Conceptualizing People Who Use Substances

Writing Client Conceptualizations

Counselors need to know how to write client conceptualizations, which are written descriptions of the clients presenting concern, culture, diagnosis, and treatment plan. Make sure you check out the client conceptualization template in the Writing Client Conceptualizations unit in the Conceptualizing class.

Conceptualizing Video

Playback problems? This video is available on YouTube at youtu.be/V49MUcECM9g

Stages of Change or Integrative Model of Change

Counselors who understand the extent to which their clients are ready to change can custom tailor the counseling process. Some clients are enter counseling with little or no awareness that a problem exists. A counselor who tries to force such a client to change risks relationship ruptures and premature termination. Prochaska and DiClemente (1983) developed a stage model to help counselors determine a client's readiness for change. Multiple research studies have evaluated the benefits to clients when counselors conceptualize using the stages that they identified, generally with positive results. Their model is called either the Stages of Change model or the Integrative Model of Change.

Stages of Change

1. Precontemplation
   • Client has no intention to change in the foreseeable future.
   • Client lacks awareness of the problem.
2. Contemplation
   • Client is aware the problem exists, and they want to overcome the problem.
   • Client is not ready to take action, potentially due to the amount of energy or the magnitude of the problem.
3. Preparation
   • Client begins taking baby steps, however, they are not yet committed to fully taking action
4. Action
   • Client modifies their behavior, experiences, and/or environment in an effort to change.
   • The action stage requires substantial time and energy.
   • Clients who have changed their behavior for more than one day and less than six months are in the action stage.
5. Maintenance
   • After approximately six months of behavior change, clients enter the maintenance stage.
   • Energy is put toward maintaining rather than creating change.

(Norcross, Krebs, & Prochaska, 2011)

Stages of Change Exploration Questions

1. Think of a change you have made or would like to make in your own life.
   • Where do you fall in the stages of change model with regard to your change?
   • If you are not yet in the maintenance stage, what factors might motivate you to progress through the stages of change?
   • What factors have you experienced that make it difficult to advance through the stages?
2. How might the process of counseling a client with a substance use disorder vary based on the client's stage of change?
3. What techniques might you use to encourage a client with a substance use disorder to progress through the stages of change?

Counseling Theories

Counseling theories (Theories Class) are useful tools that provide counselors with a framework for understanding the causes of clients' symptoms as well as templates for how to alleviate clients' symptoms. There are a vast number of counseling theories, and counselors are encouraged to have a strong working knowledge of at least a few counseling theories, as no theory is applicable to every counseling client.

Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy enjoys extensive quantitative research support, and the theory has been shown to help clients reduce their substance use. Read Windsor, Jemal, and Alessi (2015) and Wu, Schoenfelder, and Hsiao (2016). The authors of the first citation explore differences in substance use rates for ether White or Black/Hispanic clients who are treated with CBT. The authors of the second citation propose that counselors start using CBT and Motivational Enhancement Therapy with adolescent clients who have been diagnosed with substance use disorders.

Existential

Existential counseling theories emphasize existential anxiety and angst stemming from meaninglessness, isolation, responsibility (e.g., free will), and ultimately death. Existential theories do not have as wide a body of research support as theories like CBT. This is understandable since existential theories are abstract, subjective, and difficult to research.

Read Roos, Kirouac, Pearson, Fink, and Witkiewitz (2015) and Karavalaki and Shumaker (2016).

Neuroscience

Chemical substances directly interact with neurotransmitter receptor sites. Thus, the information in the Physiology Unit forms a framework for conceptualizing the ways in which substances interact with peoples' neuro-chemistry. Additional information on physiological explanations for substance use can be found in professional journal articles. Please read Heatherton & Wagner, 2011.

Genetics

Genes are foundational to life, and our genetics influence nearly every aspect of our lives. Genetic influence is interrelated with environmental influence. Epigenetics is the study of how environmental and other events alter the way that one or more genes is expressed and transmitted. This means that the impact that our genes have on our lives can change. In their model exploring the causes of substance use and binge eating disorder, Munn-Chernoff & Baker hypothesize that "Early life events, such as childhood abuse, affect gene expression, which in turn influences both [eating disorders] and [substance use disorders]" (2016, p. 96). Munn-Chernoff and Baker propose that if the genetic causes of substance use and binge eating are similar, than it makes sense for them to categorized under one diagnostic heading. It is important to note that genes themselves do not change - for example, using substances doesn't change one's genes - changes happen in the impact that a gene has or genes have on a person.

The word sex (i.e., having male or female reproductive organs) refers to biological/anatomical traits that are genetically coded. Gender refers to social roles and the way that one defines oneself on (or off) the spectrum of masculine to genderqueer or non-conforming to feminine. There is evidence that sex and gender differences both influence addiction and substance use, as can be seen in the following video.

Playback problems? This video is available on YouTube at youtu.be/bvvunHbTWvc

Environment

Peoples' environments include their social support structures, as well as a wide range of other variables. Systemic theorists, such as Virginia Satir, Salvador Minuchin, Michael White and David Epstein, Sue Johnson, John and Julie Gottman, and many others have theorised extensively about the role that systemic variables such as self worth, social structure, narratives, attachment, and communication have on individuals, couples, families, and groups.

Environment Videos

You can calculate your ACEs score at acestoohigh.com

Additional information on the ACEs study is available at cdc.gov/violencepreventoin/acestudy

Playback problems? This video is available on YouTube at youtu.be/PY9DcIMGxMs

Nora Volkow is the director of the National Institute on Drug Abuse, which is one of the National Institutes of Health.

Playback problems? This video is available on YouTube at youtu.be/Mnd2-al4LCU

Environment Exploration Questions

1. In what ways does one's environment contribute to or prevent substance use?
2. As a counselor, what can you do to alter a client's environment to prevent or treat substance use?

Disease Models of Addiction

The disease model of addiction integrates physiology, genetics, and mental health theories, such as behaviorism, in an effort to describe the causes of substance abuse. As far as I can tell, this model was first proposed in 1849 by Huss. Since Huss' initial articulation, many authors and researchers have developed variants of the disease model. Thus, there are multiple disease models, many of which have overlapping core features. In 1997, Leshner published an updated model, which was foundational to recent updates to the model. The disease model has been the subject of extensive debate, and proponents of the disease model believe that:

...drug addiction is a chronic, relapsing disease that results from the prolonged effects of drugs on the brain. As with many other brain diseases, addiction has embedded behavioral and social-context aspects... Therefore, the most effective treatment approaches will include biological, behavioral, and social-context components.

(Leshner, 1997, p. 45)

Note that the disease model provides a theory for understanding the etiology (causes) of substance abuse, which is then used to determine which treatments are most likely to be effective. As the previous quote demonstrates, treatments are congruent with and directly related to theory.

Leshner (1997) conceptualized the model as filling...

...a wide gap between the scientific facts and public perceptions about drug abuse and addiction. For example, many, perhaps most, people see drug abuse and addiction as social problems, to be handled only with social solutions, particularly through the criminal justice system. On the other hand, science has taught that drug abuse and addiction are as much health problems as they are social problems. The consequence of this gap is a significant delay in gaining control over the drug abuse problem.

(Leshner, 1997, p. 46)

Alcoholics Anonymous conceptualizes problematic alcohol use as an illness. However, unlike other variants of the disease model that emphasize neuroplasticity, which is the idea that people who use substances are more likely to crave substances because their substance use results in alterations in their brain physiology and chemistry, AA emphasizes the idea that a belief in a higher spiritual power is the only way to treat substance use:

If, when you honestly want to, you find that you cannot quit entirely, or if when drinking, you have little control over the amount you take, you are probably alcoholic. If that be the case, you may be suffering from an illness which only a spiritual experience will conquer.

Alcoholics Anonymous World Services, Inc., 2001, p.44

Disease Model Stages

Volkow, Koob, and McLellan (2016) propose a disease model with three stages of addiction:

1. Binge and Intoxication
   • Drugs cause brain to release dopamine, which triggers classical conditioning.
   • With repeated substance use, dopamine is released when someone experiences an anticipatory cue related to substance (e.g., the sound of a lighter).
   • Eventually exposure to anticipatory cues (e.g., people, physical locations, etc.) triggers dopamine release, which results in a craving right after release, which may be resolved through binging.
   • As is true with any conditioning, the stronger the association, the more likely a person is to exert effort to obtain the substance or to endure negative consequences associated with obtaining or using the substance.
2. Withdrawal and Negative Affect
   • Every day rewards, like eating or having sex, lose motivational power, due to associating substance use with a powerful reward (dopamine).
   • Over time, the brain releases less dopamine, which results in neural reward systems being less sensitive to things that naturally feel good. This means that the longer one takes a drug, the less rewarding it is.
   • Repeat exposure to dopamine-enhancing drugs results in a person becoming more sensitive to stress and negative emotions, and negative emotions can become overwhelming when a person is not using their preferred drug.
   • This results in a person being pulled toward drugs by the drugs' natural reinforcement (dopamine release), as well as being pushed toward drugs by a desire to avoid negative emotions.
     • Hence the cycle between withdrawal and binging.
3. Preoccupation and Anticipation
   • Down-regulation of dopamine impacts prefrontal cortex, which is responsible for executive functions, like inhibition.
   • Changes in neuro-physiology due to substance use can render a person less likely to be able to say "no" to others.
   • Clients may genuinely want to stop using substances, while also behaving impulsively (and continuing to use substances), due to changes in the prefrontal cortex.

Graphic Summary of the Disease Model of Addiction

The following graphic was published by Volkow, Koob, and McLellan (2016).

Read through the following articles regarding the disease model of addiction before responding to the disease model reflection questions:

1. Leshner, A. I. (1997). Addiction is a brain disease, and it matters. Science, 278(5335), 45-47. doi: 10.1126/science.278.5335.45
2. Hall, W., Carter, A., & Forlini, C. (2015). The brain disease model of addiction: is it supported by the evidence and has it delivered on its promises?. The Lancet Psychiatry, 2(1), 105-110. doi: 10.1016/ S2215-0366(14)00126-6
3. Volkow, N. D., & Koob, G. (2015). Brain disease model of addiction: Why is it so controversial?. The Lancet Psychiatry, 2(8) 677-679.
4. Volkow, N. D., Koob, G. F., & McLellan, A. T. (2016). Neurobiologic Advances from the Brain Disease Model of Addiction. The New England Journal of Medicine, 374(4), 363-371. doi: 10.1056/NEJMra1511480

Disease Model Exploration Questions

1. What do the authors of the Disease Model propose as the cause of substance use?
2. What are some of the risks and benefits for counselors who are conceptualizing clients using the disease model?

Gateway Drugs

The gateway drug theory proposes that using alcohol, tobacco, or marijuana causes one to begin experimenting with "hard" drugs such as heroine, cocaine, amphetamines, and hallucinogens. There are a number of hypotheses regarding how the gateway drug theory might operate, including the hypothesis that using a gateway drug "primes" one's neurotransmitters for more addictive behavior. However, recent research has failed to show a relationship between alcohol use and later cocaine use in rats (Fredriksson, et al., 2016). If the gateway drug theory is correct, then one of the best means for treating substance use is to prevent adolescents from using alcohol, tobacco, and marijuana. If the gateway theory is not correct, then valuable treatment resources may have been misdirected toward scaring adolescents, with the hope of preventing their experimenting with gateway drugs. Read through the below articles before responding to the following reflection questions:

1. National Institute on Drug Abuse. (August, 2016). Is marijuana a gateway drug? Retrieved from: https://www.drugabuse.gov/publications/research-reports/marijuana/marijuana-gateway-drug
2. Nkansah-Amankra, S., & Minelli, M. (2016). "Gateway hypothesis" and early drug use: Additional findings from tracking a population-based sample of adolescents to adulthood. Preventive Medicine Reports, 4, 134-141. doi: 10.1016/j.pmedr.2016.05.003

Gateway Drugs Exploration Questions

1. What have you been told about gateway drugs?
2. How do the above articles support or refute what you have been told about gateway drugs?
3. Do you believe that mental health professionals are in a position to tell their clients that alcohol, tobacco, and marijuana are "gateway" drugs? Why or why not?

Integrative Conceptual Frameworks

As you engaged with the content on this page, hopefully you began developing a framework for the ways in which multiple conceptual frameworks can integrate with one another. Genetics, environment, and the disease model are not mutually exclusive. For example, a person can have a genetic predisposition to becoming addicted to cocaine, however, that person may use cocaine without developing an addiction, because they have protective environmental factors. The following video from the National Institute of Drug Abuse (NIDA) provides an integrative framework for conceptualizing substance use and addiction.

Playback problems? This video is available on YouTube at youtu.be/SufLpGPauII

Addiction as a Moral Failure

Note: This section is included for context, as it represents a commonly held social viewpoint. We do not encourage counselors to conceptualize substance use or addiction as a moral failure, as this theory is widely refuted by research, particularly research regarding the disease model of addiction.

Historically, substance use has been conceptualized as a moral failure. That is, people who use substances problematically are lacking the "will-power" to stop using substances. Based on this theory, people simply need to learn to make a different choice. One way to encourage people to make the correct choice is to criminalize substances.

Alcoholics Anonymous (AA) is an example of a treatment organization that, at least on paper, embraces moral failure (and, to some extent, genetics) as a cause for one's inability to sustain sobriety. Chapter 5 of the Big Book states that:

Rarely have we seen a person fail who has thoroughly followed our path. 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. 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. Their chances are less than average. There are those, too, who suffer from grave emotional and mental disorders, but many of them do recover if they have the capacity to be honest.

While the Big Book is foundational to AA, groups are numerous and diverse, so individual groups may conceptualize substance use differently.

In his original articulation of the disease model of addition, Leshner provided the following critique of moral conceptualizations of people who use substances:

...the more common view is that drug addicts are weak or bad people, unwilling to lead moral lives and to control their behavior and gratifications.

(Leshner, 1997, p. 45)

Moral Failure Exploration Questions

1. What are your beliefs about morality?
   • How can a person know what is or isn't moral?
   • How might your own beliefs about morality impact your work with clients?
2. How might people with different religious, spiritual, or atheist cultures view morality differently?
3. What role might counselors play in changing the way that broader/dominant culture conceptualizes people who use substances?
4. How might a proponent of the disease model of addiction respond to the statement in the Alcoholics Anonymous book that "Rarely have we seen a person fail who... followed our path. 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 incapable of being honest with themselves"?
   • As you will learn in the Treating Substance Use unit, most people with substance use disorders will not overcome their disorders, even after decades of use (Fleury, et al., 2016). How do you think a proponent of AA might respond to criticism that a majority of people with substance use disorders will not get better, regardless of what treatment they receive?

Conceptualizing Exploration Questions

1. How might you evaluate the trustworthiness of the conceptual models and theories on this page?
2. When might you use each of the models/theories with a client?
3. Which of the models/theories do you resonate with?
   1. Were there any theories or models that you disliked? What reactions did you have to them? What in your own life prompted your reactions?
4. How can the models/theories on this page be used to understand what is causing a client's substance use?
   1. How might you use multiple models/theories at the same time to conceptualize a client?
5. How can the models/theories on this page be used to make decision about what treatment(s) to use with a client and how to deliver the selected treatment or treatments?
6. How would you summarize the steps in the counseling process, from initial contact with a client through preparing a conceptualization and treatment plan?