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By Britt Parramore LPC, CAADC

 Abstract

Substance abuse is a major issue involved with crisis in many individuals. There are many different treatment approaches today. Many of these approaches are ineffective and some are even harmful. Perhaps lacking in the field of substance abuse prevention and treatment, is a proper understanding of Christ Centered approaches. This paper will examine how substance abuse affects crisis and the also the different therapies for the treatment of substance abuse.

 Introduction

 Issues surrounding substance abuse are associated with crisis often (Jackson-Cherry & Erford, 2014). Crisis counselors should be informed of these issues in order to better serve clients. Of paramount importance is understanding substance abuse treatment methods. There are several in use today, including; 12-step programs, psychotherapeutic approaches, and pharmacotherapies. Not all substance abusers are the same and not all treatments will work for all people. Actually, the prevalence of relapse is quite high for most therapies. Considering the idiosyncratic nature of treatments to the individual, it is important for a counselor to be well informed in order to make the best recommendation for clients. This is especially key when crisis is involved. Some therapies are shorter in nature than others. Some have also proven to be much less effective than others. A major result of crisis in adolescents today is suicide. Considering the prevalence of substance abuse amongst adolescents who commit suicide, it is important for the adolescent crisis counselor to be well informed.

One of the more popular treatments for substance related disorders in America is the 12-step approach. Considering how vital it is for counselors to learn from the experiences of one another, contained within this paper is a personal account of this authors experience with 12-step programs. Also, some of the topics discussed will be compared to a Christ-Centered approach.

Pharmacotherapies to Treat Substance Use Disorders

In the past 20 years, different pharmacological methods have been used to treat individuals diagnosed with alcohol related substance use disorders. For alcohol related disorders, one such drug used is Naltrexone (Weinried & Obrien, 1997). Considering the severity of alcoholism in the United States and the crises with stem from alcohol use, Naltrexone can be a good method of treating alcoholism during acute crisis situations. Weinried & Obrien (1997) suggest the reason for the use of medications to treat alcoholism is the lack of real progress made through psychosocial methods. Groups such as Alcoholics Anonymous don’t seem to offer much better success considering that up to 88% drop out in the first year (Hester & Miller, 2003).     Based on this information, researchers were prompted to study the effects and benefits of using pharmacotherapy to treat alcoholism. In the controlled study some subjects were given placebo and some the drug Naltexone. The study showed that the drug was effective; Abstinence rates were 54% for naltrexone vs. 31% for placebo (1997). Placebo patients were nearly twice as likely as naltrexone treated patients to drink during the twelve weeks of the trial. A comparison of subjects who did not have an episode of heavy drinking favored naltrexone subjects (75%) over placebo subjects (48%) (1997).

Considering these statistics, the use of drugs to treat addiction could be an effective method if psychosocial approaches do not work. This may especially be true if immediate abstinence is needed due to a crisis. While Naltrexone is not widely used in the United States today, other pharmacotherapies are.

In the year 2001 doctors started treating opiate addicted individuals with a trial drug called buprenorphine also known by its brand name Suboxone (Sindela & Fiellin 2001). This drug has since been approved and is in wide use today for the treatment of opiate addiction. Suboxone was created to help a range of opiate addicted patients and to give an alternative to Methadone treatment for opiate addiction.

Methadone has been used for many years to help those struggling with heroine addiction. The use of heroine and other opiate-based drugs has become a real problem for public health.  The social health of communities is also being harmed by the great cost associated with the treatment of these addicted individuals and the crime that is inevitable for communities whose members have a high rate of heroine and other drug addiction. Unfortunately, Methadone treatment has proven ineffective (Sindela & Fiellin 2001). The low effectiveness stems from the high drop out rate of those addicted people participating in Methadone treatment programs leading to their subsequent relapse. While there have been recent and important innovations in the area of psychotherapy combined with pharmacotherapies, effectiveness remains low and relapse high. Heroine addiction in itself has proven to be the cause of crisis.

The use of Methadone to treat opiate addicted individuals seems to be a bad idea. While Methadone does satisfy the cravings for opiates, what many in the treatment community fail to realize, is that methadone is more addictive that any other opiate including heroin. Many people who begin methadone treatment stay hopelessly addicted to it for the entirety of their lives. Not only this, but there are serious side effects from the drug especially for pregnant mothers (Sindela & Fiellin 2001). There have been many babies born to methadone-addicted mothers who must be detoxed after birth. The use of this drug to treat opiate addiction is simply replacing one addictive drug for another.

While these drugs are effective for addicted individuals they are certainly not ideal. Using one drug to treat addiction to another drug is really just swapping one addiction for another. The true cure for the addicted person is perhaps spiritual. One approach to treating addiction based on a spiritual foundation is Alcoholics Anonymous.

A Counselors Views On 12-Step Programs

So many have found their way into Alcoholics Anonymous (AA) meetings due to crisis. When alcohol addiction becomes a crisis, AA is often the treatment method of choice. Working as a substance abuse counselor over the past five years in various settings has afforded me the opportunity to learn a great deal about AA, to attend AA meetings, and to learn about 12-step programs in general. During my four years in Lynchburg as both an undergraduate, and graduate residential student at Liberty, I worked as a substance abuse counselor in two very different settings. Thomas Road Baptist Church operates a Christ Centered in-patient substance abuse ministry called The Elim Home. I served as a teacher and counselor at The Elim Home. I also worked as a substance abuse counselor at Blackberry Ridge (BBR). BBR is a clinical inpatient substance abuse facility, which utilizes the AA 12-step approach. BBR also facilitates pharmacological detoxification. The difference in the style of counseling, the approach to addiction classification, and the success of clients at these two facilities is striking. They are nothing alike. I think the same could be said for the many of the different models of addiction, they are vastly different in both their assumptions, and their treatment methodology (Hester & Miller, 2003).

To be honest, I think many, if not most AA members would be surprised to read Chapter One of Handbook of Alcoholism Treatment Approaches (Hester & Miller, 2003). Specifically, I think they would be surprised to read that Hester & Miller (2003) categorize AA as being based on the Spiritual Model. While AA may well be based on the Spiritual Model, I believe its members would overwhelmingly say that AA is based on the Disease Model. There is no doubt that AA is partly predicated on spiritual things, however Disease Model type talk is used at AA meetings much more often than Spiritual Model type talk. Actually, the only time I’ve really heard spirituality mentioned is in the beginning of the meetings when the 12-steps and 12-tradtions are being read. Once the conversation turns to personal experience, I have often heard members talk about their disease when referencing their addiction. To me this seems to be a result of the members coming to grips with their perception that they all have a chronic and incurable disease. This seems to bring them together. It is impressive to see how supportive they are of one another seemingly based on their shared plight. Fortunately, I know this is not indicative of all AA groups, but from my experience it is indicative of many of them.          

 There are many meeting types held by AA groups, which are described on most State AA Websites (Meeting Types & Descriptions, n.d.). I have only attended Big Book Step Study meetings and Open Discussion Meetings. At the beginning of each meeting, no matter what type, the 12 steps and 12 traditions of AA are read, which can be found in the Alcoholics Anonymous Big Book (2001). It is clear that these 12-Steps and 12-Traditions are the foundation of AA. The 12-Steps are also the road map to success for the AA members, who work the steps one at a time with a sponsor. The first three steps in the AA Big Book (2001) are: “ (1) We admitted we were powerless over alcohol – that our lives had become unmanageable. (2) Came to believe that a Power greater than ourselves could restore us to sanity. (3) Made a decision to turn our will and our lives over to the care of God as we understood Him.” (pg. 59, 60). Reading these steps would seem to indicate that the AA method holds to the Spiritual Model. I think most of the AA members I’ve talked to would admit that sobriety is dependent on help from a higher power. I also think most of them would say that addiction is a disease. To me, this has always seemed like a contradiction. Having said this though, it definitely works for many people. Somehow, AA members have made sense of incorporating both Disease Model aspects and Spiritual Model aspects into their system of recovery.

While AA does seem to work for some people, overall the statistics are not very encouraging. A study done in the past seven years showed clients receiving treatments based on the disease model of addiction have a two-year success rate of between 0%-15% (Miller, 2007). As I mentioned earlier, along with working in a clinical, 12-step environment, I have also worked in a Christ Centered environment. Success rates are hard to find for Christ Centered substance abuse treatments, but from my personal experience, they are much more effective. I personally believe hope is a tremendous motivator. I also believe an addicted person taking responsibility for their mistakes is also integral to recovery. The two things I have seen most lacking in the AA meetings I’ve attended are; members taking personal responsibility for their actions, and members speaking about hope. I feel very little hope at AA meetings. I believe having a disease to blame makes relapse more likely. While I do believe there is a biological component to addiction, I do not believe it is only biological. The foundations of AA seem strong, however, I believe the AA members have gotten away from their foundation. The 12-steps seem to indicate that addiction can be overcome with God’s help. Nowhere in the 12-steps is the word disease mentioned, although it is mentioned often by the member in AA meetings. There is little hope in a disease. There is infinite hope in God. I believe Bill W. meant for AA to be a program of hope, which is why I believe the 12-steps are so God centered. Often when listening to the AA members, I hear how horrible life is now. Seldom do I hear how wonderful life can be.

Relapse Prevention to Prevent Further Crises

The reality of relapse in addicted individuals is a real concern and methods of relapse prevention are all too often ineffective. Considering relapse is a common occurrence by individuals facing crisis, understanding relapse prevention is critical. Brandon, et al. (2007), suggest relapse is a characteristic of all behavioral disorders especially in those who struggle with addiction. They define relapse as “any return of the problem behavior or symptoms after the period of initial remission” (2007, pg. 259). The problem with this definition is it doesn’t distinguish between a “slip” and a full blown return to active substance abuse. Realizing this problem the, authors go on to categorize different theories of relapse based on their severity.  Alcoholics are listed as most prone to relapse with a 92% relapse rate (2007). The lowest relapse rate at 75% occurs among IV drug users. Brandon, et al. (2007) go on to theorize reasons for relapse such as coping skills and mental disorders. Prevention methods like self-help, inpatient, and outpatient treatment are among those the authors suggest. Since coping skills are often lacking in addicted individuals, crisis can be especially problematic.

While the prevalence of relapse is clearly widely understood, what is not clear is how relapse prevention is understood. Of the many preventative measures in use today, few are effective.  This does not mean however that relapse prevention is hopeless because it is not.  What many in the treatment community fail to take into consideration is a faith-based approach; in particular a Christ centered approach to recovery. Some studies suggest that Christ centered programs have a lower recidivism rate when compared to any secular approach.

Distinguishing Problematic Use Over Casual Non-Problematic Use

Considering how critical it may be to determine if an individual in crisis has a Substance Use Disorder, it is important to be able to distinguish between a casual user and an addicted person. Distinguishing between an individual who has a Substance Use Disorder from an individual who displays non-problematic, casual use, can be confusing. This confusion can be exacerbated in the counseling environment because honesty is not always a hallmark of someone with a Substance Use Disorder. The key to making a proper diagnosis is getting as much information as possible. This means trust must be a priority in the counseling relationship. Key information that may help a therapist includes: The client’s use patterns, their family history of substance use and/or abuse (if any), vocational issues surrounding the client’s substance use, any goals that may have been delayed as the result of substance use, physical and/or medical problems the client may be suffering with, any withdrawal symptoms the client may have experienced currently or in the past, an arrest history (if any), and any other question that may help the therapist gauge if the client’s substance use is having a significant impact on the client’s life. Also, there are a number of good assessment which can be helpful when trying to determine if there is a diagnosable problem, how severe that problem may be, and if treatment is needed. One such assessment is the Michigan Alcoholism Screening Test (MAST). This is a paper and pencil-screening instrument that can easily be administered by a trained therapist (Doweiko, 2015). The MAST covers many of the question areas mentioned above. Using the MAST can be a quick way to determine if an Alcohol Use Disorder is present in a client. The MAST can also give the trained therapist a good idea of how severe an Alcohol Use Disorder may be in a client.

Perhaps the best way to determine if someone is using socially or if they do indeed fall into one the diagnosable condition categories, is the use the diagnostic criteria listed in the DSM-5. The DSM-5 differs from the DSM-IV in its diagnostic criteria. The condition formally known as Poly-Substance Use Disorder no longer exists. Using DSM 5 criteria compels the therapist to make a separate diagnosis for each substance a client may be addicted to (DSM-5, 2013). While there are many similarities in the diagnostic criteria for each of the Substance Related Disorders, there are also many differences. For the purpose of this Discussion Board post, the criteria for a diagnosis of Alcohol Use Disorder will be used. An Alcohol Use Disorder is a “problematic pattern of alcohol use leading to clinically significant impairment or distress.” (DSM-5, 2013, p. 490). In order to determine if a client’s alcohol use is indeed problematic, the DSM-5 list specific criteria. These include: determining if a client is drinking larger amounts of alcohol than they typically intent to, if the client has had little success in trying to quit drinking, if the client spends a great deal of time trying to obtain alcohol, if tolerance is present, if physical harm has occurred as a result of extended alcohol use, if the client has experienced withdrawal, along with various other criteria (DSM-5, 2013). It is actually very helpful to rephrase the diagnostic criteria in question form when interviewing a client to determine if a Substance Use Disorder is present.

Once a therapist has determined a Substance Related Disorder is present in a client, the next issue to be addressed is treatment. Many therapists agree that if a person is diagnosed with a Substance Related Disorder, some type of treatment is needed. Popular treatments used in America today include: individual psychotherapy on a weekly basis, individual psychotherapy coupled with the client participating in a 12-step program, a 12-step program alone, intensive outpatient therapy, or in-patient treatment. The therapist should make treatment recommendations based on the severity of their client’s specific Substance Related Disorder.

Suicide and Substance Abuse

Perhaps one of the most important reasons a crisis counselor should be familiar with issues involving substance abuse is the relationship substance abuse has to suicide in adolescents. Suicide is the third leading cause of death in adolescence, and attempts at suicide occur in 3% of adolescences (Spirito & Smythers 2006). The major reasons the Spirito & Smythers (2006) give are; depression, disruptive behavior disorders, and substance abuse. Groups at high risk are; gay, lesbian, and bisexual youths, incarcerated adolescence and runaway teens. All of these groups also have a high rate of substance abuse (2006). Although depression is commonly associated with suicidal behavior, not all individual adolescents who attempt suicide are depressed. There are other emotional disorders such as anxiety and anger which are equally important to understand. Impulsive and aggressive behavioral disorders have also been found to be contributing factors to adolescent suicide especially in individuals with affective disorders (2006). Of all the risk factors, substance abuse seems to be the most preventable. “A relatively strong relationship has been found between substance abuse disorders and suicide completion in adolescence” (Spirito & Smythers, 2006, pg. 262).  In a recent study 35% of completed suicides among adolescents involved some type of substance abuse (2006).

Adolescent suicide has become far too common in this country. As we see morality and family values slip away it is no surprise that suicide has increased. Our government’s removal of God from the classroom has also been a contributing factor. In many cases children are raised with no moral instruction at home and certainly not at school. Until parents start to take an active role in their children’s lives by taking them to church and teaching them biblical truths in the home then this trend will sadly continue to increase.

Alcohol Related Deaths in College Students

Alcohol use amongst college students has long been a problem. Unfortunately, this can lead to crisis. Hingson et al., (2005) gives statistics on alcohol related injuries and deaths from 1998 to 2001 and the implications and magnitude of the problem. They state that there was an increase from 1600 to 1700 alcohol related deaths in the U.S. from 1998 to 2001. The proportion of 18-24 year-old college students who reported driving under the influence also increased from 26.5% in 1998 to 31.4% in 2001, an increase of 500,000 students (2005). The majority of these deaths stemmed form motor vehicle accidents.  The magnitude of these numbers suggests a dire need for efforts to reduce them. The colleges and universities, the authors write, need to “expand and strengthen interventions demonstrated to reduce excessive drinking among college students and their same age non-college counterparts” (2005, pg. 262).

Hingson et al., (2005) brings into the light a subject matter that is not talked about or addressed nearly enough in this country. These statistics shed light on the ever growing problem faced on almost every university campus in the U.S.  They should be given to all parents of college-aged kids. In fact it should be a requirement for all incoming college freshman to memorize these statistics. The authors were correct in suggesting that we need to expand and strengthened efforts to stop this problem. It’s not enough to just sweep it under the rug. Until education of this problem becomes commonplace on every university campuses then the problem will persist and will probably get worse.

Conclusion

With so many issues involving substance abuse and crisis, it is of paramount importance for any counselor to be at least familiar with substance abuse treatments. It is also important for counselors to understand relapse prevalence and prevention. Until substance abuse in an individual facing crisis is addressed, the crisis may continue. Unfortunately, many times, substance abuse is the actual cause of a crisis. This is especially true in adolescent suicide and in alcohol related deaths amongst college-aged students. While substance abuse is certainly the most preventable causes of crisis, in is not always addressed in time.

References

Alcoholics Anonymous: the story of how many thousands of men and women have recovered from alcoholism(4th ed.,) (2001). New York City: Alcoholics Anonymous World Services.

Brandon, T., Vidrine, J., & Litvin, E. (2007). Relapse and relapse prevention.  Annual Review of Clinical Psychology, Vol. 3: 257-284. doi:10.1146/annurev.clinpsy.3.022806.091455

Diagnostic and statistical manual of mental disorders: DSM-5 (2013). (5th ed.). Washington, D.C.: American Psychiatric Association.

Doweiko, H. E. (2015). Concepts of chemical dependency (9th ed., p. 1). Stamford, CT: Cengage Learning.

Hester, R. K., & Miller, W. R. (Eds.). (2003). Handbook of alcoholism treatment approaches: effective alternatives(3rd ed., p. 1). Boston: Allyn and Bacon.

Hingson, R., Heeren, T., Winter, M., & Wechsler, H. (2005).  Magnitude of alcohol-related mortality and morbidity among U.S. college students ages 18-24: changes from 1998 to 2001. Annual Review of Public Health,Vol. 26: 259-279 doi:10.1146/annurev.publhealth.26.021304.144652

Jackson-Cherry, L. R., & Erford, B. T. (2014). Crisis assessment, intervention, and prevention(second ed., p. 1). Boston: Pearson.

Meeting Types and Description (n.d.). Retrieved September 2nd, 2014 from http://rhodeisland-aa.org/meetings/meeting-types

 

Miller, John Clark. (2008). 12-step treatment for alcohol and substance abuse revisited: best available evidence suggests lack of effectiveness or harm. International Journal of Mental Health, Vol. 6:568-576 doi 10.1007/s11469-008-9146-4

Sindelar, J., & Fiellin, D. (2001). Innovations in treatment for drug abuse: solutions to a public health problem.  Annual Review of Public Health, Vol. 22: 249-272, doi: 10.1146/annurev.publhealth.22.1.249

Spirito, A., & Smythers, C. (2006). Attempted and completed suicide in adolescence.  Annual Review of Clinical Psychology, Vol. 2: 237-266.  doi: 10.1146/annurev.clinpsy.2.022305.095323

Weinrieb, R., O’Brien, C. (1997).  Naltrexone in the treatment of alcoholism.  Annual Review of MedicineVol. 48: 477-487, doi: 10.1146/annurev.med.48.1.477