discontinued immediately if a woman discovers she is pregnant
(Mortola 1989).

The physician should discuss the safety of antidepressant medications before

starting, continuing, or discontinuing medication treatment with all women of
childbearing age who may be or think they may be pregnant. Substance abuse
counselors may have a role in encouraging this discussion between their clients
and the prescribing physician.
Antianxiety Medications
Generic Brand

See also SSRI Antidepressants

Benzodiazepines
Alprazolam Xanax
Chlordiazepoxide Librium, Libritabs, Librax
Clonazepam Klonopin
Clorazepate Tranxene
Diazepam Valium
Lorazepam Ativan
Oxazepam Serax

Beta-blockers
Propranolol Inderal

Other
Buspirone BuSpar
Gabapentin Neurontin
Hydroxyzine Atarax, Vistaril
Olanzapine Zyprexa, Zyprexa Zydis
Pregabalin Lyrica
quetiapine fumarate Seroquel
risperidone Risperdal
tiagabine hydrochloride Gabitril
Purpose
Antianxiety medications are used to help calm and relax the anxious person as
well as remove troubling symptoms associated with generalized anxiety disorder,
posttraumatic stress disorder (PTSD), panic, phobias, and obsessive-compulsive
disorders (OCD). The most common antianxiety medications are the
antidepressants and the benzodiazepines. Positive treatment response to
antianxiety medications varies a great deal by medication class.

SSRI antidepressants have become first line medications for the treatment of
panic, social phobia, obsessive-compulsive disorders (in higher doses) and, more
recently, generalized anxiety disorder. Positive treatment response to
antidepressant medications includes a gradual reduction in anxiety, panic, and
PTSD or OCD symptoms over weeks to months.

Benzodiazepines have a depressant effect on the central nervous system. Positive

treatment response to benzodiazepines occurs rapidly, within days. However,
especially among persons with co-occurring substance use disorders, the response
may be short-lived and tolerance develops leading to the need for increased
doses. Additionally, benzodiazepines are cross tolerant18 with alcohol and have a
market as street drugs. For these reasons, most addiction medicine physicians only
use them for a short time as alcohol withdrawal medicines, or as sedatives in
acute19 psychotic or manic episodes. If used in outpatient settings, careful
monitoring for tolerance and abuse is needed.

Beta-blockers work on the central nervous system to reduce the flight or fight
response. Propranolol (Inderal), occasionally prescribed for performance
anxiety, is not addictive.

Buspirone (BuSpar) works through the serotonin system to induce calm. It takes 3
to 4 weeks for buspirone (BuSpar) to reach adequate levels in the brain to
successfully combat anxiety. Hydroxyzine (Atarax, Vistaril) is an antihistamine
that uses the drowsiness side effect of the antihistamine group to calm and relax.
Hydroxyzine works within an hour of being taken. Buspirone (BuSpar) and
hydroxyzine (Atarax, Vistaril) are not addictive.

Low doses of risperidone (Risperdal), quetiapine fumarate (Seroquel),

olanzapine (Zyprexa), or other atypical antipsychotics are sometimes used “off
label” as non-addictive antianxiety medications. They are usually used when
several other medications have failed (though use of atypical antipsychotics is
expensive and not FDA approved for treatment of anxiety disorders). Their
special formulation works to reduce anxiety and help the person think more
clearly, though the mechanism for this is unclear.

Gabapentin (Neurontin), tiagabine (Gabitril), and pregabalin (Lyrica) have all

been used to treat anxiety (off label) especially in those persons with an addiction
history and for whom antidepressants have been effective. These agents are all-
mildly sedative, and do not cause a high dependence, or withdrawal. They are
thought to enhance the effects of the body’s own naturally produced calmative
agent, gamma aminobutyric acid (GABA).20 None are FDA approved for
treatment of anxiety disorders.
Usual Dose, Frequency & Side Effects
All medications have specific doses and frequencies. The physician will specify
the exact amount of medication and when it should be taken. This information is
provided on the prescription bottle. Usually, people are started on a low dose of
medication, which is raised gradually until symptoms are removed or diminished.
Major factors considered in establishing the correct dose are individual body
chemistry, weight, and ability to tolerate the medication.

People taking benzodiazepines for longer than 4 to 8 weeks may develop physical
tolerance to the medication. Benzodiazepines have a relatively low potential for
abuse in those without addiction histories, but moderate or higher potential in
those with addiction histories. Even when taken as directed, withdrawal
symptoms may occur if regular use of benzodiazepines is abruptly stopped.
Withdrawal from high dose abuse of benzodiazepines may be a life-threatening
situation. For these reasons benzodiazepines are usually prescribed for brief
periods of time—days or weeks—and sometimes intermittently for stressful
situations or anxiety attacks. Except for treating alcohol or benzodiazepine
withdrawal, or for acute sedation in manic or psychotic states, benzodiazepines
are not recommended for most people with a past or current history of substance
abuse or dependence.

Beta-blockers act on the sympathetic nervous system and are not considered
addictive. They also are used to treat high blood pressure, thus side effects might
be low blood pressure or dizziness. Beta-blockers may enhance the effects of
other psychotropic medications and are inexpensive. Propranolol (Inderal) is
taken as needed for performance anxiety. It is taken regularly (as prescribed) for
treatment of high blood pressure or other heart conditions.

Buspirone (BuSpar) is often used to control mild anxiety and is considered safe
for long-term therapy but is expensive.

Hydroxyzine (Atarax and Vistaril) are safe, and nonaddictive medications used to
reduce anxiety. They are inexpensive and may be used for longer-term therapy.
Common side effects are dry mouth and sedation. A less common side effect is
urinary retention in older men; this is a serious condition.
Potential Side Effects
Blood cell irregularities
Constipation
Depression
Drowsiness or lightheadedness
Dry mouth
Fatigue
Heart collapse (weakened heart muscles)
Loss of coordination
Memory impairment (Inderal)
Mental slowing or confusion
Slowed heart beat (Valium)
Stomach upset
Suppressed breathing (restrained or inhibited)
Weight gain
Potential for Abuse or Dependence
Between 11 and 15 percent of people in the U.S. take a form of antianxiety
medication—including benzodiazepines—at least once each year. If
antidepressants are included, this figure is doubled. Benzodiazepines may cause at
least mild physical dependence in almost everyone who uses the medication for
longer than 6 months (i.e., if the medicine is abruptly stopped, the person will
experience anxiety, increased blood pressure, fast heartbeat, and insomnia).
However, becoming physically dependent on benzodiazepines does not
necessarily mean a person will become psychologically dependent or addicted to
the medication. Most people can be gradually withdrawn from the medication—
when indicated—and will not develop psychological dependence.

In general, abuse and dependence occur at lower rates with long-acting antianxiety
medications (e.g., Klonopin, Serax, and Tranxene). Abuse and dependence are
more likely to occur with faster-acting, high-potency antianxiety medications (e.g.,
Ativan, Valium, and Xanax).

Risk Factors Related to Developing Dependency on

Antianxiety Medication:
Less than 1% of persons who do not have a current substance abuse problem or
a history of substance abuse becomes dependent on antianxiety medications.
These people are at little or no risk. They are more likely to skip doses, take
lower doses than prescribed, or decrease their dose over time.

People with a prior history of substance abuse or dependence who are in recovery
are at increased risk of becoming dependent on antianxiety medications. These
people are at moderate risk.

Those with a history of abusing antianxiety medications or those who are opiate
users are at higher risk of becoming dependent on antianxiety medications. Some
studies indicate there is a moderately higher risk for alcohol dependent persons to
become dependent on antianxiety medications.
Emergency Conditions
High doses of diazepam (Valium) can cause slowed heartbeat, suppression of
breathing, and stop the heart from beating. Overdose on the older tricyclic
antidepressant medications, which are often used for combined anxiety depression
disorders, can be life threatening and immediate referral to emergency care is
indicated.

Withdrawal from regular use of any of the benzodiazepines and similar

medications must be done slowly over a month’s time. Abrupt withdrawal from
these medications can cause hallucinations, delusions and delirium, disorientation,
difficulty breathing, hyperactivity, and grand mal seizures. A protocol for
decreasing or tapering off doses of benzodiazepines is needed.
Cautions
Doctors and pharmacists should be told about all medications being taken
and dosage, including over-the-counter preparations, vitamins, minerals, and
herbal supplements (i.e., St. John’s wort, Echinacea, ginkgo, ginseng).
People taking antianxiety medications should not increase their dose unless
this has been checked with their physician and a change is ordered.
People should not stop using these medications without talking to a doctor.
People taking antianxiety medication are particularly vulnerable to adverse
medical consequences if they concurrently use alcohol and/or street drugs.
Using alcohol in combination with benzodiazepines may result in breathing
failure and sudden death.
Special Considerations for Pregnant Women
The current state of knowledge suggests that benzodiazepine therapy in general
does not pose as much risk of producing a deformed baby as compared to
anticonvulsants (e.g., valproic acid) as long as they are given over a short time
period. It appears that short-acting benzodiazepines, like those used to treat
alcohol withdrawal (detoxification21), can be used in low doses even in the first
trimester (Robert et al. 2001). Long-acting benzodiazepines should be avoided—
their use during the third trimester or near delivery can result in a withdrawal
syndrome in the baby (Garbis and McElhatton 2001). For use of the SSRIs in
pregnancy, see page 679.

During pregnancy, the capacity of many drugs to bind to proteins22 is decreased,

including diazepam (a benzodiazepine) and Methadone (Adams and Wacher
1968; Dean et al. 1980; Ganrot 1972) with the greatest decrease noted during the
third trimester (Perucca and Crema 1982). From a clinical standpoint, pregnant
women could be at risk for developing greater toxicity23 and side effects to these
medications. Yet at the same time, increased metabolism of the medication may
result, reducing the therapeutic effect (such as with methadone since many women
seem to require an increase in their dose of methadone during the last trimester)
(Pond et al. 1985). In addition, there is a documented withdrawal syndrome in
newborns exposed to benzodiazepines in utero (Sutton and Hinderliter 1990).
Onset of this syndrome may be delayed more so than that associated with other
drugs.

For all women of childbearing age who may be or think they may be pregnant, the
physician should discuss the safety of this medication before starting, continuing,
or discontinuing medication treatment. Substance abuse counselors may have a
role in encouraging this discussion by suggesting their clients talk with the
prescribing physician.
Stimulant Medications
Generic Brand
d-amphetamine Dexedrine
l & d-amphetamine Adderall, Adderall CII, Adderall XR
methamphetamine Desoxyn
methylphenidate Ritalin, Ritalin SR, Concerta, Metadate ER, Metadate CD,
Methylin ER, Focalin
pemoline Cylert
modafinil Provigil

Non-stimulants for AD/HD24

atomoxetine hydrochloride Strattera
bupropion Wellbutrin
guanfacine Tenex
Purpose
Stimulant medications are used to treat attention deficit/hyperactivity disorder
(AD/HD), which is typically diagnosed in childhood but also occurs in adults.
Symptoms consistent with AD/HD include short attention span, excessive activity
(hyperactivity), impulsivity, and emotional development below the level expected
for the person’s age. The underlying manifestation of AD/HD is that it severely
impacts and interferes with a person’s daily functioning. Other conditions that may
be treated with stimulants are narcolepsy25, obesity, and sometimes depression.

Positive treatment responses to stimulant medications include increased attention,

focus and/or ability to stay on task, less hyperactivity, and moderation of
impulsive behavior. People with AD/HD generally report that they feel “normal”
when taking stimulants.

Non-stimulant medications for AD/HD differ somewhat. Atomoxetine (Strattera)

blocks the reuptake of norepinephrine, which helps reduce the symptoms of
AD/HD. Guanfacine (Tenex) and bupropion (Wellbutrin) are non-stimulants that
have been used successfully to treat symptoms of AD/HD. The advantage of these
medications is that they are non-addictive, and do not cause a “high” even in
larger doses. Atomoxetine (Strattera) is FDA approved. While studies have
shown bupropion (Wellbutrin) to be effective, it is not FDA approved.
Usual Dose, Frequency & Side Effects
All medications have specific doses and frequencies. The physician will specify
the exact amount of medication and when it should be taken. This information is
provided on the prescription bottle. With stimulants, there may be periods when
the medication is not to be taken. The most common side effects of the stimulants
are nervousness, sleeplessness, and loss of appetite. Some of these medications
are expensive, but others are generic and quite inexpensive.
Potential Side Effects

Stimulants
Blood disorders (Ritalin and Cylert)
Change in heart rhythm
Delayed growth
Dilated pupils
Elevated blood pressure
Euphoria
Excitability
Increased pulse rate
Insomnia
Irritability
Liver damage (Cylert)
Loss of appetite
Rash
Seizures (Ritalin and Cylert)
Tourette’s syndrome (Cylert)
Tremor

Non-stimulants for AD/HD

Strattera side effects include:

High blood pressure

Nervousness, and side effects similar to some antidepressants

Wellbutrin side effects include:

Increased chance of seizure activity

Tenex side effects include:

Constipation
Dizziness
Dry mouth
Low blood pressure
Sleepiness
Potential for Abuse or Dependence
Stimulant medications may be misused. Recreational or non-medically indicated
uses have been reported for performance enhancement and/or weight loss. People
with AD/HD or narcolepsy, however, rarely abuse or become dependent on
stimulant medications unless they have an addiction problem with other
substances. Most addiction medicine doctors use antidepressants or atomoxetine
(Strattera) (both non-stimulants) to treat AD/HD in adults with co-occurring
substance use disorders. Using stimulant medications to treat AD/HD in children
has been shown to reduce the potential development of substance use disorders.
Emergency Conditions
Psychiatric symptoms including paranoid delusions, thought disorders, and
hallucinations have been reported when stimulants are used for long periods or
taken at high dosages. Overdose with stimulants is a medical emergency. Seek
help immediately.
Cautions
Doctors and pharmacists should be told about all medications being taken
and dosage, including over-the-counter preparations, vitamins, minerals, and
herbal supplements (i.e., St. John’s wort, Echinacea, ginkgo, ginseng).
People taking stimulant medications should not increase their dose unless this
has been checked with their physician and a change is ordered.
People taking stimulant medications are particularly vulnerable to adverse
medical consequences if they concurrently use alcohol and/or street drugs.
With stimulants, there is the potential for development of tolerance and
dependence on the medications with accompanying withdrawal. The
potential for abuse and misuse is high, as is true with all Schedule II drugs.26
Special Considerations for Pregnant Women
For women of childbearing age who may be or think they may be pregnant, the
physician should discuss the safety of this medication before starting, continuing,
or discontinuing medication treatment. Substance abuse counselors may have a
role in encouraging this discussion by suggesting their clients talk with the
prescribing physician.
NARCOTIC AND OPIOID ANALGESICS

Natural opioids
Opium, morphine and codeine products

Pure, semi or totally synthetic derivatives

Heroin, Percodan, Demerol, Darvon, oxycodone, and others
Generic Brand
buprenorphine Buprinex
buprenorphine Subutex, Suboxone*
butorphanol tartarate Stadol spray
codeine phosphate Codeine tablets
codeine sulfate Codeine tablets
dihydromorphone hydrochloride Dilaudid-5, Dilaudid HP
fentanyl transdermal Duragesic patches
fentanyl transmucosal Fentanyl, Oraley
hypromorphone hydrochloride Dilaudid
meperidine hydrochloride Demerol
methadone hydrochloride Methadone
morphine hydrochloride Morphine
morphine sulfate Oramorph, Roxanol, Statex
oxycodone hydrochloride Roxicodone, OxyContin
oxymorphone hydrochloride Numorphan
pentazocine hydrochloride Talwin
propoxyphene hydrochloride Darvon
propoxyphene napsylate Darvon-N
tramadol hydrochloride Ultram

*Combined with naloxone27 and taken under the tongue (sublingually).

The following products use a combination of an opioid or narcotic along with

aspirin, Tylenol, or other pain reliever to treat mild to moderate pain.

Anesxia 5/50 Percocet

Capital with Codeine Percodan
Darvocet N 100 Roxicet
Darvocet N 50 Roxicet oral solution (contains alcohol)
E-Lor or Wygesic Roxiprin
Empirin or Phenaphen with Codeine #3 Talacen
Empirin or Phenaphen with Codeine #4 Talwin Compound
Endocet Tylenol with Codeine
Fioricet with Codeine Tylenol with Codeine syrup (contains alcohol)
Fiorinal with Codeine Tylox
Lorcet Plus Vicodin
Lortab Vicodin ES
Purpose
Opiate medications are commonly used to control moderate to severe acute pain.
They are typically used for a short time because they cause physiological
tolerance (takes more to get the same analgesic effect) and physical dependence
(get withdrawal symptoms if abruptly stopped) as amount and duration of doses
increase. Longer-term use is indicated to alleviate the chronic pain associated
with cancer and certain other conditions, and research has shown that abuse or
addiction to these medications rarely occurs in such patients. Severe and chronic
pain has long been under treated in the United States due to irrational fears that
anyone prescribed opiates will become addicted. This has clearly been shown to
be not the case. People with substance use disorders need pain management just
like anyone else. Opioids are appropriately prescribed to manage chronic cancer
pain—especially oxycodone (OxyContin) and methadone.

Methadone is a synthetic opioid used in heroin detoxification treatment programs

to maintain sobriety from heroin addiction. Many people who have been addicted
to heroin have returned to a productive life because of methadone treatment.
Methadone is also frequently used to provide relief for specific types of pain,
especially in pain clinics. The management of chronic pain in a person who has
been opiate abusing and dependent is one of the most challenging tasks in
addiction medicine.

Heroin is a drug of abuse.

Usual Dose & Frequency
All narcotic and opioid analgesics have specific doses and frequencies. The
physician will specify the exact amount of medication and when it should be
taken. This information is provided on the prescription bottle. Many narcotic or
opioid medications are taken two or more times a day. Some medications are
taken in pill or liquid form. A few are taken in a nasal spray or as transdermal
patches. Injectable narcotics are not listed here because they are not often used
outside a hospital setting.
Potential Side Effects
Constipation
Decreased ability to see clearly
Decreased ability to think clearly
Flushing and sweating
Pupil constriction
Respiratory depression (slowed breathing rate)
Stomach upset
Tolerance
Potential for Abuse or Dependence
With narcotic and opioid medications, there is a potential for the development of
tolerance and dependence as well as the possibility of abuse and severe
withdrawal reactions. There are many nonaddictive pain medications available
for pain management that can be used after acute pain is reduced.
Emergency Conditions
Convulsions and/or cardiac arrest with high dosages.
Overdose may increase pulse rate, result in convulsions followed by coma or
death.
Overdose may depress the breathing centers in the brain leading to inability
to breathe.
An overdose is always considered an emergency and treatment should be
sought immediately.
Cautions
Doctors and pharmacists should be told about all medications being taken
and dosage, including over-the-counter preparations, vitamins, minerals, and
herbal supplements (i.e., St. John’s wort, Echinacea, ginkgo, ginseng).
People taking narcotic and opioid analgesics should not increase their dose
unless this has been checked with their physician and a change is ordered.
Persons taking an opioid medication are particularly vulnerable to adverse
medical consequences if they concurrently use alcohol and/or street drugs,
because alcohol and street drugs can increase the sedation effects of the
opioids.
Potential for development of tolerance and dependence exists.
Special Considerations for Pregnant Women
For all women of childbearing age who may be or think they may be pregnant, the
physician should discuss the safety of this medication before starting, continuing,
or discontinuing medication treatment. Both pregnant women and their unborn
infants can become tolerant and physically dependent on opioids. This
dependence as well as possible withdrawal syndromes needs to be assessed.
Substance abuse counselors may have a role in encouraging this discussion by
suggesting their clients talk with the prescribing physician. See page 683 for
information about methadone use during pregnancy.
Hypnotics (Sleep-Aids)
Generic Brand

Barbiturates
secobarbital Seconal

Benzodiazepines
clonazepam Klonopin
diazepam Valium
estazolam ProSom
flurazepam Dalmane
lorazepam Ativan
oxazepam Serax
quazepam Doral
temazepam Restoril
triazolam Halcion

Non-benzodiazepines
anticonvulsants Neurontin*, Depakote*, Topamax*
sedating antidepressants Desyrel, Remeron, Serzone, Sinequan
sedating antipsychotics Seroquel*, Zyprexa*, Zyprexa Zydis*
zaleplon Sonata
zolpidem Ambien

*Use of these medications for sleep aid is “off-label.”

Purpose
Hypnotics are used to help people with sleep disturbances get restful sleep. Lack
of sleep is one of the greatest problems faced by those with chemical dependency
and psychiatric illnesses. It can cause the symptoms of these disorders to worsen.
For example, mood changes, psychosis and irritability increase with insomnia.
Lack of sleep diminishes a person’s ability to think clearly or process information.
Sleep-wake cycles and the body’s ability to heal itself also suffer when a person
is sleep deprived. Older hypnotics, like barbiturates, cause the body to slow
down and “pass out” or sleep. However, they also have a tendency to disturb
sleep cycles. For this reason, and because of their potential for abuse and
dependence, barbiturates are now rarely used.

Benzodiazepines enhance the body’s natural calming agents, which induces sleep.
Non-benzodiazepines such as zolpidem (Ambien) and zaleplon (Sonata) affect
one of the body’s receptors for the natural calming agent, GABA. These
medications are short acting and do not disturb sleep-staging cycles. Rebound
insomnia is a side effect of both, however, if the medications are used for more
than two weeks and then abruptly stopped.

Sedating antidepressants work by using their sleep producing side effects to

induce sleep. They are nonaddictive but have the capacity to produce all the side
effects of their class of antidepressant. Sedating antipsychotics use their calming
and sedation side effects to induce sleep. They are nonaddictive but have the
capacity to produce all the side effects of atypical antipsychotics. Anticonvulsants
may be used for sedation when treating acute or prolonged withdrawal symptoms
from alcohol.

Paradoxically, those with addiction disorders can become rapidly tolerant and
dependent on the most commonly used hypnotics, which are the benzodiazepines
and even one of the non-benzodiazepines— zolpidem (Ambien). Tolerance can
lead to decreasing effectiveness, escalating doses, and an even worse sleep
disorder when the agent is withdrawn. For this reason, most addiction medicine
doctors use sedating antidepressants, anticonvulsants, or sedating antihistamines if
the sleep problem continues past acute withdrawal symptoms.
Usual Dose & Frequency
All medications have specific doses and frequencies. The physician will specify
the exact amount of medication and when it should be taken. This information is
provided on the prescription bottle. All of these medications are generally used
for limited periods (3 to 4 days for barbiturates or up to a month for others). All
of these medications quickly develop tolerance and eventually the usual dose will
no longer help the person sleep.
Potential Side Effects
Breathing difficulty (Seconal)
Dizziness
Drowsiness
Hangover feeling or daytime sleepiness
Headache
Lethargy
Weakness
Potential for Abuse or Dependence
With hypnotics, there is the potential for development of tolerance and
dependence on the medications with accompanying withdrawal. The potential for
abuse and misuse is high. See Potential for Abuse or Dependence for
benzodiazepines, page 682. There are many drawbacks to long-term use of
hypnotics such as damaged sleep staging and addiction. Even zolpidem (Ambien)
and zaleplon (Sonata), if taken for longer than 7 to 14 days, can have a
discontinuation rebound insomnia effect. Nonaddictive medications are available
to treat insomnia.
Emergency Conditions
Overdose with any of these medications can be life threatening. Seek help
immediately.

Combinations of alcohol and barbiturates or alcohol and benzodiazepines can be

deadly.
Cautions
Doctors and pharmacists should be told about all medications being taken
and dosage, including over-the-counter preparations, vitamins, minerals, and
herbal supplements (i.e., St. John’s wort, Echinacea, ginkgo, ginseng).
People taking hypnotic medications should not increase their dose unless this
has been checked with their physician and a change is ordered.
People taking hypnotic medications are particularly vulnerable to adverse
medical consequences if they concurrently use alcohol and/or street drugs.
There is potential for development of tolerance and dependence with
accompanying withdrawal. Potential for abuse and misuse is high.
Special Considerations for Pregnant Women
Barbiturate use during pregnancy has been studied to some extent, but the risk of
taking this medication should be discussed with the client (Robert et al. 2001).
There also are reports of a withdrawal syndrome in newborns following prenatal
exposure to some barbiturates (Kuhnz et al. 1988). For all women of childbearing
age who may be or think they may be pregnant, the physician should discuss the
safety of this medication before starting, continuing, or discontinuing medication
treatment. Substance abuse counselors may have a role in encouraging this
discussion by suggesting their clients talk with the prescribing physician.
Addiction Treatment Medications
ALCOHOL

Generic Brand

Alcohol withdrawal agents*

benzodiazepines (e.g., lorazepam) Ativan
anticonvulsants (e.g., carbamazepine,
divalproex sodium, gabapentin) Tegretol, Depakote, Neurontin
barbiturates (e.g., secobarbital) Seconal

*For more information on benzodiazepines, anticonvulsants and barbiturates see

Antimanic Medications, Antianxiety Medications and Hypnotics sections in this
publication.

Alcohol relapse prevention agents

disulfiram Antabuse
naltrexone hydrochloride ReVia
naltrexone extended-release injection Vivitrol
acamprosate Campral
nalmefene hydrochloride Revex
topiramate Topamax
Purpose
Medications involved in alcohol treatment include those used for acute alcohol
withdrawal as well as a growing number used for alcohol relapse prevention.
Alcohol relapse prevention medications are just starting to be accepted in the
field. It is anticipated that within the next few years, medications like naltrexone
(ReVia) and acamprosate (Campral) will be more widely used given the
developing body of research indicating that these medications work.

Alcohol withdrawal: Though usually only treated for 1 to 5 days, signs and
symptoms of alcohol withdrawal go on for weeks or months. Signs and symptoms
especially include sleep disorder, anxiety, agitation, and craving alcohol, knowing
that a few drinks may temporarily make the alcoholic with “protracted
withdrawal” feel more normal.

Benzodiazepines are by far the most commonly used medications for acute
withdrawal. If used longer than a few days, they induce tolerance and dependence.
Anticonvulsants such as carbamazepine, divalproex sodium, and gabapentin are
more commonly used in Europe. The advantage in using these medications is that
they can be prescribed for weeks and months versus only days. A well-designed
U.S. study (Malcolm et al. 2002) demonstrated that carbamazepine is much
superior to lorazepam, a commonly used benzodiazepine, in treating alcohol
withdrawal. Propranolol (Inderal), a beta-blocker, is sometimes used in alcohol
withdrawal treatment along with either benzodiazepines or anticonvulsants to
decrease anxiety, heart rate, sweating, and blood pressure. Antipsychotics may be
used if the person develops severe alcohol withdrawal with hallucinations.

Alcohol relapse prevention: The oldest medication used in alcohol relapse

prevention is disulfiram (Antabuse). It has been used for over 50 years.
Disulfiram (Antabuse) blocks the breakdown of alcohol, resulting in toxic
acetaldehyde28 levels in the body. This in turn leads to severe nausea and
vomiting. Research indicates disulfiram (Antabuse) works better than placebo
only in persons motivated enough to take it regularly, or in those that receive it in
a “monitored” fashion 3 to 5 times per week. It works by causing the person to
rethink a move to impulsive drinking, since they know if they have disulfiram
(Antabuse) on board, they will get sick.

Naltrexone (ReVia) was first developed as an opioid receptor blocker and used
in monitored treatment programs for opioid dependence. Many opioid addicts,
however, stopped taking it and returned to opioid use or they preferred methadone
maintenance therapy. In spite of this, clinical observation of persons taking
naltrexone showed that those who also used alcohol seemed to drink less and
reported that alcohol use affected them less. Subsequent controlled, clinical trials
comparing use of naltrexone to placebo condition have shown its effectiveness
over placebo to decrease alcohol craving and relapse potential. Research with
community populations (where persons are not monitored as closely for
medication adherence) has not supported its effectiveness over a placebo
condition to promote abstinence.

A new long-acting injectable form of naltrexone is now available. Use of this

monthly treatment with even those persons who are less motivated about their
recovery has led to a reduction in days drinking; and when drinking does occur,
they consume less alcohol. Thus, naltrexone may be best seen as a “harm
reduction” medicine versus a “complete abstinence” treatment enhancer.

Naltrexone is nonpsychoactive29 and as an opioid receptor blocker, it can

interfere with the use of opioids for treatment of acute pain. For more information
on Naltrexone, see TIP 28: Naltrexone and Alcoholism Treatment (CSAT 1998).

Acamprosate (Campral) was FDA approved in early 2005. It has been available
in Europe and other countries for over 10 years. Acamprosate appears to work
through the GABA system and holds promise for alcohol craving and preventing
relapse through a method different than naltrexone. It is reported to be
nonpsychoactive, does not interact with most other medications, and does not
cause any kind of tolerance or withdrawal symptoms even if the person uses
alcohol when taking the medication.

Unlike the injectable naltrexone, acamprosate does not appear to be effective in

persons who are less than moderately motivated to abstain from alcohol use.
Because of the way the medication is absorbed in the body, it must be taken
several times a day. Outcome studies indicate that acamprosate is best at
increasing complete abstinence from alcohol, or increasing the time before the
first drink (relapse). The profile of the person for whom acamprosate would be
selected is one seeking complete abstinence and who is moderately to highly
motivated to abstain from alcohol use.

Nalmefene (Revex) is beginning to be used in its oral form to reduce alcohol

craving; it is also beginning to be used in gambling and nicotine addictions.

Topiramate (Topamax) is an anticonvulsant that at higher doses can cause

sedation and confusion.
Opioids
Generic Brand

Opioid withdrawal agents

buprenorphine Subutex
buprenorphine and naloxone Suboxone
clonidine Catapres
methadone hydrochloride Methadone
naltrexone hydrochloride ReVia
naltrexone extended-release injection Vivitrol
nalmefene hydrochloride Revex

Opioid maintenance agents

buprenorphine Subutex
buprenorphine and naloxone Suboxone
methadone hydrochloride Methadone
Purpose
Medications for opioid withdrawal and maintenance are a key component in the
stabilization of persons addicted to opiates. These medications have shown
marked ability to decrease illness, crime, and deaths in this population.
Methadone maintenance treatment is extensively researched. See TIP 19:
Detoxification from Alcohol and Other Drugs (CSAT 1995) and TIP 20:
Matching Treatment to Patient Needs in Opioid Substitution Therapy (CSAT
1995).

Opioid withdrawal: Mild opioid withdrawal can be accomplished with

clonidine, a medication for treatment of high blood pressure. Usually clonidine is
used in combination with sedatives such as benzodiazepines, antihistamines or
even phenobarbital. Major opioid withdrawal is usually treated with either an
equivalent dose of methadone gradually decreased over time, or more recently, a
single dose of 24 mg of buprenorphine. In pilot studies, buprenorphine appears
superior to clonidine.

Opioid maintenance agents: Methadone has been used in the U.S. for
maintenance treatment of opioid addiction since the 1960s. It is a synthetic, long-
acting medication used in heroin detoxification programs to maintain abstinence
from heroin use. When used in proper doses, methadone stops the cravings but
does not create euphoria, sedation, or an analgesic30 effect. Many people who
have been addicted to heroin have returned to a productive life because of
methadone treatment programs. Methadone also is occasionally used to provide
relief for specific types of pain. (See also Narcotic and Opioid Analgesics, page
686.)

Buprenorphine, or Subutex, is a prescription medication approved in 2002 for

treating opioid addiction. It can be used for both opioid withdrawal and as a
substitute for opioids in long-term treatment. Buprenorphine is the first medication
available to doctors for use in their office-based practice. At low doses, it acts
like methadone and satisfies the dependent person’s need for an opioid to avoid
painful withdrawal. It does not provide the user with the euphoria or rush
typically associated with use of other opioids or narcotics. At moderate to high
doses, it can precipitate withdrawal. It is, therefore, safer in overdose than
methadone. Suboxone is buprenorphine combined with naloxone, a narcotic
antagonist31 used to reverse the effects of opioids. Suboxone is also approved for
treating opioid addiction and offers the same benefits as those previously stated
for buprenorphine.

Naltrexone and nalmefene completely block the pleasurable reinforcement that

comes from opioids. They are beginning to be more widely used for alcohol
relapse prevention (see pages 691–692). Nalmefene is more commonly used in its
injectable form to reverse the effects of opioids when used for anesthesia. It is
beginning to be used in its oral form to reduce alcohol craving; it is also beginning
to be used in gambling and nicotine addictions.
Tobacco
Generic Brand

Nicotine Replacement Therapies (NRT)

nicotine patch/transdermal nicotine Nicoderm CQ, Nicotrol, Habitrol,
Prostep
nicotine polacrilex gum Nicorette
nicotine polacrilex lozenges Commit
nicotine inhaler Nicotrol Inhaler
nicotine nasal spray Nicotrol NS

Pharmacotherapies for Smoking Cessation

varenicline tartrate Chantix
bupropion, bupropion SR Wellbutrin, Wellbutrin SR, Zyban
nortriptyline Aventyl, Pamelor
clonidine Catapres
Purpose
Complete long-term abstinence from all nicotine-containing products is the goal of
tobacco cessation therapies. Medications and products for tobacco cessation
assist clients with nicotine dependence32 to achieve abstinence by alleviating or
reducing common nicotine withdrawal symptoms33 and cravings. Numerous
scientific studies have shown that is easier for individuals to quit tobacco when
supported by a medical or a mental health clinician. For this reason,
recommended treatment strategies incorporate both behavioral counseling and
pharmacotherapy. Nonetheless, pharmacotherapy is contraindicated for some
specific populations (i.e., pregnant women, smokeless tobacco users, light
smokers, and adolescents). Empirically validated tobacco treatment strategies are
available as cited in the 2008 Treating Tobacco Use and Dependence Guidelines
(DHHS 2008).

Nicotine, the addictive chemical in cigarettes and other forms of tobacco, crosses
the blood-brain barrier and activates the brain’s reward center. This causes the
brain to release noradrenaline and dopamine, which act as stimulants (implicated
in mood, memory, and a sense of well-being). Nicotine remains active for 20-40
minutes in the brain, and then withdrawal symptoms begin, leading to cravings for
more nicotine.

Nicotine Replacement Therapies (NRT) such as transdermal nicotine patch,

nicotine polacrilex gum and lozenge, nicotine nasal spray, and nicotine inhaler are
FDA approved. These therapies reduce withdrawal symptoms and cravings by
replacing nicotine that would be ingested through chewing tobacco or smoking
cigarettes. Numerous clinical trials involving NRT have demonstrated the
effectiveness of these products for smoking cessation.

Bupropion, as an antidepressant, can help with withdrawal anxiety and

depression. Sustained-release bupropion (bupropion SR) is one of the few non-
nicotine pharmaceutical aids that are FDA approved for smoking cessation. This
agent is thought to affect dopamine34 and norepinephrine35 levels, and blocks
nicotinic acetylcholinergic receptors,36 thereby decreasing cravings for cigarettes
and symptoms of nicotine withdrawal. The use of bupropion roughly doubles
cessation rates relative to placebo, and the combination of bupropion with the
nicotine patch has shown higher quit rates than using the patch alone.
Varenicline (Chantix) is a more recently FDA approved smoking cessation
medication and the first in its class targeting specifically the neurobiology of
nicotine addiction. It reduces the smoker’s craving for nicotine by binding to
nicotine receptors in the brain and thereby reducing withdrawal symptoms as well
as resulting in a less satisfying smoking experience. Smokers using varenicline
have better rates of smoking cessation compared to those who use bupropion.
Chantix offers a new option for those who cannot tolerate the adverse effects
associated with NRT and bupropion, and represents an alternative for clients with
contraindications to such therapies.
Others
Stimulant intoxication: Agitation, paranoia and psychosis are treated with
antipsychotics, often combined with benzodiazepines. Both alcohol and stimulant
intoxication together commonly appear to cause these symptoms.

Stimulant withdrawal: There are no standard effective agents to treat stimulant

withdrawal, though dopamine-enhancing agents such as amantadine, bupropion
(Wellbutrin), and desipramine have been tried with mixed results. This area has
not been well researched.

Stimulant relapse prevention: Again, dopamine-enhancing agents such as

bupropion (Wellbutrin) and desipramine have mixed results. The National
Institute on Drug Abuse (NIDA) is researching agents that might alter how
stimulants act on a person, including the development of “inoculation” agents that
might inactivate stimulants.

Club Drugs: Little research has occurred in this area. There are reports that
SSRI’s may be protective of the damage caused to nerve cells by some of these
drugs. Antipsychotics and sedatives are used to treat induced psychoses
associated with club substance abuse.

Marijuana: Recently, a withdrawal syndrome to marijuana dependence has been

described and validated. Medications for treating this syndrome have not been
adequately tested. THC37, the chief intoxicant in marijuana, is a strong
anticholinergic agent and is sedating. Therefore some clinicians have used
moderate doses of the older tricyclic antidepressants (e.g., Elavil or Tofranil) to
treat withdrawal from marijuana as they also have anticholinergic and sedating
qualities but do not cause a high, nor are they abused.
Usual Dose & Frequency
All medications have specific doses and frequencies. The physician will specify
the exact amount of medication and when it should be taken; this information is
provided on the prescription bottle. Disulfiram (Antabuse) should never be given
to people without their full knowledge or when they are intoxicated. It should not
be given until the person has abstained from alcohol for at least twelve hours. A
daily, uninterrupted dose of disulfiram (Antabuse) is continued until the person is
in full and mature recovery and has reorganized his or her life to maintain
recovery. Maintenance therapy may be required for months or even years.

Naltrexone (ReVia) in its oral form is usually taken once a day but can be taken at
a higher dose every second or third day. It is usually started at full dose. The
injectable form of naltrexone (Vivitrol) is taken once a month. Because of the way
acamprosate (Campral) is absorbed, it must be taken as two pills three times a
day with each dose separated by at least four hours.

Buprenorphine combined with naloxone (Suboxone) is given as a sublingual

tablet (it is absorbed under the tongue). It is not absorbed if swallowed or
chewed. If injected intravenously, Suboxone will cause opioid withdrawal.
Suboxone and buprenorphine (Subutex) can be given by prescription and do not
require daily attendance at a clinic. This is an advantage for persons who do not
live near a methadone clinic.

People should continue to take naltrexone, acamprosate or Suboxone until they

have reached full and mature recovery and have reorganized their life to maintain
recovery.

Some Nicotine Replacement Therapy NRT medications can be obtained without a

prescription, including the nicotine patch, gum, and lozenge. Specific information
on how to use NRT products correctly, recommended dosing schedules, symptoms
of overdose, and proper storage/disposal of the products are included on the
product label or inside the package.

The nicotine patch is available in three strengths and a “step-down” approach is

used: 21 mg for 6 weeks, then 14 mg for 2 weeks, then 7 mg for 2 weeks. For
those who smoke less than one pack a day, consider starting at 14 mg dose. A new
patch needs to be reapplied each day, at roughly the same time each day.
The nicotine polacrilex gum and lozenge are offered in 2 milligrams (mg) and 4
mg. Individuals who smoke fewer than 25 cigarettes per day should initiate
therapy with the 2 mg strength, and heavier smokers should initiate with the 4 mg
strength. During the initial 6 weeks of therapy, one piece of gum should be chewed
every 1 to 2 hours while awake; at least nine pieces of gum daily. The gum should
be used for up to 12 weeks and no more than 24 pieces should be chewed a day. A
“chew and park” technique is necessary for nicotine to absorb correctly and food
or beverages should be avoided 15 minutes before or after using the nicotine gum.

Unlike other forms of NRT, which are dosed based on the number of cigarettes
smoked per day; the recommended dosage of the nicotine lozenge is based on the
“time to first cigarette” of the day. Some studies suggest that the best indicator of
nicotine dependence is having a strong desire or need to smoke soon after waking.
Clients who smoke their first cigarette of the day within 30 minutes of waking are
likely to be more highly dependent on nicotine and require higher dosages than
those who delay smoking for more than 30 minutes after waking. During the initial
6 weeks of therapy, clients should use one lozenge every 1 to 2 hours while
awake; at least nine lozenges daily. Clients can use additional lozenges (up to 5
lozenges in 6 hours or a maximum of 20 lozenges per day) if cravings occur
between the scheduled doses. The lozenges should be used for up to 12 weeks
with no more than 20 lozenges used a day. Lozenges should be allowed to
dissolve in the mouth and food or beverages should be avoided 15 minutes before
or after using the nicotine lozenge.

Bupropion should be started 7-14 days before a targeted smoking cessation date.
Generally, for the first 3 days of treatment, individuals take 150 mg, then 150 mg
twice a day for 7 to 12 weeks, and for some individuals, up to 6 months to
increase the likelihood of long-term tobacco cessation.

The approved course of varenicline (Chantix) treatment is 12 weeks; however, an

additional 12 weeks of treatment may increase the likelihood of long-term
smoking cessation for some individuals. For the first 3 days of treatment,
individuals take 0.5 mg once a day, followed by 0.5 mg twice a day for the next
four days, and then 1 mg twice a day for the remainder of the treatment period.

For certain groups of smokers, it may be appropriate to continue NRT treatment or

pharmacotherapies for periods longer than is usually recommended. In general, the
more intense the treatment for tobacco cessation (e.g., combined use of NRT and
pharmacotherapies), the higher the likelihood of successful cessation. Specific
combinations of first line medications shown to be effective include the nicotine
patch and bupropion SR, the nicotine patch and the inhaler, and long-term nicotine
patch (greater than 14 weeks) and ad libitum NRT use. Chantix is not
recommended for use in combination with NRT because of its nicotine antagonist
properties.
Potential Side Effects
Potential side effects for disulfiram (Antabuse) (rare at lower doses mostly
occur at higher doses > 500 mg day):

Dark urine
Drowsiness
Eye pain
Fatigue
Impotence
Indigestion
Inflammation of optic nerve
Jaundice
Light colored stool
Liver inflammation
Loss of vision
Psychotic reactions
Skin rashes, itching
Tingling sensation in arms and legs

Potential side effects for acamprosate (Campral) (Side effects on therapeutic

doses of acamprosate are rare, other than mild transient gastrointestinal symptoms
during the first week):

Agitation
Coma
Confusion
Decreased urine output
Depression
Dizziness
Headache
Irritability and hostility
Lethargy
Muscle twitching
Nausea
Rapid weight gain
Seizures
 Swelling of face ankles or hands
Unusual tiredness or weakness

Potential side effects for opioid treatment medications (See also Narcotic and
Opioid Analgesics, page 686):

Abdominal cramps
Body aches lasting 5–7 days
Diarrhea
Dizziness
Fatigue
Headache
Insomnia
Nausea
Nervousness
Opioid withdrawal (in some cases)
Runny eyes and nose
Severe anxiety
Vomiting

Potential side effects for NRT and pharmacotherapies for smoking cessation*

Nicotine patch: Skin reactions (i.e., itching, burning, redness or rash at patch site)
are usually mild and often resolved by rotating patch site. Other side effects
include insomnia and/or vivid dreams.

Nicotine gum: Mouth soreness, hiccups, indigestion, jaw muscle aches. Most of
these are mild and subside with continued use of the gum.

Nicotine lozenges: nausea, hiccups, heartburn. For 4mg. lozenge, increased rates
of headaches and coughing reported.

Bupropion: dry mouth, insomnia.

Chantix: nausea, trouble sleeping, abnormal/vivid/strange dreams.

*See FDA package insert for each product for a more complete list of side effects.
Emergency Conditions
An overdose of any addiction treatment medication is always considered an
emergency and treatment should be sought immediately.

Symptoms of a nicotine overdose may include nausea, vomiting, diarrhea, stomach

pain, cold sweats, headache, dizziness, problems with hearing or vision,
confusion, an irregular heartbeat, chest pain, seizures, and death.
Cautions
Doctors and pharmacists should be told about all medications being taken
and dosage, including over-the-counter preparations, vitamins, minerals, and
herbal supplements (i.e., St. John’s wort, Echinacea, ginkgo, ginseng).
People taking disulfiram (Antabuse) should be warned to avoid even small
amounts of alcohol in other food products or “disguised forms” as this will
cause a reaction (i.e., vanilla, sauces, vinegars, cold and cough medicines,
aftershave lotions, liniments).
People taking disulfiram (Antabuse) should be warned that consuming even
small amounts of alcohol will produce flushing, throbbing in head and neck,
headache, difficulty breathing, nausea, vomiting, sweating, thirst, chest pain,
rapid heart rate, blurred vision, dizziness, and confusion.
People taking opioid medications should not increase or decrease their dose
unless this has been checked with their physician and a change is ordered.
People taking opioid medications are particularly vulnerable to adverse
medical consequences if they concurrently use alcohol and/or street drugs.
People taking naltrexone or nalmefene should be warned that if they are
dependent on opioids, taking these medications will cause opioid
withdrawal for up to three days and block the effect of any opioids taken for
up to three days.
Smoking can have an effect on the way the body processes other prescribed
medications. Substances found in tar in cigarettes stimulate enzymes in the
liver, and fluctuations in an individual’s smoking pattern can result in higher
or lower doses of medications needed to reach therapeutic levels.
Although studies have now documented the lack of association between the
nicotine patch and acute cardiovascular events, even with individuals who
continued to smoke while on the patch, all NRT products should be used with
caution for individuals who had a recent (within 2 weeks) myocardial
infarction (MI),38 those with severe arrhythmias, or those with unstable
angina pectoris.39
NRT products should be properly disposed of to insure safety of children and
pets. Nicotine on hands can get into nose or eyes, causing stinging and
redness. Wash hands with soap and water after handling the patch.
Because seizures have been reported in 0.1% of patients, bupropion is
contraindicated in individuals who have a history of seizure disorder, have a
current or prior diagnosis of anorexia40 or bulimia,41 are currently using
another form of bupropion, are currently using or have used a Monoamine
Oxidase (MAO) Inhibitor within the past two weeks. Other factors that might
increase the odds of seizure and are classified as warnings for this
medication include a history of head trauma, central nervous system tumor,
the presence of severe hepatic cirrhosis, and concomitant use of medications
that lower the seizure threshold. Bupropion can be used safely in
combination with NRT and may be beneficial for use in clients with
underlying depression.
Although varenicline (Chantix) is well tolerated in most individuals, recent
case reports describe exacerbations of existing psychiatric illness in clients
who took varenicline prompting the FDA to add a warning regarding the use
of varenicline in February 2008. Specifically, the warning notes that
depressed mood, agitation, changes in behavior, suicidal ideation, and
suicide have been reported in clients attempting to quit smoking while using
varenicline (Chantix).
Because varenicline (Chantix) is eliminated almost entirely unchanged in the
urine, it should be used with caution in clients with severe renal dysfunction.
Special Considerations for Pregnant Women
A National Institutes of Health consensus panel recommended methadone
maintenance as the standard of care for pregnant women with opioid dependence.
Pregnant women should be maintained on an adequate (i.e., therapeutic)
methadone dose. An effective dose prevents the onset of withdrawal for 24 hours,
reduces or eliminates drug craving, and blocks the euphoric effects of other
narcotics. An effective dose usually is in the range of 50–150mg (Drozdick et al.
2002). Dosage must be individually determined, and some pregnant women may
be able to be successfully maintained on less than 50mg while others may require
much higher doses than 150mg. The dose often needs to be increased as a woman
progresses through pregnancy, due to increases in blood volume and metabolic
changes specific to pregnancy (Drozdick et al. 2002; Finnegan and Wapner 1988).

Generally, dosing of methadone is for a 24-hour period. However, because of

metabolic changes during pregnancy it might not be possible to adequately manage
a pregnant woman during a 24-hour period on a single dose. Split dosing (giving
half the dose in the morning and half in the evening), particularly during the third
trimester of pregnancy, may stabilize the woman’s blood methadone levels and
effectively treat withdrawal symptoms and craving.

Women who are on methadone may breastfeed their infant(s). Very little
methadone comes through breast milk. The American Academy of Pediatrics
(AAP) Committee on Drugs lists methadone as a “maternal medication usually
compatible with breastfeeding” (AAP 2001, pp. 780–781).

The Federal government mandates that prenatal care be available for pregnant
women on methadone. It is the responsibility of treatment providers to arrange this
care. More than ever, there is need for collaboration involving obstetric,
pediatric, and substance abuse treatment providers. Comprehensive care for the
pregnant woman who is opioid dependent must include a combination of
methadone maintenance, prenatal care, and substance abuse treatment. While it is
not recommended that pregnant women who are maintained on methadone undergo
detoxification, if these women require detoxification, the safest time is during the
second trimester. In contrast, it is possible to detoxify women dependent on heroin
who are abusing illicit opioids by using a methadone taper. For further
information, consult the forthcoming.
Buprenorphine has been examined in pregnancy and appears not to cause birth
defects but it may be associated with a withdrawal syndrome in the newborn
(Jones and Johnson 2001). Buprenorphine has not yet been approved for use with
this population. More data are needed about the safety and effectiveness of
buprenorphine with pregnant women.

Naloxone should not be given to a pregnant woman even as a last resort for severe
opioid overdose. Withdrawal can result in spontaneous abortion, premature labor,
or stillbirth (Weaver 2003).

Inderal, Trandate, and Lopressor are the beta-blockers of choice for treating
high blood pressure during pregnancy (McElhatton 2001). However, the impact of
using them for alcohol detoxification during pregnancy is unclear.

Nicotine replacement therapy (NRT) is contraindicated during pregnancy.

For all women of childbearing age who may be or think they may be pregnant, the
physician should discuss the safety of these medications before starting,
continuing, or discontinuing medication treatment. Substance abuse counselors
may have a role in encouraging this discussion by suggesting their clients talk with
the prescribing physician.
Tips for Communicating With Physicians About
Clients and Medication
Send a written report.
The goal is to get your concerns included in the client’s medical record. When
information is in a medical record, it is more likely to be acted on. Records of
phone calls and letters may or may not be placed in the chart.
Make it look like a report—and be brief.
Include date of report, client name and Social Security Number. Most medical
consultation reports are one page. Longer reports are less likely to be read.
Include and prominently label sections:

Presenting Problem
Assessment
Treatment and Progress
Recommendations and Questions
Keep the tone neutral.
Provide details about the client’s use or abuse of prescription medications. Avoid
making direct recommendations about prescribed medications. Allow the
physician to draw his or her own conclusions. This will enhance your alliance
with the physician and makes it more likely that he or she will act on your input.

Do your best to become a “team.”

When the Physician Does Not Respond
Professional duty dictates that a report should be updated whenever a client’s
condition or situation changes in a manner thought to affect the client’s general
health and/or medical care. Continue attempts to coordinate care when it is in the
client’s best interest even if the physician appears not to respond.

Download The Substance Abuse Treatment Coordination Report (available in

English and Spanish)—[Link].
References
Adams, J. B., and Wacher, A. Specific changes in the glycoprotein components of
seromucoid in pregnancy. Clinica Chimica Acta: International Journal of
Clinical Chemistry 21(1):155-157, 1968.

American Academy of Pediatrics, Committee on Drugs. The transfer of drugs and

other chemicals into human milk. Pediatrics 108(3):776-789, 2001.

Buhrich, N., Weller, A., and Kevans, P. Misuse of anticholinergic drugs by people
with serious mental illness. Psychiatric Services 51(7):928-929, 2000.

Center for Substance Abuse Treatment. Detoxification from Alcohol and Other
Drugs. Treatment Improvement Protocol (TIP) Series 19. DHHS Publication No.
(SMA) 95-3046. Rockville, MD: Substance Abuse and Mental Health Services
Administration, 1995.

Center for Substance Abuse Treatment. Matching Treatment to Patient Needs in

Opioid Substitution Therapy. Treatment Improvement Protocol (TIP) Series 20.
DHHS Publication No. (SMA) 95-3049. Rockville, MD: Substance Abuse and
Mental Health Services Administration, 1995.

Center for Substance Abuse Treatment. Naltrexone and Alcoholism Treatment.

Treatment Improvement Protocol (TIP) Series 28. DHHS Publication No. (SMA)
98-3206. Rockville, MD: Substance Abuse and Mental Health Services
Administration, 1998.

Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons
with Co-Occurring Disorders. Treatment Improvement Protocol (TIP) Series 42.
DHHS Publication No. (SMA) 05-3992. Rockville, MD: Substance Abuse and
Mental Health Services Administration, 2005.

Cohen, L. S. Psychotropic drug use in pregnancy. Hospital & Community

Psychiatry 40(6):566-567, 1989.

Dean, M., Stock, B., Patterson, R. J., and Levy, G. Serum protein binding of drugs
during and after pregnancy in humans. Clinical Pharmacology and Therapeutics
28(2):253-261, 1980.
Drozdick, J., III, Berghella, V., Hill, M., and Kaltenbach, K. Methadone trough
levels in pregnancy. American Journal of Obstetrics and Gynecology
187(5):1184-1188, 2002.

Finnegan, L. P., and Wapner, R. J. Narcotic addiction in pregnancy. In: Niebyl, J.

R., ed. Drug Use in Pregnancy. 2d ed. Philadelphia: Lea and Febiger, 1988. pp.
203-222.

Fiore, M. C., Hatsukami, D. K., & Baker, T. B. Effective tobacco dependence

treatment. JAMA, 288(14), 1768-1771, 2002.

Fiore, M. C., Jaén, C. R., Baker, T. B., et al. Treating Tobacco Use and
Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S.
Department of Health and Human Services. Public Health Service. May 2008.

Fiore, M. C., & Schroeder, L. L. Effective interventions for persons who use
tobacco. Key findings from the United States public health service clinical
practice guideline: Treating tobacco use and dependence. Journal of Clinical
Psychiatry Monographs, 18(1), 64-73, 2003.

Ganrot, P. O. Variation of the concentrations of some plasma proteins in normal

adults, in pregnant women and in newborns. Scandinavian Journal of Clinical
and Laboratory Investigation Supplementum 124:83-88, 1972.

Garbis, H., and McElhatton, P. R. Psychotropic, sedative-hypnotic and Parkinson

drugs. In: Drugs During Pregnancy and Lactation: Handbook of Prescription
Drugs and Comparative Risk Assessment: With Updated Information on
Recreational Drugs. New York: Elsevier, 2001. pp. 182-191.

Hudmon, K. S., Kroon, L. A., and Corelli R. L. Smoking Cessation. In: Handbook
of nonprescription drugs: An interactive approach to self-care, 15th Edition.
Washington DC: American Pharmacists Association, 2006. pp.1021-1044.

Jones, H. E., and Johnson, R. E. Pregnancy and substance abuse. Current Opinion
in Psychiatry 14:187-193, 2001.

Kuhnz, W., Koch, S., Helge, H., and Nau, H. Primidone and phenobarbital during
lactation period in epileptic women: Total and free drug serum levels in the
nursed infants and their effects on neonatal behavior. Developmental
Pharmacology and Therapeutics 11(3):147-154, 1988.
Malcolm, R., Myrick, H., Roberts, J., Wang, W., and Anton, R. The differential
effects of medication on mood, sleep disturbance, and work ability in outpatient
alcohol detoxification. American Journal on Addictions 11(2):141-150, 2002.

McElhatton, P. Heart and circulatory system drugs. In: Schaefer, C. Drugs During
Pregnancy and Lactation: Handbook of Prescription Drugs and Comparative
Risk Assessment. Amsterdam: Elsevier Science B.V., 2001. pp. 116-131.

Mortola, J. F. The use of psychotropic agents in pregnancy and lactation.

Psychiatric Clinics of North America 12:69-88, 1989.

National Tobacco Cessation Collaborative (NTCC). Key points to help dispel the
myths about nicotine and NRT: For consumers, patients, quitline operators, and
health care providers. Retrieved on November 06, 2007, from:
[Link]

National Tobacco Cessation Collaborative (NTCC). NTCC news: March 2007.

Retrieved on November 06, 2007, from: [Link]
[Link]/news_march.htm

National Tobacco Cessation Collaborative (NTCC). Resources: Tobacco

cessation medications (FDA approved). Retrieved on November 06, 2007, from:
[Link]

Northwest Network Mental Illness Research and Education Center and Center for
Excellence in Substance Abuse Treatment and Education of the VA Puget Sound
Health Care System. Brief Smoking Cessation Treatment for Substance
Dependent Populations: Clinician Training Manual (n.d.).

Okuyemi, K. S., Nollen, N. L., & Ahluwalia, J. S. Interventions to facilitate

smoking cessation. American Family Physician, 74, 262-271, 2006.

Perucca, E., and Crema, A. Plasma protein binding of drugs in pregnancy. Clinical
Pharmacokinetics 7(4):336-352, 1982.

Pond, S. M., Kreek, M. J., Tong, T. G., Raghunath, J., and Benowitz, N. L. Altered
methadone pharmacokinetics in methadone-maintained pregnant women. Journal
of Pharmacology and Experimental Therapeutics 233(1):1-6, 1985.

Potts, L.A., Garwood, C.L. Varenicline: The newest agent for smoking cessation.
Am J Health Syst Pharm 64: 1381–4, 2007.

Robert, E., Reuvers, M., and Shaefer, C. Antiepileptics. In: Schaefer, C. H., ed.
Drugs During Pregnancy and Lactation: Handbook of Prescription Drugs and
Comparative Risk Assessment: With Updated Information on Recreational
Drugs. Amsterdam: Elsevier, 2001. pp. 46-57.

Sernyak, M. J., Leslie, D. L., Alarcon, R. D., Losonczy, M. F., and Rosenheck, R.
Association of diabetes mellitus with use of atypical neuroleptics in the treatment
of schizophrenia. American Journal of Psychiatry 159(4):561-566, 2002.

Sutton, L. R., and Hinderliter, S. A. Diazepam abuse in pregnant women on

methadone maintenance: Implications for the neonate. Clinical Pediatrics 29:108-
111, 1990.

The Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and
Consortium Representatives. A clinical practice guideline for treating tobacco use
and dependence: A US Public Health Service report. The Journal of the
American Medical Association, 283(24), 3244-3254, 2000.

Tobacco Free Coalition of Oregon (TOFCO). Make it your business: Insure a

tobacco-free workforce. Cessation fact sheet. Retrieved on November 02, 2007,
from:
[Link]

US Food and Drug Administration, Center for Drug Evaluation and Research.
FDA Patient Information Sheet for Varenicline (marketed as Chantix).
Retrieved on November 02, 2007, from:
[Link]

Weaver, M. F. Perinatal addiction. In: Graham, A. W., Schultz, T. K., Mayo-Smith,

M. F., Ries, R. K., and Wilford, B. B., eds. Principles of Addiction Medicine, 3d
ed. Chevy Chase, MD: American Society of Addiction Medicine, 2003. pp. 1231-
1246.
Acknowledgments
This 2011 revision was made possible because of the dedication and commitment
of many individuals and organizations. It includes an adaptation of the 2008
edition that was modified and enhanced by CSAT for inclusion in their TIP 42:
Substance Abuse Treatment for Persons with Co-Occurring Disorders.

The Mid-America Addiction Technology Transfer Center gratefully acknowledges

the following contributors:

Sally Baehni, MDiv

Jan Campbell, MD
Merritt Engel, MA
Joseph Parks, MD
Richard K. Ries, MD
Joyce Sasse, MS, APRN-BC, CARN
Pat Stilen, LCSW, CADAC

Main Editors for the 2008 edition:

Ignacio Alejandro Barajas Muñoz, MS, Project Manager of Evaluation at the

Mid-America Addiction Technology Transfer Center, University of Missouri-
Kansas City, Kansas City, MO

Alicia M. Wendler, PhD, VA Eastern Kansas Health Care System, Dwight D.

Eisenhower VAMC, Leavenworth, KS
Talking with Clients about their Medication
Untreated psychiatric problems are a common cause for treatment failure in
substance abuse treatment programs. Supporting clients with mental illness in
continuing to take their psychiatric medications can significantly improve
substance abuse treatment outcomes.

Getting Started. Take 5-10 minutes every few sessions to go over these
topics with your clients:
Remind them that taking care of their mental health will help prevent relapse.
Ask how their psychiatric medication is helpful.
Acknowledge that taking a pill every day is a hassle.
Acknowledge that everybody on medication misses taking it sometimes.
Do not ask if they have missed any doses, rather ask, “How many doses have
you missed?”
Ask if they felt or acted different on days when they missed their medication.
Was missing the medication related to any substance use relapse?

Without judgment, ask “Why did you miss the medication? Did you forget, or did
you choose not to take it at that time?”
For clients who forgot, ask them to consider the
following strategies:
Keep medication where it cannot be missed: with the TV remote control, near the
refrigerator, or taped to the handle of a toothbrush. Everyone has two or three
things they do every day without fail. Put the medication in a place where it cannot
be avoided when doing that activity, but always away from children.

Suggest they use an alarm clock set for the time of day they should take their
medication. Reset the alarm as needed.

Suggest they use a Mediset: a small plastic box with places to keep medications
for each day of the week, available at any pharmacy. The Mediset acts as a
reminder and helps track whether or not medications were taken.
For clients who admit to choosing NOT to take their
medication:
Acknowledge they have a right to choose NOT to use any medication.

Stress that they owe it to themselves to make sure their decision is well thought
out. It is an important decision about their personal health and they need to discuss
it with their prescribing physician.

Ask their reason for choosing not to take the medication.

Don’t accept “I just don’t like pills.” Tell them you are sure they wouldn’t make
such an important decision without having a reason.

Offer as examples reasons others might choose not to take medication. For
instance, they:

1. Don’t believe they ever needed it; never were mentally ill
2. Don’t believe they need it anymore; cured
3. Don’t like the side effects
4. Fear the medication will harm them
5. Struggle with objections or ridicule of friends and family members
6. Feel taking medication means they’re not personally in control

Transition to topics other than psychiatric medications. Ask what supports or

techniques they use to assist with emotions and behaviors when they choose not to
take the medication.

General Approach: The approach when talking with clients about psychiatric
medication is exactly the same as when talking about their substance abuse
decisions.

Explore the triggers or cues that led to the undesired behavior (either taking drugs
of abuse or not taking prescribed psychiatric medications).

Review why the undesired behavior seemed like a good idea at the time.
Review the actual outcome resulting from their choice.
Ask if their choice got them what they were seeking.
Strategize with clients about what they could do differently in the future.
Brief Counselor Strategies for Tobacco Users—the
Five As*
ASK About Tobacco Use and Past Quit Efforts

Get the conversation started:

“Do you currently use any form of tobacco? Have you used it in the past? How old
were you when you started? Tell me about your efforts to quit. What helped, what
didn’t help?”
ADVISE Abstinence

Advice should be:

Clear: “Quitting is the most important thing you can do for your health.
Cutting down is not enough.”
Strong: “You are more likely to die from smoking than from all other drugs
and alcohol use combined.”
Personalized: “You have powerful reasons to quit. For example . . .” [tie
tobacco use in with current symptoms or health concerns].
ASSESS Willingness for a Quit Attempt During Next
30 Days

Determine motivation level to quit:

“On a scale from 1 to 10, with 1 being ‘not at all motivated’ to 10 being
‘extremely motivated,’ how ready are you to quit in the next 30 days?”

If willing to make a quit attempt:

Communicate research in quitting, “Research shows that quitting is possible for
all populations. In fact, more people have quit than are still smoking and about
80% of all Americans are smoke free.”

Discuss effective treatments available, such as nicotine replacement therapies

(NRTs), medications, self-help resources (help lines or support groups), and
counseling.

Initiate agreed upon treatment plan, “Let’s come up with a plan.”

If unwilling to make a quit attempt, provide motivational intervention (see Five Rs

section).
ASSIST Quit Attempt Effort

Develop a quit plan (STAR):

Set a specific quit date, ideally within two weeks, that has some meaning (e.g.,
anniversary, stress-free weekend).

Tell family, friends, coworkers others about quitting, request extra support and
understanding; ask other smokers in the household to not smoke inside; identify at
least one non-smoker to talk to when tempted to smoke.

Anticipate challenges that will occur including withdrawal symptoms, cravings,

and high-risk situations.

Remove environmental triggers (e.g., ashtrays, lighters); avoid smoking in

‘favorite’ places (e.g., car, dinner table, easy chair); limit smoking to
uncomfortable places (e.g., outside); recommend visiting only smoke-free
establishments.

Provide problem-solving strategies and skills training:

Track tobacco use patterns (e.g., time, circumstances) and identify high risk
situations:
Internally—mood swings, negative self-talk, smoking urges
Externally—drinking coffee, taking a break, watching TV, driving, seeing
other smokers

Identify substitute behaviors to smoking and other cognitive behavioral activities

for coping (e.g., keep hands busy with a ‘worry stone;’ chew gum; exercise;
engage in ‘self-soothing’ activities such as warm bath, listen to soothing music;
imagine telling people you are a non-smoker, practice asking others to not smoke
around you or leave cigarettes around; change daily routine).

Provide basic information about smoking and successful quitting (e.g., educate on
the addictive nature of smoking; discuss that even a single puff increases the
likelihood of a full relapse; withdrawal symptoms typically peak within 1–2
weeks after quitting but may persist for months).
Recommend use of NRTs, tobacco cessation
medications:
Explain how these products increase smoking cessation rates and reduce
withdrawal symptoms and cravings.

Provide materials on dosages, contraindications, side effects, etc.

Assist in obtaining prescription.

ARRANGE Follow-Up Help

Timing:
Schedule first follow-up within one week of quit date and a second within one
month; schedule additional follow-ups as indicated, encouraging and allowing
phone calls as needed.

Make sure that NRTs, medications, and educational materials are received prior
to quit date.

If abstinent during follow-up:

Congratulate on success; consider giving a certificate or other reinforcement.
Check on whether cravings increased for other substances (alcohol, other
drugs).
Discuss relapse prevention.
Start planning ahead for a smoke-free life.

If slip or relapse occurred:

Normalize the difficulty in quitting.
Reframe relapse as a learning experience and does not mean failure or
necessitate a return to full tobacco use.
Motivate to try to quit again immediately.
Reassess and re-initiate quit plan.
Brief Counselor Strategies for Tobacco Users
Unwilling to Quit— the Five Rs*
RELEVANCE of Quitting

Discuss the relevance of quitting for health and

economic concerns:
Encourage identifying why quitting is personally relevant to him/her (health status,
family or social situation, age, gender, prior quitting experiences, etc.).

Write down personal incentives for quitting, rank order reasons, focus on them as
often as possible, carry around on card in cigarette pack.
RISKS of Continued Use

Discuss short- and long-term impact to person and

family:
Highlight risks specific to him/her and prioritize, “Spouses, children, and other
people exposed to secondhand smoke are at higher risk to get colds, the flu, ear
infections, and lung infections than people who are not around second-hand
smoke.”

Inform him/her that reducing number of cigarettes, using alternative tobacco

products (cigars), or switching brands will not eliminate risks.

Discuss acute (e.g., harm to pregnancy) and long-term (e.g., lung and other
cancers) risks.
REWARDS of Quitting

Discuss physical changes (some immediate) as a result

of quitting and highlight those most relevant:
Pulmonary Benefits:
Carbon monoxide and oxygen levels in the blood return to normal after 8
hours.
Bronchial tubes relax, making it easier to breathe after 72 hours.
Cilia regrow in lungs, increasing ability to fight infection after 1-9 months.
Coughing, sinus infection, and shortness of breath decrease after 1-9 months.

Cardiac Benefits:
Blood pressure and body temperature returns to normal after 20 minutes.
Chance of heart attack decreases after only 24 hours.
Risk of coronary heart disease is half that of a smoker within 1 year.
Heart attack risk drops to near normal within 2 years.
Stroke risk is reduced after 5 years.
Risk of coronary heart disease is the same as nonsmokers within 15 years.

Reduced Cancer Risk Benefits:

Lung cancer death rates for a former pack per day-smoker is cut in half after
5 years.
Risk of throat, mouth, and esophageal cancers is cut in half after 5 years.
Lung cancer death rate is similar to that of nonsmokers within 10 years.
Precancerous cells are replaced within 10 years.

Other Benefits:
Expect to save $2000/year or more, list ideas for how to spend money saved
Improved taste and smell, improved smell of home and car, reduce aged
appearance
Improved sleep, reduced anxiety, reduced depression, and improved sexual
functioning after period of abstinence
Strengthened sobriety from other addictive substances (when sobriety from
those substances is already established)
Identify ROADBLOCKS to Quitting

Encourage each individual to discuss his/her

perceived barriers to quitting and offer strategies that
address these challenges:
Examples of roadblocks could include fear of failure, weight gain, lack of
support, mood or emotional problems, withdrawal symptoms, life circumstances,
presence of another smoker in the household, enjoyment of tobacco, etc.
Use REPETITION

Use motivational interventions each session:

Repeat the Relevance, Risks, and Rewards

*The Five As and Five Rs are available in the 2008 update of the Treating
Tobacco Use and Dependence Guidelines (DHHS 2008).

Source: Mid-America Addiction Technology Transfer Center. (2011).

Psychotherapeutic medications 2008: What every counselor should know (7th
ed.). Kansas City, MO: Author. Retrieved from
[Link]

1. psychosis: A mental disorder characterized by distinct distortions of a person’s

mental capacity, ability to recognize reality, and relationships to others to such a
degree that it interferes with that person’s ability to function in everyday life.

2. tardive dyskinesia: A central nervous system disorder characterized by

twitching of the face and tongue, and involuntary motor movements of the trunk
and limbs; occurring especially as a side effect of prolonged use of antipsychotic
medications.

3. neuroleptic malignant syndrome: A very rare but life-threatening neurological

disorder most often caused by a reaction to antipsychotic/neuroleptic medications.
Typically developing within the first 2 weeks of treatment; it can develop at any
time. The syndrome can also occur in people taking antiparkinsonian medications
if discontinued abruptly.

4. sedation: Inducing a relaxed easy state especially by the use of sedatives

(drugs).

5. lipids: Any of various substances including fats, waxes, and phosphatides that
with proteins and carbohydrates make up the principal structural components of
living cells.

6. diabetes mellitus: An endocrine disorder in which insulin is inadequately

secreted or used by the body.

7. blood dyscrasias: A disease of the blood usually involving cellular

abnormalities (i.e., poorly functioning or fewer than normal platelets or loss of
certain blood proteins called “clotting factors”; poorly functioning or decreased
numbers of red and/or white blood cells.

8. agranulocytosis: A condition in which there are too few of a specific type of

white blood cell called neutrophils in the blood. Affected people are susceptible
to infections.

9. microencapsulated: To enclose in a tiny capsule material (as a medicine) that

is released when the capsule is broken, melted, or dissolved.

10. extended release formulations: Medications that have been made so that they
act over a long period of time and do not have to be taken as often; may be
referred to as CR (controlled release), ER or XR (extended release), or SR
(sustained release).

11. lithium toxicity: The quality, state, or relative degree of being poisonous, in
this instance because of the presence or concentration of too much of the drug
lithium in the blood.

12. anticonvulsants: Usually refers to an agent that prevents or stops convulsions;

an abnormal violent, involuntary contraction or series of contractions of the
muscles.

13. decompensate: Loss of the body’s ability to correct a defect by over

development of or increased functioning of another organ or unimpaired parts of
the same organ; loss of psychological ability to counterbalance feelings of
inferiority, frustration, or failure in one area by achievement in another.

14. serotonin: A type of neurotransmitter in the brain.

15. norepinephrine: A hormone secreted by the adrenal gland, which (together

with epinephrine) brings about changes in the body known as the “fight or flight”
reaction. It works as a neurotransmitter in the brain.

16. heart block: A condition where the heart beats irregularly or much more
slowly than normal. Sometimes the heart may even stop for up to 20 seconds;
caused by a delay or disruption of the electrical signals that usually control the
heartbeat.

17. high blood pressure crisis: A severe increase in blood pressure that can lead
to stroke. Two types—emergency and urgent—require immediate medical
attention.

18. cross tolerant: Refers to a drug that produces a similar effect as the misused
substance but does not produce the “high.” Withdrawal symptoms can be
minimized through use of cross-tolerant substances (i.e., alcohol withdrawal
symptoms can be minimized through use of cross-tolerant sedatives, like
benzodiazepines).

19. acute: Marked by sharpness of severity (an acute pain). Having a sudden
onset and short duration (acute disease); urgent or critical condition.

20. gamma aminobutyric acid (GABA): A type of neurotransmitter in the brain.

21. detoxification: A medical and biopsychosocial procedure that assists a person

who is dependent on one or more substances to withdraw from dependence on all
substances of abuse.

22. protein binding: The affinity of a drug to attach (bind) to blood plasma
proteins. The extent to which a drug is bound to plasma proteins can affect the
distribution of the drug in the body. In most cases, binding to plasma proteins is
reversible.

23. toxicity: Poisonous nature; poisonous quality.

24. AD/HD: Refers to two types of disorders. Attention deficit disorder without
hyperactivity (ADD), and attention deficit disorder with hyperactivity (ADHD).
The terms are often used interchangeably.

25. narcolepsy: A condition characterized by brief attacks of deep sleep.

26. Schedule II drugs: Drugs classified in Schedule II of the Controlled

Substances Act; have a high potential for abuse with severe liability to cause
psychic or physical dependence but have some approved medical use.

27. naloxone: A narcotic antagonist used to reverse the effects of opioids.

28. acetaldehyde: A chemical compound produced when the body metabolizes
alcohol; the liver enzyme, alcohol dehydrogenase, converts ethanol into
acetaldehyde, which is then further converted into the harmless acetic acid by
acetaldehyde dehydrogenase.

29. psychoactive: Substances or drugs that affect the mind, especially mood,
thought, or perception.

30. analgesic: Producing relief or insensibility to pain without loss of

consciousness.

31. antagonist: A substance that blocks the normal physiological function of a

receptor site in the brain.

32. nicotine dependence: Nicotine dependence is a recognized mental health

disorder that is often overlooked by counselors. This addiction significantly
reduces the overall quality of life and is considered the deadliest yet most
preventable disease to be treated. Cigarette smoking is a primary cause of cancers
of the esophagus, lung, throat, mouth and is associated with the development of
cancers of the bladder, cervix, kidneys, pancreas, stomach and some leukemias.
Smoking is also a major cause of heart disease, bronchitis, emphysema, and
stroke.

33. nicotine withdrawal symptoms: Common nicotine withdrawal symptoms

include irritability, anger, impatience, restlessness, difficulty concentrating,
insomnia, increased appetite, anxiety, and depressed mood. The replacement of
nicotine in the brain during withdrawal produces the sense of “relief” and
“relaxation” commonly expressed by individuals when they readminister nicotine
to the body.

34. dopamine: A type of neurotransmitter in the brain.

35. norepinephrine: A type of neurotransmitter in the brain.

36. acetylcholinergic receptors: A type of neurotransmitter receptor in the brain

activated by the neurotransmitter acetylcholine.

37. THC: Tetrahydrocannabinol: an active chemical from hemp plant resin that is
the chief intoxicant in marijuana.
38. myocardial infarction (MI): Myocardial infarction, more commonly known as
a heart attack, is a medical condition that occurs when the blood supply to a part
of the heart is interrupted.

39. unstable angina pectoris: Commonly known as angina, this chest pain is due
to ischemia (a lack of blood and hence oxygen supply) of the heart muscle,
generally due to obstruction or spasm of the coronary arteries (the heart’s blood
vessels).

40. anorexia: An eating disorder marked by an extreme fear of becoming

overweight that leads to excessive dieting to the point of serious ill-health and
sometimes death.

41. bulimia: A condition in which periods of overeating are followed by under-

eating, use of laxatives, or self-induced vomiting. It is associated with depression
and anxiety about putting on weight.
Appendix 56: Drug Abuse Screening Test
Each item is scored one point. Six or more points to a substance abuse problem.
Appendix 57: Clinical Opiate Withdrawal
Scale

Resting Pulse Rate: Measured after client is sitting or lying for one minute

0 = pulse rate 80 or below

1 = pulse rate 81–100

2 = pulse rate 101–120

4 = pulse rate greater than 120

GI Upset: Over past half hour

0 = no GI symptoms

1 = stomach cramps

2 = nausea or loose stool

3 = vomiting or diarrhea

5 = multiple episodes of diarrhea or vomiting

Sweating: over past half hour not accounted for by room temperature or client
activity

0 = no report of chills or flushing

1 = subjective report of chills or flushing

2 = flushed or observable moistness on face

3 = beads of sweat on brow or face

4 = sweat streaming off face

Restlessness: Observation during assessment

0 = able to sit still

1 = reports difficulty sitting still, but is able to do so

3 = frequent shifting or extraneous movements of legs/arms

5 = Unable to sit still for more than a few seconds

Pupil Size:

0 = pupils pinned or normal size for room light

1 = pupils possibly larger than normal for room light

2 = pupils moderately dilated

5 = pupils so dilated that only the rim of the iris is visible

Bone or Joint Aches: If client was having pain previously, only the additional
component attributed to opiate withdrawal is scored

0 = not present

1 = mild diffuse discomfort

Tremor: Observation of outstretched hands

0 = no tremor

1 = tremor can be felt, but not observed

2 = slight tremor observable

4 = gross tremor or muscle twitching

Yawning: Observation during assessment

0 = no yawning
1 = yawning once or twice during assessment

2 = yawning three or more times during assessment

4 = yawning several times/minute

Anxiety or Irritability:

0 = none

1 = client reports increasing irritability or anxiousness

2 = client obviously irritable/anxious

4 = client so irritable/anxious that participation in the assessment is difficult

Gooseflesh skin: Score:

0 = skin is smooth; 5–12 = Mild Withdrawal

3 = piloerection of skin can be felt or hairs standing up on arms; 13–24 =

Moderate Withdrawal

5 = prominent piloerection; 25–36 = Severe Withdrawal

Source: Wesson D. R., Ling W. The Clinical Opiate Withdrawal Scale (COWS).
Journal of Psychoactive Drugs 2003; 35(2):253–59;
[Link]
Appendix 58: Adult Nurses Intake

Julie Braaten, RN, and Carol Regier, RN

Date: _______________________

What events precipitated your admission?

______________________________________________________

___________________________________________________________________________

Who referred you?

__________________________________________________________________________

___________________________________________________________________________
Chemical Use History
Have you ever had a previous treatment for chemical dependency? Yes_____
No_____ (If yes, complete the following questions.)

Please list any alcohol and/or drug education you may have had such as PPP/IPP
classes. ______________

___________________________________________________________________________

Do you have an alcohol and/or drug free environment to live in? Yes___
No____ If no, why not?
___________________________________________________________________________

___________________________________________________________________________

Have you ever attended Alcoholics Anonymous (AA)/Narcotics Anonymous (NA)

or Gamblers Anonymous (GA) meetings in the past? Yes _________ No
_________
Alcohol:
Diagnostic and Statistical Manual of Mental Disorders (DSM–5) DIAGNOSIS:
303.00 Alcohol Intoxication; 291.80 Alcohol Withdrawal; 305.00 Alcohol Abuse;
303.90 Alcohol Dependence With or Without Physiological Dependence

What was your age of first use of alcohol?

______________________________________________________

How old were you when you started drinking alcohol on a regular basis?
___________________________

___________________________________________________________________________

How often are you drinking alcohol? (daily, number of times per week, or number
of times per month) ___

___________________________________________________________________________

How long have you been drinking alcohol in this pattern?

_________________________________________

___________________________________________________________________________

How much alcohol do you usually drink at one time?

_____________________________________________

___________________________________________________________________________

What is your maximum amount of alcohol that you can drink at one time?
____________________________

When was your last drink of alcohol, and how much alcohol did you consume at
that time? ____________

___________________________________________________________________________

Do you feel you have a problem with alcohol? Yes _____ No _____ If yes, how
long has your alcohol use been causing problems?
______________________________________________________________________

Do you require increased alcohol amounts to achieve intoxication or your desired

effect?

Yes _______ No _______

Do you experience a diminished effect with continued use of the same amount of
alcohol? Yes _______ No _______

Have you ever had to go to an emergency room or physician’s office for an

alcohol-related illness or accident?

Yes _______ No _______ If yes, explain:

_________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Have you ever experienced alcohol poisoning? Yes _______ No _______ If yes,
explain: ________________

____________________________________________________________________________

____________________________________________________________________________

Have you ever experienced the following withdrawal symptoms?

Do you drink alcohol or use other drugs to relieve or avoid withdrawal
symptoms? Yes ____ No ____

Have you ever experienced blackouts? Yes _____ No _____

Have you tried to quit drinking alcohol before? Yes _____ No _____ If yes,
explain:
___________________________________________________________________________

Have you ever tried to control your drinking before? Yes _____ No _____ If yes,
explain: ______________

___________________________________________________________________________

___________________________________________________________________________

What was the longest period you went without drinking alcohol in the past 12
months? ______________

___________________________________________________________________________

Why did you abstain from drinking alcohol during that time period?
_______________________________

___________________________________________________________________________

Has drinking created any problems with interpersonal relationships in the

following areas:

When drinking alcohol, have you ever been involved in any of the following:
Cannabis:
DSM–5 DIAGNOSIS: 305.20 Cannabis Abuse; 304.30 Cannabis Dependence
With or Without Physiological Dependence

Have you ever used cannabis, marijuana, pot, THC, hashish, weed, dope, green
goddess, hydro, indo, KGB, locoweed, Mary Jane, sinsemilla, homegrown, and so
on? Yes _______ No _______ The following are not applicable if the previous
question was answered no.

Have you ever experienced the following with use or after use of cannabis?
Cocaine:
DSM–5 DIAGNOSIS 305.60 Cocaine Abuse; 304.20 Cocaine Dependence With
or Without Physiological Dependence

Have you ever used crack, coke, powder, white, snow, flake, devil’s dandruff, fast
white lady, uptown, white boy, white dragon, 24-7, cookies, glo, hard ball, rock,
and so on? Yes _______ No _______ The following are not applicable if the
previous question was answered no.

Have you ever seen things that other people could not see or heard things other
people could not hear (hallucinations and/or delusions)? Yes _____ No _____

Have you experienced the following withdrawal symptoms?

Hallucinogens:
DSM–5 DIAGNOSIS: 305.30 Hallucinogen Abuse; 304.50 Hallucinogen
Dependence With or Without Physiological Dependence

Have you ever used LSD, acid, DMT, peyote, buttons, mushrooms, mescaline,
psilocybin, battery acid, dots, zen, window pane, boomers, yellow sunshine, and
so on? Yes _______ No _______ The following are not applicable if the
previous answer was no.

Have you ever had a flashback? Yes _______ No _______

Opioids & Other Analgesics (Including Narcotics):
DSM-5 DIAGNOSIS: 305.50 Opioid Abuse; 304.00 Opioid Dependence With or
Without Physiological Dependence

Have you ever used heroin, eighth, H, hell dust, horse, junk, poppy, smack, train,
thunder, opium, Darvon (propoxyphene hydrochloride), Darvocet (propoxyphene
napsylate), Lortab (hydrocodone bitartrate & acetaminophen), Lorcet, Percocet
(oxycodone and acetaminophen), Percodan, Roxicet, Roxanol, Tylox, Codeine,
Demerol (meperidine hydrochloride), Morphine, Oxycontin, Oxycodone, MS
Contin, Oxy IR, Hydrocodone, Flexeril (cyclobenzaprine hydrochloride), Fioricet
with Codeine, Fiorinal with Codeine, Fentanyl (Duragesic) patch, Sublimaze
(fentanyl citrate), Dilaudid, Methadone, Vicodin, Stadol (butorphanol tartrate),
Talwin (pentazocine hydrochloride), Ultram (tramadol hydrochloride), and so on?

Yes _______ No _______ The following are not applicable if the previous
question was answered no.

Have you experienced the following withdrawal symptoms?

Inhalants:
DSM–5 DIAGNOSIS: 305.90 Inhalant Abuse; 304.60 Inhalant Dependence With
or Without Physiological Dependence

Have you ever sniffed or inhaled aerosols, lighter fluid, gasoline, model cements,
solvents, rush, white out, glue, paint, paint thinner, felt tip markers, nail polish,
nail polish remover, rubber cement, ether, amyl nitrite, butyl nitrite, nitrous oxide,
cooking sprays (like Pam), Freon, markers, and so on? Yes _______ No _______
The following are not applicable if the previous question was answered no.

Have you experienced the following?

Amphetamines (Including Methamphetamines) &
Stimulants:
DSM–5 DIAGNOSIS: 305.70 Amphetamine Abuse; 304.40 Amphetamine
Dependence With or Without Physiological Dependence

Have you ever used speed, ecstasy, MDMA, speeders, methamphetamine, glass,
ice, white crosses, ephedrine, crank, crystal, uppers, Adderall
(dextroamphetamine sulfate), Ritalin (methylphenidate hydrochloride), Dexedrine
(dextroamphetamine sulfate), Dexedrine Spansules, Cylert (pemoline), and so on?
Yes _______ No _______ The following are not applicable if the previous
question was answered no.

Have you experienced the following withdrawal symptoms?

Sedative, Hypnotic Or Anxiolytic:
DSM–5 DIAGNOSIS: 305.40 Sedative, Hypnotic or Anxiolytic Abuse; 304.10
Sedative, Hypnotic or Anxiolytic Dependence With or Without Physiological
Dependence

Have you ever used a barbiturate, downer, sleeping medication, Valium

(diazepam), chloral hydrate, Dalmane (flurazepam hydrochloride), Klonopin
(clonazepam), Seconal (secobarbital sodium), Restoril (temazepam), Halcion
(triazolam), Ambien (zolpidem tartrate), Ativan (Lorazepam), Xanax
(alprazolam), Librium (chlordiazepoxide hydrochloride), Tranxene (clorazepate
dipotassium), Atarax (hydroxyzine hydrochloride), Serax (oxazepam), and so on?
Yes _______ No _______

The following are not applicable if the previous question was answered no.

Have you experienced the following withdrawal symptoms?

Phencyclidine:
DSM–5 DIAGNOSIS: 305.90 Phencyclidine Abuse; 304.90 Phencyclidine
Dependence With or Without Physiological Dependence

Have you ever used phencyclidine (PCP), angel dust, animal tranquilizer,
embalming fluid, ozone, rocket fuel, wack, happy sticks, magic dust, Peter Pan,
trank, and so on? Yes _______ No _______

The following are not applicable if the previous question was answered no.

Have you experienced the following?

Anabolic Androgenic Steroids (AAS):
DSM–5 DIAGNOSIS: (Other or Unknown Substance—Related Disorders) 305.90
Abuse; 304.90 Dependence (You need to specify the individual substance that is
being abused in relation to the previous abuse and dependence diagnosis.
Example: 304.90 AAS Dependence.)

Have you ever used steroids, roids, rage, anabolics, juicers, step ups, and so on?
Yes _______ No _______

The following are not applicable if the previous question was answered no.

Have you experienced the following?

Gamma Hydroxybutyrate (GHB) & ANALOGS:
DSM–5 DIAGNOSIS: (Other or Unknown Substance-Related Disorders) 305.90
Abuse; 304.90 Dependence (You need to specify the individual substance that is
being abused in relation to the previous abuse & dependence diagnosis. Example:
304.90 GHB Dependence.)

Have you ever used GHB, Georgia home boy, G, goop, liquid ecstasy, cherry
meth, fantasy, G-riffic, jib, liquid E, liquid X, salty water, scoop, sleep, sleep –
500, soap, vita – G, and so on? Yes _______ No _______

The following are not applicable if the previous question was answered no.

Have you experienced the following?

Over-The-Counter Medication(s):
Do you use and/or abuse antihistamines, Nytol, Nyquil, laxatives, Primatene, diet
pills, Mydol, Coricidin Cold & Cough, Robitussin, and so on?

Yes _______ No _______ The following are not applicable if the previous
question was answered no.
Nicotine:
Do you smoke cigarettes? Yes _______ No _______ If yes, age of first use of
cigarettes?

___________________________________________________________________________

How many packs of cigarettes do you smoke per day?

___________________________________________

Do you use smokeless tobacco? Yes _____________ No ____________ How

much do you use in one day?
___________________________________________________________________________

Do you experience a chronic cough, possibly related to your tobacco use?

Yes_____ No_____

Have you ever coughed up or expectorated blood, possibly related to your

tobacco use?

Yes _______ No _______

Do you have any sores on the inside of your mouth? Yes _______ No _______

Have you attempted to quit or control your use of nicotine? Yes _____ No _____
If yes, how long were you able to quit your tobacco use, and what were the
reason(s) why you attempted to quit? ___________

___________________________________________________________________________

***************************************************************************

Do you use drugs to relieve or avoid withdrawal symptoms? Yes _______ No

_______

Do you require increased amounts of your drugs or medications to achieve

intoxication or your desired effect?

Yes _______ No _______

Do you experience a markedly diminished effect with continued use of the same
amount of drugs/medications?

Yes _______ No _______

Have you ever had to go to an emergency room or physician’s office for a

drug/medication related illness or accident?

Yes _______ No _______ If yes, explain:

________________________________________________________

____________________________________________________________________________

Have you ever experienced a drug or medication overdose? Yes _____ No _____
If yes, explain: ________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Have you tried to quit your drug use before? Yes _____ No _____ If yes, explain:
____________________

____________________________________________________________________________

____________________________________________________________________________

Have you ever tried to control your drug use before? Yes _____ No _____ If yes,
explain: _____________

____________________________________________________________________________

What was the longest period you went without using drugs in the past 12 months?
___________________

____________________________________________________________________________

Why did you abstain from using drugs during that time period?
___________________________________
___________________________________________________________________________

___________________________________________________________________________

Has your drug use created any problems with interpersonal relationships in the
following areas:

When using drugs have you ever been involved in any of the following:
Additional Critical Life Areas
Yes_____ No_____ Have you ever used injectable drugs or drugs intravenously?

Yes_____ No_____ Have you stayed drunk and/or high for more than one day?

Yes_____ No_____ Have you ever drank alcohol and/or used drugs in dangerous
situations (driving, swimming, etc.)?
Gambling History:
DSM 5 (312.31 Gambling Disorder)

When was the last time you gambled?

__________________________________________________________

Have you ever been assessed and/or had previous treatment for gambling? Yes
_____ No _____ If yes, please answer the following questions in the table.

Have you ever had credit counseling? Yes_____ No_____ If yes, when and where
was the credit counseling completed?
___________________________________________________________________________

What forms of gambling do you participate in?

What was the largest dollar amount that you have ever won?
_____________________________________

What was the largest dollar amount that you have ever lost?
_______________________________________
What was your age at your first gambling episode?
_______________________________________________

If “no” is answered on all of the previous questions, the following questions do

not need to be asked.

Do you feel that you have a problem with gambling? Yes _____ No _____ If yes,
how long has gambling been a problem for you?
_____________________________________________________________________

How much money do you spend on average on gambling per month?

_______________________________

How often do you gamble (daily, weekly, monthly, or yearly), and how much
(number of times weekly, monthly, or yearly)?
_________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

What is your current gambling related debt (weekly and monthly, yearly)?
__________________________

Have you ever filed bankruptcy due to your gambling? Yes _____ No _____ If
yes, explain: ____________

____________________________________________________________________________

____________________________________________________________________________
Physical Assessment:
Are you currently under the care of a physician(s)? Yes _____ No _____

When was the last time you saw a physician?

___________________________________________________

What was the reason for the visit?

_____________________________________________________________

Name and address of family physician:

_________________________________________________________

___________________________________________________________________________

Name(s) and address(es) of other physician(s) you are seeing:

_____________________________________

___________________________________________________________________________

Do you have any medical or physical problems for which you see a physician?
Yes _____ No _____ If yes, what are your problems or concerns?
__________________________________________________________

___________________________________________________________________________

How would you assess your health? Good ( ) Fair ( ) Poor ( )

Do you feel that your alcohol and/or drug use has affected your health? Yes
______ No ______ If yes, explain how your health has been affected?
_____________________________________________________

Have you ever been told that the use of alcohol and/or drugs is a serious threat to
your health? Yes _____ No _____ If yes, who told you and why?
______________________________________________
Tuberculosis:
Have you ever had tuberculosis (TB)? Yes ________ No________ Have you ever
had a BCG vaccination? Yes ________ No ________

Have you ever been exposed to someone else who has had TB? Yes _____ No
_____

Have you ever experienced any of the following symptoms within the previous 3
months?

**If aclient responds yes to any of the previous four questions, he or she
shall be referred to the physician for a medical evaluation to determine the
absence or presence of active disease. A Mantoux skin test may or may not
be given during this evaluation based on the opinion of the evaluating
physician.

Have you ever had a TB tine of Mantoux test? Yes_____ No_____

Did you have a reaction to the test? Yes_____ No_____

If you reacted, when was your last chest X-ray, and where did you have the chest
X-ray taken? ________

___________________________________________________________________________

**********************************************************************************
Seizures/Convulsions:
Have you ever had a seizure or convulsion? Yes _____ No _____ If yes, explain:
___________________________________________________________________________

When was your last seizure activity?

___________________________________________________________________________

Was your seizure activity directly related to your alcohol and/or drug use? Yes
_____ No _____

Did the seizure occur during your alcohol and/or drug use? Yes _____ No _____

Did the seizure occur during withdrawal from alcohol and/or drug use? Yes _____
No _____

Are you currently taking medication(s) for your seizure activity? Yes _____ No
_____

Have you taken medication(s) in the past to control your seizure activity? Yes
_____ No

**********************************************************************************

Have you had any of the following?

Do you currently have any sores, cuts, bruises, or any injuries? Yes _______ No
_______ If yes, explain:

___________________________________________________________________________

___________________________________________________________________________

Do you have any of the following?

If yes is answered to any of the previous questions, please write down the number
and explain: ________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________
___________________________________________________________________________

List medications that the client has previously taken but not taking currently:

________ Client unable to recall names of previous medications that he or she has
taken.

***************************************************************************
Females Only:
Do you experience any menstrual problems? Yes _____ No _____ If yes, explain:
_____________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Date of your last menstrual period:

____________________________________________________________

Date of your last Pap smear:

_________________________________________________________________

Are you currently pregnant? Yes ______ No ______ If yes, when is your
estimated due date, and which physician are you seeing for this pregnancy?
____________________________________________________

___________________________________________________________________________

Have you ever been pregnant? Yes ______ No ______ If yes, number of
pregnancies: __________________

___________________________________________________________________________

Have you ever had a miscarriage? Yes ______ No ______

Have you ever had an abortion? Yes ______ No ______ If yes, give date(s):
__________________________

___________________________________________________________________________

Describe any complications during your pregnancy(ies):

__________________________________________

___________________________________________________________________________
____________________________________________________________________________

****************************************************************************
Auditory Assessment:
Do you have a hearing loss? Yes _____ No _____ If yes, which ear is affected?
________________________

___________________________________________________________________________

Do you wear any hearing aid devices? Yes _____ No _____

***************************************************************************
Visual Assessment:
Do you wear contacts and/or glasses? Yes _____ No _____

Is your vision blurred or do you see double? Yes _____ No _____

Eye Chart Results: Both eyes: __________ Right eye: __________ Left eye:
__________

**********************************************************************************
Nutritional Assessment:
How would you assess your eating habits? Good ( ) Fair ( ) Poor ( )

If there is a yes response to questions 1, 2, 4, and/or 5, please inform the dietary

staff so that the dietician may visit with the client.

***************************************************************************
Sexual History:
Age of your first sexual experience:
____________________________________________________________

Do you have any concerns about sex and/or your sexuality? Yes ________ No
________ If yes, explain:

___________________________________________________________________________

___________________________________________________________________________

Does your alcohol and/or drug use affect your choices about sex? Yes _______
No _______ If yes, explain:

___________________________________________________________________________

___________________________________________________________________________

Have you ever been in trouble because of sexual behavior(s)? Yes ________ No
________ If yes, explain:

___________________________________________________________________________

___________________________________________________________________________

Do you currently have or ever have been treated for a sexually transmitted
disease? Yes ______ No ______ If yes, explain:
___________________________________________________________________________

Do you use protection during sexual intercourse? Yes _____ No _____

Have you had sexual intercourse with more than one partner? Yes _____ No
_____

***************************************************************************
Pain Assessment:
Pain Level: □ 0 □1 □2 □3 □4 □5 □6 □7 □8 □9 □ 10

(0 being no pain)

What is your acceptable level of pain?

_________________________________________________________

Are you currently experiencing pain? Yes _____ No _____ If yes, answer the
following questions:

Location and description of pain:

_____________________________________________________________

What relief measures do you use to decrease your pain?

__________________________________________

Pain management booklet given to the client: Yes _____ No _____ (In the Client
Handbook)

***************************************************************************
Psychological History/Screening/Mental Health
Issues:
Have you ever seen a counselor, psychologist, or psychiatrist? Yes _____ No
_____ If yes, answer the following questions:

When was your last visit?

____________________________________________________________________

How long have you been seeing this therapist?

__________________________________________________

___________________________________________________________________________

Have you ever been hospitalized for mental health issues? Yes _____ No _____

Have you ever received treatment for any of the following mental health or
psychiatric problems?
If yes, please
explain:_____________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________
How would you assess your sleeping habits? Good ________ Fair ________
Poor ________

How many hours of sleep do you get per night?

_________________________________________________

Do you have problems with falling asleep? Yes ________ No ________ Do you
have problems awakening frequently throughout the night? Yes ________ No
________

Do you feel sad, down, and/or depressed? Constantly ________ Often ________
Occasionally ________ Infrequently _________________________________

Explain:
_______________________________________________________________________

Do you feel fearful, anxious and/or nervous? Constantly ________ Often

________ Occasionally ________ Infrequently
_____________________________________________

Explain:
_______________________________________________________________________

Have you ever had a panic attack (suddenly fearful without cause)? Yes ________
No ________ If yes, explain (when was your last panic attack, did you go to the
hospital, etc.?): ____________________________

Do you have feelings of uncontrollable anger, rage, or violence? Yes ________

No _ If yes, please explain:

___________________________________________________________________________

___________________________________________________________________________

What do you do when you are angry?

__________________________________________________________

Are you or have you been in the past physically abusive to others? Yes _____ No
_____
 When and
explain:_________________________________________________________________
Was this abuse reported? Yes ________ No ________

Have you ever been physically abused? Yes ________ No ________

When and explain:

________________________________________________________________________

____________________________________________________________________________

Was this abuse reported? Yes _____ No _____

Did you ever tell anyone? Yes _____ No _____

Do you ever physically abuse yourself? Yes _____ No _____ If yes, explain:
__________________________

____________________________________________________________________________

Are you or have you been in the past sexually abusive to others? Yes _____ No
_____

When and explain:

__________________________________________________________________________

Was this abuse reported? Yes _____ No _____

Have you ever been sexually abused? Yes _____ No _____
When and explain:
________________________________________________________________________
________________________________________________________________________
Was this abuse reported? Yes _____ No _____
Did you ever tell anyone? Yes _____ No _____

Do you have thoughts of harming other people? Yes _____ No _____ If yes, when
and explain: _________

____________________________________________________________________________

____________________________________________________________________________
Have you ever been verbally aggressive toward others? Yes _____ No _____ If
yes, explain: ____________

___________________________________________________________________________

___________________________________________________________________________

Have you ever been physically aggressive? Yes _____ No _____ If yes, explain
(when, where, how violent, was there property destruction, and was a weapon
involved?): _____________________________________

___________________________________________________________________________

___________________________________________________________________________

Was law enforcement involved when you were physically aggressive? Yes _____
No _____ N/A _____ If yes, please explain:
__________________________________________________________________________

___________________________________________________________________________

Have you ever had thoughts of harming yourself? Yes _____ No _____ If yes,
explain (when was the last time you had these thoughts, etc.?):
____________________________________________________________

___________________________________________________________________________

Are you currently experiencing any thoughts of harming yourself? Yes ______ No
______ If yes, explain:

___________________________________________________________________________

___________________________________________________________________________

Have you made plans for carrying out any of these thoughts? Yes ________ No
________ If yes, explain:

___________________________________________________________________________

___________________________________________________________________________
Have you ever attempted suicide? Yes _______ No _______ If yes, explain (when
was last attempt, etc.?):

____________________________________________________________________________

____________________________________________________________________________

Has anyone in your family tried to hurt themselves? Yes _____ No _____

Have you ever self-mutilated (cutting, burning, etc.)? Yes _____ No _____ If yes,
please explain (describe when, where on the body, with what, how long you have
engaged in this behavior, the date of your most recent behavior, and if you
required medical intervention):
________________________________________

____________________________________________________________________________

____________________________________________________________________________

Do you use alcohol and/or drugs to relieve or avoid your problems? Yes _____
No _____

Do you feel unable to change things? Yes _____ No _____

Do you use alcohol and/or drugs to escape? Yes _____ No _____

Do you have plans for the future? Yes _____ No _____

Briefly describe how you react when things do not go your way.
___________________________________

____________________________________________________________________________

****************************************************************************
Educational:
What was your highest grade of education completed?
___________________________________________

___________________________________________________________________________

Do you have a college degree? Yes _____ No _____ If yes, what degree and what
major? ______________

___________________________________________________________________________

What types of grades did you obtain in school?

_________________________________________________

Did you attend an individualized educational program (IEP/special education)?

Yes ______ No _______

Did you drink alcohol and/or use drugs: Yes _____ No ______

***************************************************************************
Vocational:
Do you currently have a job? Yes _____ No _____ If yes, answer the following
questions:

Do you work full time? Yes _____ No _____ Do you work part time? Yes _____
No _____

Name of your employer:

_____________________________________________________________________

What is your position or title at work?

_________________________________________________________

How long have you been employed with this company or business?
________________________________

Have you ever been placed on probation or suspension at work due to your
alcohol and/or drug use and/or gambling?

Yes _____ No _____ If yes, explain:

____________________________________________________________

___________________________________________________________________________

If you are unemployed, how long have you been unemployed?

____________________________________
****************************************************************************
Financial:
How much money do you earn in a week?
______________________________________________________

How much money do you spend on alcohol and/or drugs in a week?

_______________________________

Where do you obtain your money from to purchase alcohol and/or drugs?
___________________________

Have you ever had to file for bankruptcy? Yes _____ No _____ If yes, explain:
_______________________

___________________________________________________________________________

___________________________________________________________________________

***************************************************************************
Legal History:
Have you ever been arrested? Yes _____ No _____ If yes, how many
convictions? ____________________

___________________________________________________________________________

List all of the charges that you can remember with dates and years:

How old were you when you experienced your first contact with the law?
__________________________

___________________________________________________________________________

Do you have any current legal problems? Yes _____ No _____ If yes, explain
(date of arrest, court date, charge, etc.)?
___________________________________________________________________________

___________________________________________________________________________

Do you have a probation officer/parole officer (PO)/court services officer

(CSO)/juvenile court authority (JCA)?

Yes_____ No_____ If yes, answer the following:

Name of person listed:
_______________________________________________________________________

Address of person listed:

_____________________________________________________________________

Telephone number of person listed:

____________________________________________________________

____________________________________________________________________________

****************************************************************************
Social/Leisure:

***************************************************************************
Family:
What is your birth order?
____________________________________________________________________

Name of the town and state where you were raised:

______________________________________________

____________________________________________________________________________

Name the people who raised you:

______________________________________________________________

____________________________________________________________________________

Name the person and his or her relationship to you whom you felt closest to while
growing up: ________
___________________________________________________________________________

Describe your childhood (happy, sad, normal, etc.):

______________________________________________

How were you disciplined, and who disciplined you?

_____________________________________________

Did you feel that you were loved while growing up? Yes _____ No _____

What is or was your parents’ relationship like?

__________________________________________________

Are you married? Yes _____ No _____ If yes, what is your wife or husband’s
name: ___________________

___________________________________________________________________________

Does your wife or husband use or abuse alcohol and/or drugs? Yes _____ No
_____

Have you been previously married? Yes _____ No _____ If yes, explain:
_____________________________

___________________________________________________________________________

___________________________________________________________________________

Do you have children? Yes _____ No _____ If yes, please list the children:

Who will be caring for your children while you are in treatment?
___________________________________

With whom do you currently live?

_____________________________________________________________

Number of people in the household?

___________________________________________________________

Does anyone in your family have any emotional or physical problems? Yes _____
No _____ If yes, explain:

____________________________________________________________________________

____________________________________________________________________________

Are there any family conflicts? Yes _____ No _____

How do you get along with your family?

_______________________________________________________

Have family members expressed concern over your alcohol and/or drug use? Yes
_____ No _____ If yes, who expressed the concern and why?
___________________________________________________________

____________________________________________________________________________

Has anyone in your family gone to alcohol and/or drug and/or gambling treatment?
Yes _______________

No _____________

Are any of your family members in a 12-step recovery program? Yes _____ No
_____

****************************************************************************
Spiritual:
Do you believe in a higher power (e.g., God or other) Yes _____ No _____

Do you have any concerns about your spiritual beliefs/practices? Yes _____ No
_____

What things lift your spirit?

___________________________________________________________________

What are your strengths?

_____________________________________________________________________

What are your weaknesses?

___________________________________________________________________

***************************************************************************
Mental Status Examination:
Problem Solving:

1. If the flag floats to the south, from which direction is the wind?

North = 3 points _____

2. At what time of the day is your shadow the shortest?

Noon = 3 points _____

3. Why does the moon look larger than the stars?

It is lower = 2 points Nearer objects appear larger = 4 points _____

4. If your shadow points to the northeast, where is the sun?

Southwest = 4 points _____

Knowledge:

5. What are houses made of?

1 point for each material up to 4 points _____

6. Tell me the names of some fish.

1 point for each species up to 4 points _____

7. Give me the names of some large cities.

1 point for each city up to 4 points. Excluded are small towns. _____

8. What is sand used for?

Playing = 1 point Construction = 2 points Glass = 4 points _____

9. What metal is attracted by a magnet?

 Steel = 2 points Iron = 4 points _____

10. How many stripes are in the U.S. flag?

13 = 4 points _____

KENT SCORE ___________

WILSON SCORE: (Ask the client the following multiplication equation

questions. Stop at the last correct answer. You do not have to go beyond. Locate
the scoring guide on the next page.)

2 x 12 = __________ 2 x 24 = __________ 2 x 48 = ___________

2 x 96 = __________ 2 x 192 = __________ 2 x 384 = __________

2 x ? = ____________

Instructions: Place a check mark in the box if the item was answered correctly.
Write incorrect or unusual answers in the space provided. If necessary, urge client
once to complete the task.
_______________TOTAL SCORE: (If the client’s score is less than 20, the
medical director and/or the psychologist should be notified.)

Client was cooperative __________ Uncooperative __________ Depressed

__________ Lethargic __________ Other __________

Safety Screening Assessment

□ Admit

□ Admit with a safety plan. Describe in detail:

___________________________________________________

□ Do not admit. Explain:

_____________________________________________________________________

Physical appearance on admission:

_____________________________________________________________

____________________________________________________________________________

Mental state, behaviors, and attitude on admission:

______________________________________________

____________________________________________________________________________

On admission the client was accompanied by

____________________________________________________

Age _____________ B/P _____________ Temperature _____________

Pulse _______________

Respirations _________ Height _________ Weight _________

CIWA score on admission ________________ Vital sign score on admission

________________

Summary
____________________________________________________________________________
___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________
DSM–5 Impressions:
______________________________________________________
___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Nursing Signature & Title Date

___________________________________________________________________________

Physician Signature Date

Appendix 59: Adolescent Nurses Intake

Julie Braaten, RN, and Carol Regier, RN

Date: ________________

What events precipitated your admission to Keystone Treatment Center?

_______________________________

___________________________________________________________________________

Who referred you to Keystone Treatment Center?

__________________________________________________

___________________________________________________________________________
Chemical Use History
Have you ever had a previous treatment for chemical dependency? Yes _______
No _______ (If yes, complete the following questions.)

Please list any alcohol and/or drug education you may have had such as PPP/IPP
classes. ________________

___________________________________________________________________________

___________________________________________________________________________

Do you have an alcohol and/or drug free environment to live in? Yes ______ No
_____ If no, why not?

___________________________________________________________________________

___________________________________________________________________________

Have you ever attended Alcoholics Anonymous (AA)/Narcotics Anonymous (NA)

or Gamblers Anonymous (GA) meetings in the past? Yes_____ No_____
Alcohol:
Diagnostic and Statistical Manual of Mental Disorders (DSM–5) DIAGNOSIS:
303.00 Alcohol Intoxication; 291.80 Alcohol Withdrawal; 305.00 Alcohol Abuse;
303.90 Alcohol Dependence with or without Physiological Dependence

What was your age of first use of alcohol?

________________________________________________________

How old were you when you started drinking alcohol on a regular basis?
_____________________________

___________________________________________________________________________

How often are you drinking alcohol? (daily, number of times per week, or number
of times per month)

___________________________________________________________________________

How long have you been drinking alcohol in this pattern?

___________________________________________

___________________________________________________________________________

How much alcohol do you usually drink at one time?

_______________________________________________

___________________________________________________________________________

What is your maximum amount of alcohol that you can drink at one time?
____________________________

___________________________________________________________________________

When was your last drink of alcohol, and how much alcohol did you consume at
that time? _____________

___________________________________________________________________________
____________________________________________________________________________

Do you feel you have a problem with alcohol? Yes _____ No _____ If yes, how
long has your alcohol use been causing problems?
_________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Do you require increased alcohol amounts to achieve intoxication or your desired

effect?

Yes ________ No ________

Do you experience a diminished effect with continued use of the same amount of
alcohol?

Yes ________ No ________

Have you ever had to go to an emergency room or physician’s office for an

alcohol related illness or accident? Yes ______ No ______ If yes, explain:
________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Have you ever experienced alcohol poisoning? Yes ______ No ______ If yes,
explain: ___________________

____________________________________________________________________________

____________________________________________________________________________

Have you ever experienced the following withdrawal symptoms?

Do you drink alcohol or use other drugs to relieve or avoid withdrawal
symptoms? Yes _____ No _____

Have you ever experienced blackouts? Yes ______ No ______

Have you tried to quit drinking alcohol before? Yes ______ No ______ If yes,
explain: ____________________

___________________________________________________________________________

___________________________________________________________________________

Have you ever tried to control your drinking before? Yes _____ No _____ If yes,
explain: _________________

___________________________________________________________________________

___________________________________________________________________________

What was the longest period you went without drinking alcohol in the past 12
months? _________________

___________________________________________________________________________

Why did you abstain from drinking alcohol during that time period?
________________________________

____________________________________________________________________________

____________________________________________________________________________

Has drinking created any problems with interpersonal relationships in the

following areas?

When drinking alcohol have you ever been involved in any of the following:
Cannabis:
DSM–IV DIAGNOSIS: 305.20 Cannabis Abuse; 304.30 Cannabis Dependence
with or without Physiological Dependence

Have you ever used cannabis, marijuana, pot, THC, hashish, weed, dope, green
goddess, hydro, indo, KGB, locoweed, Mary Jane, sinsemilla, homegrown, etc.?
Yes_____ No_____ The following are not applicable if the previous question was
answered no.

Have you ever experienced the following with use or after use of cannabis?
Cocaine:
DSM–IV DIAGNOSIS: 305.60 Cocaine Abuse; 304.20 Cocaine Dependence with
or without Physiological Dependence

Have you ever used crack, coke, powder, white, snow, flake, devil’s dandruff, fast
white lady, uptown, white boy, white dragon, 24-7, cookies, glo, hard ball, rock,
etc.? Yes_____ No_____ The following are not applicable if the previous
question was answered no.

Have you ever seen things that other people could not see, or heard things other
people could not hear (hallucinations and/or delusions)? Yes _____ No _____

Have you experienced the following withdrawal symptoms?

Hallucinogens:
DSM–IV DIAGNOSIS: 305.30 Hallucinogen Abuse; 304.50 Hallucinogen
Dependence with or without Physiological Dependence

Have you ever used LSD, acid, DMT, peyote, buttons, mushrooms, mescaline,
psilocybin, battery acid, dots, zen, window pane, boomers, yellow sunshine, etc.?
Yes _____ No _____ The following are not applicable if the previous question
was answered no.

Have you ever had a flashback? Yes _____ No _____

Opioids & Other Analgesics (Including Narcotics):
DSM–IV DIAGNOSIS: 305.50 Opioid Abuse; 304.00 Opioid Dependence with
or without Physiological Dependence

Have you ever used heroin, eighth, H, hell dust, horse, junk, poppy, smack, train,
thunder, opium, Darvon (propoxyphene hydrochloride), Darvocet (propoxyphene
napsylate), Lortab (hydrocodone bitartrate & acetaminophen), Lorcet, Percocet
(oxycodone & acetaminophen), Percodan, Roxicet, Roxanol, Tylox, Codeine,
Demerol (meperidine hydrochloride), Morphine, Oxycontin, Oxycodone, MS
Contin, Oxy IR, Hydrocodone, Flexeril (cyclobenzaprine hydrochloride), Fioricet
with Codeine, Fiorinal with Codeine, Fentanyl (Duragesic) patch, Sublimaze
(fentanyl citrate), Dilaudid, Methadone, Vicodin, Stadol (butorphanol tartrate),
Talwin (pentazocine hydrochloride), Ultram (tramadol hydrochloride)? Yes_____
No_____ The following are not applicable if the previous question was answered
no.

Have you experienced the following withdrawal symptoms?

Inhalants:
DSM–IV DIAGNOSIS: 305.90 Inhalant Abuse; 304.60 Inhalant Dependence with
or without Physiological Dependence

Have you ever sniffed/inhaled aerosols, lighter fluid, gasoline, model cements,
solvents, rush, white out, glue, paint, paint thinner, felt tip markers, nail polish,
nail polish remover, rubber cement, ether, amyl nitrite, butyl nitrite, nitrous oxide,
cooking sprays (like Pam), Freon, markers? Yes_____ No_____ The following
are not applicable if the previous question was answered no.

Have you experienced the following?

Amphetamines (Including Methamphetamines) &
Stimulants:
DSM–IV DIAGNOSIS: 305.70 Amphetamine Abuse; 304.40 Amphetamine
Dependence with or without Physiological Dependence

Have you ever used speed, speeders, ecstasy, methamphetamine, glass, ice, white
crosses, ephedrine, crank, crystal, uppers, MDMA, Adderall (dextroamphetamine
sulfate), Ritalin (methylphenidate hydrochloride), Dexedrine (dextroamphetamine
sulfate), Dexedrine Spansules, Cylert (pemoline)? Yes_____ No_____ The
following are not applicable if the previous question was answered no.

Have you experienced the following withdrawal symptoms?

Sedative, Hypnotic Or Anxiolytic:
DSM–IV DIAGNOSIS: 305.40 Sedative, Hypnotic or Anxiolytic Abuse; 304.10
Sedative, Hypnotic or Anxiolytic Dependence with or without Physiological
Dependence

Have you ever used a barbiturate, downer, sleeping medication, Valium

(diazepam), chloral hydrate, Dalmane (flurazepam hydrochloride), Klonopin
(clonazepam), Seconal (secobarbital sodium), Restoril (temazepam), Halcion
(triazolam), Ambien (zolpidem tartrate), Ativan (Lorazepam), Xanax
(alprazolam), Librium (chlordiazepoxide hydrochloride), Tranxene (clorazepate
dipotassium), Atarax (hydroxyzine hydrochloride), Serax (oxazepam), etc.?
Yes_____ No_____ The following are not applicable if the previous question was
answered no.

Have you experienced the following withdrawal symptoms?

Phencyclidine:
DSM–IV DIAGNOSIS: 305.90 Phencyclidine Abuse; 304.90 Phencyclidine
Dependence with or without Physiological Dependence

Have you ever used phencyclidine (PCP), angel dust, animal tranquilizer,
embalming fluid, ozone, rocket fuel, wack, happy sticks, magic dust, Peter Pan,
trank, etc.? Yes_____ No_____ The following are not applicable if the previous
question was answered no.

Have you experienced the following?

ANABOLIC ANDROGENIC STEROIDS (AAS):
DSM–IV DIAGNOSIS: (Other or Unknown Substance-Related Disorders) 305.90
Abuse; 304.90 Dependence (You need to specify the individual substance that is
being abused in relation to the above abuse & dependence diagnosis. Example:
304.90 AAS Dependence)

Have you ever used steroids, roids, rage, anabolics, juicers, step ups, etc.? Yes
_____ No _____ The following are not applicable if the previous question was
answered no.

Have you experienced the following?

Gamma Hydroxybutyrate (GHB) & ANALOGS:
DSM–IV DIAGNOSIS: (Other or Unknown Substance-Related Disorders) 305.90
Abuse; 304.90 Dependence (You need to specify the individual substance that is
being abused in relation to the above abuse & dependence diagnosis. Example:
304.90 GHB Dependence)

Have you ever used GHB, Georgia home boy, G, goop, liquid ecstasy, cherry
meth, fantasy, G-riffic, jib, liquid E, liquid X, salty water, scoop, sleep, sleep –
500, soap, vita – G, etc.? Yes_____ No_____ The following are not applicable if
the previous question was answered no.

Have you experienced the following?

OVER-THE-COUNTER MEDICATION(S):
Do you use and/or abuse antihistamines, Nytol, Nyquil, laxatives, Primatene, diet
pills, Mydol, Coricidin Cold & Cough, Robitussin, etc.? Yes_____ No_____ The
following are not applicable if the previous question was answered no.
NICOTINE:
Do you smoke cigarettes? Yes __________ No __________

If yes, age of first use of cigarettes? _______________________

How many packs of cigarettes do you smoke per day?

____________________________________________

___________________________________________________________________________

Do you use smokeless tobacco? Yes __________ No __________

How much do you use in one day? _______________________

Do you experience a chronic cough, possibly related to your tobacco use? Yes
__________ No __________

Have you ever coughed up or expectorated blood, possibly related to your

tobacco use?

Yes __________ No __________

Do you have any sores on the inside of your mouth? Yes _____ No _____

Have you attempted to quit or control your use of nicotine? Yes _____ No _____
If yes, how long were you able to quit your tobacco use and what were the
reason(s) why you attempted to quit? _________________

___________________________________________________________________________

***************************************************************************

Do you use drugs to relieve or avoid withdrawal symptoms? Yes _____ No _____

Do you require increased amounts of your drugs/medications to achieve

intoxication or your desired effect?

Yes _____ No _____

Do you experience a markedly diminished effect with continued use of the same
amount of drugs/medications?

Yes ____ No ____

Have you ever had to go to an emergency room or physician’s office for a

drug/medication related illness or accident? Yes _____ No _____ If yes, explain:
__________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Have you ever experienced a drug/medication overdose? Yes _____ No _____ If

yes, explain: ____________

____________________________________________________________________________

____________________________________________________________________________

Have you tried to quit your drug use before? Yes _____ No _____ If yes, explain:
_________________________

____________________________________________________________________________

Have you ever tried to control your drug use before? Yes _____ No _____ If yes,
explain: _______________

____________________________________________________________________________

____________________________________________________________________________

What was the longest period you went without using drugs in the past 12 months?
____________________

____________________________________________________________________________

Why did you abstain from using drugs during that time period?
______________________________________

____________________________________________________________________________
Has your drug use created any problems with interpersonal relationships in the
following areas:

When using drugs have you ever been involved in any of the following:

Additional Critical Life Areas

Yes _____ No _____ Have you ever used injectable drugs/drugs

intravenously?

Yes _____ No _____ Have you stayed drunk and/or high for more than one
day?

Yes _____ No _____ Have you ever drank alcohol and/or used drugs in
dangerous situations (driving, swimming, etc.)?

GAMBLING HISTORY: (312.31 Gambling Disorder)

When was the last time you gambled?

____________________________________________________________

___________________________________________________________________________

Have you ever been assessed and/or had previous treatment for gambling? Yes
_____ No _____ If yes, please answer the following questions in the table.
Have you ever had credit counseling? Yes _____ No _____ If yes, when and
where was the credit counseling completed?
____________________________________________________________________________

____________________________________________________________________________

What forms of gambling do you participate in?

What was the most dollar amount that you have ever won?
________________________________________

What was the most dollar amount that you have ever lost?
________________________________________

What was your age at your first gambling episode?

_______________________________________________

If “no” is answered on all of the previous questions, the following questions

do not need to be asked.

Do you feel that you have a problem with gambling? Yes _____ No _____ If yes,
how long has gambling been a problem for you?
___________________________________________________________________________

___________________________________________________________________________

How much money do you spend on average on gambling per month?

_____________________________

___________________________________________________________________________

How often do you gamble (daily, weekly, monthly, yearly) and how much (number
of times weekly and monthly, yearly)?
___________________________________________________________________________

___________________________________________________________________________

What is your current gambling related debt?

_____________________________________________________

___________________________________________________________________________

Have you ever filed bankruptcy due to your gambling? Yes _____ No _____ If
yes, explain: _____________

___________________________________________________________________________

___________________________________________________________________________
PHYSICAL ASSESSMENT:
Are you currently under the care of a physician(s)? Yes _____ No _____

When was the last time you saw a physician?

______________________________________________________

___________________________________________________________________________

What was the reason for the visit?

________________________________________________________________

___________________________________________________________________________

Name and address of family physician:

___________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Name and address of other physicians you are seeing:

_______________________________________________

___________________________________________________________________________

___________________________________________________________________________

Do you have any medical or physical problems for which you see a physician?
Yes _______ No ______ If yes, what are your problems or concerns?
_______________________________________________________

___________________________________________________________________________

___________________________________________________________________________

How would you assess your health? Good ( ) Fair ( ) Poor ( )

Do you feel that your alcohol and/or drug use has affected your health? Yes _____
No _____ If yes, explain how your health has been affected.
____________________________________________________________

____________________________________________________________________________

Have you ever been told that the use of alcohol and/or drugs are a serious threat to
your health?

Yes _____ No _____ If yes, who told you and why?

______________________________________________

____________________________________________________________________________
TUBERCULOSIS:
Have you ever had tuberculosis (TB)? Yes _____ No _____ Have you ever had a
BCG vaccination?

Yes _____ No _____

Have you ever been exposed to someone else who has had tuberculosis? Yes
_____ No _____

Have you ever experienced any of the following symptoms within the previous 3
months?

**If aclient responds yes to any of the previous four questions, he or she
shall be referred to the physician for a medical evaluation to determine the
absence or presence of active disease. A Mantoux skin test may or may not
be given during this evaluation based on the opinion of the evaluating
physician.

Have you ever had a TB tine of Mantoux test? Yes _____ No _____

Did you have a reaction to the test? Yes _____ No _____

If you reacted, when was your last chest X-ray and where did you have the chest
X-ray taken?___________

___________________________________________________________________________
____________________________________________________________________________

****************************************************************************
SEIZURES/CONVULSIONS:
Have you ever had a seizure/convulsion? Yes _____ No _____ If yes, explain:
__________________________

___________________________________________________________________________

___________________________________________________________________________

When was your last seizure activity?

______________________________________________________________

___________________________________________________________________________

Was your seizure activity directly related to your alcohol and/or drug use? Yes
_____ No _____

Did the seizure occur during your alcohol and/or drug use? Yes _____ No _____

Did the seizure occur during withdrawal from alcohol and/or drug use? Yes _____
No _____

Are you currently taking medication(s) for your seizure activity? Yes _____ No
_____

Have you taken medication(s) in the past to control your seizure activity? Yes
_____ No _____

***************************************************************************

Have you had any of the following?

***************************************************************************
Do you currently have any sores, cuts, bruises, or any injuries? Yes _____ No
_____ If yes, explain: _______

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Do you have any of the following?

If yes is answered to any of the previous questions, please write down the number
and explain: ________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________
____________________________________________________________________________

List medications that the client has previously taken but not taking currently:

_______________ Client unable to recall names of previous medications that he

or she has taken.
FEMALES ONLY:
Do you experience any menstrual problems? Yes _____ No _____ If yes, explain:
_______________________

___________________________________________________________________________

___________________________________________________________________________

Date of your last menstrual period?

______________________________________________________________

___________________________________________________________________________

Date of your last Pap smear:

_____________________________________________________________________

___________________________________________________________________________

Are you currently pregnant? Yes _____ No _____ If yes, when is your estimated
due date and what physician are you seeing for this pregnancy?
____________________________________________________________

___________________________________________________________________________

Have you ever been pregnant? Yes _____ No _____ If yes, number of
pregnancies: ______________________

___________________________________________________________________________

Have you ever had a miscarriage? Yes _____ No _____

Have you ever had an abortion? Yes _____ No _____ If yes, give date(s):
______________________________

___________________________________________________________________________

Describe any complications during your pregnancy(ies):

____________________________________________
____________________________________________________________________________

****************************************************************************
AUDITORY ASSESSMENT:
Do you have a hearing loss? Yes _____ No _____ If yes, which ear is affected?
_______________________

___________________________________________________________________________

Do you wear any hearing aide devices? Yes _____ No _____

***************************************************************************
VISUAL ASSESSMENT:
Do you wear contacts and/or glasses? Yes _____ No _____

Is your vision blurred or do you see double? Yes _____ No _____

Eye Chart Results: Both eyes: __________ Right eye: __________ Left eye:
__________

***************************************************************************
NUTRITIONAL ASSESSMENT:
How would you assess your eating habits? Good ( ) Fair ( ) Poor ( )

If there is a yes response to questions 1, 2, 4, and/or 5, please inform the

dietary staff so that the dietician may visit with the client.

***************************************************************************
SEXUAL HISTORY:
Age of your first sexual experience:
____________________________________________________________

___________________________________________________________________________

Do you have any concerns about sex and/or your sexuality? Yes ________ No
________ If yes, explain:

___________________________________________________________________________

___________________________________________________________________________

Does your alcohol and/or drug use affect your choices about sex? Yes ______ No
_____ If yes, explain:

___________________________________________________________________________

___________________________________________________________________________

Have you ever been in trouble because of sexual behavior(s)? Yes _______ No
_______ If yes, explain:

___________________________________________________________________________

___________________________________________________________________________

Do you currently have or ever have been treated for a sexually transmitted
disease? Yes _____ No _____ If yes, explain:
___________________________________________________________________________

___________________________________________________________________________

Do you use protection during sexual intercourse? Yes _____ No _____

Have you had sexual intercourse with more than 1 partner? Yes _____ No _____

***************************************************************************
PAIN ASSESSMENT:
Pain Level: □ 0 □1 □2 □3 □4 □5 □6 □7 □8 □9 □ 10 (0
being no pain)

What is your acceptable level of pain:

_____________________________________________________________

Are you currently experiencing pain? Yes _____ No _____ If yes, answer the
following questions:

Location and description of pain:

________________________________________________________________

What relief measures do you use to decrease your pain?

_____________________________________________

___________________________________________________________________________

Pain Management Booklet given to the client: Yes _____ No _____ (In the Client
Handbook)

***************************************************************************
PSYCHOLOGICAL
HISTORY/SCREENING/MENTAL HEALTH
ISSUES:
Have you ever seen a counselor/psychologist/psychiatrist? Yes _____ No _____
If yes, answer the following questions:

When was your last visit?

_______________________________________________________________________

How long have you been seeing this therapist?

_____________________________________________________

Have you ever been hospitalized for mental health issues? Yes _____ No _____

Have you ever received treatment for any of the following mental health or
psychiatric problems?
If yes, please explain:
___________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

How would you assess your sleeping habits? Good __________ Fair
__________ Poor __________

How many hours of sleep do you get per night?

____________________________________________________

Do you have problems with falling asleep? Yes __________ No __________ Do

you have problems awakening frequently throughout the night? Yes _____ No
_____

Do you feel sad, down, and/or depressed? Constantly ______________ Often

______________

Occasionally ______________ Infrequently ______________

Explain:
_______________________________________________________________________

Do you feel fearful, anxious and/or nervous? Constantly ______________ Often

______________

Occasionally ______________ Infrequently ______________

Explain:
_______________________________________________________________________

Have you ever had a panic attack (suddenly fearful without cause)? Yes _____ No
_____ If yes, explain (when was your last panic attack, did you go to the hospital,
etc.?): ___________________________________

___________________________________________________________________________

Do you have feelings of uncontrollable anger, rage, or violence? Yes _______ No

______ If yes, explain:

___________________________________________________________________________

___________________________________________________________________________

What do you do when you are angry?

_____________________________________________________________

___________________________________________________________________________

Are you or have you been in the past physically abusive to others? Yes _____ No
_____

When and explain:

_______________________________________________________________________
 Was this abuse reported? Yes _____ No _____

Have you ever been physically abused? Yes _____ No _____

When and explain:

________________________________________________________________________
Was this abuse reported? Yes _____ No _____
Did you ever tell anyone? Yes _____ No _____

Have you ever been bullied or bullied others on the Internet? Yes _______ No
_______ If yes, explain:

____________________________________________________________________________

Do you ever physically abuse yourself? Yes _____ No _____ If yes, explain:
____________________________

____________________________________________________________________________

Are you or have you been in the past sexually abusive to others? Yes _____ No
_____

When and explain:

________________________________________________________________________
Was this abuse reported? Yes _____ No _____

Have you ever been sexually abused? Yes _____ No _____

When and explain:

________________________________________________________________________
Was this abuse reported? Yes _____ No _____
Did you ever tell anyone? Yes _____ No _____

Do you have thoughts of harming other people? Yes ________ No ________ If

yes, when and explain:

____________________________________________________________________________

____________________________________________________________________________
Have you ever been verbally aggressive toward others? Yes __________ No
__________ If yes, explain:

___________________________________________________________________________

___________________________________________________________________________

Have you ever been physically aggressive? Yes _____ No _____ If yes, explain
(when, where, how violent, was there property destruction, was a weapon
involved?): ___________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Was law enforcement involved when you were physically aggressive? Yes _____
No _____ N/A _____ If yes, please explain:
___________________________________________________________________________

___________________________________________________________________________

Have you ever had thoughts of harming yourself? Yes _____ No _____ If yes,
explain (when was the last time you had these thoughts, etc.?):
_______________________________________________________________

___________________________________________________________________________

Are you currently experiencing any thoughts of harming yourself? Yes ______ No
_____ If yes, explain:

___________________________________________________________________________

___________________________________________________________________________

Have you made plans for carrying out any of these thoughts? Yes _______ No
________ If yes, explain:

___________________________________________________________________________
____________________________________________________________________________

Have you ever attempted suicide? Yes _____ No _______ If yes, explain (when
was last attempt, etc.?):

____________________________________________________________________________

____________________________________________________________________________

Has anyone in your family tried to hurt themselves? Yes _________ No ________
If yes, please explain:

____________________________________________________________________________

____________________________________________________________________________

Have you ever self-mutilated (cutting, burning, etc.)? Yes _____ No _____ If yes,
please explain (describe when, where on body, with what, how long you have
engaged in this behavior, and the date of most recent behavior, and if you required
medical intervention): _______________________________________________

____________________________________________________________________________

____________________________________________________________________________

Do you use alcohol and/or drugs to relieve or avoid your problems? Yes _____
No _____

Do you feel unable to change things? Yes _____ No _____

Do you use alcohol and/or drugs to escape? Yes _____ No _____

Do you have plans for the future? Yes _____ No _____

Briefly describe how you react when things do not go your way:
____________________________________

____________________________________________________________________________

****************************************************************************
SCHOOL HISTORY:
Did you drink alcohol and/or use drugs:

Are you currently attending school? Yes _____ No _____

If yes, answer the following questions:

What school are you attending?

__________________________________________________________________

What grade are you currently in?

_________________________________________________________________

What are your current grades in the classes you are taking?
__________________________________________

Has the use of alcohol and/or drugs caused a deterioration of your school grades?
Yes _____ No _____

If yes, explain:
___________________________________________________________________________

If not attending school, are you working on your GED? Yes _____ No _____

If you quit school, in what grade did you quit?

_____________________________________________________

Are you currently active in extracurricular activities? Yes _____ No _____ If yes,
what activities? _________

___________________________________________________________________________
Have you quit being involved in extracurricular activities? Yes _____ No _____
If yes, explain: ___________

____________________________________________________________________________

Has the use of alcohol and/or drugs caused absences in your school attendance?
Yes _____ No _____

If yes, explain:
____________________________________________________________________________

Have you ever been suspended or expelled from school? Yes _____ No _____ If
yes, explain: _____________

____________________________________________________________________________

Have you experienced any conflicts with your teachers and/or coaches? Yes
_____ No _____

If yes, explain:
____________________________________________________________________________

Have you ever been intoxicated or high (stoned) at school? Yes _____ No _____
If yes, explain: __________

____________________________________________________________________________

Have you ever been caught at school for alcohol and/or drug possession? Yes
_____ No _____

If yes, explain:
____________________________________________________________________________

Have you recently dropped some of your old friends and started going with a new
group?

Yes ______________ No ______________

If yes, explain:
____________________________________________________________________________
Have any of your friends been admitted to an alcohol and/or drug treatment
center? Yes _____ No _____

If yes, explain:
___________________________________________________________________________

***************************************************************************
VOCATIONAL:
Do you currently have a job? Yes _____ No _____ If yes, answer the following
questions:

Do you work full-time? Yes _____ No _____ Do you work part-time? Yes _____
No _____

Name of your employer:

_____________________________________________________________________

What is your position/title at work?

____________________________________________________________

How long have you been employed with this company/business?

___________________________________

Have you ever been placed on probation or suspension at work due to your
alcohol and/or drug use and/or gambling?

Yes _____ No _____ If yes, explain:

____________________________________________________________

If you are unemployed, how long have you been unemployed?

_____________________________________
****************************************************************************
FINANCIAL:
How much money do you earn in a week?
______________________________________________________

How much money do you spend on alcohol and/or drugs in a week?

________________________________

Where do you obtain your money from to purchase alcohol and/or drugs?
_______________________________

***************************************************************************
LEGAL HISTORY:
Have you ever been arrested? Yes _____ No _____ If yes, how many
convictions? _____________________

___________________________________________________________________________

List all of the charges that you can remember with dates and years:

How old were you when you experienced your first contact with the law and what
was the charge or incident?

___________________________________________________________________________

Do you have any current legal problems? Yes _____ No _____ If yes, explain
(date of arrest, court date, and charge, etc.)?
___________________________________________________________________________

___________________________________________________________________________

Do you have a probation officer or parole officer (PO)/court services officer

(CSO)/juvenile court authority (JCA)? Yes _____ No _____ If yes, answer the
following:
Name of person listed:
_______________________________________________________________________

Address of person listed:

_____________________________________________________________________

Telephone number of person listed:

____________________________________________________________

****************************************************************************
SOCIAL/LEISURE:

***************************************************************************
FAMILY:

What is your birth order?

_____________________________________________________________________

Name of the town and state where you were raised:

______________________________________________

Name the people who raised you:

______________________________________________________________

Name the person and their relationship to you that you felt closest to while
growing up: ________________

___________________________________________________________________________

Describe your childhood (happy, sad, normal, etc.):

_______________________________________________

___________________________________________________________________________
How were you disciplined, and who disciplined you?
_____________________________________________

____________________________________________________________________________

Did you feel that you were loved while growing up? Yes _____ No _____

What is or was your biological parents’ relationship like?

__________________________________________

____________________________________________________________________________

If applicable, what is your biological and stepparents’ relationship like?

_____________________________

____________________________________________________________________________

Are you married? Yes _____ No _____ If yes, what is your wife/husband’s name?
______________________

____________________________________________________________________________

Does your wife or husband use or abuse alcohol and/or drugs? Yes _____ No
_____

Do you have children? Yes _____ No _____ If yes, please list the children:

Who will be caring for your children while you are in treatment?
___________________________________

____________________________________________________________________________

With whom do you currently live?

_________________________________________________________
Number of people in the household?
___________________________________________________________

Does anyone in your family have any emotional or physical problems? Yes _____
No _____ If yes, explain:
___________________________________________________________________________

___________________________________________________________________________

Are there any family conflicts? Yes _____ No _____

How do you get along with your family?

________________________________________________________

Have family members expressed concern over your alcohol and/or drug use? Yes
_____ No _____ If yes, who expressed the concern and why?
___________________________________________________________

Has anyone in your family gone to alcohol and/or drug and/or gambling treatment?
Yes _____ No _____

Are any of your family members in a 12-step recovery program? Yes _____ No
_____

Have you ever run away from home? Yes _____ No _____ If yes, please explain
(was the law involved, how long were you gone, where did you go, etc.):
_____________________________________________________

___________________________________________________________________________

___________________________________________________________________________

***************************************************************************
SPIRITUAL:
Do you believe in a Higher Power? (Example: God or Tunkashila) Yes _____ No
_____

Do you have any concerns about your spiritual beliefs/practices? Yes _____ No
_____

What things lift your spirit?

______________________________________________________________________

What are your strengths?

_______________________________________________________________________

What are your weaknesses?

______________________________________________________________________
Mental Status Examination:
Problem Solving:

1. If the flag floats to the south, from which direction is the wind?

North = 3 points _____

2. At what time of the day is your shadow the shortest?

Noon = 3 points _____

3. Why does the moon look larger than the stars?

It is lower = 2 points Nearer objects appear larger = 4

points _____

4. If your shadow points to the northeast, where is the sun?

Southwest = 4 points _____

Knowledge:

5. What are houses made of?

1 point for each material up to 4 points
_____
6. Tell me the names of some fish.
1 point for each species up to 4 points
_____
7. Give me the names of some large cities.
1 point for each city up to 4 points. Excluded are small
towns. _____
8. What is sand used for?
Playing = 1 point Construction = 2 points Glass = 4
points _____
9. What metal is attracted by a magnet?
Steel = 2 points Iron = 4 points _____
10. How many stripes are in the U.S. flag?
 13 = 4 points _____

KENT SCORE _____

(Ask the client the following multiple equation questions. Stop at the last correct
answer. You do not have to go beyond. Locate the scoring guide on the next page.)

2 × 12 = __________ 2 × 24 = __________ 2 × 48 = __________

2 × 96 = __________ 2 × 192 = __________ 2 × 384 = __________

2 × ? = __________

Instructions: Place a check mark in the box if the item was answered correctly.
Write incorrect or unusual answers in space provided. If necessary, urge client
once to complete the task.
_________________ TOTAL SCORE (If the client’s score is less than 20, the
medical director and/or the psychologist should be notified.)

Client was cooperative ________________________ Uncooperative

________________________

Depressed ________________________ Lethargic

________________________

Other
____________________________________________________________________________

Physical appearance on admission:

_______________________________________________________________

____________________________________________________________________________

Mental state, behaviors, and attitude on admission:

________________________________________________

____________________________________________________________________________

____________________________________________________________________________

On admission the client was accompanied by

____________________________________________________________________________

Age _________ B/P _________ Temperature _________ Pulse _________

Respirations _________ Height _________ Weight _________

CIWA Score on admission __________________ Vital sign score on admission

__________________

Safety Screening Assessment

□ Admit

□ Admit with a safety plan. Describe in detail:

____________________________________________________
___________________________________________________________________________

□ Do not admit. Explain:

_______________________________________________________________________

___________________________________________________________________________

Summary
___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

DSM–IV IMPRESSIONS:
_______________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Nursing Signature & Title Date

___________________________________________________________________________

Physician Signature Date

Appendix 60: National Cancer Institute Guide
to Quitting Smoking
Introduction

From those of us at the National Cancer Institute: Congratulations! You are

taking the first step to quitting cigarette smoking.

We wrote this booklet with the help of ex-smokers and experts. It can help
you prepare to quit and support you in the days and weeks after you quit. It
also describes problems to expect when you quit. Being prepared can help
you through the hard times.

Many tips are offered in this booklet—choose what works best for you. You
can quit for good, even if you’ve tried before. In fact, most smokers try to
quit many times before they succeed.

Stay upbeat. Keep trying. Use what you learn each step of the way until you
quit for good. Soon, you too will be an ex-smoker.

Source: The National Cancer Institute (NCI) is part of the National Institutes of
Health, one of the agencies in the U.S. Department of Health and Human Services.
NCI is the U.S. Government’s principal agency for cancer research and training.
Before you START a Smoke-Free Life
Quitting is hard
Many ex-smokers say quitting was the hardest thing they ever did.

Do you feel hooked? You’re probably addicted to nicotine. Nicotine is in all

tobacco products. It makes you feel calm and satisfied, yet also alert and focused
But the more you smoke, the more nicotine you need to feel good. Soon, you don’t
feel “normal” without nicotine. This is nicotine addiction.

It takes time to break free from nicotine addiction. It may take more than one try to
quit for good. So don’t give up too soon. You will feel good again.

Quitting is also hard because smoking is a big part of your life. You may enjoy
holding a cigarette and puffing on it. You may smoke when you are stressed,
bored, or angry. You may light up when you drink coffee or alcohol, talk on the
phone, drive, or are with other smokers. After months and years, smoking has
become part of your daily routine. You may light up without even thinking about it.

Quitting isn’t easy. Just reading this booklet won’t do it. You may try to quit
several times before you’re finally done with cigarettes. But you will learn
something each time you try. It takes willpower and strength to beat your addiction
to nicotine. Remember that millions of people have quit smoking for good. You
can be one of them.

Just thinking about quitting may make you anxious. But your chances will be better
if you get ready first. Quitting works best when you’re prepared.
Preparing to quit

Think about why you want to quit

Decide for sure that you want to quit, and then promise yourself you’ll do it. It’s
okay to have mixed feelings. Don’t let that stop you. There will be times every day
that you don’t feel like quitting. You will have to stick with it anyway. Find
reasons that are important to you.

Think of health reasons, such as:

My body will start healing right away.

I will have more energy and focus.
I will feel more physically fit.
I will have whiter teeth and healthier gums.
I will cough less and breathe easier.
I will lower my risk of cancer, heart attack, stroke, emphysema, chronic
bronchitis, and cataracts.
I will reduce the risk of fertility problems, premature births, and lower
birthweight babies.
I will no longer expose my family and friends to secondhand smoke.
KEEP IN MIND
Your body gets more than nicotine when you smoke.

Cigarette smoke contains more than 4,000 chemicals. Some of these chemicals are
also found in wood varnish, the insecticide DDT, rat poison, and nail polish
remover.

The ashes, tar, gases, and other poisons—such as arsenic—in cigarettes harm your
body over time. They damage your heart and lungs. They also make it harder for
you to taste and smell things and to fight infection.

Source: U.S. Department of Health and Human Services. Reducing Tobacco Use:
A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and
Human Services, Centers for Disease Control and Prevention, National Center for
Chronic Disease Prevention and Health Promotion, Office on Smoking and Health,
2000.
KEEP IN MIND
Even a little secondhand smoke is dangerous.

Secondhand smoke—also called environmental tobacco smoke—comes from a

burning tobacco product and from the smoke exhaled by smokers. Inhaling
secondhand smoke is called involuntary or passive smoking.

Nonsmokers who breathe secondhand smoke may:

develop cancer or heart disease

have breathing problems
get colds and the flu more easily
die younger than people who don’t breathe secondhand smoke

Pregnant women who breathe secondhand smoke may:

give birth to low-weight babies

have babies who are more likely to die of sudden infant death syndrome
(SIDS)

Children who breathe secondhand smoke may:

have breathing problems, such as asthma

get more ear infections
develop more lung infections, such as pneumonia

Source: U.S. Department of Health and Human Services. The Health

Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the
Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention, Coordinating Center for Health
Promotion, National Center for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health, 2006.

Think of some other reasons to quit, such as:

I will be proud of myself.

I will make my family, friends, and coworkers proud of me.
 I will be a better role model for others, especially my kids.
I will feel more in control of my life.
I will have more money to spend.
I will save time by not taking cigarette breaks, buying cigarettes, or searching
for a light.

Write down why you want to quit

Write down all the reasons you want to quit.

Keep your list where you’ll see it often. Good places for your list are:

where you keep your cigarettes

in your wallet or purse
in your kitchen
in your car

When you reach for a cigarette, find your list of reasons for quitting. It will remind
you why you want to stop.

My reasons to quit are

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________
___________________________________________________________________________

___________________________________________________________________________
KEEP IN MIND
Pregnancy and smoking are not a good mix.

If you are pregnant or thinking about having a baby, there’s no better time to quit
smoking than now. Women who smoke have a harder time getting pregnant. If they
do get pregnant, they risk losing the baby or having a stillborn baby. And babies
born to mothers who smoke:

may be smaller than normal at birth

are more likely to die of sudden infant death syndrome (SIDS)
may be cranky, restless, and get sick more often
are more likely to have learning problems as they develop

The good news is that quitting can help you have a healthy baby. It helps to quit
any time during your pregnancy, but it’s even better to quit before you become
pregnant. Information to help you stop smoking is available in English and Spanish
at [Link]/[Link].

Source: U.S. Department of Health and Human Services. Women and Smoking: A
Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and
Human Services, Centers for Disease Control and Prevention, National Center for
Chronic Disease Prevention and Health Promotion, Office on Smoking and Health,
2001.

Learn how much you depend on nicotine

Knowing how addicted you are to nicotine can help you quit. It can help you
decide if you need extra support, such as joining a quit-smoking program or taking
medication to help you quit.

Answer the six simple questions in this nicotine addiction test. Your score will
help you figure out how much you depend on nicotine.
Understand what your score means
If you scored even a single point, you may be dependent on nicotine. The higher
your score, the more dependent you are. Remember—no matter what your score,
you’ll have to work hard to quit.

Source: Heatherton, T. F., Kozlowski, L. T., Frecker, R. C., Fagerstrom, K. O.

The Fagerstrom Test for Nicotine Dependence: a revision of the Fagerstrom
Tolerance Questionnaire. British Journal of Addictions. 1991; 86:1119 -1127

Understand what makes you want to smoke

Wanting to smoke is not just an unhealthy habit. You want to smoke because your
body now relies on nicotine. When the amount of nicotine in your body runs low,
it triggers a craving—a strong, almost uncontrollable urge—for another cigarette.
You may feel jittery, short-tempered, or anxious when you haven’t smoked. Your
body wants nicotine.

Triggers—people, places, activities, and feelings you associate with smoking—

also make you want to smoke. Your triggers might be hearing the sounds of a party,
finishing a task, or smelling coffee. Whatever your triggers, they can make you
crave a cigarette.

Know your triggers

If you know your triggers, you have a head start on avoiding situations that tempt
you to smoke.

Think about what might tempt you to smoke. Put a check next to the triggers on
page 781 that apply to you.

Many smokers find that all these triggers make them want to smoke. You may only
check a few. The point is to recognize all the situations that trigger your craving
for a cigarette.

❑ Waking in the morning

❑ Drinking coffee, tea, or alcohol
❑ Smelling a cigarette
❑ Being with other smokers
❑ Seeing someone smoke
❑ Taking a break
❑ Talking on the phone
❑ Checking email
❑ Surfing the Internet
❑ Watching TV
❑ Driving my car
❑ Being a passenger
❑ After eating
❑ After having sex
❑ After completing a task
❑ Feeling stressed
 ❑ Feeling lonely or depressed
❑ Being or feeling less tolerant
❑ Feeling bored
❑ Feeling angry, irritable, or impatient

Meet your triggers head on

You can get prepared to quit smoking by thinking of ways to avoid some triggers
and creating alternatives for others. You’ll find that the urge to smoke only lasts a
few minutes. Even if it lasts longer, it will go away, whether or not you smoke.
Fighting the urge to smoke is easier if you:

take a deep breath

keep your hands busy—write, doodle, or hold a coin or pencil
put something else in your mouth, such as a toothpick, sugar-free lollipop, or
celery stick
go places where smoking isn’t allowed, such as a library or nonsmoking
restaurant
hang out with people who don’t smoke
avoid or reduce alcoholic drinks; try to drink water or juice instead

I will deal with my triggers by

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________
Know your options for quitting smoking
Quitting is hard. Success partly depends on how much you depend on nicotine.
With many quit methods to choose from, be aware that no single approach works
best for everyone. And you may need to try more than one method before you quit
for good.

Some quit methods require a doctor’s prescription. While others do not, it’s
always a good idea to discuss your plan to quit smoking with your doctor. Check
the box of the options you want to talk about with your doctor.
❑ Cold turkey
For some smokers, “going cold turkey” seems like the easiest way to quit: Just
stop smoking and tell yourself you’ll never light up again. This works for some
smokers—usually those with the lowest level of nicotine dependence—but not
many. Fewer than 5 percent of smokers can quit this way. Most people aren’t
prepared when smoking habits and withdrawal symptoms trigger an intense urge
to smoke. Research shows that most smokers have more success with one of the
assisted quit methods discussed below. These methods have been tested and all of
them are included in the U.S. Public Health Service guidelines for treating
tobacco use and dependence.
❑ Over-the-counter medications
You don’t need a prescription to buy certain medications that can improve your
success with quitting. Nicotine replacement therapy (NRT) products—lozenges,
gum, or a patch—provide nicotine to help reduce your craving for nicotine and
withdrawal symptoms, if any. This allows you to focus on changing the behavior
and habits that trigger your urge to smoke. To read more about NRT, see page 787.
❑ Prescription medications
Your doctor can prescribe medications to help you quit smoking. Some—inhalers
and nasal sprays—act much like nonprescription nicotine replacement therapy.
Other medications do not contain nicotine and work in different ways to help
reduce your urge to smoke. To read more about prescription medications, see page
787.
❑ Counseling and group support
Many smokers quit with support provided by individual counseling or group
treatment. You can combine these therapies with over-the-counter or prescription
medications. Counseling can help you identify and overcome situations that trigger
the urge to smoke. Research shows that success rates for all quit methods are
higher when they are combined with a support program that provides
encouragement through regularly scheduled one-on-one or group meetings, or
quitlines.
❑ Quitlines
Quitlines are free, telephone-based counseling programs that are available
nationwide. When you call a quitline, you are teamed with a trained counselor
who can help you develop a strategy for quitting or help you stay on the program
you have chosen. The counselor often provides material that can improve your
chances of quitting. You can call the National Cancer Institute’s Smoking Quitline
at 1–877–44U–Quit (1–877–448–7848) or the National Quitline at 1–800–
QUITNOW (1–800–784–8669). These are national quitlines that can help you
anywhere in the United States.
KEEP IN MIND
Not everyone has feelings of withdrawal, but many smokers do. You may
experience one or many symptoms of withdrawal and they may last for different
periods of time.

Common feelings of smoking withdrawal include:

feeling down, blue, or depressed

feeling anxious, nervous, or restless
having trouble thinking clearly
being unable to sleep
feeling tired or run down
feeling hungry or gaining weight
Now Let’s START
START Set a quit date
Finding a time to quit isn’t easy. Any time can be a good time to quit when you are
ready to try. Some smokers like to pick a day that is meaningful to them, such as:

a birthday or wedding anniversary

the first day of vacation
New Year’s Day (January 1)
Independence Day (July 4)
World No Tobacco Day (May 31)
The Great American Smokeout (the third Thursday of each November)

It doesn’t have to be a special day to quit. For many people, today is the day. You
can choose any day to be your quit day. When you are ready to take the first step
toward quitting, take it.
KEEP IN MIND
Some smokers find it difficult to quit at certain times—after a bad day or personal
loss, during a crisis, or at a stressful time, such as a divorce. Examine how you
view such times in your life. Can you afford to wait before setting your quit date?

My quit date is

________________________
START: Tell your family, friends, and coworkers you
plan to quit
Quitting smoking is easier with the support of others. Tell your family, friends, and
coworkers you plan to quit and how they can help you.

Some people like to have others ask them how things are going, while some find it
annoying. Tell the people you care about exactly how they can help you. Here are
some ideas:

Ask everyone to understand if you have a change in mood; assure them it

won’t last long.
Ask smokers who are close to you to quit with you or at least not smoke
around you.
Tell yourself and others: “The longer I go without cigarettes, the sooner I’ll
feel better.”
Tell yourself and others: “The worst withdrawal symptoms from smoking—
irritability and trouble sleeping—may be over within 2 weeks.”

In addition to the support of family, friends, and coworkers, you can get support if
you:

talk one-on-one or in a group with others who are quitting

text-message experts on LiveHelp at [Link]
call the National Cancer Institute Quitline at 1–877–44U–QUIT (1–877–
448–7848)
contact the National Quitline at 1–800–QUITNOW (1–800–784–8669)

The family, friends, and coworkers I want to tell are

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________
____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________
START: Anticipate and plan for the challenges you
will face while quitting
Expecting challenges is an important part of getting ready to quit. Quitting presents
both short- and long-term challenges. You may need different strategies for
handling each.
Short-term challenges
Most people who have a hard time quitting and resume smoking do so in the first 3
months after trying to quit. Difficulty quitting is often caused by withdrawal
symptoms—the physical discomfort smokers feel when they give up nicotine. It is
your body’s way of telling you it is learning to be nicotine-free. These feelings
will go away in time.
Long-term challenges
Even as your physical withdrawal is decreasing, you may still be tempted to
smoke when you feel stressed or down. Although it’s a challenge to be ready for
these times, knowing that certain feelings can trigger a craving to smoke will help
you handle the tough times.
Smoking journal
To understand your short- and long-term challenges, start by examining your
smoking habits. Keeping a smoking journal can help you track how many
cigarettes you smoke a day and what you are doing when you light up.

Check for patterns in your smoking. You may find triggers you aren’t even aware
of. Perhaps cigarettes you smoke at certain times or circumstances mean different
things to you. Some may be more important than others. Understanding what
tempts you to smoke in the short and long term will help you control the urge to
smoke before it hits.

You can copy the journal in this booklet or make your own. Keep your journal
with you so you can easily use it. Be sure to record the time you smoke, where you
are, what you are doing, and what you are thinking or feeling. Rate how much you
want the cigarette each time you smoke.

Try this activity for at least a few days, making sure to record 1 day during the
week and 1 day on the weekend. You may even find that the time you take to
complete the journal helps you smoke less.

0 → None
1 → Just a little
2 → Some
3 → A lot
START: Remove cigarettes and other tobacco
products from your home, car, and workplace.
Getting rid of things that remind you of smoking also will help you get ready to
quit. You should:

Throw away all your tobacco supplies (cigarettes, lighters, matches, and
ashtrays). Don’t forget to check your drawers, coats, and bags.
Make things clean and fresh in your home and car and at work; for instance,
clean your drapes, carpets, and clothes.
Have your teeth cleaned and remove those nicotine stains.

Don’t save the “just in case” pack of cigarettes!

Saving one pack just makes it easier to start smoking again.

I can remove reminders of smoking by

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________
____________________________________________________________________________
KEEP IN MIND
All forms of tobacco are harmful.

Tobacco products and delivery methods come in many forms. However tobacco is
packaged or delivered, it causes disease and addiction. Light or low-tar cigarettes
are just as harmful as regular cigarettes. Clear your home, car, and workplace of
all forms of tobacco.
START: Talk to your doctor about getting help to quit
It is important to tell your doctor when you are ready to quit—especially if you
are pregnant, thinking of becoming pregnant, or have a serious medical condition.
Your doctor can help you connect with the right resources to make your quit
attempt successful. Remember—quitting “cold turkey” isn’t your only choice.

Make sure to let your doctor or pharmacist know what medications you are taking.
Nicotine changes how some drugs work. Your doctor may need to adjust some of
your medications after you quit.

You can learn more about medications before you see your doctor from the
summaries below and the up-to-date medication guide at
[Link]/quit-smoking/medicationguide.
Medications to help you quit
The Food and Drug Administration (FDA) has approved nicotine and non-nicotine
cessation products to reduce withdrawal symptoms and the urge to smoke. Studies
show that these medications, compared with trying to quit without them, can
double or triple your chances of quitting for good. You will get the most benefit
from these medications when you follow the instructions completely. You should
not use any product that has not been tested and approved by the FDA.

Nicotine cessation products

Nicotine cessation products—also called nicotine replacement therapy (NRT)—
contain small amounts of nicotine but not the hundreds of other harmful chemicals
found in cigarettes. NRT helps you handle the physical symptoms of quitting by
providing nicotine at much lower levels than found in cigarettes. This satisfies
your nicotine craving and lessens your urge to smoke. Over-the-counter NRT
options include a patch, gum, or lozenges that contain nicotine. Nicotine inhalers
and nasal sprays are available only by prescription.

Non-nicotine cessation products

Some products that help withdrawal symptoms and nicotine cravings don’t contain
nicotine. They help by reducing symptoms and smoking urges. A prescription is
needed for these medications. See your physician to discuss the details of your
medication plan and to get a prescription.

My next doctor’s appointment is

Date________________________Time_________________
KEEP IN MIND
Medications alone can’t do all the work. They can help with cravings and
withdrawal, but they won’t completely prevent withdrawal symptoms. Even if you
use medication to help you stop smoking, quitting may still be hard at times.

Many people find it helps to combine medication with behavior strategies. For
example, you can keep healthy snacks handy to beat cravings, limit time with
smokers, and enroll in a smoking cessation program.
My Quitting Worksheet
Review what you have done so far to prepare yourself to quit smoking successfully.

My reasons to quit are

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

My nicotine addiction test score is

________________________________________________________
My triggers
❑ Waking in the morning
❑ Drinking coffee, tea, or alcohol
❑ Smelling a cigarette
❑ Being with other smokers
❑ Seeing someone smoke
❑ Taking a break
❑ Talking on the phone
❑ Checking email
❑ Surfing the Internet
❑ Watching TV
❑ Driving my car
❑ Being a passenger
❑ After eating
❑ After having sex
❑ After completing a task
❑ Feeling stressed
❑ Feeling lonely or depressed
❑ Being or feeling less tolerant
❑ Feeling bored
❑ Feeling angry, irritable, or impatient

I will deal with my triggers by

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

The quit method I’m interested in

❑ Cold turkey
❑ Over-the-counter medication (gum, patch, lozenges)
❑ Prescription medication (inhaler, nasal spray)
❑ Counseling and group support
❑ Quitlines

My quit date is
________________________________________________________________________

The family, friends, and coworkers I want to tell are

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

I can remove reminders of smoking by

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

My next doctor’s appointment is

Date __________________________________________ Time

__________________________________
Today’s the Big Day–Your Quit Date
So today is the big day—your quit date. Quitting is not easy, so to help you get
through your first smoke-free days, we suggest that you:

keep busy and find new things to do

stay away from what tempts you
plan to reward yourself
Keep busy and find new things to do
Keep busy today, spending as much time as you can in nonsmoking places. Create
some new habits and mix up your daily routine. Today and the days ahead will be
easier if you avoid things that remind you of smoking. Remember—it’s harder to
smoke if you are keeping yourself busy and finding new things to do.

Here are some examples to get you started.

Go to nonsmoking places Be active
gyms
libraries
malls
museums
places of worship
smoke-free restaurants
walk or run
take a bike ride
go for a swim
shoot hoops
try a yoga class
Distract your hands Distract your mind
hold something—a tennis ball, pen, or coin
squeeze Silly Putty®
knit or crochet
do a crossword puzzle
read a book
play cards
Drink the right stuff
avoid alcoholic drinks
drink a lot of water and low-sugar fruit juice
replace coffee or tea with a new healthy beverage
Fool your mouth
write a letter
try a toothpick or straw
eat a lollipop
chew sugar-free gum
eat carrot or celery sticks
brush your teeth often and use mouthwash

You may have a hard time concentrating in your early days as a nonsmoker. Mental
activities, such as doing crossword puzzles or even reading a book or magazine,
may be more challenging. Recognize that it may be difficult to stay mentally
focused in the early stages of quitting. Remember—your skill in these activities
will return.
Stay Away from What Tempts You
You now understand that certain things trigger your urge to smoke. Today and as
you’re trying to quit, review your list of triggers. Then think of how you can avoid
them. Other helpful tips to avoid triggers are noted below.
Change your routine
Changes in your routine help you avoid times and places that trigger the urge to
smoke. Do things and go places where smoking is not allowed. Keep this up until
you feel more relaxed and confident about being smoke-free.
When you really crave a cigarette
Remember—the urge to smoke usually lasts only a few minutes. Try to wait it out.
One reason it’s important to get rid of all your cigarettes is to give yourself the
time you need for these cravings to fade. Drink water or do something else until
the urge passes. Look at the plan you made when you were getting ready to quit.
You wrote down steps to take at a time like this. Try them! You also can use any of
the tips below.

No matter what, don’t think, “Just one won’t hurt.” It will hurt. It will slow your
progress toward your goal of being smoke-free. Remember—trying something to
beat the urge is always better than trying nothing. The craving will go away,
whether you smoke a cigarette or not.
Plan to reward yourself
Don’t think of it as stopping smoking. Think of it as starting a new, healthier life
style. Staying smoke-free is challenging. It takes some time. Be patient. You will
begin to feel better. Set up rewards to remind yourself how hard you’re working.
For example, you could:

buy yourself something special to celebrate quitting

splurge on a massage or dinner at a new restaurant
see a movie or sporting event
start a new hobby
begin exercising
My list of rewards
Make your own list of rewards. If they require a purchase, figure out the cost.
Then plan for rewards that equal the amount of time you’ve succeeded in quitting
(1 day, 1 week, 1 month, and so on). Put aside cigarette money to save for or buy
some of them. You’ll be amazed at how fast the money you used to spend on
cigarettes adds up and how soon you’ll be able to buy your rewards.

I would like to reward myself by

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________
____________________________________________________________________________

____________________________________________________________________________
KEEP IN MIND
You have to be careful with food rewards.

It’s a great idea to go out to dinner or have a scoop of ice cream. Just be
reasonable. Treat yourself without overeating. Make sure you are really hungry
and not just searching for a substitute for a cigarette craving.

Now that you aren’t buying cigarettes, you probably have more spending money.
For example, if you smoke one pack a day:*
Quitting for Good–You Can Do It!
Beating an addiction to nicotine takes a lot more than just willpower and
determination. You should feel great about yourself for making it this far. Now’s
the time to focus on sticking with it. To continue your success, make sure you:

keep your guard up

don’t get discouraged if you slip
stay upbeat
focus on a new, healthier lifestyle
Keep your guard up
Your brain has learned to crave nicotine. Although you have quit, the urge to
smoke often hits at the same time as when you smoked. For a long time, you have
connected certain people, places, activities, and feelings with smoking a cigarette.
Although you have quit, triggers such as drinking coffee or using your cell phone
don’t just disappear. These triggers may cause you to smoke again.

Be cautious and understand that most of the cravings connected to your triggers
should disappear within a few months. But others may last longer. That’s why you
should never take a puff again, no matter how long it’s been since you quit.

Continue to review your smoking journal to see when you might be tempted. Then
use the skills you’ve learned to continue to get through your urges without
smoking.
Don’t get discouraged if you slip
Don’t be discouraged if you slip and smoke one or two cigarettes. It’s not a lost
cause. One cigarette is better than an empty pack. But that doesn’t mean you can
safely smoke every now and then, no matter how long ago you quit. One cigarette
may seem harmless, but it can quickly lead back to your old smoking habits.

Many ex-smokers tried stopping many times before finally succeeding. When
people slip, it’s usually within the first few months after quitting, when resisting
the urge to smoke can be especially challenging. If you do slip, here are some
strategies that can help you get back on track.
Realize you slipped
Acknowledge that you slipped. You’ve had a small setback. This doesn’t make
you a smoker again. Feel good about all the time you went without smoking. Focus
on strengthening your coping skills.
Don’t be too hard on yourself
One slip doesn’t make you a failure. It doesn’t mean you can’t quit for good. But
don’t be too easy on yourself, either. If you slip, don’t say, “Well, I’ve blown it. I
might as well smoke the rest of this pack.” It’s important to get back on the
nonsmoking track right away. Remember, your goal is no cigarettes—not even one
puff.
Understand why you slipped
Find the trigger. Exactly what was it that made you smoke? Be aware of that
trigger. If you are using medication to help you quit, don’t assume that it isn’t
working if you slip and have a cigarette or two. Stay with it. It will help you get
back on track.
Learn from your experience
What has helped you the most to keep from smoking? Make sure to do that on your
next try. If you need to visit your doctor or other health professional again, do so.
He or she can help motivate you to continue your effort to quit. Talk to your family
and friends. It’s okay to ask for support.

Know and use the tips in this booklet. People with even one coping skill are more
likely to stay ex-smokers than those who don’t know any. START to stop again!
It’s never too late to try.
Stay upbeat
As you go through the first days and weeks without smoking, stay positive. Don’t
blame yourself if you slip and smoke a cigarette. Don’t think of smoking as “all or
nothing.” Take it one day at a time.

Remember—you didn’t learn to smoke overnight. You may have taken months or
even longer to adjust your routines to smoking. Quitting is a learning process, too.
Staying positive will help you choose new activities and patterns to replace old
habits.
Focus on a new, healthier lifestyle
Watch your weight
Many ex-smokers gain some weight because food tastes and smells better after
quitting. You may notice that you snack more as a way to cope with the stress of
quitting. Because your body uses food more slowly when you first stop smoking,
you may gain weight.

If you’re worried about gaining weight, remember that the benefits from quitting
far outweigh the initial possibility of a few extra pounds. And by being aware of
possible weight gain, you can do something about it. Get in shape and eat regular,
nutritious meals to prevent unhealthy weight gain. Talk to your doctor or a
nutritionist about meals and snacks with healthy amounts of protein, fruits, and
vegetables. Also, check the suggestions below.
Get in shape
Exercise is a great distraction from smoking. It lowers the stress and reduces the
cravings that make you want a cigarette. Try to make time to be physically active
every day. Experts recommend:

30 minutes a day of moderate physical activity for at least 5 days a week, or

at least 20 minutes of vigorous physical activity at least 3 days a week

Keep in mind most physical activities will help you burn calories and control
weight gain. When you talk to your doctor about quitting, ask about exercises or
activities that can get you back on the road to being fit. Find activities you like to
do and that will fit into your schedule. You can also add activity to your day by
walking during lunch, taking the stairs, parking farther away from your destination,
or stretching during breaks. Possible activities include:

walking or running
dancing
martial arts
yoga
tennis
basketball
aerobics
cycling
Eat healthy foods
Don’t stress over your eating patterns. Just try to make healthy food choices as you
begin to increase your exercise. Any small changes will help. Here are some tips
to get you started today:

replace high-calorie foods with healthy, low-calorie ones, such as fresh

fruits, vegetables, juices, yogurt, or air-popped popcorn without butter
eat sugar-free candy or juice pops, or chew sugar-free gum
choose foods that take longer to eat and keep your hands busy, such as
oranges or sunflower seeds
try crunchy foods, such as pretzels and rice cakes, so your mouth has to work
drink water before and between meals

If you need to have something sweet on occasion, choose foods that taste sweet
but have reduced fat and sugar, such as low-fat frozen yogurt.

For more information on how to eat healthy foods, talk to your doctor or
nutritionist. Remember to be patient. It takes time to get good at eating healthily
and staying smoke-free!
Remember The Long-Term Rewards
Tobacco use in the United States causes more than 440,000 deaths each year. Of
those deaths, 170,000 are from cancer.

Once you quit smoking, you will add healthy days and years to your life. And you
will significantly lower your risk of death from lung cancer and other diseases,
including:

heart disease
stroke
emphysema
cervical cancer
kidney cancer
acute myeloid leukemia
pancreatic cancer
stomach cancer
bladder cancer
esophageal cancer
laryngeal cancer
oral cancer
throat cancer

The health of your loved ones also will benefit from your quitting—they’ll no
longer be exposed to dangerous secondhand smoke. Finally, by quitting smoking,
you’re setting a good example. You’re showing others, especially young people,
that a life without cigarettes is a longer, healthier, happier life.

Within 20 minutes of smoking that last cigarette, your body starts making healthy
changes that will continue for years. You can look forward to the following
dramatic changes the moment you become an ex-smoker.
Congratulations!
20 minutes after quitting
Your heart rate drops.
12 hours after quitting
The carbon monoxide level in your blood drops to normal.
2 weeks to 3 months after quitting
Your heart attack risk begins to drop. Your lung function begins to improve.
1 to 9 months after quitting
Your coughing and shortness of breath decrease.
1 year after quitting
Your added risk of coronary heart disease is half that of a smoker’s.
5 years after quitting
Your stroke risk is reduced to that of a nonsmoker’s 5–15 years after quitting.
10 years after quitting
Your lung cancer death rate is about half that of a smoker’s.
15 years after quitting
Your risk of coronary heart disease is back to that of a nonsmoker’s.

Source: U.S. Department of Health and Human Services. The Health

Consequences of Smoking: What It Means to You. Atlanta, GA: U.S. Department
of Health and Human Services, Centers for Disease Control and Prevention,
National Center for Chronic Disease Prevention and Health Promotion, Office on
Smoking and Health, 2004.
For More Information
National Cancer Institute
[Link]

The National Cancer Institute (NCI) website provides two key tools to help you
quit smoking: LiveHelp, an online text messaging service, and the toll-free number
to NCI’s Smoking Quitline. LiveHelp offers you live, online assistance from
information specialists who provide cancer information and can help you navigate
the NCI website. Click on the LiveHelp link, Monday through Friday.

NCI’s Smoking Quitline also is staffed by specialists who can help you quit
smoking. Call 1–877–44U–Quit (1–877–448–7848), Monday through Friday.
Cancer Information Service
[Link]

NCI’s Cancer Information Service provides accurate, up-to-date information on

cancer. Information specialists can help you quit smoking and explain the latest
cancer information in easy-to-understand English or Spanish. Call 1–800–4–
CANCER (1–800–422–6237); TTY, 1–800–332–8615.
American Cancer Society
[Link]

The American Cancer Society (ACS) has volunteers and offices all over the
country. ACS can help you learn about the health hazards of smoking and how to
become an ex-smoker. Its programs include the Great American Smokeout each
November. ACS also has many booklets and other information to help you quit.
Check online or call 1–800–ACS–2345 (1–800–227–2345) to find your local
office or for more information.
American Heart Association
[Link]

The American Heart Association (AHA) has thousands of volunteers and 130,000
members—doctors, scientists, and others—in 55 state and regional groups AHA
offers books, tapes, and videos on how smoking affects the heart. It also has a
guidebook on weight control in quit-smoking programs. Check online or call 1–
800–AHA–USA1 (1–800–242–8721) to find your local office or for more
information.
American Legacy Foundation
[Link]

The American Legacy Foundation® develops programs that address the health
effects of tobacco use. Through grants, training, partnerships, and grassroots
marketing, the Foundation aims to help young people reject tobacco and give
everyone access to tobacco prevention and cessation services. Vulnerable
populations are a key focus. Check online for more information.
American Lung Association
[Link]

The American Lung Association (ALA) helps smokers who want to quit through
its Freedom From Smoking® self-help quit-smoking program. ALA actively
supports laws and information campaigns for nonsmokers’ rights. It also provides
public information programs on the health effects of smoking. Check online or call
1–800–LUNG–USA (1–800–586–4872) to find your local office or for more
information.
Centers for Disease Control and Prevention
[Link]/tobacco/osh/

The Office on Smoking and Health, a program office within the Centers for
Disease Control and Prevention (CDC), funds booklets on smoking topics such as
relapse, helping a friend or family member quit smoking, the health hazards of
smoking, and the effects of parental smoking on teenagers. Check online or call 1–
800–CDC–INFO (1–800–232–4636) for more information.

*Prices are based on an average of $5.00 per pack of cigarettes. The cost of a
pack may differ, depending on where they are bought.
Appendix 61: Post-traumatic Stress Disorder
(PTSD) Checklist Civilian Version
PCL-M for DSM-IV (11/1/94)
Name: ______________________________________________________

INSTRUCTIONS TO CLIENT: Below is a list of problems and complaints that

people sometimes have in response to stressful experiences. Please read each one
carefully; circle the answer to indicate how much you have been bothered by that
problem in the past month.

1. Repeated, disturbing memories, thoughts, or images of a stressful

experience?
1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

2. Repeated, disturbing dreams of a stressful experience?

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

3. Suddenly acting or feeling as if a stressful experience were happening

again (as if you were reliving it)?
1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

4. Feeling very upset when something reminded you of a stressful experience?

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

5. Having physical reactions (e.g., heart pounding, trouble breathing, sweating)

when something reminded you of a stressful experience?
1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

6. Avoiding thinking about or talking about a stressful experience or avoiding

having feelings related to it?
1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

7. Avoiding activities or situations because they reminded you of a stressful

 experience?
1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

8. Trouble remembering important parts of a stressful experience?

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

9. Loss of interest in activities that you used to enjoy?

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

10. Feeling distant or cut off from other people?

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

11. Feeling emotionally numb or being unable to have loving feelings for those
close to you?
1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

12. Feeling as if your future will somehow be cut short?

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

13. Trouble falling or staying asleep?

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

14. Feeling irritable or having angry outbursts?

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

15. Having difficulty concentrating?

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

16. Being “super-alert” or watchful or on guard?

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely
17. Feeling jumpy or easily startled?
1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

END OF TEST

Scoring: Any answer of 3–5 is considered symptomatic.

Use the following DSM criteria for diagnosis:
- Symptomatic response to at least 1 “B” item (Questions 1–5).
- Symptomatic response to at least 3 “C” items (Questions 6–12).
- Symptomatic response to at least 2 “D” items (Questions 13–17).

Source: Weathers, Litz, Huska, & Keane; National Center for PTSD—Behavioral
Science Division; This is a government document in the public domain.
Appendix 62: Post-Traumatic Stress Disorder
(PTSD) Checklist Military Version
PCL-M for DSM-IV (11/1/94)
Name: ______________________________________________________

INSTRUCTIONS TO CLIENT: Below is a list of problems and complaints that

veterans sometimes have in response to stressful military experiences. Please read
each one carefully; circle the answer to indicate how much you have been
bothered by that problem in the past month.

1. Repeated, disturbing memories, thoughts, or images of a stressful military

experience?
1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

2. Repeated, disturbing dreams of a stressful military experience?

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

3. Suddenly acting or feeling as if a stressful military experience were

happening again (as if you were reliving it)?
1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

4. Feeling very upset when something reminded you of a stressful military

experience?
1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

5. Having physical reactions (e.g., heart pounding, trouble breathing, sweating)

when something reminded you of a stressful military experience?
1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

6. Avoiding thinking about or talking about a stressful military experience or

avoiding having feelings related to it?
1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely
 7. Avoiding activities or situations because they reminded you of a stressful
military experience?
1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

8. Trouble remembering important parts of a stressful military experience?

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

9. Loss of interest in activities that you used to enjoy?

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

10. Feeling distant or cut off from other people?

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

11. Feeling emotionally numb or being unable to have loving feelings for those
close to you?
1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

12. Feeling as if your future will somehow be cut short?

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

13. Trouble falling or staying asleep?

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

14. Feeling irritable or having angry outbursts?

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

15. Having difficulty concentrating?

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

16. Being “super-alert” or watchful or on guard?

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
 Extremely

17. Feeling jumpy or easily startled?

1. Not at all 2. A little bit 3. Moderately 4. Quite a bit 5.
Extremely

END OF TEST

Scoring: Any answer of 3–5 is considered symptomatic.

Use the following DSM criteria for diagnosis:
- Symptomatic response to at least 1 “B” item (Questions 1–5).
- Symptomatic response to at least 3 “C” items (Questions 6–12).
- Symptomatic response to at least 2 “D” items (Questions 13–17).

Source: Weathers, Litz, Huska, & Keane; National Center for PTSD—Behavioral
Science Division. This is a government document in the public domain.
Appendix 63: Alcohol Abstinence Self-
Efficacy Scale

Listed below are a number of situations that lead some people to drink
alcohol.

Mark how confident you are that you would abstain from alcohol in each
situation.

Circle the number that best describes your feelings of confidence to abstain from
alcohol in each situation during the past week according to the following scale:

1 = Not at all confident

2 = Not very confident
3 = Moderately confident
4 = Very confident
5 = Extremely confident
Source: Reprinted with permission from Journal of Studies on Alcohol, vol. 55, pp. 141–148, 1994
(Presently Journal of Studies on Alcohol and Drugs). Copyright by Alcohol Research
Documentation, Inc. Rutgers Center of Alcohol Studies, Piscataway, NJ 08854.
Appendix 64: Hamilton Anxiety Rating Scale

Rating: Clinician-rated
Administration time: 10–15 minutes
Main purpose: To assess the severity of symptoms of anxiety
Population: Adults, adolescents, and children
Commentary
The HAM-A was one of the first rating scales developed to measure the severity
of anxiety symptoms, and is still widely used today in both clinical and research
settings. The scale consists of 14 items, each defined by a series of symptoms, and
measures both psychic anxiety (mental agitation and psychological distress) and
somatic anxiety (physical complaints related to anxiety). Although the HAM-A
remains widely used as an outcome measure in clinical trials, it has been
criticized for its sometimes poor ability to discriminate between anxiolytic and
antidepressant effects, and somatic anxiety versus somatic side effects. The HAM-
A does not provide any standardized probe questions. Despite this, the reported
levels of inter-rater reliability for the scale appear to be acceptable.
Scoring
Each item is scored on a scale of 0 (not present) to 4 (severe), with a total score
range of 0–56, where <17 indicates mild severity, 18–24 mild to moderate
severity, and 25–30 moderate to severe.
Versions
The scale has been translated into Cantonese for China, French, and Spanish. An
IVR version of the scale is available from Healthcare Technology Systems.
Additional References
Maier W, Buller R, Philipp M, Heuser I. The Hamilton Anxiety Scale: reliability,
validity and sensitivity to change in anxiety and depressive disorders. J Affect
Disord 1988;14(1):61–8.

Borkovec T and Costello E. Efficacy of applied relaxation and cognitive

behavioral therapy in the treatment of generalized anxiety disorder. J Clin Consult
Psychol 1993; 61(4):611–19

Source: Hamilton, M. (1959). The assessment of anxiety states by rating. British

Journal of Medical Psychology, 32, 50–55.
Address for Correspondence
The Hamilton Anxiety Rating Scale (HAM-A) is in the public domain.

Hamilton Anxiety Rating Scale

Below is a list of phrases that describe certain feelings that people have. Rate the
clients by finding the answer which best describes the extent to which he/she has
these conditions. Select one of the five responses for each of the fourteen
questions.

0 = Not present, 1 = Mild, 2 = Moderate, 3 = Severe, 4 = Very severe.

1. Anxious mood 0 1 2 3 4
Worries, anticipation of the worst, fearful anticipation, irritability.

2. Tension 0 1 2 3 4
Feelings of tension, fatigability, startle response, moved to tears easily,
trembling, feelings of restlessness, inability to relax.

3. Fears 0 1 2 3 4
Of dark, of strangers, of being left alone, of animals, of traffic, of
crowds.

4. Insomnia 0 1 2 3 4
Difficulty in falling asleep, broken sleep, unsatisfying sleep and fatigue
on waking, dreams, nightmares, night terrors.

5. Intellectual 0 1 2 3 4
Difficulty in concentration, poor memory.

6. Depressed mood 0 1 2 3 4
Loss of interest, lack of pleasure in hobbies, depression, early waking,
diurnal swing.

7. Somatic (muscular) 0 1 2 3 4
Pains and aches, twitching, stiffness, myoclonic jerks, grinding of teeth,
unsteady voice, increased muscular tone.
 8. Somatic (sensory) 0 1 2 3 4
Tinnitus, blurring of vision, hot and cold flushes, feelings of weakness,
pricking sensation.

9. Cardiovascular symptoms 0 1 2 3 4
Tachycardia, palpitations, pain in chest, throbbing of vessels, fainting
feelings, missing beat.

10. Respiratory symptoms 0 1 2 3 4

Pressure or constriction in chest, choking feelings, sighing, dyspnea.

11. Gastrointestinal symptoms 0 1 2 3 4

Difficulty in swallowing, wind abdominal pain, burning sensations,
abdominal fullness, nausea, vomiting, borborygmi, looseness of bowels,
loss of weight, constipation.

12. Genitourinary symptoms 0 1 2 3 4

Frequency of micturition, urgency of micturition, amenorrhea,
menorrhagia, development of frigidity, premature ejaculation, loss of
libido, impotence.

13. Autonomic symptoms 0 1 2 3 4

Dry mouth, flushing, pallor, tendency to sweat, giddiness, tension
headache, raising of hair.

14. Behavior at interview 0 1 2 3 4

Fidgeting, restlessness or pacing, tremor of hands, furrowed brow,
strained face, sighing or rapid respiration, facial pallor, swallowing,
etc.
Appendix 65: Strengths, Needs, Abilities, and
Preferences
Strengths
List three of your most positive qualities (strengths):

1.
2.
3.
Please check the following comments if you feel they describe yourself.

______ I believe that I am highly internally motivated to quit all mind-

altering substances.
______ I believe that I am highly externally motivated to finish this course of
treatment because of legal issues/problems, relationship issues/problems,
and/or job related consequences, etc.
______ I believe that I have the recovery support of family, significant
other(s), and/or friends.
______ I have a supportive home environment to return to.
______ I believe that I am highly imaginative and creative.
______ I am financially stable.
______ I am in good health.

List three of your greatest achievements:

1.
2.
3.

List three things you hope to achieve or to work on while in treatment:

1.
2.
3.

Please describe what you feel treatment is all about.

Please describe your beliefs and understanding of a Higher Power/God.

My spiritual/religious orientation is open to a “Higher Power” concept as it

relates to the 12 steps.

Please check the statement if it applies to you:

Yes No
Needs
______ I need help educating my family and/or significant others regarding
chemical dependency.
______ I need help stabilizing my psychological and/or emotional symptoms
specifically.
______ I need help in finding a clean and sober supportive recovery
environment to enter when I leave the facility. I prefer to live in or near the
following town: __________________________________
______ I need help in identifying my relapse triggers.
Other needs
Abilities
______ I believe that I am educated enough to understand this program’s
printed materials and complete written assignments.
______ I believe that I have natural leadership abilities.
______ I am usually well organized and able to establish priorities.
______ I am self-directive and need little external supervision to accomplish
tasks or assignments.
Other abilities/talents/skills
Preferences
Please check and explain any that apply to you. I have specific preferences related
to my:

______ Culture
______ Ethnicity
(Race)__________________________________________________________________
______
Religion_________________________________________________________________
______ Gender
______ Sexual
orientation_______________________________________________________________
______
Age____________________________________________________________________
______
Physical_________________________________________________________________
______ My preferred language is English.
______ I have English language problems and would prefer that detailed
educational materials and program assignments be modified or translated so I
can better comprehend.
______ I prefer to learn by reading materials/articles/books, etc.
______ I prefer to learn through individual contact with people.
______ I prefer to learn by watching educational DVDs.
______ I prefer to learn by __________________.
Appendix 66: Daily Craving Record

Rate your cravings every day on a scale of 0 (the least amount of craving
possible) to 10 (the most craving possible). Then put down the situation or
thoughts that triggered the craving. Have your counselor or group help you
uncover the automatic thoughts or situations that triggered craving. Do this at least
for the first 90 days of recovery. Make as many copies of these pages that you
need. In treatment, you will replace inaccurate thoughts with accurate thoughts.

0 = no craving 3 = moderate craving 10 = severe craving

Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Date ____ Craving ____ Triggers
________________________________________________________________
Appendix 67: National Association of Alcohol
and Drug Abuse Counselors (NAADAC)
Code of Ethics
Principle 1: Nondiscrimination
I shall affirm diversity among colleagues or clients regardless of age,
gender, sexual orientation, ethnic/racial background, religious/spiritual
beliefs, marital status, political beliefs, or mental/physical disability.
I shall strive to treat all individuals with impartiality and objectivity
relating to all based solely on their personal merits and mindful of the
dignity of all human persons. As such, I shall not impose my personal
values on my clients.
I shall avoid bringing personal or professional issues into the counseling
relationship. Through an awareness of the impact of stereotyping and
discrimination, I shall guard the individual rights and personal dignity of
my clients.
I shall relate to all clients with empathy and understanding no matter what
their diagnosis or personal history.
Principle 2: Client Welfare
I understand that the ability to do good is based on an underlying concern
for the well-being of others. I shall act for the good of others and exercise
respect, sensitivity, and insight. I understand that my primary professional
responsibility and loyalty is to the welfare of my clients, and I shall work
for the client irrespective of who actually pays his/her fees.
I shall do everything possible to safeguard the privacy and confidentiality
of client information except where the client has given specific, written,
informed, and limited consent or when the client poses a risk to himself or
others.
I shall provide the client his/her rights regarding confidentiality, in
writing, as part of informing the client of any areas likely to affect the
client’s confidentiality.
I understand and support all that will assist clients to a better quality of
life, greater freedom, and true independence.
I shall not do for others what they can readily do for themselves but rather
facilitate and support the doing. Likewise, I shall not insist on doing what
I perceive as good without reference to what the client perceives as good
and necessary.
I understand that suffering is unique to a specific individual and not of
some generalized or abstract suffering, such as might be found in the
understanding of the disorder. I also understand that the action taken to
relieve suffering must be uniquely suited to the suffering individual and
not simply some universal prescription.
I shall provide services without regard to the compensation provided by
the client or by a third party and shall render equally appropriate services
to individuals whether they are paying a reduced fee or a full fee.
Principle 3: Client Relationship
I understand and respect the fundamental human right of all individuals to
self-determination and to make decisions that they consider in their own
best interest. I shall be open and clear about the nature, extent, probable
effectiveness, and cost of those services to allow each individual to make
an informed decision of their care.
I shall provide the client and/or guardian with accurate and complete
information regarding the extent of the potential professional relationship,
such as the Code of Ethics and professional loyalties and responsibilities.
I shall inform the client and obtain the client’s participation including the
recording of the interview, the use of interview material for training
purposes, and/or observation of an interview by another person.
Principle 4: Trustworthiness
I understand that effectiveness in my profession is largely based on the
ability to be worthy of trust, and I shall work to the best of my ability to
act consistently within the bounds of a known moral universe, to faithfully
fulfill the terms of both personal and professional commitments, to
safeguard fiduciary relationships consistently, and to speak the truth as it
is known to me.
I shall never misrepresent my credentials or experience.
I shall make no unsubstantiated claims for the efficacy of the services I
provide and make no statements about the nature and course of addictive
disorders that have not been verified by scientific inquiry.
I shall constantly strive for a better understanding of addictive disorders
and refuse to accept supposition and prejudice as if it were the truth.
I understand that ignorance in those matters that should be known does
not excuse me from the ethical fault of misinforming others.
I understand the effect of impairment on professional performance and
shall be willing to seek appropriate treatment for myself or for a
colleague. I shall support peer assistance programs in this respect.
I understand that most property in the healing professions is intellectual
property and shall not present the ideas or formulations of others as if they
were my own. Rather, I shall give appropriate credit to their originators
both in written and spoken communication.
I regard the use of any copyrighted material without permission or the
payment of royalty to be theft.
Principle 5: Compliance With Law
I understand that laws and regulations exist for the good ordering of
society and for the restraint of harm and evil, and I am aware of those laws
and regulations that are relevant both personally and professionally and
follow them, while reserving the right to commit civil disobedience.
I understand that the determination that a law or regulation is unjust is
not a matter of preference or opinion but a matter of rational
investigation, deliberation, and dispute.
I willingly accept that there may be a penalty for justified civil
disobedience, and I must weigh the personal harm of that penalty against
the good done by civil protest.
Principle 6: Rights and Duties
I understand that personal and professional commitments and
relationships create a network of rights and corresponding duties. I shall
work to the best of my ability to safeguard the natural and consensual
rights of each individual and fulfill those duties required of me.
I understand that justice extends beyond individual relationships to the
community and society; therefore, I shall participate in activities that
promote the health of my community and profession.
I shall, to the best of my ability, actively engage in the legislative
processes, educational institutions, and the general public to change
public policy and legislation to make possible opportunities and choice of
service for all human beings of any ethnic or social background whose
lives are impaired by alcoholism and drug abuse.
I understand that the right of confidentiality cannot always be maintained
if it serves to protect abuse, neglect, or exploitation of any person or
leaves another at risk of bodily harm.
Principle 7: Dual Relationships
I understand that I must seek to nurture and support the development of a
relationship of equals rather than to take unfair advantage of individuals
who are vulnerable and exploitable.
I shall not engage in professional relationships or commitments that
conflict with family members, friends, close associates, or others whose
welfare might be jeopardized by such a dual relationship.
Because a relationship begins with a power differential, I shall not exploit
relationships with current or former clients for personal gain, including
social or business relationships.
I shall not under any circumstances engage in sexual behavior with
current or former clients.
I shall not accept substantial gifts from clients, other treatment
organizations, or the providers of materials or services used in my
practice.
Principle 8: Preventing Harm
I understand that every decision and action has ethical implication
leading either to benefit or harm, and I shall carefully consider whether
any of my decisions or actions has the potential to produce harm of a
physical, psychological, financial, legal, or spiritual nature before
implementing them.
I shall refrain from using any methods that could be considered coercive
such as threats, negative labeling, and attempts to provoke shame or
humiliation.
I shall make no requests of clients that are not necessary as part of the
agreed treatment plan.
I shall terminate a counseling or consulting relationship when it is
reasonably clear that the client is not benefiting from the relationship.
I understand an obligation to protect individuals, institutions, and the
profession from harm that might be done by others. Consequently, I am
aware that the conduct of another individual is an actual or likely source
of harm to clients, colleagues, institutions, or the profession and that I
have an ethical obligation to report such conduct to competent authorities.
Principle 9: Duty of Care
I shall operate under the principle of Duty of Care and shall maintain a
working/therapeutic environment in which clients, colleagues, and
employees can be safe from the threat of physical, emotional, or
intellectual harm.
I respect the right of others to hold opinions, beliefs, and values different
from my own.
I shall strive for understanding and the establishment of common ground
rather than for the ascendancy of one opinion over another.
I shall maintain competence in the area of my practice through continuing
education, constantly improving my knowledge and skills in those
approaches most effective with my specific clients.
I shall scrupulously avoid practicing in any area outside of my
competence.

Source: Retrieved from [Link].

Appendix 68: Gambling History

Robert R. Perkinson, PhD

This exercise will help you to become more aware of how gambling has affected
your life and the lives of those around you. Answer the questions as completely as
you can. It is time to get completely honest with yourself. Write down exactly what
happened.

1. How old were you when you first gambled? Describe what happened and
how you felt.

2. List all of the types of gambling you have ever participated in and the age at
which you first gambled.
Video lottery
Blackjack
Bingo
Scratch tickets
Poker (cards)
Horse racing
Slot machines
Powerball
Sports betting
Pull tabs
Dog racing
Other
3. What are your gambling habits? Where do you gamble? With whom? Under
what circumstances?
4. Was there ever a period in your life when you gambled too much? Explain.
5. Has gambling ever caused a problem for you? Describe the problem or
problems.
6. When you were gambling, did you find that you gambled more, or for a
longer period of time, than you had originally intended? Give some
examples.
7. Do you have to gamble more now to get the same effect you want? How much
more than when you first started?
8. Did you ever try to cut down on your gambling? Why did you try to cut down,
 and what happened to your attempt?
9. What did you do to cut down? Did you change the time, place, or game?
Limit the amount (“I’ll only spend twenty dollars tonight”)? Restrict your
gambling to a certain time of day (“I’ll only gamble after five o’clock”)?
10. Did you ever stop completely? What happened? Why did you start again?
11. Did you spend a lot of time getting over your losses?
12. Were you ever so obsessed with gambling that you had problems doing
something dangerous such as driving a car? Give some examples.
13. Did you ever gamble so much that you missed work or school? Give some
examples.
14. Did you ever miss family events or recreation because you were gambling?
Give a few examples.
15. Did your gambling ever cause family problems? Give some examples.
16. Did you ever feel annoyed when someone talked to you about your gambling?
Who was this person, and what did he or she say? Give some examples.
17. Did you ever feel bad or guilty about your gambling? Give some examples.
18. Did gambling ever cause you any psychological problems such as being
depressed? Explain what happened.
19. Did gambling ever cause you any physical problems or make a physical
problem worse? Give a few examples.
20. Did you ever lose track of time when gambling? Give some examples.
21. Did you ever get sick because you were gambling? Give some examples.
22. Did you ever have intense guilt because of gambling? Give some examples
about how you felt.
23. Did you ever get nervous or suffer withdrawal symptoms when you quit
gambling? Describe what happened to you when you stopped gambling.
24. Did you ever gamble to avoid symptoms of withdrawal? Give some
examples of when you used gambling to control withdrawal symptoms.
25. Have you ever sought help for your gambling problem? When? Who did you
see? Did the treatment help you? How?
26. Why do you continue to gamble? Give five reasons.
27. Why do you want to stop gambling? Give 10 reasons.
28. Has gambling ever affected your reputation? Describe what happened and
how you felt.
29. Describe the feelings of guilt you have about your gambling. How do you feel
about yourself?
30. How has gambling affected you financially? Give a few examples of how
you wasted money through your addiction.
31. Has your ambition decreased due to your gambling? Give an example.
32. Has your addiction changed how you feel about yourself?
33. Are you as self-confident as you were before?
34. Describe the reasons why you want treatment now.
35. List all of the types of gambling you have been involved in in the past 6
months.
36. List how often and in what amounts you have gambled in the past 6 months.
37. List the life events that have been affected by your gambling (e.g., school,
marriage, job, and children).
38. Have you ever had legal problems because of your gambling? List each
problem.
39. Have you ever lost a job because of your gambling? Describe what
happened.
40. Do you want treatment for your gambling problem? List a few reasons.
Appendix 69: Diagnostic/Integrated Summary

IDENTIFYING INFORMATION:

HISTORY OF PRESENT ILLNESS (PREVIOUS TREATMENT) & CHIEF

COMPLAINT:

MENTAL STATUS:

ASSESSMENT RESULTS SUMMARY:

MAST:

DAST:

MACI (Adolescent Patients Only):

MILLON:

WRAT:

SASSI (Adolescent Patients Only):

BECK DEPRESSION INVENTORY:

RISK ASSESSMENT (RA):

MENTAL HEALTH SCREENING FORM-III (MHSF-III):

SOUTH OAKS GAMBLING SCREENING (SOGS) – (Gambling Patients

Only):

HISTORY & PHYSICAL EXAMINATION:

CHEMICAL USE HISTORY/GAMBLING HISTORY:

PSYCHIATRIC HISTORY:

PSYCHOLOGICAL SIGNS & SYMPTOMS SCREENING:

(Depression, Mania, Anxiety, Eating, OCD, Somatoform, Adjustment,

Psychosis, PTSD, Attention/Memory; Conduct/Antisocial & Personality.)

EDUCATIONAL HISTORY:

VOCATIONAL HISTORY:

LEGAL HISTORY:

SOCIAL HISTORY:

FAMILY HISTORY:

LIVING ENVIRONMENT:

WEAKNESSES:

S – STRENGTHS:

N – NEEDS:

A – ABILITIES:

P – PREFERENCES:

STAGE OF CHANGE & REASONING:

DSM-IV

1.
2.
 3.
4.
5.

ASAM Justification Statements for III.7 or PRTF (See Approval Form)

D1 (Intoxication & Withdrawal):

D2 (Biomedical):

D3 (Emotional/Behavioral):

D4 (Readiness to Change):

D5 (Relapse, Continued Use Potential):

D6 (Recovery Environment):

TREATMENT PLAN PROBLEM AREAS:

Problem #1:

Problem #2:

Problem #3:

___________________________________________________________________________

Staff Signature & Title Date

Dictated:

Transcribed:

IDENTIFYING INFORMATION: Alec is a 17-year-old Caucasian male from

Brooklyn Park, MN. He is currently living in a tent in his parents’ backyard. He is
here with a chief complaint of “being addicted to heroin for a while and needing
help.”

HISTORY OF PRESENT ILLNESS (PREVIOUS TREATMENT) & CHIEF

COMPLAINT: He has been in multiple treatment centers over the last 5 years,
including Fairview, Abbott Northwestern, Omegon, Anthony Louis Center, and
Minnesota Teen Challenge. He has been unable to maintain sobriety. He states he
has struggled with each program and getting out, and not having much of a plan
when he got out was also a difficult thing for him. It was easy for him to lapse
back into old behaviors, especially when he can’t find a job to support himself.

MENTAL STATUS: Alec is well developed and well nourished. He appears the
same as his stated age. He is casually dressed in jeans and a shirt with fair
hygiene. He was clear and alert in the interview and oriented X3. He was
cooperative and friendly in the interview with normal motor behavior. His eye
contact was appropriate. Primary facial expressions were normal and responsive.
Speech quantity and quality were normal, perhaps a little slow, with no
impairment noted. His mood was calm. He denies any current feelings of
depression or anxiety. Range of affect was appropriate. Thought processes were
logical and coherent with no preoccupations or delusions noted. No disorders of
perception were noted. He denies obsessions, compulsions, or phobias.

ASSESSMENT RESULTS SUMMARY:

MAST: Score of 0 indicates no problems with alcohol currently.

DAST: Score of 15 indicates a substantial amount of problems related to his

substance use.

MACI (Adolescent Patients Only): The MACI highlighted Alec’s personality as

being good at making first impressions. He is stimulus seeking, self-dramatizing,
and disposed to lose his temper when things fail to go well. Under his cool,
indifferent reactions lie antagonism and tensions that he struggles dealing with.

WRAT: The Wide Range Achievement Testing indicates post-high school

reading, high school spelling, and high school math skills.

SASSI (Adolescent Patients Only): Indicates a high probability of chemical

dependency with the FVOD score being 48.

BECK DEPRESSION INVENTORY: Score of 8 indicates minimal depressive

symptoms.
RISK ASSESSMENT (RA): Identified no current risk of harming himself or
others and no history of this in the past year. His past suicide attempt was in 2009.
He has had no further suicidal ideations.

MENTAL HEALTH SCREENING FORM-III (MHSF-III): 4 yes responses out

of 11 questions, which is a positive screening for a mental health problem.

SOUTH OAKS GAMBLING SCREENING (SOGS) – (Gambling Patients

Only): N/A

HISTORY & PHYSICAL EXAMINATION: Alec’s admission history and

physical examination was completed and impressions included: alcohol abuse;
cannabis dependence with physiological dependence; cocaine dependence with
physiological dependence; hallucinogen abuse; opioid dependence with
physiological dependence; amphetamine abuse; sedative, hypnotic, anxiolytic
abuse; history of ADD; history of depression; and history of ODD.

CHEMICAL USE HISTORY/GAMBLING HISTORY: Alec first used alcohol

at age nine. Alec states he is not drinking regularly, just once every couple of
months, but when he does drink, it is generally heavy, 15 to 18 shots of vodka. His
last use of any alcohol was two or three months ago, when he drank a couple of
glasses of wine. He is positive for withdrawal and tolerance. Symptoms of
withdrawal include malaise, weakness, and headache. He has experienced
blackouts and failed attempts to control his drinking. Alec began to use cannabis
at age 10. He was using it orally daily since age 13, two to three joints at a time,
about one quarter ounce. His last use of cannabis was a month prior to admission.
He is positive for tolerance and has experienced chronic cough, cramps,
decreased exercise ability, panic issues, and sleep problems. Alec first used
cocaine at age 15. He snorted this daily for a 4- to 5-month period of time, using
anywhere from 1 1/2 grams to 4 grams. His last use of cocaine was 3 months ago.
He is positive for tolerance and withdrawal, including symptoms of fatigue,
sweats, irritability, agitation, craving, insomnia, and anxiety. Alec first used
hallucinogens at age 13 including LSD, acid, shrooms, and Mescaline orally about
once a month for a 2-year period of time. He would use two to six doses at a time.
His last use of hallucinogens was 5 months ago. Alec started to use opioids at age
16. By age 17 he was using multiple substances including heroin, Lortab,
Percocet, morphine, OxyContin, Oxycodone, Flexeril, Dilaudid, Methadone,
Vicodin, and Ultram. He used these all orally but was not opposed to smoking it
or using it intravenously daily. His use increased significantly. He is positive for
tolerance and withdrawal. His last use of opioids was 2 weeks prior to
admission. He has had symptoms of withdrawal, including craving, aches, fever,
tremor, diarrhea, vomiting, and sweats. At age 13 Alec also got involved in
inhalant use, using Air Duster weekly for a 5-month period of time, using 10 to 15
hits each time. His last use was three years ago. He states his use caused a lot of
stomach pain, memory problems, rapid pulse, vomiting, and chest pain. Alec
started to use amphetamines at age 11. By age 12 he was using fairly regularly. He
was using Adderall, Ritalin, Glass, and Vyvanse. He snorted it daily. His last use
of amphetamines was 2 months ago. He is positive for tolerance and withdrawal,
including symptoms of depression, increased heart rate, anxiety, and sweats. Alec
started to use sedatives, hypnotics, and anxiolytics at age 13, which included
Valium, Ativan, and Xanax. He used these orally about once a month over a 2-year
period of time. Dosages all increased. His last use of any of these substances was
3 months ago. He is positive for tolerance and withdrawal, including symptoms of
anxiety, shakes, vomiting, agitation, and concentration difficulties. Alec started
smoking nicotine at age nine. He is currently smoking a pack of cigarettes per day.
He also chews smokeless tobacco. He indicates he cannot quit. He is positive for
tolerance and withdrawal.

PSYCHIATRIC HISTORY: Alec has a long list of previous diagnoses, although

he complains of no current symptoms. He has a history of a diagnosis of ODD,
depression, ADHD, and sleep problems. He has been on Seroquel in the past and
has had previous counseling for some of these issues. He has been on an IVC in
the past as well. Suicidal ideation occurred 3 years ago and an attempt 4 years
ago when he tried to overdose on Tylenol.

PSYCHOLOGICAL SIGNS & SYMPTOMS SCREENING:

(Depression, Mania, Anxiety, Eating, OCD, Somatoform, Adjustment,

Psychosis, PTSD, Attention/Memory; Conduct/Antisocial & Personality.) He
denies any type of current symptoms of depression or suicidality. He denies any
type of anxiety and states his sleeping and appetite are good. He states he does
have trouble focusing, but he is not sure whether some of those symptoms might be
related to his extensive drug use. He states he was diagnosed with ADD prior to
any drug use, but he states he does not believe the symptoms are problematic at
this point. Alec definitely has a problem with authority and people in power over
him, especially if they lord it over him. He expects people in authority to be kind
and respectful; otherwise, they won’t get that type of treatment in return. He has
extensive history of breaking the law, running away, and theft that would lead
more toward a conduct disorder.

EDUCATIONAL HISTORY: Alec admits to using before, during, and after

school. He gets primarily Bs. He is currently in the 11th grade. He has quit
football. He has missed school and has been expelled for having weapons in
school. He has used at school to prevent withdrawal sicknesses. He has lost a
girlfriend and friends. Many of his friends use and have tried to talk him both in
and out of using. He has a hard time trusting people but does trust a few.

VOCATIONAL HISTORY: Patient is currently unemployed and has been

unemployed for the past 3 years.

LEGAL HISTORY: Alec has five felonies pending. He is not even sure what the
charges are but thinks that by the time he is done, he will be sitting on about 10
felonies. Even though he is still an adolescent, it is quite possible they will try him
as an adult. He is very nervous about the long-term effects of this. Charges include
grand theft auto, breaking and entering, possession, and others.

SOCIAL HISTORY: He has lost a girlfriend and friends. Many of his friends use
and have tried to talk him both in and out of using. He has a hard time trusting
people but does trust a few.

FAMILY HISTORY: His parents will not allow him in their home anymore. His
mother and father do not have any history of use. He also has a younger sister who
has no history of using either.

LIVING ENVIRONMENT: Alec currently is homeless. Alec had been living in

a tent in his parents’ backyard as his parents are unwilling to allow him in the
house without being constantly supervised.

WEAKNESSES: He indicates he is impulsive, drugs.

S – STRENGTHS: He is determined.
N – NEEDS: He needs housing, a job, and money.
A – ABILITIES: He states he likes to write poetry and music lyrics.
P – PREFERENCES: He is more spiritual than religious.

STAGE OF CHANGE & REASONING:

DSM-IV

1. (305.00) Alcohol Abuse versus (303.91) Alcohol Dependence

(304.33) Cannabis Dependence With Physiological Dependence—early

partial remission

(304.23) Cocaine Dependence With Physiological Dependence

(305.30) Hallucinogen Abuse

(304.01) Opioid Dependence With Physiological Dependence

(304.43) Amphetamine Dependence With Physiological Dependence—

early partial remission

(304.13)

Sedative/Hypnotic/Anxiolytic Dependence With Physiological Dependence

—early partial remission

(305.11) Nicotine Dependence With Physiological Dependence

(312.81) Conduct Disorder—childhood onset

(292.84) Substance Induced Mood Disorder

2. Antisocial Traits
3. None
4. Stressors include: multiple treatment attempts; previous suicide attempt and
ideation; currently homeless; extensive legal problems; school difficulties
5. Current Global Assessment of Functioning: 40

ASAM Justification Statements

for III.7 or PRTF (See Approval Form)

D1 (Intoxication & Withdrawal): No problems exist that would distract from

treatment.

D2 (Biomedical): No conditions exist that would complicate treatment.

D3 (Emotional/Behavioral): Alec struggles complying with the authority in his

life. He has not been able to live with his parents because of theft and has had
suicidal ideation and attempts in the past. He is likely to relapse without support
provided in an inpatient level of care.

D4 (Readiness to Change): Alec knows he has a problem. He is contemplative

toward change and just needs the tools and resources to accomplish his goal of an
abstinence-based recovery.

D5 (Relapse, Continued Use Potential): Alec has had multiple treatment

attempts fail at lower levels of care. He is likely to go back to use without a
structured environment.

D6 (Recovery Environment): Alec has burned a lot of bridges with loved ones
to the point they will not allow him in their home. He is nearing 18 and needs
support and to be connected with community resources that can assist him in the
transition to adulthood.

TREATMENT PLAN PROBLEM AREAS:

Problem #1: Substance abuse and dependence

Alec has been through multiple treatments and states that he is willing to
stand on his head if it means changing. He wants to be free from chemicals
and to live an abstinence-based recovery.
Problem #2: Antisocial traits
Alec states, “I have issues with people coming down on me.” Alec admits
that his way of handling authority has gotten him into significant trouble, and
he is willing to explore alternative ways of working within the structure of
society and making choices that will result in more positive consequences for
him.
Problem #3: Family issues
Alec has been homeless due to the bridges he has burned within his family.
He states he needs to work on “relationships in general. I need to rebuild
 bridges with my family.”

____________________________________________________________________________

Christy Alten-Osmera, MS LPC LAC Date

DICTATED: 07-30-13 CO

TRANSCRIBED: 07-30-13 JL
Appendix 70: Mental Health Screening
Appendix 71: Fagerstrom Test for Nicotine
Dependence

Is smoking “just a habit,” or are you addicted? Take this test, and find out your
level of dependence on nicotine.

This form is not applicable as the patient does not smoke.

1. How soon after you wake up do you smoke your first cigarette?
After 60 minutes (0)
31–60 minutes (1)
6–30 minutes (2)
Within 5 minutes (3)

2. Do you find it difficult to refrain from smoking in places where it is

forbidden?
No (0)
Yes (1)

3. Which cigarette would you hate most to give up?

The first in the morning (1)
Any other (0)

4. How many cigarettes per day do you smoke?

10 or less (0)
11–20 (1)
21–30 (2)
31 or more (3)

5. Do you smoke more frequently during the first hours after awakening than
during the rest of the day?
No
Yes

6. Do you smoke even if you are so ill that you are in bed most of the day?
No
Yes
 Total your score
____________________________________________________________________
____________________________________________________________________
Your level of dependence on nicotine is:
0–2 Very Low Dependence 3–4 Low Dependence
5 Medium Dependence 6–7 High Dependence
8–10 Very High Dependence
Scores under 5: Your level of nicotine dependence is still low. You
should act now before your level of dependence increases.
Score of 5: Your level of nicotine dependence is moderate. If you don’t
quit soon, your level of dependence on nicotine will increase until you
may be seriously addicted. Act now to end your dependence on
nicotine.
Score over 7: Your level of dependence is high. You aren’t in control of
your smoking—it is in control of you! When you make the decision to
quit, you may want to talk with your doctor about nicotine replacement
therapy or other medications to help you break your addiction.

Heatherton, T. F., Kozlowski, L. T., Frecker, R. C., Fagerstrom, K. O. (1991). The

Fagerstrom Test for Nicotine Dependence: A revision of the Fagerstrom
Tolerance Questionnaire. British Journal of Addictions, 86, 1119–1127.
References

Abelson, H. I., Fishburne, P., & Cisin, I. H. (1977). National Survey on Drug
Abuse, 1977: A nationwide study—Youth, young adults, and older adults, Vol.
1: Main findings (Publ. No. [ADM] 78–618). Washington, DC: U.S.
Government Printing Office.

Adams, R. D., & Victor, M. (1981). Principles of neurology. New York:

McGraw-Hill.

AIDS and Chemical Dependency Committee. (1988). Guidelines for facilities

treating chemical dependency clients at risk for AIDS and HIV infection (2nd
ed.). New York: American Medical Society on Alcoholism and Other Drug
Dependencies.

Aigner, T. G., & Balster, R. L. (1978). Choice of behavior in rhesus monkeys:

Cocaine versus food. Science, 201, 534–535.

Alberti, R. E., & Emmons, M. L. (1995). Your perfect right: A guide to assertive
living. Atascadero, CA: Impact Publishers.

Alcohol Abstinence Self-Efficacy Scale (1994). Journal of Studies on Alcohol,

55, 141–148.

Alcoholics Anonymous. (1976). Alcoholics Anonymous. New York: Alcoholics

Anonymous World Services.

Alcoholics Anonymous. (1981). Twelve steps and twelve traditions. New York:
Alcoholics Anonymous World Services.
Alcoholics Anonymous. (2001). Alcoholics Anonymous. New York: Alcoholics
Anonymous World Services.

Alcoholics Anonymous. (2002a). Alcoholics Anonymous (4th ed.). New York:

Alcoholics Anonymous World Services.

Alcoholics Anonymous. (2002b). Twelve steps and twelve traditions. New York:
Alcoholics Anonymous World Services.

Alcoholics Anonymous. (2014). Twelve steps and twelve traditions. New York:
Alcoholics Anonymous World Services.

Alexander, E. J. (1951). Withdrawal effects of sodium amytal. Diseases of the

Nervous System, 12, 77–82.

Alexander, J. F. (1974). Behavior modification and delinquent youth. In J. C. Cull

& R. E. Hardy (Eds.), Behavior modification in rehabilitation settings.
Springfield, IL: Charles C Thomas.

Alexander, J. F., & Parsons, B. V. (1973). Short term behavioral intervention with
delinquent families. Journal of Abnormal Psychology, 81, 219–255.

American Cancer Society. (2011). Guide to quitting smoking. Atlanta, GA:

Author.

American Psychiatric Association. (2000). Diagnostic and statistical manual of

mental disorders (Rev. ed.). Washington, DC: American Psychiatric Press.

American Psychiatric Association. (2013). Diagnostic and statistical manual of

mental disorders (DSM-5). Washington, DC: American Psychiatric Press.
Anderson, J. (1941, March). Alcoholics Anonymous. The Saturday Evening Post.

Anglin, M. D., & Hser, Y. (1990). Treatment of drug abuse. In M. Tonry & J. Q.
Wilson (Eds.), Drugs and crime (pp. 339–460). Chicago: University of Chicago
Press.

Annual causes of death in the United States. (2014). Common sense for drug
policy. Retrieved from [Link]

Anthenelli, R. M., & Schuckit, M. A. (1994). Genetic influences in addiction. In

N. S. Miller & M. C. Doot (Eds.), Principles of addiction medicine (sec. 1,
chap. 6, pp. 1–14). Chevy Chase, MD: American Society of Addiction
Medicine.

Appenzeller, O., Standefer, J., Appenzeller, J., & Atkinson, R. (1980). Neurology
of endurance training: V. Endorphins. Neurology, 30, 418–419.

Arria, A. M., Kuhn, V., Calderia, K. M., O’Grady, K. E., Vincent, K. B., & Wish,
E. D. (2008). High school drinking mediates the relationship between parental
monitoring and college drinking: A longitudinal analysis. Substance Abuse
Treatment, Prevention and Policy, 7, 6.

Atkinson, R. M., & Kofed, L. L. (1984). Substance use and abuse in old age.
Substance Abuse, 5, 30–42.

Balster, R. L., & Chait, L. D. (1978). The behavioral effects of phencyclidine in

animals. In R. C. Petersen & R. C. Stillman (Eds.), PCP phencyclidine abuse:
An appraisal (Publ. No. [ADM] 78–728, pp. 53–65). Washington, DC: U.S.
Government Printing Office.

Barlow, D. H., & Craske, M. G. (2006). Mastery of your anxiety and panic:
Workbook. New York: Oxford University Press.
Baum, R., & Iber, F. L. (1980). Initial treatment of the alcoholic client. In S. E.
Gitlow & H. S. Peyser (Eds.), Alcoholism: A practical treatment guide. New
York: Grune & Stratton.

Bearman, S. K., Presnall, K., Martinez, E., & Stice, E. (2006). The skinny on body
dissatisfaction: A longitudinal study of adolescent girls and boys. Journal of
Youth and Adolescence, 35, 217–229.

Beattie, M. (1987). Codependent no more: How to stop controlling others and

start caring for yourself. Center City, MN: Hazelden.

Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical aspects.

New York: Harper & Row.

Beck, A. T. (1972). Depression: Causes and treatment. Philadelphia: University of

Pennsylvania Press.

Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York:
International Universities Press.

Beck, A. T., & Emery, G. (1979). Coping with anxiety and panic: SCT method.
Philadelphia: Center for Cognitive Therapy.

Beck, A. T., & Greenberg, R. (1974). Coping with depression. Philadelphia:

Center for Cognitive Therapy.

Beck, A. T., Rush, J. A., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of
depression. New York: Guilford Press.

Beitman, B. D., Carlin, A. S., & Chiles, J. C. (1984). Pharmacotherapy-

psychotherapy triangle: A physician, a non-medical psychotherapist, and a
client. Journal of Clinical Psychiatry, 45, 458–459.
Benson, H. (1975). The relaxation response. New York: William Morrow.

Benson, H. (2000). The relaxation response. New York: Harper Paperbacks.

Berne, E. (1964). Games people play: The psychology of human relationships.

New York: Grove.

Bettet, P. S., & Maloney, M. J. (1991). The importance of empathy as an

interviewing skill in medicine. Journal of the American Medical Association,
266, 1831–1832.

Blakemore, J. E. O., Berenbaum, S. A., & Liben, L. S. (2009). Gender

development. Clifton, NJ: Psychology Press.

Block, J. (1971). Lives through time. Berkeley, CA: Bancroft Books.

Blumenthal, S. J. (1990). An overview and synopsis of risk factors, assessment,

and treatment of suicidal clients over the life cycle. In S. J. Blumenthal & D. I.
Kupfer (Eds.), Suicide over the life cycle: Risk factors, assessment, and
treatment of suicidal clients. Washington, DC: American Psychiatric Press.

Bradshaw, J. (1988). Healing the shame that binds you. Deerfield Beach, FL:
Health Communications.

Bradshaw, J. (1990). Homecoming: Reclaiming and championing your inner child.

New York: Bantam Books.

Braunwald, E., Isselbacher, K. T., Petersdorf, R. G., Wilson, J. D., Martin, J. B.,
& Fauci, A. S. (1987). Harrison’s principles of internal medicine. New York:
McGraw-Hill.
Brostoff, W. S. (1994). Clinical diagnosis. In N. S. Miller & M. C. Doot (Eds.),
Principles of addiction medicine (sec. 4, chap. 1, pp. 1–4). Chevy Chase, MD:
American Society of Addiction Medicine.

Brown, B. W., Monck, E. M., Carstairs, G. M., & Wing, J. K. (1962). Influence of
family life on the course of schizophrenic illness. British Journal of
Preventative Social Medicine, 16, 55–68.

Burant, D. (1990). Management of withdrawal. In A. Geller (Ed.), Syllabus for

the review course in addiction medicine. New York: Signet.

Burling, T. A., Reilly, P. M., Molten, J. O., & Ziff, D. C. (1989). Self-efficacy and
relapse among inpatient drug and alcohol abusers: A predictor of outcome.
Journal of Studies on Alcohol, 50(4), 354–360.

Burns, D. D. (1999). The feeling good handbook. New York: Penguin.

Busto, U. E., Sykora, K., & Sellers, E. M. A. (1989). A clinical scale to assess
benzodiazepine withdrawal. Journal of Clinical Psychopharmacology, 9, 412.

Cameron, J. L. (2004). Interrelationships between hormones, behavior, and affect

during adolescence: Understanding hormonal, physical, and brain changes
occurring in association with pubertal activation of the reproductive axis.
Introduction to Part III. Annals of the New York Academy of Sciences, 7027,
110–123.

Caracci, L., Megone, P., & Dornbush, R. (1983). Phencyclidine in an East Harlem
psychiatric population. Journal of the National Medical Association, 75,
869–874.

Carroll, M., & Comer, S. (1994). The pharmacology of phencyclidine and the
hallucinogens. In N. S. Miller & M. C. Doot (Eds.), Principles of addiction
medicine (sec. 2, chap. 7, p. 153). Chevy Chase, MD: American Society of
 Addiction Medicine.

Carroll, M., & Comer, S. (1998). Phencyclidine and the hallucinogens. In A. W.

Graham, T. K. Schultz, & B. B. Wilford (Eds.), Principles of addiction
medicine (sec. 2, chap. 7, pp. 1–9). Chevy Chase, MD: American Society of
Addiction Medicine.

Centers for Disease Control. (1990). HIV/AIDS surveillance report. Atlanta, GA:
Author.

Centers for Disease Control and Prevention. (2010). Tobacco use: Targeting the
nation’s leading killer at-a-glance 2010. Atlanta, GA: Author.

Centers for Disease Control and Prevention. (2014). Causes of death. Atlanta,
GA: Author.

Centers for Disease Control. (2015). Injury prevention & control: Opioid
overdose. Retrieved from [Link]

Centers for Disease Control and Prevention, National Center for Health Statistics,
National Vital Statistics System, Mortality File. (2015). Number and Age-
Adjusted Rates of Drug-poisoning Deaths Involving Opioid Analgesics and
Heroin: United States, 2000–2014. Atlanta, GA: Center for Disease Control
and Prevention. Available at
[Link]
[Link].

Chatlos, J. C., & Jaffe, S. L. (1994). A developmental biopsychosocial model of

adolescent addiction. In N. S. Miller & M. C. Doot (Eds.), Principles of
addiction medicine (sec. 17, chap. 1, pp. 1–5). Chevy Chase, MD: American
Society of Addiction Medicine.

Chopra, G. S., & Smith, J. W. (1974). Psychotic reactions following cannabis use
 in East Indians. Archives of General Psychiatry, 30, 24–27.

Cloptin, P. L., Janowsky, D. S., Cloptin, J. M., Judd, L. L., & Huey, L. (1979).
Marihuana and the perception of affect. Psychopharmacology, 61, 203–206.

Cohen, H. L., & Filipczak, J. A. (1971). A new learning environment. San

Francisco: Jossey-Bass.

Cohen, S. (1979). Inhalants. In R. I. DuPont, A. Goldstein, & J. O’Donnell (Eds.),

Handbook on drug abuse (pp. 213–220). Washington, DC: U.S. Government
Printing Office.

Conigliaro, J., Reyes, C. D., Parran, T. V., & Schultz, J. E. (2003). Principles of
screening and early intervention. In A. W. Graham, T. K. Schultz, M. F. Mayo-
Smith, & R. K. Ries (Eds.), Principles of addiction medicine (3rd ed.). Chevy
Chase, MD: American Society of Addiction Medicine, Inc.

Conte, H. R., Plutchik, R., Wild, K. V., & Karasu, T. B. (1986). Combined
psychotherapy and pharmacotherapy for depression: A systematic analysis of
the evidence. Archives of General Psychiatry, 43, 471–479.

Cook, R. F., Hostetter, R. S., & Ramsay, D. A. (1975). Patterns of illicit drug use
in the army. American Journal of Psychiatry, 132, 1013–1017.

Courtwright, D. T. (2001). Forces of habit: Drugs and the making of the modern
world. Cambridge, MA: Harvard University Press.

Craske, M. G., Antony, M. M., & Barlow, D. H. (2006). Mastering your fears and
phobias: Workbook. New York: Oxford University Press.

Creager, C. (1989, July–August). SASSI test breaks through denial. The

Professional Counselor, 65.
Csikszentmihalyi, M., & Larson, R. (1984). Being adolescent. New York: Basic
Books.

Custer, R. L. (1984a). Forward in sharing recovery through Gamblers

Anonymous. Los Angeles: Gamblers Anonymous Publishing.

Custer, R. L. (1984b). Profile of a pathological gambler. Journal of Clinical

Psychiatry, 45(12, Pt. 2), 35–38, 998–1011.

Dahl, R. E. (2004). Adolescent brain development: A period of vulnerabilities

and opportunities. Annals of the New York Academy of Sciences, 1021, 1–22.

Davidson, W. S., & Seidman, E. (1974). Studies of behavior modification and

juvenile delinquency: A review, methodological critique, and social
perspective. Psychological Bulletin, 81, 998–1011.

Davis, B. C. (1982). The PCP epidemic: A critical review. International Journal

of Addiction, 17, 1137–1155.

Dickinson, W. E., & Eickelberg, S. J. (2009). Management of sedative-hypnotic

intoxication and withdrawal. In R. K. Miller & S. C. Miller (Eds.), Principles
of addiction medicine (sec. 6, chap. 43). Chevy Chase, MD: American Society
of Addiction Medicine.

DiClemente, C. C. (2006a). Addiction and change: How addictions develop and

addicted people recover. New York: Guilford Press.

DiClemente, C. C. (2006b). Natural change and the troublesome use of

substances: A life-course perspective. In W. R. Miller & K. M. Carroll (Eds.),
Rethinking substance abuse: What the science shows, and what we should do
about it. New York: Guilford Press.
Dietch, J. (1983). The nature and extent of benzodiazepine abuse: An overview of
recent literature. Hospital and Community Psychiatry, 34, 1139–1145.

Domino, E. F. (1978). Neurobiology of phencyclidine: An update. In R. C.

Peterson & R. C. Stillman (Eds.), PCP phencyclidine abuse: An appraisal
(Publ. No. [ADM] 17–728, pp. 18–43). Washington, DC: U.S. Government
Printing Office.

Dorland’s illustrated medical dictionary. (1965). Philadelphia: W. B. Saunders.

Dorus, W., Kennedy, J., Gibbons, R. D., & Raci, S. D. (1987). Symptoms and
diagnosis of depression in alcoholics. Alcoholism, 11, 150–154.

Douvan, E., & Adelson, J. (1966). The adolescent experience. New York: John
Wiley.

DuPont, R. L. (1994). Laboratory diagnosis. In N. S. Miller & M. C. Doot (Eds.),

Principles of addiction medicine (sec. 4, chap. 2, pp. 1–8). Chevy Chase, MD:
American Society of Addiction Medicine.

Earley, P. H. (2009). Physician health programs and addiction among physicians.

In R. K. Ries (Ed.), Principles of addiction medicine, fourth edition. Chevy
Chase, MD: American Society of Addiction Medicine.

Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle-Stuart.

Emrick, C. D. (1987). Alcoholics Anonymous: Affiliation process and

effectiveness as treatment. Alcoholism, 11, 416–423.

Evans, M. A., Marty, R., Brown, D. J., Rodda, B. E., Kippinger, G. F., Lemberger,
L., & Forney, R. B. (1973). Impairment of performance with low doses of
marijuana. Clinical Pharmacological Therapy, 14, 936–940.
Ewing, J. A. (1984). Detecting alcoholism: The CAGE questionnaire. Journal of
the American Medical Association, 252, 1905–1907.

Eysenck, H. J., & Eysenck, S. B. J. (1976). Personality structure and measurement.

London: Routledge & Kegan Paul.

Featherly, J. W., & Hill, E. B. (1989). Crack cocaine overview, 1989.

Washington, DC: U.S. Department of Justice.

Fischman, M. W., Schuster, C. R., Rosnekov, L., Shick, J. F. E., Krasnegor, N. A.,
Fennell, W., & Freedman, D. X. (1976). Cardiovascular and subjective effects
of intravenous cocaine administration in humans. Archives of General
Psychiatry, 33, 983–989.

Florentine, R., & Hillhouse, M. P. (2000). Drug treatment and 12-step program
participation. The effects of integrated recovery activities. Journal of Substance
Abuse Treatment, 18, 64–74.

Folkins, C. H., & Sime, W. E. (1981). Physical fitness training and mental health.
American Psychologist, 36, 373–389.

Folstein, M. F., Folstein, S. W., & McHugh, P. R. (1975). Mini-mental state: A

practical method of grading the cognitive state of clients for the clinician.
Journal of Psychiatric Research, 12, 189–198.

Frances, R. J., Bucky, S., & Alexopolos, G. S. (1984). Outcome study of familial
and nonfamilial alcoholism. American Journal of Psychiatry, 141, 11.

Frances, R. J., & Franklin, J. E., Jr. (1988). Alcohol and other psychoactive
substance use disorders. In J. A. Talbott, R. E. Hales, & S. C. Yudofsky (Eds.),
The American Psychiatric Press textbook of psychiatry. Washington, DC:
American Psychiatric Press.
Freedman, D. X. (1968). The use and abuse of LSD. Archives of General
Psychiatry, 18, 300–347.

Freud, S. (2000). The standard edition of the complete psychological works of

Sigmund Freud. New York: Norton.

Fultz, J. M., & Senay, E. C. (1975). Guidelines for the management of hospitalized
narcotics addicts. Annals of Internal Medicine, 82, 815–818.

Gabel, R. H., Barnard, N., Norko, M., & O’Connell, R. A. (1986). AIDS
presenting as mania. Comparative Psychiatry, 27, 251–254.

Gambert, S. R. (1992). Substance abuse in the elderly. In J. H. Lowinson, P. Ruiz,

R. B. Millman (Eds.), Substance Abuse: A Comprehensive Textbook. (2nd ed.).
Baltimore: Williams & Wilkins.

Gamblers Anonymous. (1989a). The combo book. Los Angeles: G.A. Publishing.

Gamblers Anonymous. (1989b). G.A.: A new beginning. Los Angeles: G.A.

Publishing.

Gary, V., & Guthrie, D. (1972). The effect of jogging on physical fitness and self-
concept in hospitalized alcoholics. Quarterly Journal of Studies on Alcohol, 33,
1073–1078.

Gawin, F. H., & Ellinwood, E. H. (1988). Cocaine and other stimulants: Actions,
abuse, and treatments. New England Journal of Medicine, 318, 1173–1182.

Gawin, F. H., & Kleber, H. S. (1986a). Abstinence symptomatology and

psychiatric diagnosis in cocaine abusers. Archives of General Psychiatry, 43,
107–113.
Gawin, F. H., & Kleber, H. S. (1986b). Pharmacologic treatments of cocaine
abuse and substance abuse. Psychiatry in Clinics of North America, 9,
573–583.

Geller, A. (1990). Protracted abstinence. In A. Geller (Ed.), Syllabus of the

review course in addiction medicine. Washington, DC: American Society of
Addiction Medicine.

Geller, A. (1994). Management of protracted withdrawal. In N. S. Miller & M. C.

Doot (Eds.), Principles of addiction medicine (sec. 11, chap. 2, pp. 1–6).
Chevy Chase, MD: American Society of Addiction Medicine.

Gerstein, D. R., & Harwood, H. J. (Eds.). (1990). Treating drug problems.

Washington, DC: National Academy Press.

Gessner, P. K. (1979). Drug withdrawal therapy of the alcohol withdrawal

syndrome. In E. Majchowicz & E. Moble (Eds.), Biochemistry and
pharmacology of ethanol (Vol. 2). New York: Plenum.

Gilman, A. G., Goodman, L. S., & Gilman, A. (1980). Goodman and Gilman’s the
pharmacological basis of therapeutics. New York: Macmillan.

Glynn, T. J. (1990). Methods of smoking cessation: Finally some answers. Journal

of the American Medical Association, 263, 2795–2796.

Gold, M. S. (1994a). Marijuana. In N. S. Miller & M. C. Doot (Eds.), Principles

of addiction medicine (sec. 2, chap. 8, pp. 1–6). Chevy Chase, MD: American
Society of Addiction Medicine.

Gold, M. S. (1994b). Opioids. In N. S. Miller & M. C. Doot (Eds.), Principles of

addiction medicine (sec. 2, chap. 4, pp. 1–6). Chevy Chase, MD: American
Society of Addiction Medicine.
Goldman, A. R. (1989). Accreditation and certification: For providers of
psychiatric, alcoholism, and drug abuse services. Bala Cynwyd, PA: Practical
Communications.

Goodwin, D. W. (1971). Blackouts and alcohol induced memory dysfunction. In

N. K. Mello & J. H. Mendelson (Eds.), Recent advances in studies in alcohol.
Rockville, MD: National Institute on Mental Health.

Goodwin, D. W. (1985). Alcoholism and genetics. Archives of General

Psychiatry, 42, 171–174.

Goodwin, D. W., Crane, J. B., & Guze, S. B. (1969). Alcoholic blackouts: A

review and clinical study of 100 alcoholics. American Journal of Psychiatry,
126, 174–177.

Gorski, T. T. (1989). Passages through recovery. Center City, MN: Hazelden.

Gorski, T., & Miller, M. (1982). Counseling for relapse prevention.

Independence, MO: Independence Press.

Gottschalk, L. A., McGuire, F. L., Heiser, J. F., Dinovo, E. C., & Birch, H.
(1979). Drug abuse deaths in nine cities: A survey report (Research Monograph
No. 29). Rockville, MD: National Institute on Drug Abuse.

Gould, L. C., & Keeber, H. D. (1974). Changing patterns of multiple drug use
among applicants to a multimodality drug treatment program. Archives of
General Psychiatry, 31, 408–413.

Graziano, A. M., & Mooney, K. C. (1984). Children and behavior therapy. New
York: Aldine.

Greenberg, R. L., & Beck, A. T. (1987). Panic attacks: How to cope, how to
 recover. Philadelphia: Center for Cognitive Therapy.

Greenfield, S., Hufford, M., Vagge, L., Muenz, L., Costello, M., & Weiss, R.
(2000). The relationship of self-efficacy expectations to relapse among alcohol
dependent men and women: A prospective study. Journal of Studies on Alcohol,
61, 345–351.

Greist, J. H., Klein, M. H., Eischins, R. R., Faris, J., Gurman, A. S., & Morgan,
W. P. (1979). Running as treatment for depression. Comprehensive Psychiatry,
20, 41–54.

Griffith, J. D., Cavanaugh, J., Held, J., & Oates, J. A. (1972). Dextroamphetamine.
Archives of General Psychiatry, 26, 97–100.

Group for the Advancement of Psychiatry Committee on Alcoholism and the

Addictions. (1991). Substance abuse disorders: A psychiatric priority.
American Journal of Psychiatry, 148, 1291–1300.

Gunderson, J. G., & Zanarine, M. C. (1987). Current overview of the borderline

diagnosis. Journal of Clinical Psychiatry, 48(Suppl. 8), 5–11.

Hamilton, M. (1959). The assessment of anxiety states by rating. British Journal of

Medical Psychology, 32, 50–55.

Hamilton, M. (1960). A rating scale for depression. Journal of Neurology,

Neurosurgery & Psychiatry, 23, 56–62. Retrieved from
[Link]
access_num=14399272&link_type=MED

Hamilton, M. (1979). The Hamilton rating scale for depression. Journal of

Operational Psychiatry, 10(2):149–165.
Hardman, J., Limbird, L. E., Molinoff, P. B., Ruddon, R. W., & Gilman, A. G.
(1996). Goodman and Gilman’s the pharmacological basis of therapeutics (9th
ed.). New York: McGraw-Hill.

Harris, M. J., Jeste, D. V., Gleghorn, A., & Sewell, D. D. (1991). New-onset
psychosis in HIV-infected clients. Journal of Clinical Psychiatry, 52, 369–376.

Havens, L. (1978). Explorations in the use of language in psychotherapy: Simple

empathetic statements. Psychiatry, 41, 336–345.

Heatherton, T. F., Kozlowski, L. T., Frecker, R. C., Fagerstrom, K. O. (1991). The

Fagerstrom Test for Nicotine Dependence: A revision of the Fagerstrom
Tolerance Questionnaire. British Journal of Addictions, 86, 1119–1127.

Henningfield, J. E. (1984). Pharmacologic basis and treatment of cigarette

smoking. Journal of Clinical Psychiatry, 45, 24–34.

Herbert, M. (1982). Conduct disorder. In A. E. Kazdin & B. B. Lahey (Eds.),

Advances in clinical and child psychology (Vol. 5). New York: Plenum.

Heron, M., Hoyert, D. L., Murphy, S. L., Xu, J., Kochanek, K., & Tejada-Vera, B.
(2009, April 17). Deaths: Final data for 2006. National Vital Statistics Reports,
57(14), 11. Retrieved from
[Link]

Hesselbrock, M. N., Meyer, R. E., & Kenner, J. J. (1985). Psychopathology in

hospitalized alcoholics. Archives of General Psychiatry, 46, 3–5.

Hingson, R. W., Heeren, T., & Winter, M. R. (2006). Age at drinking onset and
alcohol dependence: Age at onset, duration, and severity. Archives of Pediatric
and Adolescent Medicine, 160, 739–746.
Hirschfeld, R. M. A., & Goodwin, F. K. (1988). Mood disorders. In J. A. Talbott,
R. E. Hales, & S. C. Yudofsky (Eds.), The American Psychiatric Press textbook
of psychiatry. Washington, DC: American Psychiatric Press.

Hoffmann, N. G. (1991, June). Treatment outcomes from abstinence based

programs. Paper presented at the meeting of the International Institute on the
Prevention and Treatment of Alcoholism, Stockholm, Sweden.

Hoffmann, N. G. (1994). Assessing treatment effectiveness. In N. S. Miller & M.

C. Doot (Eds.), Principles of addiction medicine (sec. 9, chap. 5, pp. 1–9).
Chevy Chase, MD: American Society of Addiction Medicine.

Hoffmann, N., & Harrison, P. (1987). A 2-year follow-up of inpatient treatment.

St. Paul, MN: Chemical Abuse Treatment Outcome Registry.

Hollister, L. E. (1974). Interactions in man of delta-9-tetrahydrocannabinol. I:

Alphamethylparatyrosine. Clinical Pharmacological Therapy, 15, 18–21.

Hollister, L. E. (1986). Health aspects of cannabis. Pharmacology Review, 38,

1–20.

Hubbard, R. L. (1992). Evaluation and treatment outcome. In J. H. Lorvinson, P.

Ruiz, R. B. Millman, & J. G. Langrod (Eds.), Substance abuse: A
comprehensive textbook. Baltimore: Williams & Wilkins.

Hubbard, R. L., & Anderson, J. A. (1988). Follow-up study of individuals

receiving alcoholism treatment. Research Triangle Park, NC: Research Triangle
Institute.

Hubbard, R. L., & DesJarlais, D. C. (1991). Alcohol and drug abuse. In E. E.

Holland, R. Petels, & G. Knox (Eds.), Oxford textbook of public health (Vol. 3,
2nd ed.). London: Oxford University Press.
Hubbard, R. L., Marsden, M. E., Rachel, J. V., Harwood, H. J., Cavanaugh, E. R.,
& Ginzburg, H. M. (1989). Drug abuse treatment: A national study of
effectiveness. Chapel Hill: University of North Carolina Press.

Hughes, J. R., & Hatsukami, D. (1986). Signs and symptoms of tobacco

withdrawal. Archives of General Psychiatry, 43, 289–294.

Hunt, W. A., Barnett, L. W., & Branch, L. G. (1971). Relapse rates in addiction
programs. Journal of Clinical Psychology, 27, 455–456.

Inaba, D., & Cohen, W. E. (2014). Uppers, downers, all arounders (8th ed.).
Medford, OE: CNS Publications,

Institute of Medicine. (1989). Research effectiveness in the prevention and

treatment of alcohol related problems. Washington, DC: National Academy
Press.

Institute of Medicine. (1995). Federal regulation of methadone treatment.

Washington, DC: National Academy Press.

Institute of Medicine, Committee for the Study and Treatment and Rehabilitation
Services for Alcoholism and Alcohol Abuse. (1990). Broadening the base of
treatment for alcohol problems. Washington, DC: National Academy of
Science.

Jacobs, J. W., Bernhard, M. R., Delgado, A., & Strain, J. J. (1977). Screening for
organic mental syndromes in the medically ill. Annals of Internal Medicine, 86,
40–46.

Jaffe, J. H. (1980). Drug addiction and drug abuse. In A. G. Gilman, L. S.

Goodman, & A. Gilman (Eds.), Goodman and Gilman’s the pharmacological
basis of therapeutics. New York: Macmillan.
Jay, D. (2006). No more letting go: The spirituality of taking action against
alcoholism and drug addiction. New York: Bantam.

Jay, J., & Jay, D. (2001). Love first: A new approach to intervention for
alcoholism and drug addiction. Center City, MN: Hazelden.

Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2008).

Monitoring the future: National results on adolescent drug use, National
Institute on Drug Abuse. Bethesda, MD: U.S. Department of Health and Human
Services.

Joint Commission on Accreditation of Healthcare Organizations. (1988).

Consolidated standards manual. Chicago: Author.

Joint Commission on Accreditation of Healthcare Organizations. (1992). Client

records in addiction treatment: Documenting the quality of care. Oakbrook
Terrace, IL: Author.

Jones, R. T. (1971). Marijuana-induced “high”: Influence of expectation, setting,

and previous drug experience. Pharmacological Review, 23, 359–369.

Jones, R. T., Bennowitz, N., & Bachman, J. (1976). Clinical studies of cannabis
tolerance and dependence. Annals of the New York Academy of Science, 282,
221–239.

Juergens, S. M. (1994). Sedative-hypnotics. In N. S. Miller & M. C. Doot (Eds.),

Principles of addiction medicine (sec. 2, chap. 3, pp. 1–10). Chevy Chase, MD:
American Society of Addiction Medicine.

Kagan, J. (1989). Temperament contribution to social behavior. American Journal

of Psychology, 44, 668–674.
Kagan, J., Reznick, J. S., & Gibbons, J. (1989). Inhibited and uninhibited types of
children. Child Development, 60, 838–845.

Kagan, J., Reznick, J. S., & Snidman, N. (1987). The physiology and psychology
of behavioral inhibition in children. Child Development, 58, 1459–1473.

Kalant, H., Engel, J. A., Goldberg, L., Griffiths, R. R., Jaffe, J. H., Krasnegor, N.
A., . . . Van Ree, J. M. (1978). Behavioral aspects of addiction: Group report.
In J. Fishman (Ed.), The basis of addiction: Report of the Dahlem workshop on
the basis of addiction (pp. 463–495). Berlin: Abakon Verlagsgesellschaft.

Kaminer, Y., Bukstein, O. G., & Tarter, R. E. (1991). The teen addiction severity
index: Rationale and reliability. International Journal of Addiction, 26,
219–226.

Kandel, D. (1978). Antecedents of adolescent initiation into stages of drug use. In

D. Kandel (Ed.), Longitudinal research on drug use. Washington, DC:
Hemisphere.

Karasu, T. B. (Chair). (1989). Treatments of psychiatric disorders. Washington,

DC: American Psychiatric Press.

Kasser, C. L., Geller, A., Howell, E., & Wartenberg, A. (1998). Principles of
detoxification. In A. W. Graham, T. K. Schultz, & B. B. Wilford (Eds.),
Principles of addiction medicine (2nd ed., sec. 6, chap. 7, p. 423). Chevy
Chase, MD: American Society of Addiction Medicine.

Kazdin, A. E., & Weisz, J. R. (2003). Evidence-based psychotherapies for

children and adolescents. New York: Guilford Press.

Khantzian, E. J., & Treece, C. (1985). DSM-III psychiatric diagnosis of narcotics

addicts: Recent findings. Archives of General Psychiatry, 42, 1067–1071.
King, G. S., Smialick, J. E., & Troutman, W. G. (1985). Sudden death in
adolescents resulting from the inhalation of typewriter correction fluid. Journal
of the American Medical Association, 253, 1604–1609.

Klein, D. F., Gittelman, R., Quitkin, F., & Rifkin, A. (1980). Diagnosis and drug
treatment of psychiatric disorders: Adults and children. Baltimore: Williams &
Wilkins.

Klerman, G. L., Weissman, M. M., Rounsaville, B. J., & Chevron, E. S. (1984).

Interpersonal psychotherapy of depression. New York: Basic Books.

Kosten, T. R., Rounsaville, B. J., & Kleber, H. D. (1985). Comparison of clinical

ratings to self-reports of withdrawal during clonidine detoxification of opiate
addicts. American Journal of Drug and Alcohol Abuse, 11, 1–10.

Kranzler, H. R., Ciraulo, D. A., & Jaffe, J. H. (2009). Medications for use in
alcohol rehabilitation. In R. K. Miller & S. C. Miller (Eds.), Principles of
addiction medicine (sec. 7, chap. 46). Chevy Chase, MD: American Society of
Addiction Medicine.

Larson, R. W., Brown, B. B., & Mortimer, J. T. (Eds.). (2003). Adolescents’

preparation for the future: Perils and promise: A report of the study group on
adolescence in the 21st century. New York: Wiley.

Leaper, C., & Friedman, C. K. (2007). The socialization of gender. In J. E. Grusec

& P. D. Hastings (Eds.), Handbook of socialization. New York: Guilford Press.

Ledwidge, B. (1980). Run for your mind: Aerobic exercise as a means of

alleviating anxiety and depression. Canadian Journal of Behavioral Science,
12, 127–140.

Lerner, R. M., & Steinberg, L. (2009). Handbook of adolescent psychology (2-vol

set). New York: Wiley.
Leshner, A. L. (1997). Addiction is a brain disease, and it matters. Science, 278,
45–47.

Leshner, A. L. (1998, May–June). Research advances in treating heroin addiction.

The Counselor, p. 8.

Lesieur, H. R., & Blume, S. D. (1987). The South Oaks Gambling Screen
(SOGS): A new instrument for the identification of pathological gamblers.
American Journal of Psychiatry, 144, 1184–1188.

Linehan, M. M. (1993). Skills training manual for treating borderline personality

disorder. New York: Guilford Press.

Littleton, J. (1995). Acamprosate in alcohol dependence: How does it work?

Addiction, 90, 1179–1188.

Littleton, J. (1996). The neurobiology of craving: Potential mechanisms for

acamprosate. In M. Soyka (Ed.), Acamprosate in relapse prevention of
alcoholism (pp. 27–46). Berlin: Springer-Verlag.

Lowinson, J. H., Marion, I. J., Herman, J., & Dole, V. P. (1992). Methadone
maintenance. In J. Lowinson, P. Ruiz, R. B. Millman, & J. G. Langrod (Eds.),
Substance abuse: A comprehensive textbook. Baltimore: Williams & Wilkins.

Manthey, M. (1991). Commitment to my co-workers. In S. Cox & D. Miller

(Eds.), Leaders empower staff. Minneapolis, MN: Creative Management.

Marlatt, A. G., & Donovan, D. M. (2008). Relapse prevention: Maintenance

strategies in the treatment of addictive behaviors. New York: Guilford Press.

Marlatt, A. G., & Gordon, J. R. (1985). Relapse prevention. New York: Guilford
Press.
Masterson, J. F., Jr., & Costello, J. (1980). From borderline adolescent to
functioning adult: The test of time. New York: Brunner/Mazel.

Mayer, J., & Filstead, W. J. (1979). The Adolescent Alcohol Involvement Scale:
An instrument for measuring adolescents’ use and misuse of alcohol. Journal of
Studies on Alcohol, 40, 291–300.

Mayo-Smith, M. (2009). Management of alcohol intoxication and withdrawal. In

R. K. Ries & S. C. Miller (Eds.), Principles of addiction medicine (4th ed.,
sec. 5, chap. 42, pp. 431–440). Chevy Chase, MD: American Society of
Addiction Medicine.

McCauley, K. (2009). Pleasure unwoven [DVD]. Salt Lake City, UT: The Institute
for Addiction Study.

McKay, J. R. (2005). Is there a case for extended interventions for alcohol and
drug disorders. Addiction, 100, 1594–1610.

McKay, M., Rogers, P. D., & McKay, J. (1989). When anger hurts: Quieting the
storm within. Oakland, CA: New Harbinger.

McLellan, A. T. (2006). What we need is a system: Creating a responsive and

effective substance abuse treatment system. In W. R. Miller & K. M. Carroll
(Eds.), Rethinking substance abuse: What the science shows and what we
should do about it. New York: Guilford Press.

McLellan, A. T. (2010). On science and service: An interview with Tom

McLellan, Ph.D., Deputy Director White House Office of National Drug
Control Policy by Bill White. Counselor: The Magazine for Addiction
Professionals, 10(4), 24–35.

McLellan, A. T., Luborsky, L., & Woody, G. E. (1980). An improved diagnostic

evaluation instrument for substance abuse clients: The Addiction Severity
 Index. Journal of Nervous and Mental Disease, 168, 26–33.

Mee-Lee, D. (1985). The Recovery Attitude and Treatment Evaluator (RAATE):

An instrument for client progress and treatment assignment. Proceedings of the
34th International Congress on Alcoholism and Drug Dependence (pp.
424–426).

Mee-Lee, D. (1988). An instrument for treatment progress and matching: The

Recovery Attitude and Treatment Evaluator (RAATE). Journal of Substance
Abuse Treatment, 5, 183–186.

Mee-Lee, D. (Ed.). (2001). ASAM PPC-2R ASAM client placement criteria for
the treatment of substance-related disorders, second edition revised. Chevy
Chase, MD: American Society of Addiction Medicine.

Mee-Lee, D., Hoffmann, N. G., & Smith, M. B. (1992). The recovery attitude and
treatment evaluator manual. St. Paul, MN: New Standards, Inc.

Melges, F. T., Tinklenberg, J. R., Hollister, L. E., & Gillespie, H. K. (1970).

Temporal disintegration and depersonalization during marijuana intoxication.
Archives of General Psychiatry, 23, 204–210.

Mid-America Addiction Technology Transfer Center. (2008). Psychotherapeutic

medications 2008: What every counselor should know (7th ed.). Kansas City,
MO: Author. Retrieved from
[Link]/images/pdf/resources/[Link]

Miller, G. A. (1985). The Substance Abuse Subtle Screening Inventory manual.

Bloomington, IN: SASSI Institute.

Millon, T. (1981). Disorders of personality: DSM-III Axis II. New York: John
Wiley.
MMWR. (2006, June 9). Youth risk behavior surveillance—United States, 2005
(Vol. 255). Atlanta: Centers for Disease Control and Prevention.

Monti, P. M., Kadden, R. M., Rohsenow, D. J., Cooney, N. L., & Abrams, D. B.
(2002). Treating alcohol dependence: A coping skills training guide (2nd ed.).
New York: Guilford Press.

Morrison, M. A., & Smith, Q. T. (1990). Psychiatric issues of adolescent

chemical dependence. In A. Geller (Ed.), Syllabus for the review course in
addiction medicine. Washington, DC: American Society of Addiction Medicine.

Morse, R. M. (1994). Elderly clients. In N. S. Miller & M. C. Doot (Eds.),

Principles of addiction medicine (sec. 18, chap. 2, pp. 1–6). Chevy Chase, MD:
American Society of Addiction Medicine.

Mueser, K. T., Drake, R. E., Turner, W., & McGovern, M. (2006). Comorbid
substance use disorders and psychiatric disorders. In W. R. Miller & K. M.
Carroll (Eds.), Rethinking substance abuse: What the science shows, and what
we should do about it. New York: Guilford Press.

Naditch, M. P., & Fenwick, S. (1977). LSD flashbacks and ego functioning.
Journal of Abnormal Psychiatry, 86, 352–359.

Nahas, G. G. (1973). Marihuana: Deceptive weed. New York: Raven.

Narcotics Anonymous. (1988). Narcotics Anonymous. Van Nuys, CA: Narcotics

Anonymous World Service Office.

Nathan, P. E., & Gorman, J. M. (2007). A guide to treatments that work (3rd ed.).
New York: Oxford University Press.

National Institute on Drug Abuse. (2005, May). Heroin abuse and addiction (Rev.
 ed.). Bethesda, MD: Author.

National Sleep Foundation. (2006). 2006 Sleep in America poll. Washington, DC:
Author.

National Vital Statistics Reports. (2008, June 11). Table 7. Deaths and death rates
for the 10 leading causes of death in specified age groups. United States,
preliminary 2006. National Vital Statistics Reports, 56 (No. 16), 30.

Nestler, E. J. (1998). Neuroadaptation in addiction. In A. W. Graham, T. K.

Schultz, & B. B. Wilford (Eds.), Principles of addiction medicine (2nd ed., sec.
1, chap. 5, pp. 57–71). Chevy Chase, MD: American Society of Addiction
Medicine.

Nunes, E. V., & Weiss, R. D. (2009). Co-occurring addiction and affective

disorders. In R. K. Miller & S. C. Miller (Eds.), Principles of addiction
medicine (sec. 11, chap. 84). Chevy Chase, MD: American Society of
Addiction Medicine.

Offer, D. (1986). Adolescent development: A normative perspective. In American

Psychiatric Association annual review (Vol. 5). Washington, DC: American
Psychiatric Press.

Offer, D., & Offer, J. B. (1975). From teenage to young manhood: A psychological
study. New York: Basic Books.

Offer, D., Ostrov, E., & Howard, K. I. (1981). The adolescent: A psychological
self-portrait. New York: Basic Books.

Ollendick, T. H., & Cerny, J. A. (1981). Clinical behavior therapy with children.
New York: Plenum.
O’Malley, S. S., Jaffe, A. J., Chang, G., Schottenfeld, R. S., Meyer, R. E., &
Rounsaville, B. (1992). Naltrexone and coping skills therapy for alcohol
dependence: A controlled study. Archives of General Psychiatry, 49, 881–887.

Patterson, G. R. (1977). Families: Applications of social learning to family life

(Rev. ed.). Champaign, IL: Research Press.

Patterson, G. R., & Gullion, M. E. (1976). Living with children: New methods for
parents and teachers (Rev. ed.). Champaign, IL: Research Press.

Perkinson, R. R. (2000). God talks to you. Bloomington, IN: 1st Books Library.

Perkinson, R. R. (2004). Treating alcoholism: How to help your clients enter

recovery. New York: John Wiley.

Perkinson, R. R. (2008). A communication from God [CD]. cdbaby

Perkinson, R. R. (2017). The alcoholism and drug abuse client workbook (3ed.
ed.). Thousand Oaks, CA: Sage.

Perkinson, R. R. (2012). Chemical dependency counseling: A practical guide (4th.

ed.). Thousand Oaks, CA: Sage.

Perkinson, R. R. (2017). The gambling addiction client workbook (3ed. ed.).

Thousand Oaks, CA: Sage.

Perkinson, R. R. (2015). Bath salts, spice, KhAT, Ecstasy, Rophies, K2, DXM,
PCP, GHB, MDMA, Salvia, Embalming Fluid, 25-i, E-cigarettes, etc. A Paper
presented at the NAADAC annual meeting. National Association of Alcohol
and Drug Abuse Counselors. Washington, DC.
Perkinson, R. R., Jongsma, A., & Bruce, T. (2009). The addiction treatment
planner (4th ed.). New York: John Wiley.

Perkinson, R. R., Jongsma, A., & Bruce, T. (2014). The addiction treatment
planner (5th ed.). New York: John Wiley.

Perkinson, R. R., & LaCour, J. (2004). Faith-based addiction curriculum.

Orlando, FL: The Net Institute.

Perry, S. W., & Jacobsen, P. (1986). Neuropsychiatric manifestations of AIDS-

spectrum disorders. Hospital and Community Psychiatry, 37, 135–142.

Phillips, E. L. (1968). Achievement place: Token reinforcement procedures in a

home-style rehabilitation setting for “pre-delinquent” boys. Journal of Applied
Behavior Analysis, 1, 213–223.

Pierce, J. P., Fiore, M. C., Novotny, T. E., Hatziandreu, E. J., & Davis, T. (1989).
Trends in cigarette smoking in the United States: Projections to the year 2000.
Journal of the American Medical Association, 261, 61–65.

Plutchik, R. (1980). Emotion: A psychoevolutionary synthesis. New York: Harper

& Row.

Post, R. M., Kotin, J., & Goodwin, F. K. (1974). The effects of cocaine in
depressed clients. American Journal of Psychiatry, 131, 511–517.

Prochaska, J. O. (2003). Enhancing motivation to change. In A. W. Graham, T. K.

Schultz, M. F. Mayo-Smith, & R. K. Ries (Eds.), Principles of addiction
medicine (3rd ed.). Chevy Chase, MD: American Society of Addiction
Medicine, Inc.

Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-

 change of smoking: Toward an integrative model of change. Journal of
Consulting and Clinical Psychology, 51, 390–395.

Prochaska, J. O., & DiClemente, C. C. (1984). The transtheoretical approach:

Crossing the traditional boundaries of therapy. Malabar, FL: Krieger.

Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how

people change: Applications to the addictive behaviors. American
Psychologist, 47, 1102–1114.

Prochaska, J. O., Norcross, J. C., & DiClemente, C. C. (1994). Changing for

good. New York: William Morrow.

Reifler, B., Raskind, M., & Kethley, A. (1982). Psychiatric diagnosis among
geriatric clients seen in an outreach program. Journal of the American
Geriatrics Society, 30, 530–533.

Richels, K., Case, W. G., Downing, R. W., & Winokur, A. (1983). Long-term
diazepam therapy and clinical outcome. Journal of the American Medical
Association, 12, 767–771.

Ries, R. K., & Miller, S. C. (Eds.). (2009). Principles of addiction medicine (sec.
1, chap. 1). Chevy Chase, MD: American Society of Addiction Medicine.

Rosenbaum, J. F., Biederman, J., Hirshfeld, D. R., Bolduc, E. A., & Chaloff, J.
(1991). Behavioral inhibition in children: A possible precursor to panic
disorder or social phobia. Journal of Clinical Psychiatry, 52(11, Suppl.), 5–9.

Sanders, M. R., & Glynn, T. (1981). Training parents in behavioral self-

management: An analysis of generalization and maintenance. Journal of Applied
Behavior Analysis, 14, 223–237.
Santrock, J. W. (2010). Adolescence (13th ed.). New York: McGraw-Hill.

Schore, A. N. (2003). Affect dysregulation and disorders of the self. New York:
Norton.

Schuckit, M. A. (1984). Drug and alcohol abuse: A clinical guide to diagnosis and
treatment. New York: Plenum.

Schuckit, M. A. (1994). Dual diagnosis: Psychiatric pictures among substance

abusers. In N. S. Miller & M. C. Doot (Eds.), Principles of addiction medicine
(sec. 6, chap. 1, pp. 1–4). Chevy Chase, MD: American Society of Addiction
Medicine.

Secretary of Health, Education, and Welfare. (1977). Marihuana and health:

Seventh annual report to the U.S. Congress. Washington, DC: U.S. Government
Printing Office.

Sells, S. (2001). Parenting your out-of-control teenager: 7 steps to reestablish

authority and reclaim love. New York: St. Martin’s Griffin.

Selye, H. (1956). The stress of life. New York: McGraw-Hill.

Selzer, M., Winokur, A., & van Rooijen, C. (1975). A self-administered Short
Michigan Alcoholism Screening Test. Journal of Studies on Alcohol, 36,
117–126.

Shaffer, H. J., & LaPlante, D. A. (2008). Treatment of gambling disorders. In A.

G. Marlatt & D. M. Donovan (Eds.), Relapse prevention: Maintenance
strategies in the treatment of addictive behaviors. New York: Guilford Press.

Sharp, C. W., & Brehm, M. L. (Eds.). (1977). Review of inhalants: Euphoria to

dysfunction (Publ. No. [ADM] 77–553). Washington, DC: U.S. Government
 Printing Office.

Sharp, C. W., & Carroll, L. T. (Eds.). (1978). Voluntary inhalation of industrial

solvents (Publ. No. [ADM] 79–779). Washington, DC: U.S. Government
Printing Office.

Short Michigan Alcoholism Screening Test. (1975). Journal Studies of Alcohol,

36, 117–126.

Siever, L. J., & Davis, K. L. (1991). A psychobiological perspective on the

personality disorders. American Journal of Psychiatry, 148, 1647–1658.

Siever, L. J., Llar, H., & Coccaro, E. (1985). Psychobiology substrates of

personality. In Biological response styles: Clinical implications. Washington,
DC: American Psychiatric Press.

Simmons, R. G., & Blyth, D. A. (1987). Moving into adolescence. Hawthorne,

NY: Aldine.

Skipper, G. E. (1997). Treating the chemically dependent health professional.

Journal of Addictive Disorders, 16(3), 67–73.

Skipper, G. E., & DuPont, R. L. (2010). Physician health programs: A model of

successful treatment of addictions. Counselor: The Magazine for Addiction
Professionals, 11(6).

Smith, C. M. (1977). The pharmacology of sedative/hypnotics, alcohol, and

anesthetics: Sites and mechanisms of action. In W. R. Martin (Ed.), Drug
addiction: I. Morphine, sedative/hypnotics, and alcohol dependence. Berlin:
Springer-Verlag.

Soujanen, W. W. (1983). Addiction and the minds of adolescents. In R. C.

 Bersinger & W. W. Suojanen (Eds.), Management and the brain: An integrative
approach to organization behavior (pp. 77–92). Atlanta: Georgia State
University Press.

Spalt, L. (1979). Evidence of an X-linked recessive genetic characteristic in

alcoholism. Journal of the American Medical Association, 241, 2543–2544.

Spelberger, C. D. (1983). Manual for the State-Trait Anxiety Inventory. Palo Alto,
CA: Consulting Psychologists Press.

Spitzer, R. L. (1987). Diagnostic and statistical manual of mental disorders (3rd

ed., Rev. ed.). Washington, DC: American Psychiatric Press.

Spon, A. R. (1999). Blueprint for change: Corrective thinking facilitator’s guide.

Roscoe, IL: Truthought, LLC.

Stahl, S. M. (2008). Stahl’s essential psychopharmacology: Neuroscientific basis

and practical applications (3rd ed.). New York: Cambridge University Press.

Stern, M. J., & Cleary, P. (1981). National Exercise and Heart Disease Project:
Psychosocial changes observed during a low-level exercise program. Archives
of Internal Medicine, 141, 1463–1467.

Stimmel, B., Goldberg, J., Rotkopf, E., & Cohen, M. (1977). Ability to remain
abstinent after methadone detoxification: A six year study. Journal of the
American Medical Association, 237, 1216–1220.

Stuart, R. B. (1971). Behavioral contracting within the families of delinquents.

Journal of Behavior Therapy and Experimental Psychology, 2, 1–11.

Stulis, C. A. (2009). HIV, TB and other infectious diseases related to alcohol and
other drug use. In R. K. Ries & S. C. Miller (Eds.), Principles of addiction
 medicine (sec. 10, chap. 77). Chevy Chase, MD: American Society of
Addiction Medicine.

Substance Abuse and Mental Health Services Administration. (2006). Addiction

counseling competencies: The knowledge, skills, and attitudes of professional
practice. Retrieved from [Link]

Substance Abuse and Mental Health Services Administration. (2007). Results

from the 2007 National Survey on Drug Use and Health: National findings.
Retrieved from [Link]

Substance Abuse and Mental Health Services Administration. (2009a). Results

from the 2008 National Survey on Drug Use and Health: National findings
(Office of Applied Studies, NSDUH Series H-36, HHS Publication No. SMA
09-4434). Rockville, MD.

Substance Abuse and Mental Health Services Administration. (2009b). The role
of biomarkers in the treatment of alcohol use disorders. Substance Abuse
Treatment Advisory, 5(4) 1–8.

Substance Abuse and Mental Health Services Administration. (2014). Results

from the 2013 National Survey on Drug Use and Health: Summary of National
findings (Office of Applied Studies, NSDUH Series H-48, HHS Publication
No. SMA 14-4863). Rockville, MD.

Substance Abuse and Mental Health Services Administration. (2015). Alcohol,

tobacco, and other drugs. Retrieved from [Link]

Sue, D. W., & Sue, D. (1999). Counseling the culturally different: Theory and
practice (3rd ed.). New York: John Wiley.

Talbott, J. A., Hales, R. E., & Yudofsky, S. C. (Eds.). (1988). American

Psychiatric Press textbook of psychiatry. Washington, DC: American
 Psychiatric Press.

Tarasoff v. Regents of the University of California, 551 P.2d, 334 at 340 (1976).

Tarokh, L., & Carskadon, M. A. (2008). Sleep in adolescents. In L. R. Squire

(Ed.), New encyclopedia of neuroscience. Oxford, UK: Elsevier.

Tasker, F. L., & Golombok, S. (1997). Growing up in a lesbian family: Effects on

child development. New York: Guilford Press.

Tennant, F. S., Jr., & Grossbeck, C. J. (1972). Psychiatric effects of hashish.

Archives of General Psychiatry, 27, 133–136.

Tetrault, J. M., & O’Connor, P. G. (2009). In R. K. Miller & S. C. Miller (Eds.),

Principles of addiction medicine (sec. 6, chap. 44). Chevy Chase, MD:
American Society of Addiction Medicine.

Thacore, V. R., & Shukla, R. S. P. (1976). Cannabis psychosis and paranoid

schizophrenia. Archives of General Psychiatry, 33, 383–386.

Thompson, T., & Pickens, R. (1970). Stimulant self-administration by animals:

Some comparisons with opiate self-administration. Federal Processes, 29,
6–12.

Turner, C. E. (1980). Chemistry and metabolism. In R. L. Peterson (Ed.),

Marijuana research findings (Research Monograph No. 13, Publ. No. [ADM]
AD-1001). Rockville, MD: National Institute on Drug Abuse.

Uhl, G. R., & Grow, R. W. (2004). The burden of complex genetics in brain
disorders. Archives of General Psychiatry, 61, 223–229.
U.S. Department of Health and Human Services. (1999). National Household
Survey on Drug Abuse 1999. Washington, DC: Department of Health and
Human Services, Substance Abuse and Mental Health Services Administration.

U.S. Department of Health and Human Services. (2009). National Household

Survey on Drug Abuse 2009. Washington, DC: Department of Health and
Human Services, Substance Abuse and Mental Health Services Administration.

U.S. Department of Health and Human Services. (2014). National Household

Survey on Drug Abuse 2013. Washington, DC: Department of Health and
Human Services, Substance Abuse and Mental Health Services Administration.

U.S. Department of Justice. (1983). Let us all work to fight drug abuse.
Washington, DC: Author.

U.S. Department of Labor. (1994). America in jeopardy: The young employee and
drugs in the workplace. Washington, DC: U.S. Department of Labor, Office of
the Assistant Secretary for Policy.

U.S. Surgeon General. (1979). Smoking and health (Publ. No. [PHS] 79–50066).
Washington, DC: U.S. Government Printing Office.

U.S. surgeon general releases advisory on alcohol use in pregnancy. (2005,

February 21). U.S. Department of Health & Human Services, Office of the
Surgeon General. Retrieved from
[Link]

Vaillant, G. E. (1977). Adaptation to life. Boston: Little, Brown.

Vaillant, G. E. (2003). Natural history of addiction and pathways to recovery. In

A. W. Graham, T. K. Schultz, M. F. Mayo-Smith, & R. K. Ries (Eds.),
Principles of addiction medicine (3rd ed.). Chevy Chase, MD: American
Society of Addiction Medicine, Inc.
van den Berg, S. M., & Boomsma, D. I. (2007). The familial clustering of age at
menarche in extended twin studies. Behavior Genetics, 37, 661–667.

Vardy, M. M., & Kay, F. R. (1983). LSD psychosis or LSD induced

schizophrenia? Archives of General Psychiatry, 40, 877–883.

Volkow, N. D., & Li, T.-K. (2009). Drug addiction: The neurobiology of behavior
gone awry. In R. K. Ries & S. C. Miller (Eds.), Principles of addiction
medicine (sec. 1, chap. 1). Chevy Chase, MD: American Society of Addiction
Medicine.

Volpicelli, J. R., Alterman, A. L., Hayashida, M., & O’Brian, C. P. (1992).

Naltrexone in the treatment of alcohol dependence. Archives of General
Psychiatry, 49, 876–880.

Walker, R. (1992). Twenty-four hours a day. Center City, MN: Hazelden.

Wallach, J. (1992). Interpretation of diagnostic tests: A synopsis of laboratory

medicine (5th ed.). Boston: Little, Brown.

Weedman, R. (1992). Dancing the tightrope. Naples, FL: Healthcare Network.

Weinhold, B. K., & Weinhold, J. B. (1989). Breaking free of the co-dependency

trap. Walpole, NH: Stillpoint.

Weiss, R. D., Mirin, S. N., Griffin, M. L., & Michaels, J. K. (1988).

Psychopathology in cocaine abusers: Changing trends. Journal of Nervous and
Mental Disorders, 176, 719–725.

Wells, K. C., & Forehand, R. (1981). Childhood behavior problems in the home.
In S. M. Turner, K. S. Calhoun, & H. E. Adams (Eds.), Handbook of clinical
behavior therapy. New York: Wiley, 527–567.
Wells, K. C., & Forehand, R. (1984). Conduct and oppositional disorders. In P. H.
Bornstein & A. E. Kaydin (Eds.), Handbook of clinical behavior therapy with
children. New York: Dorsey.

Wesson, D. R., & Smith, D. E. (1977). Cocaine: Its use for central nervous system
stimulation including recreational and medical uses. In R. C. Peterson & R. C.
Stillman (Eds.), Cocaine: 1977 (Research Monograph No. 13, pp. 137–150).
Washington, DC: U.S. Government Printing Office.

Westley, W. A., & Epstein, N. B. (1969). The silent majority. San Francisco:
Jossey-Bass.

White, W. L. (2009). Recovery-oriented systems of care: scientific rationale and

promising practices. Counselor: The Magazine for Addiction Professionals,
10(1), 1–152.

White, W. L. (2010). Interviews with pioneers: Robert L. DuPont, MD on

addiction, treatment, recovery and a life of service. Counselor: The Magazine
for Addiction Professionals, 11(1), 38–48.

Widiger, T., & Frances, A. (1989). Epidemiology, diagnosis, and comorbidity of

borderline personality disorders. In American Psychiatric Association annual
review (Vol. 8). Washington, DC: American Psychiatric Press.

Wikler, A. (1976). Aspects of tolerance to and dependence on cannabis. Annals of

the New York Academy of Science, 282, 126–147.

Wilcox, R. E., Gonzales, R. A., & Erickson, C. K. (1994). In N. S. Miller & M. C.

Doot (Eds.), Principles of addiction medicine (sec. 1, chap. 3, p. 4). Chevy
Chase, MD: American Society of Addiction Medicine.

Wilkins, J. N., Danovitch, I., & Gorelick, D. A. (2009). In R. K. Miller & S. C.

Miller (Eds.), Principles of addiction medicine (sec. 6, chap. 45). Chevy
 Chase, MD: American Society of Addiction Medicine.

Wilson, B. J. (2008). Media and children’s aggression, fear and altruism. The
Future of Children, 18(1), 87–118.

Wise, R. A., & Kelsey, J. E. (1998). Behavioral models of addiction. In A. W.

Graham, T. K. Schultz, & B. B. Wilford (Eds.), Principles of addiction
medicine (2nd ed., sec. 1, chap. 3, pp. 37–49). Chevy Chase, MD: American
Society of Addiction Medicine.

Woodward, J. J. (1994). Alcohol. In N. S. Miller & M. C. Doot (Eds.), Principles

of addiction medicine (sec. 2, chap. 2, pp. 1–12). Chevy Chase, MD: American
Society of Addiction Medicine.

Woody, G. G., Lubrorsky, L., McLellan, T., O’Brien, C. P., Beck, A. T., Blaine, J.,
Herman, I., & Hole, A. (1984). Psychotherapy for opiate addicts: Does it help?
Archives of General Psychiatry, 40, 639–643.

Zegans, L. S. (1982). Stress and the development of somatic disorders. In L.

Goldberger & S. Brenznitz (Eds.), Handbook of stress: Theoretical and clinical
aspects. New York: Free Press.

Zung, W. W. K. (1971). A rating instrument for anxiety disorders. Psychosomatics,

12, 371–379.
Index

Abandonment, fear of, 146–147

Abilify (aripiprazole), 668, 670, 673
Abilities exercise, 808
Abrams, D. B., 101
Abstinence, 11, 13
Abstinence syndrome, 34
Abusive relationship, 287
Acamprosate (Campral), 13, 126, 691, 692, 696
Acceptance
exercise, 276
of Higher Power, 131, 153, 362, 383
Accreditation and Certification (Goldman), 54
Accurate thinking, 78–79, 93, 161, 178, 301–302
Acetaldehyde, 691n
Acquired immune deficiency syndrome (AIDS), 181–182
Action stage, 14, 22
Active listening, 122, 241
Activities
pleasurable, 397–400
youth participation in, 545–546
Acute, defined, 680n
Acute alcohol withdrawal, 150
Acute organic brain syndrome, 179
Adderall, 683
Addiction
adolescent, 10
as biopsychosocial disease, 141–144
comorbidity and, 155
diagnosis of, 11–12
disease concept, 2, 104, 140–143
as family disease, 217
natural history of, 11
as not moral problem, 140–141
as not weak will, 140, 141
 pain and, 4–5
physical, lecture on, 148–150
as physiological problem, 142
red flags for, 9–10, 11
risk factors for, 11 (See also High-risk friends; High-risk situations)
root of, 429
social consequences of, 142–143
as social problem, 141
See also individual addictions
Addictionologist, 222
Addiction Severity Index (ASI), 12, 22
Addiction treatment medications, 690–692
The Addiction Treatment Planner (Perkinson, Jongsma & Bruce), 52, 53
Addictive relationships, 122
cycle of, 285–286
exercises, 285–287
Addicts
excuses, 4–5
personality of, 3
thinking process, 74–79, 89–91
See also Clients
ADHD (attention deficit/hyperactivity disorder), 683–686, 684n
Adolescent Alcohol Involvement Scale (AAIS), 12
Adolescent chemical dependency counselor, 203–204
Adolescents
activities participation by, 545–546
ages 13-16, 199–201
ages 16-19, 201–203
alcohol use among, 552
alcohol use by, 511–512, 516–519
chemically dependent, 202–203
cocaine and methamphetamine and, 111
delinquent behavior, 544–545
fighting by, 544–545
first interview questions, 10
illicit drug use rates, 500–501, 504
inpatient program schedule, 632–633
inpatient treatment criteria, 31–32
marijuana use (See Marijuana)
 normal, 197–198
normal development in, 147–148
outpatient program schedule, 637–639
outpatient treatment criteria, 31
parental involvement effects on, 546–547
red flags for alcohol use/addiction, 10
religious beliefs, 545
substance use estimates, 613–614
trends in alcohol and substance use among, 563–567
See also Adolescent treatment; Nurse intake questions, for adolescents;
Youth prevention-related measures
Adolescent treatment
behavioral contracts, 210
communication skills and, 205–206
continuing care, 209
continuing education, 208–209
counselor’s role, 203–204
exercise programs for, 206
fun activities during, 206
group therapy, 207–208
honesty and, 206
inpatient program schedule, 632–633
inpatient treatment criteria, 31–32
outpatient program schedule, 637–639
outpatient treatment criteria, 31
parents’ support group, 210
peer pressure and, 208
phases of, 210–211
point system, 204–205, 210
primary elements of, 205
reinforcers for, 207
rules and, 205
spirituality and, 207
unit level system, 204, 355–361
unit point system, 204–205, 357–361, 480–483
Adults
addiction red flags, 9
development characteristics, 148
first interview questions, 8–10
 illicit drug use by, 502–503
inpatient program schedule, 630–631
inpatient treatment criteria, 30–31
outpatient program schedule, 634–636
outpatient treatment criteria, 29–30
substance use trends among young, 567–574
See also Nurse intake questions, for adults
Affect of psychotic client, 180
Against medical advice. See AMA (against medical advice)
Age
alcohol use rates, 511–512, 516–519
illicit drug use rates, 498–503
initiation of substance abuse and, 528–538
substance abuse rates, 551–552, 553
tobacco use rates, 521, 522, 526
Agenda groups, 85–87
Aggressive response, 303
Agranulocytosis, 669n
AIDS dementia complex, 181
AIDS-related complex (ARC), 181
Alanine aminotransferase (ALT), 23
Al-Anon, 213, 218, 383
Alateen, 213
Alatot, 213
Alberti, R. E., 302
Alcohol, 106
abuse history, 8–10
alcohol-induced organic mental disorders, 107–108
cellular effects of, 148–149
CNS effects of, 106, 107, 108, 149
dependence on, 551–552
detoxification and, 33
intoxication, 107
profile, 626–627
sedatives with, 108
tolerance to, 149
Alcohol Abstinence Self-Efficacy Scale, 125, 802–803
Alcohol amnestic disorder (blackouts), 107, 130
exercises, 323–324, 331
Alcoholics Anonymous (AA), 97
lecture on, 150–152
meetings, 152
program, 128
root of addiction, 429
sanity in, 131
Twelve Steps, 128, 152
See also Narcotics Anonymous (NA); Twelve Step programs
Alcoholism, 106
death from, 1–2
delirium, 108
disease concept, 2, 3–4
incidence of, 2
physical addiction, 148–150
screening tests, 12, 21–22
suicide and, 164
The Alcoholism and Drug Abuse Client Workbook (Perkinson), 129
Alcohol treatment
generic/brand names of medications, 690–691
medications for, 690–692
needs, 557–559, 560–561
purpose of medications, 691–692
relapse prevention, 691
withdrawal treatment, 690–691
Alcohol use, 486–487
age and, 486–487, 511–512
among adolescents, 203
binge drinking, 539–540
college students, 514–515
driving and, 516, 517
education effects on, 514
employment effects on, 515
frequency of, 486–487
gender and, 512–513, 519
geographic area and, 515–516
illicit drug use association, 508–509, 516
initiation of, 536
lifetime prevalence estimates, 569, 572
NSDUH data, 511–519
 nurse intake questions, 712–713, 744–746
past month prevalence estimates, 571, 574
past year prevalence estimates, 570, 573
pregnant women, 513
race/ethnicity, 513–514
risk perception of use, by youth, 539–540, 541–542
screening tests, 12, 21–22
tobacco association, 516, 526–527
treatment, 555
treatment needs, 557–559, 560–561
trends in, 563, 567
underage use, 516–519
use estimates, 548–549, 551–552, 613–614
Alcohol withdrawal, 107–108
scale, 250–252
seizures, 108
treatment for, 690–691
Alcohol withdrawal delirium (delirium tremens), 108
Alexander, J. F., 210
Alibis, 347, 457
Alkaline phosphatase, 23
Alprazolam (Xanax), 680, 682
AMA (against medical advice)
family programs and, 213
responding to clients who leave, 36
team and, 35–36
threat, 34–35
Amantadine hydrochloride (Symmetrel; Symadine), 671
Ambien (zolpidem), 689, 690
Amends, making, 136, 193, 218
American Cancer Society, 797
American Heart Association, 797
American Legacy Foundation, 797
American Lung Association, 797
American Medical Association, 140
American Psychiatric Association, 140
American Society of Addiction Medicine (ASAM), 9, 233
patient placement criteria, 13, 25–26
Amitriptyline (Flavil), 676
Amoxapine (Asendin), 676
Amphetamines, 32, 105, 110–111, 621, 683
nurse intake questions, 717–718, 749–750
Anabolic androgenic steroids (AAS), nurse intake questions, 720, 752
Anafranil (clomipramine), 676
Analgesic, defined, 693n
Anderson, Jack, 151
Anger, 153, 277–278, 346
behavior change and, 302–303
blaming and, 418, 420
choosing, 417
effect of anger, 416–417
escalation of, 420–423
gamblers exercises, 456–457
myth of, 416
stress and, 418
taking responsibility and, 419
trigger thoughts, 419–423
as two-step process, 417
Anger management, 166
anger journal, 415–416
coping script, 426–427
coping skills for, 418–419
self-talk and, 425–426
time-out contract, 427–428
time-out technique, 124, 423–425
Angry clients, 165–169
assertiveness in, 166
disengagement of, 167
duty to warn, 168
forgiveness and, 166–167
handling, 165–166
with homicidal ideation, 168
remaining calm with, 168
self-recognition of, 167
time-out for, 167–168
Anorexia, 698n
Antabuse (disulfiram), 13, 691, 696
Antagonist, 693n
Antianxiety medications, 680–683
abuse/dependence potential, 682
cautions, 682–683
dose/frequency, 681
emergency conditions, 682
genetic and brand names of, 680
nurse intake questions, 718–719, 750–751
pregnancy and, 683
purpose of, 680–681
risk factors for dependency, 682
side effects, 681–682
Anticipation, 276–277
Anticonvulsants, 673–675, 674n, 689, 690, 691
Antidepressant medications, 676–679, 689
cautions, 679
dose/frequency, 677
emergency conditions, 679
generic and brand names of, 676
pregnancy and, 679
purpose of, 676–677
side effects, 677–679
types of, 677
Antimanic medications, 673–675
cautions, 675
dose/frequency, 674
emergency conditions, 675
generic/brand names of, 673
pregnancy and, 675
purpose of, 673–674
side effects, 674–675
Antiparkisonian medications, 671–673
abuse/dependence potential, 672
cautions, 672
dose/frequency, 672
emergency conditions, 672
generic/brand names of, 671
pregnancy and, 672–673
purpose of, 672
side effects, 672
Antipsychotics/neuroleptics, 668–671, 689
cautions, 671
diabetes mellitus symptoms and, 669, 670
dose/frequency, 669–670
emergency conditions, 671
generic/brand names of, 668
neuroleptic malignant syndrome, 669, 670, 671
pregnancy and, 671
purpose of, 668–669
side effects, 670–671
tardive dyskinesia, 669, 670, 671
Antisocial personality disorder, 169–171
characterization, 169
client family and, 171
empathy disorder in, 169–170
moral development and, 171
rule violations by, 170–171
treatment, 170
Anxiety disorder
cognitive therapy for, 177–178
daily logs for, 177
measuring, 175–176
panic attacks, 178–179
post-traumatic stress disorder, 178
psychological component of, 176
psychopharmacology, 176
relaxation techniques for, 176–177
Anxiolytics, 108. See also Antianxiety medications
Aripiprazole (Abilify), 668, 670, 673
Artane (trihexyphenidyl hydrochloride), 671
ASAM PPC-2R, ASAM Patient Placement Criteria for the Treatment of
Substance-Related Disorders, 2nd edition-Revised (Mee-Lee), 25
Asendin (amoxapine), 676
Aspartate aminotransferase (AST), 23
Assertive formula, 153–154, 302–303
Assertiveness, 166, 401–402
skills group, 101–102
Assertive skills, 124, 153–154
Assessments
 auditory, 728, 761
depression, 157
DSM criteria, 26–27
initial, 12, 20–23
motivation, 14–16
physical, 725, 757–758
placement criteria, 13, 25–26
safety screening, 732–733, 764–765
visual, 728, 761
See also Biopsychosocial assessment
Atarax (hydroxyzine), 680, 681
Ativan (lorazepam), 680, 682, 688, 690
Atkinson, R.M., 183
Atypical anti-psychotics, 158
Auditory assessment, 728, 761
Autobiography exercises, 344–352, 462
Automatic thoughts, 74–75
behavior chain and, 301–302
correcting, 75, 76–77, 420
scoring, 76, 77
Avarice, 456
Aversive chains
breaking, 423–425
description of, 420–421
example of, 423

Balance, 461
Barbiturates, 33, 620, 688, 690
Barriers in thinking, 663–665
Bath salts, 114
Beck, Aaron, 74, 159, 301
Behavior, 64
aversive chain of, 420–425
delinquent, 544–545
drugs effects on, 149
red flags for addiction, 9, 10
Behavioral contract, 366–369
adolescent treatment and, 210
detailing what each party wants, 368
 developing, 367–369
habits, 366–367
love and, 367
reward and punishment and, 366
sample, 369
school performance chart, 367–368
Behavioral Risk Factor Surveillance System (BRFSS), 602–603
Behavior chain, 69–70, 126, 299–305
behavior, 303–304
consequence, 304–305
description
feelings, 300, 302–303
impulse control and, 299–305
interpersonal conflict, 300
negative feelings, 300
positive events, 300
relapse prevention and, 304–305, 317–319, 476–477
social pressure, 300
thought, 301–302
triggers, 299–300
Behavior therapy
behavior chain and, 69–70
benefits, 71
for depression, 158–159
habits, 68–69
for heroin addiction, 658
individual treatment, 67–71
objectives, 67–68
punishment, 69, 70
reinforcements, 69, 70
rule breaking and, 70–71
Benedryl (diphenhydramine hydrochloride), 671
Benson, H., 394
Benzodiazepines, 680–683
abuse/dependence potential, 682
for alcohol withdrawal, 690, 691
cautions, 682–683
detoxification and, 33
dose/frequency, 681
 emergency conditions, 682
generic/brand names of, 680
pregnancy and, 683
purpose of, 680
side effects, 681–682
as sleep-aids, 688–689, 690
use of, 108, 111
See also Antianxiety medications
Benzodiazepine Scale, 25
Benztropine mesylate (Cogentin), 671
Berne, E., 188
Beta-blockers, 681, 683
“Big Book” (Alcoholics Anonymous), 91, 140, 151
Bilirubin, 23
Binge drinking among youths, 539–540
Biopsychosocial assessment
family history, 408
form for, 37
medical history, 408
mental status examination, 408–414
personal history, 405–407
sample, 405–414
See also Biopsychosocial interview
Biopsychosocial disease, addiction as, 141–144
Biopsychosocial interview
conducting, 38–42
diagnosis, 43, 255–256
family history, 40–41, 255
impressions, 42–43
medical history, 255
mental status, 255
personal history, 39–42, 254–255
purpose of, 37–38
sample, 43–50, 254–260
summary of, 42–43, 256
treatment plans, 43, 57–59, 256–259
Bipolar affective disorder, 158
Bi-TechNostix, 12
Blackouts (alcohol amnestic disorder), 107, 130
 exercises, 323–324, 331
Blaming, 72, 264, 418, 420, 436
Blood dyscrasias, 669n
Body language, therapeutic alliance and, 66
Body movements, as trigger, 422–423
Borderline personality disorder, 172–174
characterization, 172
client family, 173–174
emotional regulation, 172
interpersonal relationships, 172
setting limits, 173
stress tolerance, 173
transference, 173
treatment, 172–173
Boundaries
among staff, 221, 228–229
counselors and, 239, 241–242
Bradshaw, J., 99
Brain development, 105, 201
Breathalyzers, 12
Bulimia, 698n
Buprenorphine (Subutex), 109–110, 658, 692–693, 695, 699
Bupropion (Wellbutrin), 676, 677, 684, 693, 694, 696, 697
Burns, David, 77, 82, 301
Buspirone (BuSpar), 680, 681

Caffeine, 105
CAGE questionnaire, 12, 21
Campral (acamprosate), 13, 126, 691, 692, 696
Cancer Information Service, 796
Cannabis, 113–114, 619
effects, 32
nurse intake questions, 714, 746
profile, 625–626
See also Marijuana
Carbamazepine (Tegretol), 158, 673
Carbohydrate deficient transferrin (CDT), 23
Cardiovascular fitness, 396
Caretaking, 215, 378
Carroll, Lynn, 133, 191
Case presentation, 226–227
Catapres (clonidine), 111, 692–693, 693
Catastrophizing, 177
Celexa (citalopram), 676, 677
Centers for Disease Control and Prevention, 797
Central nervous system depressants, 105, 106
Central nervous system stimulants, 33, 105
Chantix (varenicline tartrate), 693, 694, 696, 697
Character, 169
Character defects
having God remove, 135
identifying, 133
Chart, 56
Cheerfulness, 461
Chemical dependency, 202–203
Chemical dependency counselor, 224
adolescent, 203–204
Chemical use history, 119, 711–712, 743–744
exercises, 261–262
Chevron, E. S., 162
Childhood
early traumas, 99–100, 184–185
groups, 98–100
Children, behavioral contract, 366–369
Chlordiazepoxide (Librium), 680
Cigarette smoking. See Tobacco use
Citalopram (Celexa), 676, 677
Client-centered counselors, 242
Client Records in Addiction Treatment (Goldman), 54
Client relationship. See Therapeutic alliance
Clients
angry, 165–169
antisocial personality, 169–171
anxious, 175–178
assessing readiness for change, 8
attitude of, 5–6
borderline, 172–174
complaints about rules, 230
 dislike of counselor, 229–230
with early childhood trauma, 184–185
elderly, 183–184
greeting protocol, 17–18
with HIV/AIDS, 181–182
homicidal, 168
illiterate, 182–183
intoxicated, 32–33
leaving against medical advice, 34–36
love between, 185–186
with low intellectual functioning, 182–183
narcissistic, 174–175
placement criteria, 25–26
presenting to staff, 226–227
psychotic, 179–181
reactions in detoxification, 33–34
reaction to intoxication, 32
relationship with, 815
saying good-bye to, 237
talking about medications with, 701–703
violent, 165
welfare of, 814–815
Clinical director, 224
Clinical Institute Withdrawal Assessment of Alcohol Scale, 25
Clinical Opiate Withdrawal Scale, 25, 709–710
Clinical record, 56
Clinical staff
boundaries among, 221, 228–229
characteristics of, 221
chemical dependency counselor, 224
client rule complaint, 230
clinical directors, 224
clinical supervisors, 224
commitment to coworkers, 228
importance of, 221
interaction guidelines, 226
meetings among, 225–227
nurses, 223
physician/addictologist, 222
 presenting client to, 226–227
psychologist/psychiatrist, 222–223
recreational therapist, 225
rehabilitation technician/aide, 224–225
rule violations by client, 230
social worker/mental health counselor, 223
staff-client problems, 229–230
staffing, 225–227
supervisors, 224
team building among, 227–228
work environment, 230–231
See also Counselors
Clinical supervisor, 224
Clomipramine (Anafranil), 676
Clonazepam (Klonopin), 680, 682, 688
Clonidine (Catapres), 111, 692–693
Clorazepate (Tranxene), 680, 682
Clozapine (Clozaril), 668, 669
Club drugs, 115–116, 694
CNS (central nervous system)
alcohol effects on, 106, 107, 108, 149
depressants, 105, 106
psychoactive drug effects on, 104
stimulants, 105
Cocaine, 32, 104, 105, 110–111, 621
availability, perceived, 543
initiation of use, 529, 530, 531–532
nurse intake questions, 714–715, 746–747
profile, 622
risk perception of use, by youth, 542
treatment for, 556
trends in use, 563, 567
use estimates, 496, 497, 501, 549, 550, 569, 570, 571, 572, 573, 574,
613–614
Cocaine Anonymous, 128
Codeine, 620, 686
Code of ethics, 243–244, 814–817
Codependency, 376–383
caretaking, 378
 communication skills and, 382–383
defense mechanisms, 376–378
dependency and, 382
enabling, 378–379
of family members, 214, 217
feelings of worthlessness and, 381–382
inability to know feelings, 379
inability to know what you want, 379–380
lack of trust and, 380
people pleasing and, 380–381
recovery tools and, 383
Codes of ethics, 243–244, 814–817
Cogentin (benztropine mesylate), 671
Cognitive Capacity Screening Examination, 20, 245–246
Cognitive therapy, 74
addict thinking, 72
for antisocial personality disorder, 171
for anxiety disorder, 177–178
applying, 73–74
automatic thoughts and, 74–75
for borderline personality, 173
for clients with early childhood trauma, 185
correcting inaccurate thoughts in, 75–79
defense mechanisms and, 72–73
for depression, 159–162
example of, 159–162
individual, 72–79
post-traumatic stress disorder, 178
session example, 78–79
Cognitive triad, 74, 75
Cohen, W. E., 104
Cold turkey, 782
College students
alcohol use by, 514–515
illicit drug use by, 501–502, 505
tobacco use by, 525
Commission on Accreditation of Rehabilitation Facilities (CARE), 223, 224
Commitment, 120
exercises, 268–274, 281
 statement of, 387
A Communication from God (meditation tape), 98
Communication skills
adolescent treatment and, 205–206
codependency and poor, 382–383
exercises, 288–292
family members and, 217
practicing, 290–292
as recovery tools, 122–123
Community groups, 100
Comorbidity, 155
Compliance with law, 815–816
Comprehensive Assessment and Treatment Outcome Research (CATOR),
117
Compromise, 282–283
Conflict
borderline disorder and, 172
insecurity, 147
interpersonal, 300, 313, 472
Confrontations, 67
Conjoint counseling, 186, 219–220
Contemplation stage, 14, 22
Continuing care, 61–62, 209, 236. See also Discharge
Continuing care case manager, 232
Continuing care plan, 236
Continuing education, 208–209
Control, family members and loss of, 215
Convulsions, nurse intake questions, 726, 758–759
Cooney, N. L., 101
Coping, 304
with anger, 418–419, 426–427
with cravings, 318–319, 477
with peer pressure, 364–365
physiological, 426
stress management and, 126, 127
Coping script, 426–427
Coping With Anxiety and Panic: SCT Method (Beck & Emery), 177
Coping With Depression (Beck & Greenberg), 159
Cormorbidity, screening for, 156
Counselors
active listening by, 241
for adolescents, 203–204
boundaries, respecting, 239, 241–242
chemical dependency, 203–204, 224
client-centered, 242
client dislike of particular, 229–230
code of ethics, 243–244, 814–817
emotional neutrality of, 240–241
ethics and, 243–244
honesty of, 239
interpersonal relationship skills of, 242–243
mental health, 223
patience of, 241
personal qualities of, 238–241
sensitivity of, 239–240
strategies for tobacco users, 703–706
talking about medications with clients, 701–703
tips for communicating with physicians, 699–700
Countertransference, 82
borderline personality and, 173
counselors and, 240–241
therapeutic alliance and, 66
See also Transference
Courtesy, 461
Covetousness, 456
Crack cocaine, profile, 622–623. See also Cocaine
Cravings
coping with, 318–319, 477
daily craving record, 810–813
record of, 34
Criminal justice population, illicit drug use, 507, 554
Crisis intervention, 23–25
Cross-tolerance, 106, 149
defined, 680n
Cylert, 683, 684, 685
Cymbalta (duloxetine), 676

Daily Craving Record, 34, 810–813

Daily log of anxiety, 177
Daily relapse prevention plan, 319–321, 478–479
Daily relationship plan, 283–284
DAST (Drug Abuse Screening Test), 707–708
Day treatment program schedule, 645–648
Decompensate, 677n
Defense mechanisms, 376–378
cognitive therapy and, 72–73
defined, 19
denial, 377–378
lecture on, 143–144
minimization, 376–377
rationalization, 377
Delayed gratification, 293–294
Delinquent behavior, 544–545
Delirium, 32
Delirium tremens, 108
Delusions, 32, 179
Demerol (meperidine), 620, 658, 686
Denial
codependency and, 377–378
as defense mechanism, 72, 73
early, 19–20
exercises, 263
family members and, 371
gamblers and, 436
lecture on, 144
making conscious, 16
Depakene (valproate sodium; valproic acid), 673, 675
Depakene (valproic acid), 158
Depakote (divalproex sodium), 673
Department of Defense Health Related Behaviors Survey of Active Duty
Military Personnel, 610
Dependency
chemical, 202–203
codependency and, 382
family members and, 216–217
hypnotics, 690
narcotics/opioid analgesics, 688
 nicotine, 693n
properties of, 106
stimulants, 685
Depressants, 619
CNS and, 105, 106
profile, 620–621
withdrawal from, 116
Depression
assessing, 157, 349
automatic thoughts and, 74–75
behavior therapy for, 158–159
cognitive therapy for, 159–162
coping skills, 56
gamblers exercise, 459
grief, 163–164
interpersonal therapy for, 162–163
psychopharmacology for, 157–158
as secondary diagnosis, 156–157
suicide, 164
treating, 157–163
See also Antidepressant medications
Designer drugs, 114
Desipramine (Nopramin; Pertofrane), 676
Desyrel (trazodone), 676
Detoxification, 33
client reaction in, 33–34
defined, 683n
heroin, 657
Development. See Normal development
Dexedrine, 683
Dextromethorphan (DXM), 112
Diabetes mellitus, antipsychotics/neuroleptics and, 669, 670
Diagnosis
of addiction, 11–12
criteria for, 26–27
DSM-based
of pathological gambling, 28
primary vs. secondary, 155
of substance abuse disorder, 27–28
Diagnostic and Statistical Manual of Mental Disorders (DSM)
chemical dependency criteria, 26–28
diagnosis based on, 247–249
drug abuse criteria, 247–249
gambling criteria, 28
inpatient discharge criteria, 234–235
inpatient treatment criteria, 30–31, 31–32
outpatient discharge criteria, 233
outpatient treatment criteria, 29–30, 31
Diagnostic summary, 52, 821–827
Dialectical therapy, 172
Dianabol, 628
Diazepam (Valium), 680, 682, 688
DiClemente, C. C., 309
Discharge summary, 237
care plans contracting, 232–233
continued treatment, 236
developing discharge summary, 235–236
halfway houses, 236
inpatient criteria, 234–235
outpatient criteria, 233–234
sample summary, 388–392
saying good-bye, 237
Disease, defined, 140
Disease concept
addiction, 2, 104, 140–143
biopsychosocial issue, 141–142
genetic links, 141
lecture on, 140–143
moral problem vs., 140–141
obsession, 142
physiological issue, 142
problems, 142–143
weak will vs., 140, 141
Disengagement, 167
Disgust, 278
Dishonest thinking, 347, 457–458
Dissociative anesthetics, 112
Disulfiram (Antabuse), 13, 691, 696
Divalproex sodium (Depakote), 673
Diversion, 265
Diverting, 436
Documentation, of treatment plan, 59–60
Dorland’s Illustrated Medical Dictionary, 140
Doxepin (Sinequan), 676
Driving
under the influence of alcohol, 516, 517
under the influence of illicit drugs, 509–510
Drug Abuse Screening Test (DAST), 707–708
Drug category profiles, 619–629
alcohol, 619, 626–627
cannabis, 619, 625–626
cocaine, 622
crack, 622–623
depressants, 619, 620–621
hallucinogens, 619, 624–625
ice, 623
inhalants, 623
marijuana, 626
narcotics, 619, 620
steroids, 619, 628–629
stimulants, 619, 621–622
Drug refusal skills, 92
Drugs Anonymous, 128
Drug screening, 12
Drug Screens, Inc., 12
Drugs of abuse, 104–117
alcohol, 106–108
cannabis, 113–114
club drugs, 115–116
hallucinogens, 112
incidence of use, 105
inhalants, 114
nicotine, 114–115
opioids, 108–112
overview, 104–106
polysubstances, 116
reinforcing properties of drugs, 105
 tolerance and dependence, 106
treatment outcome, 117
Dual relationships, 816
Duloxetine (Cymbalta), 676
Duty of care, 817
Duty to warn, 168

E-cigarettes, 114
Ecstasy (MDMA), 114, 624
characteristics of, 115–116
initiation of, 529, 530, 531
usage trends, 563, 565, 567
use estimates, 569, 570, 571, 572, 573, 574
See also Hallucinogens
Education, effect on
alcohol use rates, 514
illicit drug use rates, 505
substance abuse rates, 553–554
tobacco use rates, 525
Effexor (venlafaxine), 676, 677
Elderly clients, 183–184
Eleventh Step group, 97
Ellis, Albert, 159
Emergency card, 313
Emery, G., 74, 301
Emmons, M. L., 302
Emotional neutrality, counselors and, 240–241
Emotional regulation, borderline personality and, 172
Emotions. See Feelings
Empathy, 288
antisocial personality disorder and, 169–170
counselors and, 240
development exercise, 291–292
examples of empathic statements, 66
learning, 132
narcissistic personality and, 175
skills, 123
therapeutic alliance and, 65–66
Employment, effect on
 alcohol use, 515
illicit drug use, 506
substance abuse, 554
tobacco use, 525
Enabling
co-dependency and, 378–379
family members and, 215–216
Encouragement, 281
Endurance training, 396
Entitlement fallacy, 420
Envy, 346, 456
Escitalopram oxalate (Lexapro), 676
Ethics, NAADAC code of, 243–244, 814–817
Ethyl glucuronide (EG) testing, 22
Euphoric recall group, 88–91
Exaggerating, 177
Exercise
adolescent treatment and, 206
anxiety disorder and, 178
smoking cessation and, 794–795
stress management and, 126, 127, 396
Eye contact, 290

Facial expressions, 422

Fagerstrom test for nicotine dependence, 830–831
Fairness fallacy, 420
Faith exercises, 350, 460
Fallacy of fairness, 420
Family history, 40–41, 408
nurse intake questions, 736–738, 769–771
Family members
of antisocial personality clients, 171
behavioral contract and, 367
of borderline personality client, 171
of client with low intelligence, 183
greeting protocol, 18
of psychotic client, 181
Family program
characteristics of, 217–218
 common family problems, 214–217
conjoint session, 219–220
first contact, 213
group session, 219
against medical advice risks, 213
purpose of, 212–213
schedule for, 218
Family Questionnaire, 213, 370–375
Family recovery plan, 219–220
Fears
of abandonment, 146–147
effects of, 153, 303, 349, 459
exercises, 277
Feedback, in group therapy, 86
The Feeling Good Handbook (Burns), 77, 82
Feelings
adaptiveness of, 153
appropriate use of, 278–279
assertive skills and, 153–154
behavior chain and, 300, 302–303
core, 275–276
easily hurt, 348, 459
exercises, 275–279
expressing in group therapy, 84
family members and inability to know, 216
group therapy and, 85
impulse control and, 298–299, 302
inability to know, 379
of inadequacy, 349, 459
interpersonal therapy and, 80–81
lecture on, 152–154
motivation for recovery and, 120–121
negative, exercises, 309–311
positive, exercises, 313–315
purpose of, 275
uncovering, 75
of worthlessness, 381–382
Feelings and action groups, 94
Fentanyl, 658, 686
Fighting, 544–545
First interview questions
adolescents, 10
adults, 8–10
caregiver, 10
parent, 10
First use
coping with, 475–476
plan for, 316–317
Five A’s strategy for smoking cessation, 703–704
Five R’s strategy for smoking cessation, 705–706
FLAKKA, 112
Flavil (amitriptyline), 676
Flunitrazepam, 114
Fluoxetine (Prozac; Sarafem), 676, 677
Fluvoxamine (Luvox), 676
Follow-up plans, adolescent treatment and, 209
Forgiveness, 133
angry client and, 166–167
early childhood trauma and, 185
Gamblers Anonymous and asking for, 193–194
Formal review of treatment plan, 61–62
Freud, Sigmund, 129, 188

Gabapentin (Neurontin), 673, 680, 681

Gabitril (tiagabine hydrochloride), 673, 680, 681
Gallic Prayer, 98
Gam-Anon, 218
Gamblers
DSM criteria for, 28
exercise for, 435–438
gambling history exercise, 818–820
honesty issues, 435–438
inpatient program schedule, 640–641
outpatient program schedule, 642–644
in recovery, 187
relapse prevention exercises, 465–479
South Oaks Gambling Screen, 660–662
Gamblers Anonymous (GA), 97, 128
 description, 186–187
honesty and, 187–188
pressure relief group, 649–656
program overview, 187
relapse prevention, 195–196
Step Eight, 193
Step Eleven, 194
Step Five, 191–192
Step Five exercises, 463–464
Step Four, 191
Step Four exercises, 455–462
Step Nine, 193–194
Step One, 188–189
Step One exercises, 439–445
Step Seven, 192–193
Step Six, 192
Step Ten, 194
Step Three, 190
Step Three exercises, 451–454
Step Twelve, 195
Step Two, 189–190
Step Two exercises, 446–450
Gambling history
adolescent, 755–757
exercise, 818–820
nurse intake questions, 723–725
Gamma-glutamyl transferase (GGT), 22–23
Gamma hydroxybutyrate (GHB), 114, 116
nurse intake questions, 720–721, 753
Gender
alcohol use and, 512–513
substance abuse and, 552–553
tobacco use and, 519, 521, 523
Generalizations, uncovering, 77–78
Genetics, 141
Geodon (ziprasidone), 668, 670, 673
Geographic area
alcohol use and, 515–516
illicit drug use, 506–507
 substance abuse and, 554
tobacco use and, 525–526
Gestures, trigger, 422
GGT alcohol screen, 12
Gluttony, 457
Goals
examples of, 54, 57–59
impulse control and developing, 299
treatment plan, 53–54, 57–59
God, problems with word, 132–133, 190. See also Higher power
God Talks to You (Perkinson), 98
Goldman, Arnold, 54
Gordon, J. R., 195
Gorman, Jack, 67
Gorski, T., 95
Gratification
delayed, 293–294
instant, 665
Gratitude, 461
Great lie, 144–146
Greed, 346
Grief, 82, 163–164
Group therapy
for adolescents, 207–208
agenda group, 85–87
benefits, 83–84
childhood group, 98–100
community group, 100
ending each group, 88
euphoric recall group, 88–91
family programs, 219
feedback in, 86
honesty group, 87–88
men’s group/women’s group, 100
personal inventory group, 100–101
power of, 334–336
preparation for, 84–85
pressure relief, 649–656
problem-solving skills group, 102–103
 reading group, 91
relapse prevention group, 91–96
running a group, 86–87
skills training group, 101–102
smoking cessation and, 782
spirituality group, 96–98
step work and, 130
trust in, 131
use of peer pressure, 363–364
A Guide to Treatments That Work (Nathan & Gorman), 67
Guilt, 133
of family members, 214–215

Habits
behavioral contract and, 366–367
behavior therapy and changing, 68–69
drinking or drug use as, 150
Halcion (triazolam), 689
Halfway house, 236
Hallucinations, 32, 179
Hallucinogens, 619
delusions and, 32
effects of, 105, 112
incidence of abuse, 550
initiation of, 530, 532–533, 534–535
nurse intake questions, 715, 747
profile, 624–625
psychedelic state, 112
treatment for, 556
use by adolescents, 500–501
use demographics, 495, 496
Hamilton Anxiety Rating Scale (HAM-A), 175, 804–806
Hamilton Depression Rating Scale (HAM-D), 157, 158, 164, 403–404
Harm, prevention of, 816
Heart block, 678n
Heroin, 108–109, 620, 687
availability, perceived, 543
behavioral therapies, 658
incidence of abuse, 549–550
 initiation of use, 529, 530, 531, 532
methadone programs, 657–658, 659
risk perception of use, by youth, 542
treatment, 556, 657–659
use demographics, 496, 497–498
High blood pressure crisis, 678n
Higher Power, 129
acceptance of, 131, 153, 362, 383
building relationship with, 79–80, 82, 97
exercises, 333–341
gambler exercises, 446, 449–450, 452–454
Gamblers Anonymous and, 189, 190
narcissistic personality and, 434
High-risk client, for HIV/AIDS, 181–182
High-risk friends, 312, 471
High-risk situations
avoiding, 312, 467–468
negative emotions, 309–311, 468–470
positive feelings, 313–315, 472–475
social pressure, 92, 102, 300, 312, 471
History
chemical use, 119, 261–262, 711–712, 743–744
family, 40–41, 408, 736–738, 769–771
medical, 40, 255, 408
personal, 39–42, 405–407
See also Nurse intake questions, for adolescents; Nurse intake
questions, for adults
HIV/AIDS, 181–182
Homicidal ideation, 13, 41, 168, 413
Honesty, 133, 146
adolescent treatment and, 206
counselors and, 239
euphoric recall group and, 89–91
exercise, 263–267
gamblers and, 187–188, 435–438
living the truth, 144
narcissistic personality and, 433
as recovery tool, 119–120
therapeutic alliance and, 64
Honesty group, 87–88
Hope exercises, 350, 460
Hospitalization, partial, 29
Hostility, 264, 436
Humility, 135–136, 192–193
Hydrocodone, 203
Hydromorphone, 620
Hydroxyzine (Atarax; Vistaril), 680, 681
Hypnotics (sleep-aids), 108, 688–690
abuse/dependence potential, 690
cautions, 690
dose/frequency, 689
emergency conditions, 690
generic/brand names of, 688–689
nurse intake questions, 718–719, 750–751
pregnancy and, 690
purpose of, 689
side effects, 689–690

Ice, 621
“I feel” statements, 289
Illicit drug use
by age, 485, 500–503, 504
alcohol association with, 508–509, 516
availability, perceived, 542–543
cellular effects, 148–149
by college students, 505
criminal justice population, 507
cross-tolerance of, 106
decline in use of, 485–486
dependence (See Dependency)
driving and, 509–510
educational effects on, 505
employment effects on, 506
frequency of, 485, 495–498, 507–508
by gender, 503–504
geographic area and, 506–507
initiation of, 529
nonmedical use of psychotherapeutic drugs, 485
 past month use, 505, 506, 507
by pregnant women, 504
prescription drugs, 510
by race/ethnicity, 504, 505
reinforcing properties, 105
risk perception of use, by youth, 542
tobacco association with, 508–509, 526–527
tolerance of, 106
treatment, 555–556, 557–560
treatment needs, 557–560
withdrawal (See Withdrawal)
See also Substance abuse; specific drugs
Illiterate clients, 182–183
Imagery exercises, to heal early childhood pain, 99–100
Imipramine (Tofranil), 676
Impatience, 348, 458
Impulse control
behavior and, 303–304
behavior chain and, 299–305
consequence of, 304–305
exercise, 298–305
feelings and, 298–299, 300, 302–303
goal development, 299
instant gratification, 665
as recovery tool, 124–125
“time-out” for, 124
Impulsive temperament, 294–295
Inaba, D., 104
Inaccurate thinking group, 93
Inaccurate thoughts, 102, 301–302, 345
anger and, 417–418
behavior chain and, 318
behavior therapy and, 71
cognitive therapy and, 72–82, 87, 159, 162, 178
depression and, 157
gambling and, 415–417
relapse prevention and, 92–93
Inadequacy, feelings of, 459
Independence, struggle for, 146
Inderal (propranolol), 111, 680, 692, 699
Individual treatment
behavior therapy, 67–71
cognitive therapy, 72–79
interpersonal therapy, 79–82
modality selection, 82
therapeutic alliance in, 64–67
Inhalants
characterization, 114
initiation of use, 529, 530, 531, 534
nurse intake questions, 716–717, 748–749
profile, 623
treatment for, 556
trends in use, 563
use estimates, 496, 500, 501, 550, 569, 570, 571, 572, 573, 574,
613–614
In-house intervention, 36
Initial contact
assessments, 12, 20–23
diagnosis, 11–12
example of, 20
family members, 18, 213
family programs, 213
first interview questions, 8–10
greeting clients, 17–18
interventions, 12–14
motivational interview, 3–14
motivation assessment, 14–16
prognostic factors, 13
treatment, 2–3, 29–33
Inpatient program schedule
adolescent, 632–633
adult, 630–631
gambling, 640–641
Inpatient treatment
criteria for, 30–32
description of, 29, 236
discharge criteria, 234–235
Inquiry, breaking aversive chain and, 424
Insecurity, 147
Instant gratification, 665
Institute of Medicine, 117
Integrity, 461
Intellectual functioning, clients with low, 182–183
Intellectualizing, 265, 436
Interpersonal relationships
borderline personality and, 172
conflict in, 300, 313, 472
group therapy and, 84
relapse and, 306–307, 313, 465–466, 472
relationship skills, 242–243, 383
Interpersonal therapy, 79–82
for depression, 162–163
feelings and, 80–81
grief issues, 82
Interventions
crisis, 23–25
early, 28–29
examples, 56, 57–59
in-house, 36
initial contact, 12–14
leaving against medical advice, 35–36
letter, example of, 24
treatment plan, 57–59
Intimacy, 281–282, 286
Intolerance, 348, 458
Intoxication
alcohol, 107
of clients, 32–33
reaction to, 32
stimulant, 694
Invega (paliperidone), 668, 670
Inventory of Behavioral Health Services (I-BHS), 608
Isocarbaxazid (Marplan), 676

Jay, Debra, 23
Jay, Jeff, 23
Jellinek, F. M., 140
Joint Commission on Accreditation of Healthcare Organizations (JCAHO),
53, 223, 224
Journals
anger, 415–416
treatment, 34
Joy, 276

K2, 114
Kadden, R. M., 101
Kent score, 740, 772–773
Keppra (levetiracetam), 673
Ketamine, 112, 116
Kindness, 461
Klerman, G. L., 162
Klonopin (clonazepam), 680, 682, 688
Kofed, L. L., 183

LAAM (levomethadyl acetate hydrochloride), 658, 659

Laboratory red flags, 9, 10
Laboratory tests, 22–23
Lamotrigine (Lamictal), 673
Lapse, 317, 476
Lapse group, 94–96
Lapse plan, 317, 476
Law, compliance with, 815–816
Laziness, 346
Lectures, 139–154
Alcoholics Anonymous, 150–152
defense mechanisms, 143–144
disease concept, 140–143
feelings, 152–154
great lie, 144–146
meetings, 152
normal development, 146–148
physical addiction and recovery, 148–150
structuring, 140
Legal history, 735–736, 768–769
Level system, 204
Levetiracetam (Keppra), 673
Lexapro (escitalopram oxalate), 676
Librium (chlordiazepoxide), 680
Licensed practical nurses, 223
Lies
adolescent treatment and, 206
cognitive therapy and, 72, 73–74
honesty group and, 88
self-told, 3–4
See also Honesty
Lifestyle changes, for stress management, 397–401
Limit setting, 173
Lipids, 669n
Listening skills, 122–123
Lithium products, 158, 673–675
Lithium toxicity, 674, 674n, 675
Logical errors, 74, 75
Loneliness, 95, 96, 146, 183, 206, 310, 354, 463, 469
Lopressor, 699
Lorazepam (Ativan), 680, 682, 688, 690
Lord’s Prayer, 88, 98
Loss of control
family members and, 215
personal testing of, 316, 475
Love
among clients, 185–186
behavioral contract and, 367
defining, 286
exercises, 268–274, 280–281, 286–287, 460
recovery and, 120, 350
self-discipline and, 296
Love First (Jay & Jay), 23
Low-intellectual function clients, 183
Loyalty, 461
LSD (lysergic acid diethylamide), 112, 114
availability, perceived, 543
initiation of use, 529, 530, 531
profile, 624
risk perception of use, by youth, 542
trends in use, 565
 use estimates, 569, 570, 571, 572, 573, 574
Ludiomil (maprotiline), 676
Lust, 346, 456
Luvox (fluvoxamine), 676
Lyrica (pregabalin), 680, 681

Maintenance for recovery, 137

Maintenance stage, 15, 22
Maprotiline (Ludiomil), 676
Marijuana, 104
availability, perceived, 542–543
characteristics of, 113–114
initiation of use, 116, 529–531, 532
profile, 626
risk perception of use, by youth, 539–542
treatment, 555–556, 695
trends in use, 564, 565, 566, 567
use by adolescents, 500–501, 504
use estimates, 495–496, 507–508, 549–550, 569, 570, 571, 572, 573,
574, 613–614
Marlatt, A. G., 195
Marplan (isocarbaxazid), 676
Mastering Your Fears and Phobias: Workbook (Craske, Antony & Barlow),
177
Mastery of Your Anxiety and Panic (Barlow & Craske), 179
MAST (Michigan Alcoholism Screening Test), 12
McCauley, Kevin, 141
Mean corpuscular volume (MCV), 23
Medical history, 40, 255, 408
Medications. See Psychotherapeutic medications
Meditation, 137, 393, 394
Gamblers Anonymous and, 194
how to meditate, 343
Meditation group, 97–98
Meetings, 152, 383
clinical, 225–227
narcissistic personality and, 433–434
Men’s group, 100
Mental assets exercises, 351–352, 461–462
Mental health counselor, 223
Mental health data, 493, 604–605
Mental health screening
exercise, 828–829
nurse intake questions, 730–733
Mental status examination, 156, 164, 408–414
adolescent, 772–774
adult, 739–741
Meperidine (Demerol), 620, 658, 686
Methadone, 686
opioid maintenance and, 109, 692–693
pregnancy and, 698–699
profile, 620
programs, 657–658, 659
purpose of, 687
Methamphetamine, 104, 111
initiation of use, 535
nurse intake questions, 717–718, 749–750
profile, 621, 623
use demographics, 497
Methaqualone, 620
Methylphenidate, 621
Michigan Alcoholism Screening Test (MAST), 12
Mind reading, anger and, 420
Mini-Mental State Examination, 20
Minimization
characterization, 72, 264, 436
codependency and, 376–377
family members and, 370–371
lecture on, 143–144
Mirtazapine (Remeron), 676
Monitoring the Future (MTF), 562, 603–604, 613
comparison with NSDUH, 567–574
comparison with NSDUH and YRBS, 563–567
Monoamine oxidase inhibitors (MAOIs), 158, 676, 677, 678–679
Monti, P. M., 101
Moral development, 171
Moral law, 338–339, 451–452
Morphine, 620, 686
Motivation
relapse prevention and, 309, 468
stages of, 14–15, 22
strategies for, 15–16, 22
Motivational interview, 3–14
client attitude and, 5–6
diagnosis of addiction problem, 11–12
example of, 6–8
intervention, 12–14
questions to ask the adult client, 8–10
Motivation assessment, 14–16
Myth, anger, 416

Nalmefene (Revex), 691, 692, 693

Naloxone (Suboxone), 658, 692–693, 695, 699
Naltrexone (ReVia; Vivitrol), 13, 126, 658, 691–692, 693, 695
Nandrolone, 628
Narcissistic personality, 132
characterization, 174–175, 429
exercises, 429–434
traits of, 430
worthless feelings in, 431–433
Narconon, 218
Narcotic and opioid analgesics, 619, 686–688
abuse/dependence potential, 688
cautions, 688
dose/frequency, 687
emergency conditions, 688
generic and brand names of, 686–687
natural, 686
nurse intake questions, 715–716, 748
pregnancy and, 688
profile, 620
purpose of, 687
side effects, 687
Narcotics Anonymous (NA), 97, 128, 152, 338
Narcotic Withdrawal Scale, 25, 253
Nardil (phenelzine), 676
Nathan, Peter, 67
National Association of Alcohol and Drug Abuse Counselors (NAADAC)
Code of Ethics, 243–244, 814–817
National Cancer Institute Guide to Quitting Smoking, 776–797
avoiding temptation, 790–791
challenges when quitting, 784–876
diet and, 795
enlisting family, friends and coworker support, 783–784
exercise and, 794–795
lifestyle changes, 794–795
long-term rewards, 795–796
medications to aid in quitting, 782, 787–788
Nicotine Addiction Test, 779–780
options for quitting, 781–782
preparing to quit, 777
quit date, 783, 790
Quitting Worksheet, 788–789
reasons to quit, 776–779
relapse, 793–794
removing tobacco products from environment, 786–787
resources for, 796–797
rewarding self, 791–792
smoking journal, 785–786
triggers, 780–781
weight gain and, 794
National Comorbidity Survey (NCS), 604–605
National Epidemiologic Survey on Alcohol and Related Conditions
(NESARC), 606
National Health and Nutrition Examination Survey (NHANES), 605
National Health Interview Survey (NHIS), 605–606
National Household Survey on Drug Abuse (NHSDA), 562
National Inmate Survey (NIS), 611
National Institute on Drug Abuse (NIDA), 562
National Longitudinal Alcohol Epidemiologic Survey (NLAES), 606
National Longitudinal Study of Adolescent Health (Add Health), 607
National Survey of Substance Abuse Treatment Services (N-SSATS),
608–609
National Survey on Drug Use and Health (NSDUH), 484–618
alcohol use, 486–487, 511–519
format of report, 491–493
 geographic regions covered by, 492–493
highlights, 485–489
illicit drug use, 485–486, 495–510
initiation of substance use, 487–488, 528–538
introduction, 490–494
limitations on trend measurements, 491
mental health data, new, 493
mental health problems, 604–605
other sources of data, 562–574, 602–614
other uses for data from, 493–494
reliability and, 492, 583–587, 589
statistical methods and measurement, 583–601
substance abuse/dependence, 489, 548–561
survey description, 575–582
tables and figures in report, 492
tobacco use, 487, 520–527
treatment programs, 489, 548–561, 608–610
youth prevention-related measures, 488, 539–547
youth substance abuse trends, 562–574
Needs
exercise, 808
strategies for getting needs met, 418–419
Nefazodone (Serzone), 676
Negative emotion exercises, 309–311, 468–470
Neuroleptic malignant syndrome, 669, 669n, 670, 671
Neuroleptics. See Antipsychotics/neuroleptics
Neurontin (gabapentin), 673, 680, 681
Nicotine, 105
characterization of, 114–115
Fagerstrom test for nicotine dependence, 830–831
nurse intake questions, 721–723, 754
withdrawal symptoms, 694n
Nicotine Addiction Test, 779–780
Nicotine dependence, 693n
Nicotine replacement therapy (NRT), 693, 694, 695, 697, 699, 787
nicotine lozenge, 695, 697
nicotine patch, 693, 695, 697
nicotine polacrilex gum, 693, 695, 697
No More Letting Go (Jay), 23
Nondiscrimination, 814
Nonverbal behavior, 4
Nonverbal trigger sounds, 421
Nopramin (desipramine), 676
Norepinephrine, 677n, 694n
Normal development, 146–148
abandonment fears, 146–147
adolescence, 147–148
adulthood, 148
independence, struggle for, 146
insecurity, 147
peer group pressure, 147
primary caregivers, 146
rule learning, 147
Nortriptyline (Aventyl; Pamelor), 676, 693
Nurse intake questions, for adolescents, 743–775
alcohol use, 744–746
amphetamine use, 749–750
anabolic androgenic steroids (AAS) use, 752
anxiolytics use, 750–751
auditory assessment, 761
cannabis use, 746
chemical use, 743–744
cocaine use, 746–747
family history, 769–771
females only, 760–761
financial, 767–768
gambling history, 755–757
gamma hydroxybutyrate (GHB)/analogs use, 753
hallucinogen use, 747
hypnotics use, 750–751
inhalant use, 748–749
legal history, 768–769
mental status examination, 772–774
nicotine use, 754
nutritional assessment, 761–762
opioid use, 748
over-the-counter medications use, 753
pain assessment, 762
 phencyclidine use, 751–752
physical assessment, 757–758
psychological history/screening/mental health issues, 762–766
safety issues, 764–765
school history, 766–767
sedative use, 750–751
seizures/convulsions, 758–759
sexual history, 762
social/leisure, 769
spiritual, 771
steroid use, 752
stimulant use, 749–750
tuberculosis, 758
visual assessment, 761
vocational, 767
Nurse intake questions, for adults, 711–742
alcohol use, 712–713
amphetamine and stimulant use, 717–718
anabolic androgenic steroids (AAS) use, 720
anxiolytic use, 718–719
auditory assessment, 728
cannabis use, 714
chemical use, 711–712
cocaine use, 714–715
educational, 733
family relationship, 736–738
female-only, 728
financial, 734–735
gambling history, 723–725
gamma hydroxybutyrate (GHB)/analogs use, 720–721
hallucinogen use, 725
hypnotic use, 718–719
inhalant use, 716–717
legal history, 735–736
mental status examination, 739–741
nicotine use, 721–723
nutritional assessment, 729
opioid use, 715–716
over-the-counter medications, 721
 pain assessment, 730
phencyclidine use, 719
physical assessment, 725
psychological history/screening/mental health issues, 730–733
safety screening assessment, 732–733
sedative use, 718–719
seizures/convulsions, 726
sexual history, 729
social/leisure, 736
spiritual, 738–739
steroid use, 720
stimulant use, 717–718
tuberculosis, 725–726
visual assessment, 728
vocational, 734
Nurses, 223
Nutritional assessment, 729, 761–762

Objectives
examples, 55, 57–59
treatment plan, 54–56, 57–59
Obsession, 142
Olanzapine plus fluoxetine (Symbyax), 673
Olanzapine (Zyprexa), 668, 669, 673, 680, 681
Open mindedness, exercises, 334–336
Opioids, 104
analogs, 658–659
characterization, 108–112
detoxification, 109
generic/brand names of, 692
nurse intake questions, 715–716, 748
profile, 692–693
purpose of, 692–693
treatment/maintenance agents, 693
use among adolescents, 203
See also Narcotic and opioid analgesics
Opioid withdrawal, 33, 109
Clinical Opiate Withdrawal Scale, 709–710
medication for, 692–693
Order, 461
Organic brain dysfunction, 20
Organic brain syndrome, 32
Outpatient program schedule
adolescent, 637–639
adult, 634–636
day treatment, 645–648
gambling, 642–644
Outpatient treatment
criteria for, 29–30, 31
description of, 29, 236
discharge criteria, 233–234
Overeaters Anonymous, 128
Overindulgence, 346
Over-the-counter medications
nurse intake questions, 721, 753
for smoking cessation, 782
Oxazepam (Serax), 680, 682, 689
Oxcarbazepine (Trileptal), 673
Oxycontin, 497, 535

Pain
addiction and, 4–5
assessment, 730, 762
Pain relievers
initiation of use, 529, 530, 531, 534–535
obtained for nonmedical uses, 509, 510
treatment, 556, 557
trends in use, 565–566, 567–568
use estimates, 497, 549, 550, 572, 573, 574
Paliperidone (Invega), 668, 670
Pamelor (nortriptyline), 676, 693
Panic attacks, 178–179
Panic Attacks: How to Cope, How to Recover (Greenberg & Beck), 177
Parenting Your Out-of-Control Teenager (Sells), 210
Parents
disapproval of substance use, 544
early relationships, 99
involved, 546–547
 support group, 210
Parnate (tranylcypromine), 676
Paroxetine (Paxil), 676, 677
Parsons, B. V., 210
Partnership Attitude Tracking Study (PATS), 607
Patience, 461
Patterson, George, 420
Paxil (paroxetine), 676, 677
PCP (phencyclidine), 104
characterization of, 111–112
delirium and, 32
initiation of use, 529, 530, 531
nurse intake questions, 719, 751–752
profile, 624
See also Hallucinogens
Peer pressure, 147
adolescent, 203, 208
coping with, 364–365
evolution of, 362–363
how group uses, 363–364
importance of, 363
plan to say no and, 365
relapse and, 312
sobriety risks and, 363
Peer substance abuse, 544
People pleasing, 216, 380–381
Percocet, 687
Percodan, 687
Perfectionism, 349, 459
Personal control testing, 316, 475
Personal history, 39–42, 405–407
Personal inventory, 133, 137
exercises, 344–352, 455–462
Gamblers Anonymous and, 191, 194, 455–462
Personal inventory group, 100–101
Personality
antisocial, 169–171
anxious, 175–181
borderline, 172–174
 defects, 347–349, 457–459
defined, 169
narcissistic, 174–175
Personal recovery plan, 236, 384–387
Pharmchec Drugs of Abuse Patch, 12
Phenelzine (Nardil), 676
Phenmetrazine, 621
Phoniness, 348, 458
Physical addiction, 148–150
Physical assessment
adolescent, 757–758
adult, 725
Physical assets, 351, 461
Physical liabilities, 349, 459–460
Physical proximity, communication and, 289–290
Physicians, 222
tips for communicating with, 699–700
Physiological coping, 426
Physiological dependence, 28
Pills Anonymous, 128
Placement criteria, 25–26
Pleasurable activities, 397–400
Pleasure Unwoven (McCauley), 141
Plutchik, R., 80, 275
Point system, 204–205, 210
Polysubstances, 116
Positive communication, 289
Positive events, 300
Positive feeling exercises, 313–315, 472–475
Positive outcome exercises, 308–309, 467–468
Post-traumatic stress disorder (PTSD), 178
checklist civilian version, 798–799
checklist military version, 800–801
Powerlessness
exercises, 300, 322–326
gambler exercises, 439–442
Prayer, 97, 137, 194, 394
how to pray, 342–343
Precontemplation stage, 14, 15, 16, 22
Preferences exercise, 808–809
Pregabalin (Lyrica), 680, 681
Pregnancy, medication effects on
antianxiety, 683
antidepressant, 679
antimanic, 675
antiparkinsonian, 672–673
antipsychotics/neuroleptics, 671
hypnotics, 690
narcotic and opioid analgesics, 688
stimulant medications, 686
Pregnant women
alcohol use by, 513
illicit drug use by, 504
tobacco use by, 523, 524, 778, 779
Preparation stage, 14, 15, 22
Preparation statement, 84–85
Prescription drugs
illicit use of, 495
sources of, 509, 510
trends in use among youth, 566
Pressure relief group, meeting and budget form, 649–656
Prevent (drug screening company), 12
Prevention
substance use prevention programs and messages, 545–546
youth prevention-related measures, 488, 539–547
See also Relapse prevention
Pride, 345, 456
Primary caregivers, 146
Problem list, 52–53
Problem solving
feelings and, 63
self-discipline and, 124, 296
skills, 397
stopping trigger thoughts and, 426
using feelings in, 81
Problem-solving skills group, 102–103
Prochaska, J. O., 309
Procrastination, 348, 459
Prognostic factors, 13
Progressive relaxation, 394
Progress notes, 59, 60–61
examples, 60–61, 388–392
Propranolol (Inderal), 111, 680, 691, 699
Protriptyline (Vivactil), 676
Prozac (fluoxetine), 676, 677
Psychedelic state, 112
Psychiatric/psychological assessment, 156
Psychiatrist, 222–223
Psychoactive, defined, 692n
Psychoactive substance use disorder, 247–249
Psychological history, nurse intake questions, 730–733, 762–766
Psychological testing, 158
Psychologist, 222–223
Psychopharmacology
for anxiety disorder, 176
for depression, 157–158
for psychosis, 180
Psychosis, 32
characterization of, 179
defined, 668n
delusions in, 179
family of client, 181
hallucinations in, 179
treatment, 180–181
Psychotherapeutic medications, 666–706
addiction treatment, alcohol, 690–692
ADHD, 683–686
antianxiety, 680–683
antidepressants, 676–679
antimanics, 673–675
antiparkinsonian, 671–673
antipsychotics/neuroleptics, 668–671
client communication tips, 701–703
frequency of illicit use, 495–497
hypnotics (sleep-aids), 688–690
initiation of use, 534–535
narcotic and opioid-analgesics, 686–688
 opioid withdrawal/maintenance agents, 692–693
physician communication tips, 699–700
stimulants, 683–686
tobacco, 693–699
tobacco users, counselor strategies for, 703–706
use by adolescents, 500, 501
See also specific medications
PTSD Checklist Civilian Version, 178
PTSD Checklist Military Version, 178
Puberty, 198–199
Punctuality, 461
Punishment, 69, 70, 366

Quadracyclics, 676, 678

Questions to diagnose substance abuse disorder, 27
Quetiapine fumarate (Seroquel), 668, 670, 673, 680, 681
Quitlines, for smoking, 782

RAATE-CE, 12, 22
Race/ethnicity
alcohol use and, 513–514
illicit drug use and, 504, 505
substance abuse and, 553
tobacco use and, 523–524
Random Drug Screens, Inc., 12
Rationalization
characterization, 72–73, 264, 436
codependency and, 377
family members and, 371
lecture on, 144
Readiness to change, 26
Reading groups, 91
Reassuring self, 425
Rechanneling, for anger management, 424
Recovery
people who can help in, 479
personal recovery plan, 384–387
staying on track, 350–351
way to, 350
 See also Recovery skills
Recovery Attitude and Treatment Evaluator-Clinical Evaluation (RAATE-
CE), 12, 22
Recovery skills, 118–127, 383
addictive relationships, 122
chemical use history, 119
commitment, 120
communication skills, 122–123
feelings, 120–121
honesty, 119–120
impulse control, 124–125
love, 120
relapse prevention, 125–126
relationship skills, 121–122
self-discipline, 123–124
stress management, 126–127
trust, 120
Recreational therapist, 225
Referrals, 21–23, 25
Refusal situations, 102–103
Registered nurses, 223
Rehabilitation technician/aide, 224–225
Reinforcement
in adolescent treatment, 199, 205, 207
behavioral contract and, 366
in behavior therapy, 69, 70
in communication, 290
in therapeutic alliance, 65
Relapse, 24, 26, 34
smoking cessation and, 793–794
Relapse prevention
alcohol treatment medications and, 13, 691, 696
behavior chain, 317–319
consequences and, 304–305
daily program for, 478–479
daily relapse prevention plan, 319–321
exercises, 306–321
first use exercises, 316–317, 475–476
for gamblers, 195–196, 465–479
 high-risk situations and, 312
impulse control and, 125–126
interpersonal conflict and, 313
lapse plan, 317, 476
peer pressure and, 312
personal control testing, 316, 475–476
process of, 306, 465
relapse plan, 125
social support system for, 319–321
warning signs exercises, 306–317, 465–479
Relapse Prevention for Gamblers exercise, 195–196
Relapse prevention group, 91–96
drug refusal skills, 92
feelings and action group, 94
inaccurate thinking group, 93
lapse group, 94–96
trigger group, 91–92
Relationships
abusive, 287
addictive, cycle of, 285–286
addictive, exercises, 285–287
changing, 82
developing healthy, 97
exercises, 270–274
first, 268–269
interpersonal therapy and, 79–82
normal, 286
with others, 80, 273–274
with self, 80, 270–271
Relationship skills
commitment, 281
compromise, 282–283
of counselors, 242–243
daily relationship plan, 283–284
encouragement, 281
exercise, 280–284
love, 280–281
as recovery tools, 121–122
respect, 283
 sharing, 281–282
Relaxation techniques
for anxiety, 176–177
history of, 393–394
program sample, 394–395
stress management and, 126–127
Religion
defined, 335
spirituality vs., 96, 132, 341
Religious beliefs, youth, 545
Remeron (mirtazapine), 676
Repayment schedule, 655
Repression, 72
Resentment, 347–348, 458
Resistance from family, 220
Respect, 283
Responsibility
accepting, 133
coping with anger and, 419
self-discipline and, 296–297
Revex (nalmefene), 691, 692, 693
ReVia (naltrexone), 13, 126, 658, 691, 692, 693, 695
Rewards, behavioral contract and, 366
Rights and duties, counselor, 816
Risperidone (Risperdal), 668, 669–670, 673, 680, 681
Ritalin, 683, 684, 685
Road maps, revising, 424–425
Rockefeller, John D., 151
Rohsenow, D. J., 101
Rohypnol, 114, 116
Role playing, 92, 95, 208
Rounsaville, B. J., 162
Roxicet, 687
Rules
in adolescent treatment, 205
client complaints about, 230
group therapy, 85
learning, 147
self-discipline and, 124, 295–296
 unit, 186
violations of, 70–71, 170–171, 230
Rush, J. A., 74, 301

Sadness, 278
Safety screening, 732–733, 764–765
Salvia, 114
Sanity, 131, 330
Schedule II drugs, 686n
School history, 766–767
School performance chart, 367–368
Sedation, defined, 669n
Sedatives, 108
incidence of abuse, 550
initiation of, 529, 530, 531, 534–535
nurse intake questions, 718–719, 750–751
Seizures, nurse intake questions, 726, 758–759
Self, relationship with, 80, 270–271
Self-concept, development of, 200
Self-discipline, 665
delayed gratification and, 293–294
exercises, 293–297
impulsive temperament and, 294–295
problem solving and, 296
as recovery tool, 123–124
responsibility and, 296–297
rules and, 295–296
Self-efficacy, 65, 125, 208, 306–307, 465, 466
Self-esteem, 120
Self-image, 74, 664
Self-inventory, 133–134
Selfishness, 347, 457
Self-pity, 348, 459
Self-Rating Anxiety Scale, 175
Self-recognition, in angry client, 167
Self-respect, 664
Self-talk, improving, 425–426
Sells, Scott, 210
Selye, H., 126
Sensitivity of counselors, 239–240
Serax (oxazepam), 680, 682, 689
Serenity, 336
Serenity prayer, 88, 98
Seroquel (quetiapine fumarate), 668, 670, 673, 680, 681
Serotonin, 677n
Sertraline (Zoloft), 676
Serzone (nefazodone), 676
Seventh Step prayer, 354
Sexual abuse, 184–185
Sexual history, 729, 762
Shame, 215, 347, 458
Sharing, 281–282
Shaw, B. F., 74, 301
Short Michigan Alcoholism Screening Test (SMAST), 12, 21
Signs of relapse, 95–96
Silent assumptions, 74, 75
Sincerity, 461
Sinequan (doxepin), 676
Skills training group, 101–102
Skills Training Manual for Treating Borderline Personality Disorder
(Linehan), 173
Sloth, 457
(SMAST) Short Michigan Alcoholism Screening Test, 247–249
Smoking journal, 785–786
Sobriety, peer pressure and risk to, 363
Social pressure, 92, 102, 300, 312, 471
Social situations, high-risk, 312
Social skills, 401–402
training psychotic client in, 180–181
Social support system, relapse prevention and, 319–321, 478
Social worker, 223
Sonata (zaleplon), 689, 690
South Oaks Gambling Screen, 187, 660–662
Speech, caution in, 461
Spice (designer drug), 114
Spirituality
adolescent treatment, 207
nurse intake questions, 738–739, 771
 relationships and, 79–80, 82
religion vs., 96, 132, 341
twelve-step programs and, 331
Spirituality group, 96–98
Eleventh Step group, 97
healthy relationship development and, 97
Higher Power relationship, 97
meditation group, 97–98
meeting frequency, 96
preparation for, 96
SSRIs (selective serotonin reuptake inhibitors), 158, 176, 676, 677–678,
679, 683. See also Antidepressant medications
Staff. See Clinical staff
Staff-client problems, 229–230
State, 169
Statement of commitment, 387
State-Trait Anxiety Inventory, 175
Steroids, 619
nurse intake questions, 720, 752
profile, 628–629
Stimulants, 619, 683–686
abstinence syndrome, 111
abuse/dependence potential, 685
cautions, 685–686
dose/frequency, 684
emergency conditions, 685
frequency of use, 497
generic and brand names of, 683–684
incidence of abuse, 550
initiation of, 529, 530, 531
intoxication reactions, 694
nurse intake questions, 717–718, 749–750
pregnancy and, 686
profile, 621–622
purpose of, 684
side effects, 684–685
treatment for, 556
withdrawal, 694
Strattera, 684, 685
Strength program, 396
Strengths exercise, 807–808
Stress management
benefits of, 393
exercise, 396
lifestyle changes, 397–402
as recovery tool, 126–127
relaxation, 393–395
Stressors, 418
Stress tolerance, borderline personality and, 173
Stretching, 396
Subjective units of distress, 159
Suboxone (naloxone), 658, 692–693, 695, 699
Substance abuse
age and, 551–552
criminal justice populations and, 554
demographics, 548–551
diagnosis of, 27–28
drug category profiles, 619–629
education effect on, 553–554
employment effect on, 554
frequency of, 489
gender differences in, 552–553
geographic areas and, 554
initiation of use, 528–538, 551
past year treatment for, 554–556
perceived risk of, 539–542
race/ethnicity and, 553
specialty treatment, 556–561
trends, 562–574
unmanageability exercises, 326–329
validity of self-reported, 589
youth prevention-related measures, 539–547
See also Illicit drug use
Substance Abuse Subtle Screening Inventory (SASSI), 12, 21–22
Substance Abuse Treatment Coordination Report, 700
Substance use prevention programs and messages, 545–546
Subutex (buprenorphine), 109–110, 658, 692–693, 695, 699
Suicide, 164
Surprise, 277
Surrender step, 129–130, 189
Surveys of Inmates in State and Federal Correctional Facilities (SISCF,
SIFCF), 611–612
Symadine (amantadine hydrochloride), 671
Symbyax (olanzapine plus fluoxetine), 673
Symmetrel (amantadine hydrochloride), 671
Symptoms of relapse, 95–96
Synthetic designer drugs, 114

Talacen, 687
Tardive dyskinesia, 669, 669n, 670, 671
Team building, 227–228
Teen-Addiction Severity Index (T-ASI), 12
Tegretol (carbamazepine), 158, 673
Temperament, 169
impulsive, 294–295
Tenex, 684, 685
THC (9-tetrahydrocannabinol), 113, 695n
Therapeutic alliance
antisocial personality and, 171
beginning of, 18–19
being confrontive, 67
being reinforcing, 65
countertransference and, 66
denial and, 19–20
developing, 5, 20, 64–65
empathic statement examples, 66
transference and, 66
trust building, 19
using empathy, 65–66
Therapeutic modality, choosing, 82, 87
TheraScribe 5.0, 53
Thoughts
accurate, 78–79, 93, 161, 178, 301–302
automatic (See Automatic thoughts)
barriers, 663–665
behavior chain and, 301–302
dishonest, 347, 457–458
 inaccurate (See Inaccurate thoughts)
trigger, 420, 425–426
uncovering, 75
Tiagabine hydrochloride (Gabitril), 673, 680, 681
Time out
for angry client, 124, 167–168, 423–424
exercises, 349–350
from gambling, 460
Time-out contract, 427–428
Time use, 461
Tobacco cessation treatment, 693–699
cautions, 697–698
dose/frequency, 695–696
emergency conditions, 697
nicotine replacement therapy, 693, 694
pharmacotherapies, 693, 695–696
pregnancy and, 698–699
purpose of, 693–694
side effects, 696–697
strategies for counselors, 703–706
See also National Cancer Institute Guide to Quitting Smoking
Tobacco use
age and, 487, 521, 522, 526
alcohol use and, 516, 526–527
by college students, 525
education effects, 525
employment effects, 525
Fagerstrom test for nicotine dependence, 830–831
frequency of, 487, 526, 527
gender differences in, 519, 521, 523
geographic area and, 525–526
illicit drug use association, 508–509, 526–527
initiation of, 536–538
nurse intake questions, 721–723, 754
pregnant women and, 523, 524
race/ethnicity, 523–524
risk perception of use, by youth, 540, 541
tobacco addiction, 114–115
trends in, 563, 564, 565, 567
 use estimates, 520–521, 569, 570, 571, 572, 573, 574, 613–614
Tofranil (imipramine), 676
Tolerance (drug)
alcohol, 149
characterization, 106
cross-, 106, 149, 680n
defined, 27
physiological dependence and, 28
stress, 173
Tolerance (virtue), 461
Topiramate (Topamax), 673, 691, 692
Touch, 290
Toxicity, defined, 683n
Trait, 169
Trandate, 699
Tranquilizers
frequency of use, 497
incidence of abuse, 550
initiation of, 529, 530, 531, 534–535
treatment for, 556
Transference
borderline personality and, 173
counselors and, 243
defined, 82
therapeutic alliance and, 66
See also Countertransference
Tranxene (clorazepate), 680, 682
Tranylcypromine (Parnate), 676
Trauma, early childhood, 184–185
Trazodone (Desyrel), 676
Treating Alcohol Dependence (Monti et al.), 205
Treatment
adult inpatient program schedule, 630–631
adult outpatient program schedule, 634–636
of antisocial personality disorder, 170
of borderline personality, 172–173
for cessation of tobacco use, 693–699, 703–706
data sources, 608–610
day treatment program schedule, 645–648
 defined, 489
of depression, 157–163
efficacy of, 2–3
frequency of, 489
gambling inpatient program schedule, 640–641
gambling outpatient program schedule, 642–644
heroin, 657–659
inpatient, 29, 30–31, 31–32, 236
level of care needed, 28–29
location for, 555
needs, 556–561
NSDUH report, 554–561
outpatient, 29–30, 31, 236
past estimates, 554–556
of psychosis, 180–181
See also Adolescent treatment; Alcohol treatment; Tobacco cessation
treatment; Individual treatment
Treatment Episode Data Set (TEDS), 609–610
Treatment facility locator, 25
Treatment Outcome Prospective Study (TOPS), 117
Treatment plans
biopsychosocial sample, 57–59
building, 52
continuing care discussion, 61–62
defined, 51
developing, 56, 156
diagnostic summary, 52
documentation, 59–60
evaluation of, 56
formal review, 61–62
goals, 53–54, 57–59
interventions, 57–59
objectives, 54–56, 57–59
problem list, 52–53
progress notes, 59, 60–61
review of, 59
Treatments of Psychiatric Disorders, 187
Triazolam (Halcion), 689
Tricyclics, 158, 676, 677, 678
Trigger groups, 91–92
Triggers, 69
anger and, 419–420
in behavior chain, 299–300
body movements, 422–423
changing trigger thoughts, 420
coping with, 318, 477
facial expressions, 422
gestures, 422
nonverbal sounds, 421
smoking, 780–781
stopping trigger thoughts, 425–426
verbal behaviors, 421
voice quality, 422
Trileptal (oxcarbazepine), 673
Trust
accepting higher power and, 131
codependency and lack of, 380
exercises, 268–274
family members and lack of, 216
gamblers and, 189–190
as recovery tool, 120
therapeutic alliance and, 5, 19, 64
Trustworthiness, 815
Truth. See Honesty
Truthought Corrective Thinking Process, 170
Tuberculosis, nurse intake questions, 725–726, 758
“Twelve and Twelve,” 91
Twelve Step programs, 83, 152
client internal turbulence and, 129
overview, 128–129
Step Eight, 136
Step Eleven, 137
Step Five, 134
Step Five exercises, 353–354
Step Four, 133–134
Step Four exercises, 344–352
Step Nine, 136
Step One, 129–130
 Step One exercises, 322–329
Step Seven, 135–136
Step Six, 135
Step Ten, 137
Step Three, 132–133
Step Three exercises, 337–343
Step Twelve, 137–138
Step Two, 130–131
Step Two exercises, 330–336
See also Alcoholics Anonymous (AA); Gamblers Anonymous (GA);
Group therapy; Narcotics Anonymous (NA)
Twelve Steps and Twelve Traditions, 140
25i, 114
Twenty-Four Hours a Day (Walker), 319

Underage alcohol use, 516–519

Unit level system, for adolescents, 355–361
Unit point system, 204–205, 357–361, 480–483
point card, 482–483
Unit rules, 186
Unmanageability
exercises, 326–329
gambler exercises, 443–445
Uppers, Downers, All Arounders (Inaba & Cohen), 104
Uric acid, 23

Validation, 288
Valium (diazepam), 680, 682, 688
Valproate sodium (Depakene; Depacon), 673
Valproic acid (Depakene), 158, 673, 675
Varenicline tartrate (Chantix), 693, 694, 696, 697
Venlafaxine (Effexor), 676, 677
Verbal trigger behaviors, 421
Vicodin, 687
Victim role, 663–664
Violence, aversive chains and, 421
Violent clients, 165
Virtues, 460
little, 461
Vistaril (hydroxyzine), 680, 681
Visual assessment, 728, 761
Vivactil (protriptyline), 676
Vivitrol (naltrexone), 13, 126, 658, 691–692, 693, 695
Voice quality triggers, 422

Wants
behavioral contracts and, 368
family members and inability to know, 216
inability to know own, 379–380
Warning signs of relapse, 306–317, 465–479
Weissman, M. M., 162
Wellbutrin (bupropion), 676, 677, 684, 685, 693, 694, 696, 697
Wernicke-Korsakoff syndrome, 107
Wernicke’s encephalopathy, 20
When Anger Hurts (McKay, Rogers & McKay), 415
Willingness, 339
exercises, 339–341, 452
steps and, 130–131, 132–133, 189, 190
Wilson, Bill, 150–151
Wilson scores, 739–740, 772–773
Withdrawal
alcohol, 107–108, 250–252, 690–691
depressants, 116
education client about, 33
effects of, 149–150
manifestations of, 27
measuring, 25
nicotine, 694n
opioid, 33, 109, 692–693, 709–710
physiological dependence and, 28
polysubstances, 116
stimulants, 694
symptoms, 106
See also Detoxification
Women’s group, 100
Work environment, 230–231
Worship, defined, 335–336
Worthlessness, feelings of, 381–382, 431–433
 family members and, 216
narcissistic personality and, 431–433

Xanax (alprazolam), 680, 682

Your Perfect Right: A Guide to Assertive Living (Alberti & Emmons), 166,
302
Youth prevention-related measures, 488
availability, perceptions of, 542–543
delinquent behavior, 544–545
exposure to messages and programs, 545–546
fighting, 544–545
parental disapproval, 544
parental involvement, 546–547
peer substance abuse, 544
religious beliefs, 545
risk, perceptions of, 539–542
Youth Risk Behavior Survey (YRBS), 562, 607–608, 614
comparison with NSDUH and MTF trends for youths, 563–567, 571

Zaleplon (Sonata), 689, 690

Ziprasidone (Geodon), 668, 670, 673
Zoloft (sertraline), 676
Zolpidem (Ambien), 689, 690
Zyban (bupropion), 693, 694
Zyprexa (olanzapine), 668, 669, 673, 680, 681
About the Author

Robert R. Perkinson
is the clinical director of Keystone Treatment Center in Canton, South
Dakota. He is a licensed psychologist; licensed marriage and family
therapist; internationally certified alcohol and drug counselor; South Dakota-
Licensed Addiction counselor; and a nationally certified gambling counselor
and supervisor. His specialty areas focus on treating alcoholics, addicts, and
pathological gamblers. He is the author of Chemical Dependency
Counseling: A Practical Guide (4th ed.) (2012), which is the leading
treatment manual in the world for chemical dependency counselors. With Dr.
Arthur E. Jongsma Jr. and Timothy Bruce (2009; 2014) he is the coauthor of
The Addiction Treatment Planner, which is the best-selling treatment
planner and computer software program for mental health and addiction
professionals. He has also written The Alcoholism and Drug Abuse Client
Workbook (2012) and the Gambling Addiction Client Workbook (2012).
These workbooks have all of the exercises patients need to enter a stable
recovery. His book entitled Treating Alcoholism: How to Help Your Clients
Enter Recovery (2004) trains professionals how to treat patients with
alcohol problems. He is the author of the book God Talks to You (2000) and
the meditation tape A Communication From God (2008) by cdbaby, which
helps addicts make their first conscious contact with a higher power of their
own understanding. He is a composer and has completed his second CD,
Peace Will Come, music that helps addicts learn the essentials of a spiritual
journey. With Dr. Jean LaCour (2004), he wrote the Faith-Based Addiction
Curriculum to teach professionals of faith how to treat addiction. Dr.
Perkinson is an international motivational speaker and regular contributor to
numerous professional journals. He is the webmaster of several Web pages,
including [Link], [Link], and
[Link], where he gets more than 2.6 million visitors a year
and answers questions on addiction for free. His biographies can be found in
Who’s Who in America, Who’s Who in Medicine and Healthcare, Who’s
Who in Science and Engineering, and Who’s Who in the World.