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Clinical Evaluation Performance Domain Back to Course Index



Understanding the extent and nature of a mental health or substance use disorder and its effect on other areas of life is essential for careful diagnosis, appropriate case management, and successful treatment. This understanding begins during the screening and assessment process, which helps match the client with appropriate treatment services and continues through treatment and aftercare. To ensure that important information is obtained and evaluated, providers are well trained in addiction, mental health, resources, diagnosis, interviewing techniques, risk factors, and screening instruments.  Providers frequently use standardized screening and assessment instruments and interview protocols, some of which have been studied for their sensitivity, validity, and accuracy in identifying problems.



Approximately 15 million Americans meet diagnostic criteria for alcohol abuse or dependence every year.  During an assessment, some individuals give you all of the signs, such as arrests for DUI’s, positive drug screenings, family and employment problems.   Others deny problematic use with under-reporting and contradiction.

An evaluation is broken down into two steps: screening and an assessment. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines them as:

  • Screening is a process for evaluating the possible presence of a particular problem. The outcome is normally a simple yes or no.
  • Assessment is a process for defining the nature of that problem, determining a diagnosis, and developing specific treatment recommendations for addressing the problem or diagnosis.


The screening is a preliminary evaluation that helps the professional to determine if there is a situation present that warrants a more in-depth look. It is an important element of the process because it can allow for preemptive care and support if it does indeed highlight a risk factor, thus helping a person before their substance abuse progresses even further. This is the first step in helping them to see if drug or alcohol abuse may in fact be present.

Here are examples of some of the most commonly used screening tools. They may be either administered online or in person.

  • CAGE Questionnaire: This is a widely used method that has four questions which are asked in a brief, yet sensitive manner. One concern is its measure of usefulness in circumstances where a person may be trying to shield the extent of their alcohol abuse.
  • Alcohol Use Inventory (AUI): This is a self-administered screening tool used for people who are thought to have an issue with alcohol abuse. It is suitable only for people who are able and willing to be honest about their misuse of alcohol. This inventory is useful because it recognizes that each person has a set of unique perspectives associated with the risks, results, and lifestyle choices associated with their drinking.
  • Substance Abuse Subtle Screening Inventory (SASSI): The NIAAA defines SASSI as “a brief self-report, easily administered psychological screening measure that… helps identify individuals who have a high probability of having a substance dependence disorder with an overall empirically tested accuracy of 93 percent.” According to The SASSI Institute, it “identifies the high or low probability of substance use disorders and provides clinical insight into the level of defensiveness, willingness to acknowledge problems, and the desire for change.” This inventory is useful as it is easy to both administer and score. It also helps the assessor determine if the person’s use extends past social drinking or recreational drug use and what level of seriousness their use implies.
  • State Specific Inventories: Your state may have a screening tool that it utilizes in place or in addition to any of the former.
    Though some methods of screening can be done by the person themselves or by a family or friend, it is important to remember that in many cases this the first step towards recovery; for that reason it is most advantageous if the screening is either administered or reviewed by a professional who has the appropriate skills and knowledge to correctly ascertain results and provide the person with support and direction.


The assessment of an individual who may have substance abuse problems is more thorough. Its purpose is to find direct evidence that supports either the presence or absence of a condition that can be diagnosable, such as a drug or alcohol addiction. At this point, a diagnostic interview is performed whereupon the interviewer will go over the results of the screening and ask more questions to get a better picture of the individual’s drug or alcohol use and abuse. This may be done by one of two ways: either a structured interview or semi-structured interview.

Though the first, by way of set and structured questions, is easier for someone without an intense background in the field to administer, they do not result in as much detail, thus there is not as much information off of which to base a treatment plan. A semi-structured interview allows the professional, who is more skilled within this area, to supplement the structured questions by ones derived from their specific expertise within the field, allowing them to better cross-examine a person’s substance abuse.

information that is obtained by substance abuse and mental health professionals in an initial assessment is the cornerstone from which a comprehensive treatment plan can be developed. The effectiveness of the treatment plan relies heavily on the information gathered such as issues, disorders, obstacles, strengths, willingness, and abilities of the client.

There are several types of assessments including, assessments for status, treatment, as well as professional assessments on individuals who have very emotionally challenging careers such as police officers or professionals who have crossed the professional boundaries and have been sanctioned by professional licensing boards, law enforcement or their employer.  During this course, we will focus primarily on substance abuse and dual diagnosed mental health and addiction assessments.

“Have you ever tried to cut back on your substance use?”

“Do others annoy you by talking to you about your level of use?”

“Have you ever felt guilty about what happened after you used?”

“Have you ever needed to use in the morning or before others think it is socially acceptable?

Assessments are client-centered by their very nature and specifically relate to the distress and difficulties that each client must endure. The assessment usually consists of:

-A description of the current problem

-A complete medication history

-Mental status exam

-Alcohol and drug history

-Current living arrangements

-Support systems

-Psychiatric history


-Preliminary diagnosis

The questions refer to items such as:

History of Use

  • What substance have they used?
  • What was their age at first use?
  • Who introduced this substance to the client?
  • What was their initial level of use, escalation?
  • Did their use impact job and family, result in DUI’s or arrests, or cause health problems, what is the status on those issues now?
  • Is there a history of sexual or physical abuse, victim or perpetrator?

Family History

  • Family history of abuse, treatment, relatives used with

Current Use

  • Current use, how much and how often?
  • How does the client feel just before using?
  • Are there any signs of withdrawal when they don’t use?
  • Do they use after fights or disagreements?
  • Do they use with others or alone?
  • What do they like about using, not like about using?
  • Do they have blackouts?
  • Do they find it takes more to get “buzzed” or “high” than it used to?
  • Do they find themselves using much more than you intended to


  • Be sure to ask about depressive symptoms, and when they began versus when the alcohol abuse began… clinical depression is associated with quicker and more serious relapse after treatment, as well as loner relapse periods, and increased suicide risk after treatment.

Usually, a specific form is utilized. This form is not universal but usually created by the facility or professional. It is the counselors’ responsibility to gain sufficient information regarding the client and the client’s presenting concerns to establish an effective treatment strategy.

Ask about specific substances individually.  When a professional asked the client to describe their use the client will sometimes omit substances that they do not feel are issues such as marijuana.  

Many times objective diagnostic measurements are administered as a means of gaining more information about the clinical needs of the client so as to provide strong recommendations to the referral sources. Assessments are best-done face to face and in person. This enables body language, tone and affect to be considered.  We will explore popular assessments and tools later in the course.

As with the screening, there are many tests that can be utilized in the assessment process.  Here are two widely used tools within the assessment process.

  • Diagnostic Interview Schedule-IV (DIS-IV): This is a fully structured questionnaire that determines the presence of a diagnosis as listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Some feel that as a tool this is limited as it only considers the qualifications as set forth in the DSM-V and may not take into account any new research or theories within the realm of addictions that can lend a greater understanding to a person’s diagnosis or the circumstance that brought them there.
  • Addiction Severity Index (ASI): This is a semi-structured interview which assesses seven areas, cited by NIAAA as “medical status, employment and support, drug use, alcohol use, legal status, family/social status, and psychiatric status.” This allows the administrator to address questions not only to a person’s use over the past thirty days, but also the implications of the use over the course of their lifetime. It allows an assessor to see conditions that are both persistent and reoccurring which need to be addressed.


The Counselor and the Process of Evaluation 

Performing an evaluation involves observation, conversation, and exploration. As a professional conducting the assessment, it is important to immediately start to perceive signals and make first impressions. When listening to the client avoid stereotypes and consider the context.

The assessment should be geared to the age of the client. There would be different questions and tools used for children, adults or seniors.

A brief introduction with an explanation of what will be happening during the process can improve cooperation and reduce anxiety. The professional can talk about how the assessment will be conducted, through questions, inventories, verbally, written or both.

After the assessment is complete the professional reviews all of the data that they have obtained from the assessment process, including any tests or inventories, if administered, to make a preliminary psychological diagnosis. Frequently, the clinician will refer to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) for clarification of mental health disorder symptoms and criteria.


The Functional Assessment of Mental Health and Addiction Scale (FAMHA) was specifically designed to meet criteria for both mental health issues and addictions. 

Clients with co-occurring disorders have multiple service needs in mental health, addiction treatment, and medical interventions. Thus, functional assessments like the FAMHA are the key to not only measuring the outcomes of treatments on a broad scale but crucial to the clinician’s full understanding of the patient’s individual needs.

The FAMHA is not the only scale of this type but will give the learner an overview of information gathered for the dually diagnosed individual.


Description of the FAMHA:

The scale describes the population types as:

-Mentally Ill Substance Users (MISU)

-Substance Using Mentally Ill (SUMI)

-Medically Compromised – Substance Using Patients (MCSU)

The scale assesses these individuals across a broad range of symptom and functional domains.  The 46 items of the scale document functional deficits across all bio-psychosocial functional domains in such a way as to capture the current state of overall functioning, whilst demonstrating specific areas of need. The 46 items subdivided into 6 bio-psychosocial dimensions:

  1. Socio-legal
  2. Social community Living
  3. Social-Interpersonal Skills
  4. Mood
  5. Psychological Functioning
  6. Physical Functioning.

In addition to the dimensional scales, data as to the patients primary and secondary drug of choice, alcohol consumption, prior mental health, and addiction treatment episodes, demographics, and current medical, mental health and addiction diagnoses are also collected to add to the clarity of the diagnostic profile. It is expected that continued statistical analysis, including factor analyses of further trials, will yield more refined, discrete scale dimensions and add to the overall utility of the instrument.

It can be used as both an indicator of current functioning for diagnostic assessment and as a repeated measure to demonstrate the changes that occur to patients throughout the clinical cycle.

Because the term dual diagnosis is somewhat broad and misleading (for example; mental illness and learning disabilities are dual diagnoses). The distinction between MISU, SUMI, and MCMU patients has a significant impact on the selection and use of a variety of intervention techniques and strategies.


Development of the Scale

The FAMHA was developed with a variety of criteria in mind. It was felt that the FAMHA should not only assess the obvious symptom categories of major mental illness and addiction but should also:

  • include functional domains that are deemed important for community-based treatment clinics; demonstrate reliability and validity; 
  • possess sensitivity to treatment-related change; be appropriate and relevant to the dually diagnosed population that it functionally assesses;
  • be a useful tool for treatment planning and clinical governance;
  • have low administration costs;
  • be relatively easy to use by all levels of clinical staff.

The current version of the FAMHA meets all of these criteria and can be administered in as little as 8 minutes by a trained, experienced rater.

The FAMHA uses a seven-point, three-way anchored Likert-like scale, ranging from extremely dysfunctional symptoms or behaviors (Score 1) to normative levels of these behaviors and symptoms (Score 7).

An assessment should be done by a qualified, trained professional. The information obtained is crucial to the correct diagnosis and effective treatment planning.



When one begins to use a mind-altering substance the notion is that it will be used only on social occasions, with certain friends or for specific purposes. I think it is safe to say no one intends to become addicted; however, the history of excessive use and abuse of alcohol and other drugs indicates that many do get trapped and experience severe life-altering problems as they progress through the use stages and ultimately reach the addicted stage. Interestingly, once an individual has reached the addiction stage there is little chance of turning back.

From a broader perspective, not everyone that drinks alcohol or uses other drugs becomes addicted. Tempered use or abstinence from alcohol and other drugs is typical for most people, most of the time. Occasional use of psychoactive substances may begin because of curiosity or influence of family or friends. The early experimental stage of use of a mood-altering substance usually occurs during the adolescent years, generally between 10 and 14 years of age. The typical progression of use is from tobacco and/or alcohol followed by marijuana. As use continues, other illicit drugs that are either inhaled or ingested orally are added to the menu. Generally, the use of more potent drugs, particularly those requiring hypodermic administration, begins somewhat later.


The Stages of Drug Use 

The commonly accepted stages of alcohol and other drug use along with some of the characteristics associated with each stage are as follows:

Experimental/Recreational Use Stage (drink/use a few times per month, typically on weekends when at a party or other social event, use is generally with friends; however, individual may drink/use alone).  

  • Person experiments with drugs to satisfy curiosity;
  • To acquiesce to peer pressure;
  • To obtain social acceptance;
  • To defy parental and other authority;
  • To take risks or seek a thrill;
  • To relieve boredom; appear grown-up;
  • To produce pleasurable feelings and to diminish inhibitions in social/personal settings;
  • Alter mood in social settings.
  • To mask social ineptness.


Regular Use/Abuse Stage (Drugs are used on a regular basis (several times per week); individual may drink/use to intoxication/impairment; drug use is situational; may commence binge drinking; may use alone rather than with friends).

  • Experience the pleasure the drugs produces; alter emotions/moods;
  • Cope with stress and uncomfortable feeling such as pain, guilt, anxiety, and sadness;
  • Overcome feelings of inadequacy.
  • Avoid depression or other uncomfortable feelings when not using; substances are used to stay high or at least maintain normal feelings;
  • May begin to encounter legal problems (public intoxication; driving under the influence; spouse/child abuse).


Compulsive/Dependent Use Stage (Drug use on a daily or almost daily basis; individual is consumed with an uncontrollable and compulsive urge to seek and use, even in the face of negative health and social consequences). Note: Characteristics noted above are generally more applicable to the later phase of the Compulsive/Dependent Use stage. Characteristics may vary considerably during the early part of this stage.

  • Use is out-of-control
  • Time, energy, and money are focused on seeking and using drugs
  • Total preoccupation with drugs and drug-related activities
  • Most family, social and work functioning is impaired
  • Tolerance is noted (more of a drug is needed to reach the desired effect)
  • Relationships with others may become strained and stressful
  • Responsibilities such as family and job are neglected
  • Continue using to avoid withdrawal symptoms
  • Individuals major focus in life is when and where will I get my next fix
  • Drugs/alcohol are needed to avoid pain and depression
  • Individuals use to escape the realities of daily living
  • The individual may experience severe health, social and financial problem
  • Legal problems are a way of life

Substance Abuse:

A drug abuser is one who continues to use despite recurrent social, interpersonal and legal difficulties as a result of his or her use. Harmful use implies use that results in physical, legal or mental damage. The essential feature of Substance Abuse is a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of the substance. In order of an abuse criterion to be met, the substance-related problem must have occurred repeatedly during the same 12-month period or been persistent. There may be repeated failure to fulfill major role obligations, repeated use in situations in which it is physically hazardous, multiple legal problems, and recurrent social and interpersonal problems. Unlike the criteria for Substance Dependence, the criteria for Substance Abuse do not include tolerance, withdrawal, or a pattern of compulsive use and instead include only the harmful consequences that result from repeated use.

The criteria for Substance Abuse is:

A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

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; neglect of children or household);

Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use);

Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct);

Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences or intoxication, physical fights);

The symptoms have never met the criteria for substance dependence for this class of substance.


Substance Dependence:

The essential feature of Substance Dependence is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues the use of the substance despite significant substance-related problems. In essence, it is a pattern of repeated self-administration that can result in tolerance, withdrawal, and compulsive drug-taking behavior. Those who are substance dependent meet all of the criteria of alcohol abuse and they will also exhibit some or all of the criteria for dependence. The criteria for substance dependence is a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

(1)   Tolerance, as defined by either of the following:

(a)  A need for markedly increased amounts of the substance to achieve intoxication or desired effect;

(b)  Markedly diminished effect with continued use of the same amount of the substance;

(2)  Withdrawal as manifested by either of the following:

(a)  The characteristics of withdrawal syndrome for the substance

(b)   the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms;

(3)  The substance is often taken in larger amounts or over a longer period than was intended;

(4)  There is a persistent desire or unsuccessful efforts to cut down or control substance use;

(5)  A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects

(6)  Important social, occupational, 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 physical or psychological problem that is likely to have been caused or exacerbated by substance use (e.g., current use despite recognition of substance-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption).


Substance Intoxication 

The essential characteristic of substance intoxication is the development of a reversible substance-specific syndrome due to the recent ingestion of (or exposure to) a substance. The clinically significant maladaptive behavioral or psychological changes associated with intoxication (e.g., belligerence, mood liability, cognitive impairment, impaired judgment, impaired social or occupational functioning) are due to the direct physiological effects of the substance on the Central Nervous System, and develop during or shortly after use of the substance. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.


Substance Withdrawal

The essential feature of substance withdrawal is the development of a substance-specific maladaptive behavioral change, with physiological and cognitive concomitants, that is due to the cessation of, or reduction in, heavy and prolonged substance use. The substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

The signs and symptoms of withdrawal vary according to the substance used, with most symptoms being the opposite of those observed in intoxication with the same substance. The dose and duration of use and other factors such as the presence or absence of additional illnesses also affect withdrawal symptoms. Withdrawal develops when doses are reduced or stopped, whereas signs and symptoms of intoxication improve (gradually in some cases) after dosing stops. 


Progression/Timeline Through the Stages 

When describing the stages of substance use a factor that is often overlooked or under-evaluated is the timeline for each stage and the cumulative time it typically takes for an individual to progress through the stages and to become addicted to or dependent upon his or her drug of choice. The timeline depicted below is for alcohol; the stages and times for other types of drugs would vary considerably (time-wise) but the overall concept is valid for most psychoactive drugs. It should be noted that the stages are not absolute and do not have a precise timeline and may vary significantly from person-to-person. Also, the dependency stage is best characterized as three sub-stages: early dependency stage where individuals may very well have the ability to control their use if they are sufficiently motivated (spouse may require them to choose between alcohol and his or her family); however, in the middle and later stages, there is little chance of the individual being able to control their use without professional help.

Increased situational use (seeking out drinking functions), as well as psychological factors (need the drug to feel normal) helps to accelerate individuals through the Use/Abuse stage rather quickly. Also, during this stage, alcohol is often used as a crutch to help cope with all stressful situations and to enhance joy associated with celebratory occasions. Also, alcohol becomes the primary self-administered medication for all ills. It can become progressively more important to the individual and can become a dominant factor in all decisions and actions. 

The final stage is the Compulsive/Dependency stage. It is helpful to divide this stage into three sub-stages and look at the characteristics of each sub-stage independently. In each case, the point of focus is that alcohol is becoming more important to the individual and he/she is making more concessions to it in terms of withdrawing from family, work and community responsibilities. Typically, early in the compulsive/dependency use stage, an individual can stop drinking. It typically takes a catastrophic life incident (serious illness, accident, loss of family/family member) for the individual to revert to abstinence on his/her own. Through my years of counseling, The middle and late sub-stages are a different story. The most significant characteristic of an individual in this stage is that the most important thing on their mind is when will I get my next drink. I have met individuals in the compulsive/dependency stage that would lie, steal, cheat or do almost anything to obtain alcohol or other drugs. They demonstrate the uncontrollable, compulsive drug seeking and use, even in the face of negative health and social consequences lifestyle every day of their life.   Unfortunately, few stage 2/3 alcoholics have the physiological and psychological underpinning to get into recovery themselves.


The Compulsive/Dependency stage typically extends for several years. The early sub-stage typically does not extend beyond 5 years. The middle sub-stage is characterized by a worsening of the early sub-stage and can last up to five additional years.  The final stage is characterized by total emersion into a drug-related lifestyle and will generally last until either recovery starts or death.





Dr. Alan I Leshner, PhD., Director, National Institute of Drug Abuse, 2001 provided the following insight into drug addiction.   He states: The word addiction calls up many different images and strong emotions. But what are we reacting to? Too often we focus on the wrong aspects of addiction so our efforts to deal with this difficult issue can be badly misguided. Any discussion about psychoactive drugs, particularly drugs like nicotine and marijuana, inevitably moves to the question but is it really addicting?   The conversation then shifts to the so-called types of addiction whether the drug is physically or psychologically addicting. The issue revolves around whether or not dramatic physical withdrawal symptoms occur when an individual stops taking the drug, what we in the field call physical dependence.

The assumption that follows then is that the more dramatic the physical symptoms, the more serious or dangerous the drug must be. Indeed, people always seem relieved to hear that a substance just produces psychological addiction, or has only minimal physical withdrawal symptoms. Then they discount the dangers. They are wrong.

Defining addiction Twenty years of scientific research, coupled with even longer clinical experience, has taught us that focusing on this physical vs. psychological distinction is off the mark, and a distraction from the real issue. From both clinical and policy perspectives, it does not matter much what physical withdrawal symptoms occur. Other aspects of addiction are far more important. Physical dependence is not that important because, first, even the florid withdrawal symptoms of heroin and alcohol addiction can be managed with appropriate medications. Therefore, physical withdrawal symptoms should not be at the core of our concern about these substances. Second (and more important), many of the most addicting and dangerous drugs do not even produce very severe physical symptoms upon withdrawal. Crack cocaine and methamphetamine are clear examples. Both are highly addicting, but stopping their use produces very few physical withdrawal symptoms, certainly nothing liked the physical symptoms of alcohol or heroin withdrawal.

What does matter tremendously is whether or not a drug causes what we now know to be the essence of addiction: uncontrollable, compulsive drug seeking and use, even in the face of negative health and social consequences. This is the crux of how many professional organizations all define addiction, and how we all should use the term. It is really only this expression of addiction uncontrollable, compulsive craving, seeking and use of drugs that matters to the addict and to his or her family, and that should matter to society as a whole. These are the elements responsible for the massive health and social problems caused by drug addiction.

The Essence of Addiction Drug craving and the other compulsive behaviors are the essence of addiction. They are extremely difficult to control, much more difficult than any physical dependence. They are principal target symptoms for most drug treatment programs. For an addict, there is no motivation more powerful than drug craving.

Rethinking Addiction focusing on addiction as compulsive, uncontrollable drug use should help clarify everyone’s perception of the nature of addiction and of potentially addicting drugs. For the addict and the clinician, this more accurate definition forces the focus of treatment away from simply managing physical withdrawal symptoms and toward dealing with the more meaningful, and powerful, the concept of uncontrollable drug seeking and use. The task of treatment is to regain control over drug craving.

Rethinking addiction also affects which drugs we worry about, as well as the nature of our concerns. The message from modern science is that in deciding which drugs are addicting and those that require societal attention, we should focus primarily on whether taking them causes uncontrollable drug seeking and use. One important example is the use of opiates, like morphine to treat cancer pain. In most circumstances, opiates are addicting. However, when administered for pain, although morphine treatment can produce physical dependence which now can be easily managed after stopping use it typically does not cause compulsive, uncontrollable morphine seeking and use, addiction as defined here. This is why so many cancer physicians find it acceptable to prescribe opiates for cancer pain.

Treating Addiction: Follow The Science It is important to emphasize that addiction, as defined here, can be treated, both behaviorally and, in some cases, with medications, but it is not simple. We have a range of effective addiction treatments in our clinical toolbox although admittedly not enough. This is why we continue to invest in research, to improve existing treatments and to develop new approaches to help people deal with their compulsive drug use.

Our national attitudes and the ways we deal with addiction and addicting drugs should follow the science and reflect the new, modern understanding of what matters in addiction. We certainly will do a better job of serving everyone affected by addiction – addicts, their families, and their communities if we focus on what really matters to them. As a society, the success of our efforts to deal with the drug problem depends on an accurate understanding of the problem.


The addiction process is presented to help the clinician and the drug user to better understand the why behind their use and abuse of drugs. Our hope is that the better this process is understood, the more effective counseling and other treatment modalities can be toward helping the user to achieve a drug-free life. It is imperative that clinicians in the field of addictions understand the cognitive, behavioral and physical aspects of drug use. The objectives are for the clinician involved with treatment to recognize the special requirements of this sub-population and design treatment modalities aimed at their specific needs. For example, as it is beneficial for an insulin-dependent diabetic to be educated on all aspects of diabetes, it is equally important for the problematic drug user to be educated on all aspects of his or her drug of choice including impulse control, distorted cognitive ability and the consequences of poor decision-making.


An individuals value/belief system reflects his/her perception of self and represents values, judgments and myths that he/she believes to be true. A person’s value/belief system is fairly well established by an early age and is refined and honed as life’s experiences make us into the person we are at any given time in our lives.   It is a major control and decision-making guide and helps us to choose between right and wrong and things we do versus things we don’t do. Our value/belief system influences our thinking and decision making throughout our lives. Most individuals have a value/belief system about:

  • Religion
  • Alcohol and other drugs use
  • Sexuality
  • Race
  • Careers
  • Age
  • Peer pressure/fitting in
  • Time management
  • Social involvement
  • Community involvement
  • Family roles

A clinician should explore a clients value/belief system to better understand what they believe about various topics including topics related to drug use. An area I like to explore with clients is the environment they were exposed to during their early life. For example, I want to determine if their parents or caregivers had a permissive attitude toward drugs. I also want to know what type of neighborhood they lived in and what was the norm regarding the use of alcohol and other drugs. Other questions might include:

  • Were you exposed to limits or restrictions as a youth?
  • Did your parents use alcohol or other drugs?
  • Were you allowed to drink or use other drugs with your parents?
  • At what age did you start to drink or smoke?
  • Was there a permissive attitude toward alcohol and other drugs in your home/neighborhood?
  • Did you have a detailed schedule as a youth?
  • Did your parents involve themselves with your friends?
  • Did your parents monitor your activities?

Obviously, exposure to a permissive attitude/environment will enable a young person to form a positive image of most activities and/or to establish a distorted mental picture of a specific activity (such as the use of alcohol and/or other drugs). To give an example of how our belief/values work in the life of a drug user, let’s suppose a person forms a concept of a problem user as one who dropped out of school and is unemployed. Now, let’s suppose this individual is a compulsive user but does not meet his or her pre-programmed characteristics of how they perceive an addict to be or act. In this case, the individual would test his situation against his value/belief system and would conclude he or she does not have a drug problem. The cycle is repeated until there is a match between his/her behavior and his/her pre-programmed belief/value system about drug use. It should also be noted that an individuals belief system about drug use might change in response to his or her own experiences and influences from clinicians and treatment programs. The cycle may also be disrupted by other factors (generally a crisis) in the user’s life.


Distorted Cognitive Ability

A flawed or permissive value/belief system results in a distorted cognitive ability that, in turn, results in illogical and impaired thinking. The affected individual continues to make high-risk decisions for themselves. With respect to the use of drugs, it results in compulsive, uncontrolled drug craving, seeking and use. It follows that an individual is unable to comprehend the reality, consequences or truth about events/actions/activities. When an individual cannot see the reality or truth about things, the distorted cognitive activity is generally referred to as denial. The most common forms of denial are:

  • Rationalizing: Making excuses for drug use. Examples include, I’m restless and it helps me sleep; all of my friends use more than me.
  • Minimizing:      Indicating his/her use is less serious than it really is. Example: Sure I drink occasionally, but not that much; I only drink on weekends, real alcoholics drink every day.
  • Blaming: I drink because; everyone else does. The user admits involvement but the responsibility for it lies with some else.





People begin to use drugs due to curiosity and a desire to fit into a social group (peer pressure). Certainly, a youth who has already begun to smoke cigarettes and/or to use alcohol is at a higher risk to experiment with other drugs. Research suggests that the use of alcohol and/or other drugs by other family members is a risk factor as to whether children start using drugs. Parents, grandparents, older siblings, other relatives and caregivers are all role models for children to copy and follow. I personally like to expand the model concept to everyone who is an authority figure or in a position to influence a childs life. At times, parents blindly trust teachers, youth camps, sports figures and others with their children without being aware of the negative influences that could surround these individuals. Studies of high school students and their patterns of drug use show that very few young people use other drugs without first trying marijuana, alcohol or tobacco. The present trend is that only a few high school students use cocaine; however, the risk of doing so is much greater for youths who have tried marijuana than for those who have never tried it.






The following trends have been observed for heavy users versus their non-using counterparts:


     Lower educational achievement levels: This difference is more pronounced in math and science than in social studies and courses such as music and art. It appears that some students lack the drive or desire to remain focused to solve difficult problems, whereas it may very well increase their interest in non-technical studies. It should be noted that this is a generalized trend and specific individuals may be able to excel in math and science and use drugs.


    Experience increased personality disorders such as depression, anxiety, fear, impaired judgment, distorted sensory perceptions, difficulty in carrying out complex mental processes, and impaired motor performance: Some user experience unusual anti-social behaviors and a rebellious attitude.


     Research has indicated an adverse impact on memory and retention that can last for days or weeks after the acute effects of the drug subside. For example a study of over 100 college students found that among heavy users (of marijuana) their critical skills related to attention, memory, and learning were significantly impaired even after they had not used the drug for at least 24 hours. A follow-up to the initial study showed that a group of long-term heavy users ability to recall words from a list was impaired 1 week following cessation of use, but returned to normal by 4 weeks. The implication is that even after long-term heavy use, if an individual quits, some if not most of his or her cognitive abilities may be recovered.






The American Society of Addictive Medicines (ASAM) has taken the lead in standardization of concepts and approaches for alcohol and other drug treatment programs. The levels of care established by ASAM are:


  • Level 0.5  Early Intervention
  • Level I      Outpatient services
  • Level II     Intensive Outpatient/Partial Hospitalization Services
  • Level III   Residential/Inpatient services
  • Level IV   Medically-Managed Intensive Inpatient Services 

A referral for a specific level of care must be based on a careful assessment of the patient with an alcohol or other drug problem.   The overall objective is to place the patient in the most appropriate level of care (described as the least intensive level that could accomplish the treatment objectives while providing safety and security for the patients). The levels of care represent a continuum of care that can be used in a variety of ways depending on the patients needs and responses. For example, a patient could begin at a more intensive level and move to less intensive levels either in consecutive order or by skipping levels. A patient could also move to more intensive levels depending on need.


A study of adult drug users found that a 14-session cognitive-behavioral group and 2-sessions of individual counseling (this amount of counseling is similar to American Society of Addictive Medicine, Level 1) is effective for some patients. This counseling includes motivational interviewing and advice on ways to reduce use.   The study also indicated that focusing on what triggers their use and then help them to devise appropriate avoidance strategies could help patients. Outcome studies revealed the following results: (1) use and related problems (school, work, family) as well as psychological problems decreased for at least one year after treatment; (2) approximately 30 percent of former users were drug-free after 3 months.


A significant challenge facing recovering addicts is to avoid relapse. Marlott and Gordon in 1995 provided comprehensive relapse prevention technique for alcohol and other drug addicts. They suggested an approach where high-risk situations were assessed and then coping strategies were developed for each situation. The following factors were analyzed for each situation: 


  • Self-Efficacy: The individuals perception of his/her ability to cope with situations.
  • Expectations: What is the consequence to the user of a specific behavior?
  • Attribute: Why an individual exhibits a specific behavior.
  • Decision-Making: Methodology used when the individual chooses a specific action. 


Once this analysis is complete, Marlatt and Gordon suggest the following intervention strategies:         


Self-monitoring:  Maintaining a log of urges/needs to use drugs. Additional information such as intensity of urge and coping strategy employed may also be documented.

Direct observation:       The individual rates the degree of temptation due to various situations. The individual may respond to an imaginary past episode or a fantasy about a past episode and then describe what he/she may have done differently to avoid future encounters.

Coping Skills:     This analytical tool is used to document the clients ability to cope once a high-risk behavior is encountered. This helps the individual to identify strengths and weaknesses and helps the client focus on areas that need improvement.

Decision Matrix:
The matrix is used to document the consequences of a specific decision or action. It may be used to gather immediate, as well as delayed consequences and can document both positive and negative outcomes.

Behavioral Commitment:        This tool is intended to establish limits on drug use (if any). It is also a commitment to seek help at the first episode of use, to prevent a full-scale return to using.

Reminder Questions:    They are used to key specific avoidance actions in the event of a strong urge.


It follows that a primary goal of any prevention program is to enable the individual to cope with future, inevitable urges to use. The initial step is to identify the coping strategies that can be used in high-risk situations. It is also important to discuss an implementation plan for how these skills will be used. Some have referred to this process as setting up a self-management program. According to Ricky George (1990), The goals of self-management programs are to teach the individual to anticipate and cope with the problem of relapse. This approach generally combines behavioral skills training, cognitive interventions and lifestyle changes to help the individual modify their behavior.

The most frequently applied prevention method is the cognitive-behavioral approach. The primary feature of this approach is that it acknowledges the individual may have had little or no control over becoming a compulsive user but has total responsibility for the management of his/her recovery.



Recovery Model

This model is based on the concept that recovery is a process that requires the mastery of emotional, psychological, social and recovery-related tasks. These tasks, which become increasingly more challenging, are the foundation for recovery. Recovery is defined as the ongoing process of improving one’s level of functioning while striving to remain drug-free. A brief overview of a recovery process follows:


Pre-treatment phase: The individual experiences or becomes aware of:

  • Unpleasant consequences associated with drug use (family problems, loss of friends, loss of job, loss of freedom);
  • Loss of control of their life; and emotional pain (may motivate individual to decide to enter treatment).

Initial stabilization:

  • Stop use of all drugs; avoid former using buddies;
  • Professionally managed coping and emotional strategies (to ease the discontent associated with urges to resume using);
  • Help with controlling impulsive behavior (counseling)


Phase 1: Recovery (Getting Started)

  •  Helps individuals to accept and comprehend the addiction process
  • Identify use triggers:
    • Develop a plan to avoid and control impulses.
    • Learn problem-solving, stress management, and anger management skill.
    • Accept personal responsibility for self (choices, decisions, behaviors, and consequences);
    • Express feelings. 


Phase 2:  Recovery (Early)

  • Accepts the need for recovery
  • Accepts responsibility for the management of drug use
  • Begins to develop a drug-free self-image
  • Acknowledges the need for lifestyle changes; new friends
  • Adjusts to non-use behavior applies new problem-solving skills as needed
  • May struggle with peer and family issues as a drug-free lifestyle is demonstrated
  •  Improved self-image.


Phase 3 (Middle)

  • Changed behavior and cognitive awareness aligned with new self-concept.
  • Accepts responsibility for own recovery.
  • Recognizes and embraces success of recovery.
  • Incorporates problem-solving skills into new lifestyle.
  • Comfortable with lifestyle changes.
  • Continues to struggle with peer and family issues.
  • Learns to balance and control life.


Phase 4 (Advanced)

  • Focuses on learning coping skills to help deal with peers and family.
  • Increases scope of life; starts to fulfill potential.
  • Develops balance and takes control of life.
  • Develops independence from the treatment program develops self-initiative.
  • Accepts identity as a recovering individual.


After Care 

  • Positive experiences fuel personal growth.
  • Focus on the total person (activities, spiritual growth and independence).


Keys To Avoid A Return To Problematic Use For Clients:

  • High Activity Level: An idle mind often wanders in the wrong direction.
  • Generate To Do lists to guide daily activities.
  • Goal setting to acknowledge and reward success.
  • Individual reward system:      
  • Work toward a specific individualized reward.   For example, a new car, trip, clothes.  
  • Plan pleasurable activities:      Hobbies, travel, reading, etc.
  • Plan self-improvement activities: Items that will help the individual feel good about themselves. 

-Exercise/active lifestyle

-Nutrition program

-Rest/relaxation time

-Manage stress

-Think positive

 -Avoidance of high-risk situations and activities

-Events that previously led to use

-Avoid people/functions whose focus is on drug use

-Avoid things that have triggered previous relapses

-Develop mind-management techniques:  Block negative thought processes. The mind always leads the physical act (i.e., an individual thinks positive regarding an activity before they do the activity). Consequently, if we could train our minds to detect wrong thinking (about drug use), then we could alter or disrupt those thoughts and focus on different things or thought processes to avoid actually using.

-Avoid overconfident feelings, such as, discourage clients from thinking, “I am in control and I have this problem licked.”

-Generally, overconfidence leads to high-risk behavior and poor decision-making.

-Avoid out-of-balance emotional states. Either feeling too good (overconfident) or too bad (depression) can lead to the resumption of use.

-Forgetting or rationalizing away the pain and anguish of the former lifestyle. Our minds will sometimes focus only on the pleasurable aspects of a former activity and completely mask (or forget) the negative consequences. At times, individuals are convinced that returning to a former lifestyle would be wonderful (feeling, emotions, etc.) Also, when they actually return to that lifestyle, they become deeply depressed as the reality of their actual use is realized. The mind is a wonderful thing, but it too must be monitored and trained and one must realize that the mind can be misleading in some cases.



Abundant research in psychology, human development, and other fields has shown that events and circumstances early in peoples’ lives influence future decisions, life events, and life circumstances—or what is called the life-course trajectory. People who use drugs typically begin doing so during adolescence or young adulthood, but the ground may be prepared for drug use much earlier, by circumstances and events that affect the child during the first several years of life and even before birth.

A child’s growth and development may be divided into four periods: infancy, the preschool years, the middle childhood years, and adolescence. Other changes occur in our bodies well beyond adolescence.

What Is Growth?  

An individual’s physical growth refers to the increases in height and weight and other body changes that occur as they mature. From conception, when a single cell becomes a complex organism in which billions of cells work in concert. to death, the changes that occur in a body are too numerous to count…hair grows; teeth come in, come out, and come in again…sometimes come out again, puberty to menopause; it’s all part of the growth process.

The first year of an infant’s life is a time of astonishing change. During this time, a baby will grow rapidly. On average, babies grow 10 inches (25 centimeters) in length while tripling their birth weights by their first birthday.

Given all the growth that occurs in the first year of life, new parents may be surprised when their child doesn’t continue to grow through the roof. But no child continues the rate of growth experienced during infancy. After age 1, a baby’s growth in length slows considerably, and by 2 years, growth in height usually continues at a fairly steady rate of approximately 2 1/2 inches (6 centimeters) per year until adolescence.

A major growth spurt occurs at the time of puberty. Usually, kids enter puberty between age 8 to 13 years in girls and 10 to 15 years in boys. Puberty lasts about 2 to 5 years. This growth spurt is associated with sexual development, which includes the appearance of pubic and underarm hair, the growth and development of sex organs, and in girls, the onset of menstruation.

Approximately 2 years after puberty at about the age of 15 or 16 for girls and 16 to 18 for the growth associated with puberty will have ended for most teens and they will have reached physical maturity.

Once our genes have orchestrated the growth and development of the body to the point that it can reproduce, the primary purpose for growth is complete. Nutrition can have profound effects on one’s final growth stature though along with other variables such as lifestyle and exercise. Exercise can stimulate growth as long as it is not “overdone” and a healthy drug-free lifestyle also comes with numerous growth cycle benefits.

Factors to Ensure Proper Growth and Development  

There are several things that can help ensure proper growth and development.

Enough Rest – Sleep patterns vary by age and individual child, but most kids need an average of 10 to 12 hours of sleep per night. Sleep gives growing bodies the rest they need to continue growing properly.

Averages by age:

1 week

16.5 hrs

1 month

15.5 hrs

3 months

15 hrs

6 months

14.25 hrs

12 months

13.75 hrs

2 years

13 hrs

4 years

11-12 hrs

5 years

11 hrs

10 years

9.75 hrs


7.5 hrs (school night)


8.75 hrs (weekend)


Proper Nutrition – A balanced diet full of essential vitamins and minerals will help an individual reach his or her full growth potential.

Nutrient needs correspond with these changes in rates of growth, with an infant needing more calories for his or her size than a preschooler or school-aged child would need. Nutrient needs then increase as a child approaches adolescence.

Generally, a healthy child will follow his or her own growth curve, in spite of variable nutrient intake. Parents and caregivers should provide appropriate diets for age and be sure the diet offers a wide variety of foods to ensure nutritional adequacy.

Malnutrition has been associated with serious problems related to intellectual development. A child who is undernourished may experience early fatigue and may be unable to fully participate in learning experiences at school. Additionally, malnutrition can contribute to increased susceptibility to illness, causing a child to frequently miss school.

Children who are undernourished have unacceptable growth patterns accompanied by scholastic underachievement. A good variety of food choices and adequate intake are essential to achieving optimal intellectual development. Breakfast is particularly important as children may feel fatigued, sleepy, and unmotivated when breakfast is skimpy or is skipped altogether.

Nutrition is considered critical enough to intellectual development that government programs have been put in place to ensure at least one healthy balanced meal a day for appropriate groups of children. This is usually breakfast, as the relationship between breakfast and improved learning has been clearly demonstrated. These programs are available in impoverished and underserved areas of the country.

Adequate Exercise – Because obesity is a growing problem in kids, parents should make sure that their children exercise regularly, as well as receive proper nutrition. Bicycling, hiking, in-line skating, sports, or any enjoyable activity that will motivate your kid to get moving will promote good health and fitness and help your child maintain a healthy weight.


Failure to Thrive in Children and the Elderly

Children who fail to thrive don’t receive or are unable to take in, retain, or utilize the calories needed to gain weight and grow as expected.

Most diagnoses of failure to thrive are made in infants and toddlers – in the first few years of life – a crucial period of physical and mental development. After birth, a child’s brain grows as much in the first year as it will grow during the rest of the child’s life. Poor nutrition during this period can have permanent negative effects on a child’s mental development.

Whereas the average term baby doubles his or her birth weight by 4 months and triples it at 1 year, children with failure to thrive often don’t meet those milestones. Sometimes, a child who starts out “plump” and who shows signs of growing well can begin to fall off in weight gain. After a while, linear (height) growth may slow as well.

If the condition progresses, the undernourished child may:

  • become disinterested in his or her surroundings
  • avoid eye contact
  • become irritable
  • not reach developmental milestones like sitting up, walking, and talking at the usual age

In elderly patients, failure to thrive describes a state of decline that is multi=factorial and may be caused by chronic concurrent diseases and functional impairments. Manifestations of this condition include weight loss, decreased appetite, poor nutrition, and inactivity. Four syndromes are prevalent and predictive of adverse outcomes in patients with failure to thrive: impaired physical function, malnutrition, depression, and cognitive impairment.

Cognitive Development

Early development is characterized by rapid orderly progressions of normal patterns of physical, cognitive, emotional, and social development. This development is marked by important transitions between developmental periods and the achievement of successive developmental milestones. How successfully or unsuccessfully a child meets the demands and challenges arising from a given transition, and whether the child meets milestones on an appropriate schedule, can affect his or her future course of development, including risk for drug abuse or another mental, emotional, or behavioral problems during adolescence.

A variety of factors, known as risk factors, can interrupt or interfere with unfolding developmental patterns in all of these periods and, especially, in the transitions between them. Prevention interventions designed specifically for early developmental periods can address these risk factors by building on existing strengths of the child and his or her parents (or other caregivers) and by providing skills (e.g., general parenting skills and specific skills like managing aggressive behavior), problem-solving strategies, and support in areas of the child’s life that are underdeveloped or lacking.

The child’s stage of life, aspects of his social and physical environments, and life events he experiences over time all contribute to his physical, psychological, emotional, and cognitive development.

Life events or transitions represent points during which the individual is in a period of change, and they are sometimes called sensitive, critical, or vulnerable periods. Although vulnerability can occur at many points along the life course, it tends to peak at critical life transitions, which present risks for substance abuse as well as opportunities for intervention. Thus transitions such as pregnancy, birth, or entering preschool or elementary school are prime opportunities to introduce skills, knowledge, and competencies to facilitate development during those transitions. Therefore, interventions are often designed to be implemented around periods of transition.

The changes unfolding throughout a child’s development are influenced by a complex combination of factors. One of them is the genes the child inherits from his or her biological parents. Genetic factors play a substantial role in an individual’s development through the course of life, influencing a person’s abilities, personality, physical health, and vulnerability to risk factors for behavioral problems like substance abuse. But genes are only part of the story.

Another very important factor is the environment or the contexts into which the child is born and in which the child grows up. The family/home environment is the context that most directly influences the young child’s early development and socialization. This includes quality of parenting and other parenting influences such as genetic factors and family functioning. Also, siblings, if present, can influence a child’s development and adjustment (e.g., internalizing and externalizing behaviors and substance use, as well as positive behaviors). These influences may result from shared environmental experiences and interactions with parenting and other family factors. But conditions at home are also influenced by wider physical, social, economic, and historical realities—such as the family’s socioeconomic status and the affluence and safety (or lack thereof) of the community in which the family lives. As the child grows older and enters school, these wider environmental contexts influence him or her more directly.

What follows is an overview of the developmental influences and changes taking place during specific periods of early childhood development.

Prenatal Period

The genes, biological capacities, and innate temperament that children are born to inform the way they interact with the environment and people in it. Development is shaped by a combination of genetic and environmental factors.

Even before a child is born, the context or environment plays an important role in development. It has long been known, for example, that if the mother smokes, drinks alcohol, or uses other drugs during her pregnancy, these substances can enter the body of the developing fetus and have significant effects on the development of the body and brain, and these effects may become risk factors for substance use later in the child’s life for more information). There is also emerging evidence that both parents’ past histories of substance use may affect their children via changes to gene expression. Also, poor nutrition during the prenatal period can have adverse effects on the development of the child’s brain.

Infancy and Toddlerhood

Once the child is born, factors that contribute to the child’s development include the quality of the nutrition and health care provided by the mother and other caregivers, the personality fit between infant and caregivers, and the ability of the caregivers to provide warmth and support. The child also plays a more active role in shaping his or her environmental context.

Over the months following birth, the child adapts to and integrates into the surrounding world as he or she makes further developmental gains, including ongoing brain development. Through practice, the child ideally becomes proficient at basic skills using limited but growing sensory, motor, cognitive, and social capacities, meeting basic milestones along the way. As the infant learns to distinguish self from others, he or she instinctively focuses attention on the primary caregiver(s), usually parents.

For optimal positive development to occur, the primary caregiver(s) must consistently meet the child’s needs, be nurturing, provide a predictable schedule, and provide developmentally appropriate stimulation. The closeness of the parent-child relationship during this early period provides a context for the child’s development and his or her expectations about the world as well as for secure attachment to his or her caregiver(s). Secure attachment is one of the most crucial factors leading to healthy socialization and self-regulation, which are major protective factors against drug use and other behavioral problems.


Throughout early childhood, even when the child enters preschool or attends daycare, the family remains the most important context for development. Parents play a number of roles in the development of a young child’s social, emotional, and cognitive competence, including establishing the structure and routines for parent-child interactions; maintaining a sensitive, warm, and responsive relationship style; and providing instructional practices and experiences that help the child acquire necessary developmental skills. Development of motor abilities and language skills are important in the preschool period, influencing the child’s growing independence.

When a nurturing, responsive relationship does not exist, elevated levels of stress hormones can impede a child’s healthy brain development. Moreover, when a caregiver cannot provide attention and nurture because of a history of trauma, chronic stress, and/or mental health problems, the child is more likely to develop behavioral, social, emotional, or cognitive problems. Likewise, impaired judgment related to substance use can reduce a parent’s ability to create a warm, supportive environment for the child. Child abuse and neglect, social isolation due to illness or disability, and lack of constancy in the primary caregiver (as in the case of a child in institutionalized care) are also linked to growth (including brain growth and neuronal connectivity), cognitive, motor, social, and emotional problems. Many of the prevention interventions discussed in this guide are aimed at facilitating constant, nurturing, responsive caregiving to reduce risk and prevent child behavior problems.

Transition to School

As the child grows older, new transitions and associated challenges occur. A major transition for young children is beginning elementary school. Even children who attended preschool or had been in daycare can find the rules for behavior and academic requirements associated with elementary school difficult to adapt to and achieve. Readiness for school is something that occurs over time with experience and practice. Early intervention can help parents and schools assist children through this transition. Once in elementary school, teachers can help children to adjust by providing positive classroom management.




Detoxification is a set of interventions aimed at managing acute intoxication and withdrawal. It denotes a clearing of toxins from the body of the patient who is acutely intoxicated and/or dependent on substances of abuse. Detoxification seeks to minimize the physical harm caused by the abuse of substances. 

The detoxification process consists of three essential components, which should be available to all people seeking treatment:



•Fostering patient readiness for and entry into substance abuse treatment

Detoxification can take place in a wide variety of settings and at a number of levels of intensity within these settings. Placement should be appropriate to the patient’s needs.

Patients seeking detoxification services have diverse cultural and ethnic backgrounds as well as unique health needs and life situations. Programs offering detoxification should be equipped to tailor treatment to their client populations.

Detoxification is only one component in the continuum of healthcare services for substance-related disorders. There is a critical need for non-traditional settings—emergency rooms, medical and surgical wards in hospitals, acute care clinics, and others—to be prepared to participate in the process of getting the patient who is in need of detoxification services into treatment as quickly as possible. Furthermore, it promotes the latest strategies for retaining individuals in detoxification while also encouraging the development of the therapeutic alliance to promote the patient’s entrance into substance abuse treatment.

Programs should be addressing psycho-social issues that may impact detoxification treatment, such as providing culturally appropriate services to the patient population.

Matching patients to appropriate care represents a challenge to detoxification programs. Given the wide variety of settings and the unique needs of the individual patient, establishing criteria that take into account all the possible needs of patients receiving detoxification and treatment services is an extraordinarily complex task.

Placement will depend in part on the substance of abuse. Generally for alcohol, sedative-hypnotic, and opioid withdrawal syndromes, hospitalization or some form of 24-hour medical care is often the preferred setting for detoxification, based on principles of safety and humanitarian concerns.

A further challenge for detoxification programs is to provide effective linkages to substance abuse treatment services. Patients often leave detoxification without followup to the treatment needed to achieve long-term abstinence. 


Treatment Levels

Addiction medicine has sought to develop an efficient system of care that matches patients’ clinical needs with the appropriate care setting in the least restrictive and most cost-effective manner.

The five “Adult Detoxification” placement levels—define the most broadly accepted standard of care for detoxification services. The five levels of care are:

1. Level I-D: Ambulatory Detoxification Without Extended Onsite Monitoring

2. Level II-D: Ambulatory Detoxification With Extended Onsite Monitoring

3. Level II.2-D: Clinically Managed Residential Detoxification

4. Level III.7-D: Medically Monitored Inpatient Detoxification

5. Level IV-D: Medically Managed Intensive Inpatient Detoxification ASAM criteria are being adopted extensively on the basis of their face validity, though their outcome validity has yet to be clinically proven.


The ASAM (the American Society of Addiction Medicine) guidelines are an important set of guidelines that are of great help to clinicians. For administrators, the standards published by such groups as the Joint Commission on Accreditation of Healthcare Organizations and the Commission on Accreditation of Rehabilitation Facilities provide guidance for overall program operations. Placement will depend in part on the substance of abuse. It is generally accepted that for alcohol, sedative-hypnotic, and opioid withdrawal syndromes, hospitalization (or some form of 24-hour medical care) is often the preferred setting for detoxification, based on principles of safety and humanitarian concerns. When hospitalization cannot be provided, then a setting that provides a high level of nursing and medical backup 24 hours a day, 7 days a week is desirable.

A further challenge for detoxification programs is to provide effective linkages to substance abuse treatment services. Patients often leave detoxification without follow up to the treatment needed to achieve long-term abstinence. Each year at least 300,000 patients with substance use disorders or acute intoxication obtain inpatient detoxification in general hospitals, while additional numbers obtain detoxification in other settings. Only 20 percent of people discharged from acute care hospitals receive substance abuse treatment during that hospitalization. Only 15 percent of people who are admitted to a detoxification program through an emergency room and then discharged go on to receive treatment.

A major clinical question for detoxification is the appropriateness of the use of medication in the management of an individual in withdrawal. This can be a difficult matter because protocols have not been firmly established through scientific studies or evidence-based methods. Furthermore, the course of withdrawal is unpredictable and currently available techniques of screening and assessment do not predict who will experience life-threatening complications.

Psychological dependence, co-occurring psychiatric and medical conditions, social supports, and environmental conditions critically influence the probability of successful and sustained abstinence from substances. Research indicates that addressing psychosocial issues during detoxification significantly increases the likelihood that the patient will experience safe detoxification and go on to participate in substance abuse treatment. Staff members’ ability to respond to patients’ needs in a compassionate manner can make the difference between a return to substance abuse and the beginning of a new (and more positive) way of life.




Change happens easily when there are clear punishments for continued same behavior and clear rewards for changed behavior.  We stop touching hot stoves early on because we get hurt. If we find out that something makes us feel happy and there are no costs, we’re going to do it more often. But sometimes, change can be more complex. Making the decision to leave a romantic partner, or to switch careers, might take years of thought and heartache. There are countless pros and cons that cannot easily be boiled down to “better” or “worse”.

Psychotherapy is the art and science of helping others create change through psychological means, and the countless approaches give us several ways to achieve these goals. Some theories view change as a purely behavioral process. Others focus on genetics as the influence on behavior.  Still, others suggest that the answer is education. If a person learns about the possible consequences of a behavior, they will change.

Motivational interviewing, sometimes referred to as MI, is a client-centered, directive counseling method aimed at enhancing intrinsic motivation that helps people resolve ambivalent feelings and insecurities to find the internal motivation they need to change their behavior. It is a practical, empathetic, and short-term process that takes into consideration how difficult it is to make life changes.

Motivational interviewing is often used to address addiction and the management of physical conditions such as diabetes, heart disease, and asthma. This intervention helps people become motivated to change the behaviors that are preventing them from making healthier choices. It can also serve as a pre-curser to other types of therapies that can address other issues. Research has shown that this intervention works well with individuals who start off unmotivated or unprepared for change. Motivational interviewing is also appropriate for people who are angry or hostile regarding the changes that are necessary. They may not be ready to commit to change, but motivational interviewing can help them move through the emotional stages of change necessary to find their drive and make peace with change.

Motivational interviewing evolved from Carl Roger’s person-centered, or client-centered, approach to counseling and therapy. It shares Carl Rogers’ optimistic and humanistic theory about people’s capabilities for exercising free choice and changing through a process of self-actualization. The therapeutic relationship for both Rogerian and motivational interviewers is a democratic partnership.  Jumping off from this foundation, clinical psychologists William R. Miller and Stephen Rollnick elaborated on these fundamental concepts and approaches in 1991 in a more detailed description of clinical procedures. Core concepts evolved from experience in the treatment of problem drinkers, and Motivational Interviewing was first described by) in an article published in Behavioural Psychotherapy.   Compared with non-directive counseling, it is more focused and goal-directed and departs from traditional Rogerian client-centered therapy through this use of direction, in which therapists attempt to influence clients to consider making changes, rather than engaging in non-directive therapeutic exploration. 

Client-Centered therapy uses an empathetic style of interaction.  The therapist expresses acceptance toward the client, even if they feel their behaviors are harming them or their loved ones.  The therapist does not need to condone the behavior, but acceptance is key.  Acceptance is the willingness to listen, understand, and to respect the client as a human being. 

The Motivational Interviewing process is aimed at increasing an individual’s reason for the change and then for the individual to fully commit to the change that is necessary. As opposed to simply stating a need or desire to change, hearing themselves express a commitment out loud has been shown to help improve a client’s ability to make those changes. The role of the therapist is more about listening than intervening. Motivational interviewing is often combined or followed up with other interventions, such as cognitive therapy, support groups such as Alcoholics Anonymous and stress management and coping strategy training.

There are four overlapping processes that comprise Motivational Interviewing: engaging, focusing, evoking and planning. They are both sequential and recursive, and often depicted in diagrams as stair steps, with engaging at the bottom as the first step.

  1. Engaging: the process of establishing a working relationship based on trust and respect. The client should be doing most of the talking, as the counselor utilizes the skill of reflective listening throughout the process. Both the client and counselor make an agreement on treatment goals and collaborate on the tasks that will help the client reach those goals.
  2. Focusing: the ongoing process of seeking and maintaining direction.
  3. Evoking: eliciting the client’s own motivations for change, while evoking hope and confidence.
  4. Planning: involves the client making a commitment to change, and together with the counselor, developing a specific plan of action.


Motivational interviewing is a counseling style based on the following assumptions:

  • Ambivalence about change is normal and constitutes an important motivational obstacle in recovery.
  • Ambivalence can be resolved by working with a client’s intrinsic motivations and values.
  • The alliance between the counselor and the client is a collaborative partnership to which each brings important expertise.
  • An empathic, supportive, yet directive, counseling style provides conditions under which change can occur. (Direct argument and aggressive confrontation may tend to increase client defensiveness and reduce the likelihood of behavioral change.)


In this section, we will explore the five basic principles of Motivational Interviewing that can be used to address ambivalence and to facilitate the change process. We will also look at approaches to use with clients in the early stages of treatment.



Ambivalence is defined as the state of having mixed feelings or contradictory ideas about something whereas denial is defined as the action of declaring something untrue.  It is important to see the difference between these two.  They both might be part of an issue, but they are different.  An individual who is obese, addicted to substances or gambling or perhaps has anger issues is usually aware of the dangers of their behavior but continue anyway. They are somewhat unsure of their ability to control these behaviors.  There is certainly an element of denial in the seriousness of the issue, but everyone knows that smoking is bad for your lungs.  Everyone is aware that donuts are not a healthy snack.  An individual may want to stop smoking, but at the same time, they don’t want to quit either.  There is a positive intention and most of the time a reward for their behavior despite the knowledge they have regarding the drawbacks of continuing the behavior.  They enter treatment programs because a family member or court system makes them while they express the problem isn’t that big.  These disparate feelings can be characterized as ambivalence, and they are natural, regardless of the client’s state of readiness. It is important to understand and accept the client’s ambivalence because ambivalence is often the central problem.  If a counselor interprets ambivalence as only denial or resistance, friction between the counselor and the client tends to occur.  Ambivalence is, “I want to quit drinking because I’m an angry drunk and always fight with my wife when I drink but I enjoy the social aspects and its so hard.”  Denial is, “the only issue with my drinking is my wife is no fun and gets on my case”. 

The motivational interviewing style facilitates exploration of stage-specific motivational conflicts that can potentially hinder further progress. However, each dilemma also offers an opportunity to use the motivational style to help your client explore and resolve opposing attitudes.

To effectively implement Motivational Interviewing Dr. Miller and Dr. Rollnick developed three mnemonics to assist: RULEPACE, and OARS.

RULE can be used to remember the core principles of MI.  First, Resist the righting reflex, which means the counselor should resist giving suggestions to the client for his or her problem. While the counselor may mean well, offering suggestions might make the patient less likely to make a positive change. A counselor can attempt to Understand the client’s motivation by being a careful listener and attempting to elicit the client’s own underlying motivation for change. Listen with a patient-centered, empathic approach. Lastly, Empower the client. He must understand that he is in control of his actions, and any change he desires will require him to take steps toward that change.



PACE is the “spirit” or mindset that clinicians should have when conducting MI.  Always work in Partnership with the patient; this allows the patient and clinician to collaborate on the same level. While the counselor is a clinical expert, the client is an expert in prior efforts at trying to change his or her circumstances for the better. The therapeutic environment should be as positive as possible so that the client will find it comfortable to discuss a change. The client should see the clinician as a guide who offers information about paths the patient may choose, not someone who decides the destination.  While the counselor continues to educate the client about the harms of behaviors such as excessive drinking or substance use, they recognize that ultimately the decision is the clients. Every effort should be made to draw from the clients’ goals and values, so that the client, and not the clinician, can argue for why change is needed. This Acceptance helps foster an attitude that the counselor is on the client’s side and that his past choices in life do not negatively affect the counselor’s perception of him. The client should be accepted for who he is, and not met with disapproval over any personal decisions that he made. Exercise Compassion towards the client’s struggles and experiences, and never be punitive. Every attempt to have discussions that can be Evocative for the client should be made. Strong feelings and memories can be particularly salient to discuss, especially if they could help change the patient’s attitude towards maladaptive behaviors.



OARS is an acronym to represent core interviewing skills.  OARS stands for Open-ended questions, Affirmations, Reflection, and Summaries

Open-ended questions get the client to think before responding, providing frequent affirmations of the client’s positive traits, using reflective listening techniques while the client talks about his disorder, and providing succinct summaries of the experiences expressed by the client throughout the encounter to invite continued exploration of his behaviors are all skills for the counselor to develop.

Examples of open-ended questions include:

“What brought you here today?”
“Help me…” or “Tell me more about…”
“What will happen if you don’t….”
“Suppose you don’t make a change, what is the worst that might happen?”
“What would you like to see different about your current situation?”


Affirmations are used to recognize a client’s strengths, successes, and efforts to change.  Examples of affirmations include:

“Your commitment really shows by….”
“You showed a lot of strength by…..”
“It is clear this is important to you because you….”


Reflections keep the counselor connected to the client’s thoughts, suspending judgment, acknowledging what the client said and helps them to feel validated.  Examples of reflections include:

“What I hear you saying is….”
“It seems as if….”
“I get the sense that you want to change, and you have concerns about…”
“It sounds like…”


Summaries can be used throughout an interaction.  They are a form of reflective listening.  Examples of summarizing include:

“So what I understand you have said is….”
“If I hear you….”


Five Principals in Motivational Interviewing

Motivational interviewing has been practical in focus. The strategies of motivational interviewing are more persuasive than coercive, more supportive than argumentative. The motivational interviewer must proceed with a strong sense of purpose, clear strategies and skills for pursuing that purpose, and a sense of timing to intervene in particular ways at incisive moments (Miller and Rollnick, 1991, pp. 51-51).

The clinician practices motivational interviewing with five general principles in mind:

  1. Express empathy through reflective listening.
  2. Develop discrepancy between clients’ goals or values and their current behavior.
  3. Avoid argument and direct confrontation.
  4. Adjust to client resistance rather than opposing it directly.
  5. Support self-efficacy and optimism.



Empathy is the ability to understand and share the feelings of another.  It is the experience of understanding another person’s thoughts, feelings, and condition from his or her point of view, rather than from one’s own. Empathy facilitates pro-social or helping behaviors that come from within, rather than being forced, so that people behave in a more compassionate manner.  Reflective listening is sometimes used to build and show empathy through understanding.  It is a communication strategy involving seeking to understand a speaker’s idea, then offering the idea back to the speaker, to confirm the idea has been understood correctly. It attempts to reconstruct what the client is thinking and feeling and to relay this understanding back to the client.

Empathy should not be confused with identification with the client or the sharing of common past experiences. The key component of expressing empathy is reflective listening.

An empathetic style:

  • Communicates respect for and acceptance of clients and their feelings
  • Encourages a nonjudgmental, collaborative relationship
  • Allows you to be a supportive and knowledgeable consultant
  • Sincerely compliments rather than denigrates
  • Listens rather than tells
  • Gently persuades, with the understanding that the decision to change is the client’s
  • Provides support throughout the recovery process

Empathic motivational interviewing establishes a safe and open environment that is conducive to examining issues and eliciting personal reasons and methods for change. A fundamental component of motivational interviewing is understanding each client’s unique perspective, feelings, and values. The attitude of acceptance, but not necessarily approval or agreement, recognizing that ambivalence about change is to be expected is again a very important piece of this approach. Motivational interviewing is most successful when a trusting relationship is established between you and your client.

Understanding and empathy can be conveyed through skillful reflective listening with the knowledge that acceptance facilitates change and ambivalence is a normal feeling. 


Discrepancy Between Client’s Goals or Values and Current Behavior

Although MI is client-centered, unlike classic Rogerian therapy, it is more goal-driven and directional. That is, there is a clear positive behavioral outcome, e.g., quitting smoking, losing weight, adhering to medication. As clients experience a discrepancy between their current behavior and their personal core values or life goals through their own words a clarification of values occurs that often leads to an affliction of the comfortable.  When clients perceive discrepancies between their current situation and their hopes for future change is likely to occur.

The counselor’s task is to help focus the client’s attention on how current behavior differs from ideal or desired behavior. The discrepancy is initially highlighted by raising your clients’ awareness of the negative personal, familial, or community consequences of problem behavior and helping them confront the behavior, i.e. substance use, that contributed to the consequences. Although helping a client perceive discrepancy can be difficult, carefully chosen and strategic reflecting can underscore incongruities.

A successful strategy is to separate the behavior from the person and help the client explore how important personal goals (e.g., good health, marital happiness, financial success) are being undermined by current behavior. This requires the counselor to listen carefully to the client’s statements about values and connections to community, family, and church. If the client shows concern about the effects of personal behavior, highlighting this concern to heighten the client’s perception and acknowledgment of discrepancy can help produce the client’s own cognitive shift.

Once a client begins to understand how the consequences or potential consequences of current behavior conflict with significant personal values, the counselor can amplify and focus on this discordance until the client can articulate consistent concern and commitment to change.

One useful tactic for helping a client perceive discrepancy is sometimes called the “Columbo approach” (Kanfer and Schefft, 1988). This approach is particularly useful with a client who prefers to be in control. Essentially, the clinician expresses understanding and continuously seeks clarification of the client’s problems but appears unable to perceive any solution. A stance of uncertainty or confusion can motivate the client to take control of the situation by offering a solution to the clinician (Van Bilsen, 1991).

Motivational Interviewing information is frequently presented using an ELICIT-PROVIDE-ELICIT framework. The counselor first elicits the person’s understanding and need for information, then provides new information in a neutral manner, followed by eliciting what this information might mean for a client, using a question such as, “What does this mean to you” or “How do you make sense of all this?” MI practitioners avoid trying to persuade clients with “pre-digested” health messages and instead allow clients to process information and find what is personally relevant for them. Autonomy is supported by also asking how much information the client might desire.

Developing discrepancies include:

  • Developing awareness of consequences helps clients to examine their behavior
  • A discrepancy between present behavior and important goals motivates change.
  • The client presents the arguments for change.


Avoid Argument

A counselor may occasionally be tempted to argue with a client who is unsure about changing or unwilling to change, especially if the client is hostile, defiant, or provocative. However, trying to convince a client that a problem exists or that change is needed could precipitate even more resistance. If the counselor tries to prove a point, the client predictably takes the opposite side. Arguments with the client can rapidly degenerate into a power struggle and do not enhance motivation for beneficial change. When it is the client, not the counselor, who voices arguments for change, progress can be made. The goal is to “walk” with clients (i.e., accompany clients through treatment), not “drag” them along (i.e., direct clients’ treatment).

Resistance can be seen as a signal to change strategies or listen more carefully to the client’s reasons for a particular behavior.  Resistance offers the counselor an opportunity to respond in a new, perhaps surprising way to gain an alliance toward overcoming a legitimate obstacle to new behavior.


Roll With Resistance

Confronting clients can evoke reactance and shut them down. Therefore, Motivational Interviewing counselors “roll with resistance” rather than attempt to argue with the client. Such reflections can be thought of as “comforting the afflicted.” The counselor can “pull up alongside clients,” essentially agreeing with the client, even if the statement is factually incorrect or unfairly places blame on others. Examples include: “You really enjoy smoking weed. You look forward to lighting up at night and giving it up seems very difficult” or “eating at McDonalds has filled a need for you. It’s cheap, convenient, and really works given your busy schedule”. Such reflections help capture the client’s reasons for not changing and allow them to express their resistance without feeling pressured to change or worrying about being judged.

Resistance is a legitimate concern for the clinician because it is predictive of poor treatment outcomes and lack of involvement in the therapeutic process. One view of resistance is that the client is behaving defiantly. Another, perhaps more constructive, the viewpoint is that resistance is a signal that the client views the situation differently. This requires the counselor to understand the client’s perspective and proceed from there.

Adjusting to resistance is similar to avoiding an argument in that it offers another chance to express empathy by remaining nonjudgmental and respectful, encouraging the client to talk and stay involved. Try to avoid evoking resistance whenever possible and divert or deflect the energy the client is investing in resistance toward positive change.


Simple Reflection:

The simplest approach to responding to resistance is with nonresistance, by repeating the client’s statement in a neutral way. This acknowledges and validates what the client has said and can elicit an opposite response.

Client: I don’t plan to quit drinking anytime soon.

Clinician: You don’t think that abstinence would work for you right now.


Amplified Reflection:

Another strategy is to reflect the client’s statement in an exaggerated form–to state it in a more extreme way but without sarcasm. This can move the client toward positive change rather than resistance.

Client: I don’t know why my wife is worried about this. I don’t drink any more than any of my friends.

Clinician: So, your wife is worrying needlessly.

Amplified negative reflections are a way of arguing against change by exaggerating the benefits of or minimizing the harm associated with risky behavior.  It may take the form of “, so you see no benefit in changing XX”.  The counselor, by arguing against change can exhaust the client’s negativity. In response, clients will often then reverse their course, and start to argue for change. This type of reflection poses some potential risks and can occasionally backfire. Important here is for the counselor to avoid any tone of sarcasm. This type of reflection is particularly useful when clients appear stuck in a “yes, but” mindset.


Double-Sided Reflection:

A third strategy entails acknowledging what the client has said but then also stating contrary things they have said in the past. This requires the use of information that the client has offered previously, although perhaps not in the same session.

Client: I know you want me to give up drinking completely, but I’m not going to do that!

Clinician: You can see that there are some real problems here, but you’re not willing to think about quitting altogether.

Double-sided reflections capture client ambivalence and communicate to the client that the counselor heard their reasons both for and against change; that the counselor understands the decision is complex, and they are not going to prematurely push them to change. Double-sided reflections typically take the form of “on the one hand, you would like to change XX, but on the other hand, changing XX would mean giving up XX” or “you are torn about changing XX….”


Shifting Focus

A counselor can defuse resistance by helping the client shift focus away from obstacles and barriers. This method offers an opportunity to affirm the client’s personal choice regarding the conduct of his own life.

Client: I can’t stop smoking pot when all my friends are doing it.

Clinician: You’re way ahead of me. We’re still exploring your concerns about whether you can get into college. We’re not ready yet to decide how marijuana fits into your goals.


Reframing a client’s reflections can help them feel understood so the need for resistance is lower. 

Client:  I don’t understand why my wife attacks me about my drinking.  I drink a lot less than most people.  Everyone I know drinks after work.

Clinician:  It sounds like your wife really cares about you, but you feel judged by how she brings it to your attention.

Rolling with resistance can shift perceptions and create new ways of thinking without imposing on them on a client.  The client is a valuable resource for finding solutions to his or her problem.


Reflection On Omission

Sometimes a counselor can reflect on what clients have not said. This can include reflecting on the client’s silence or reluctance to talk about a particular issue; “you don’t seem like talking today or you didn’t have much of a reaction to what I just said. ” In such cases, an omission reflection is an extension of rolling with resistance. However, an additional permutation includes reflecting the client beliefs, solutions to problems, sources of help, etc. that have not been raised. For example, if an otherwise happily married woman states that she has no one to exercise with, the counselor could reflect “so it sounds like your husband is not the answer.” Another variation might include, “so I assume you probably have thought about trying XX solution/option but that doesn’t seem to work for you.”


Support Self-Efficacy

The client’s feeling of selfefficacy through his or her having an active role in the decision-making process ultimately has a very positive effect on the outcome of therapy.  Many clients do not have a well-developed sense of self-efficacy and find it difficult to believe that they can begin or maintain behavioral change. Improving self-efficacy requires eliciting and supporting hope, optimism, and the feasibility of accomplishing change. This requires the counselor to recognize the client’s strengths and bring these to the forefront whenever possible. Unless a client believes change is possible, the perceived discrepancy between the desire for change and feelings of hopelessness about accomplishing change is likely to result in rationalizations or denial in order to reduce discomfort. Because self-efficacy is a critical component of behavior change, it is crucial the clinician also believes in the clients’ capacity to reach their goals.

A strong sense of efficacy can be developed through mastery experiences, vicarious learning experiences, and physical and emotional states.

Mastery experiences are personal experiences that give people a sense of accomplishment and a feeling of mastery. By managing challenges through successive achievable steps, people develop a sense of mastery. Mastery experiences are the most effective way to develop a strong sense of efficacy because they offer the most authentic evidence that one can do what it takes to succeed. Success experiences help build self-efficacy, while failures undermine it. For example, using the weight loss example, a person who has lost weight in the past is more likely to have higher self-efficacy in this area than someone who has not been able to lose weight previously. 

Vicarious experiences through social modeling are another way to develop self-efficacy. If people see others similar to themselves succeed through persistent effort, they may come to believe they, too, can succeed in similar activities. The impact vicarious experiences have on self-efficacy depends on how similar to the model people perceive themselves to be. The greater the perceived similarity, the more impact the model’s successes and failures will have on a person’s self-efficacy beliefs.

Clients frequently use their physical and emotional states to judge their capabilities. An elevated mood can enhance self-efficacy, while a negative mood may diminish it. Clients tend to associate stress, tension, and other unpleasant physiological signs with poor performance and perceived incompetence. In activities requiring strength and stamina, feelings of fatigue and pain cause self-efficacy beliefs to decrease. Clients with a strong sense of efficacy are more likely to view their state of emotional arousal as energizing, while people with a weak sense of efficacy will view their state of emotional arousal as debilitating.

Discussing treatment or change options that might still be attractive to clients is helpful when helping to develop self-efficacy, even though they may have had limited success in the past. It is also helpful to talk about how persons in similar situations have successfully changed their behavior. Other clients can serve as role models and offer encouragement. Nonetheless, clients must ultimately come to believe that change is their responsibility and that long-term success begins with a single step forward. The AA motto, “one day at a time,” may help clients focus and embark on the immediate and small changes that they believe are feasible.

Education can increase clients’ sense of self-efficacy. Credible, understandable, and accurate information helps clients understand how to make changes. A process that initially feels overwhelming and hopeless can be broken down into achievable small steps toward recovery.

A belief in the possibility of change is an important motivator.  The client is responsible for choosing and carrying out personal change. 


Overview Of Motivational Interviewing As A Therapy

(Parts of this section are from Stephen Rollnick, Ph.D., & William R. Miller, Ph.D. What is motivational interviewing? Behavioral and Cognitive Psychotherapy, 23, 325-334.  Dr. Rollnick and Dr. Miller are credited in part with the developed Motivational Interviewing.)

When implementing motivational interviewing it is important to distinguish between the spirit of motivational interviewing and the specific techniques of the therapy. Clinicians who become too focused on techniques can lose sight of the concepts that are central to the approach. A counselor should focus on the idea that motivation to change is elicited from the client, and not be imposed. Other motivational approaches have emphasized coercion, persuasion, constructive confrontation, and the use of external contingencies (e.g., the threatened loss of job or family). Such strategies may have their place in evoking change, but they are quite different in spirit from motivational interviewing which relies upon identifying and mobilizing the client’s intrinsic values and goals to stimulate behavior change. 

It is the client’s task, not the counselor’s, to articulate and resolve his or her ambivalence. Ambivalence takes the form of a conflict between two courses of action (e.g., indulgence versus restraint), each of which has perceived benefits and costs associated with it. Many clients have never had the opportunity of expressing the often confusing, contradictory and uniquely personal elements of this conflict. For example, “If I stop smoking, I will feel better about myself, but I may also put on weight, which will make me feel unhappy and unattractive.” The counselor’s task is to facilitate the expression of both sides of the ambivalence impasse and guide the client toward an acceptable resolution that triggers change.  

Direct persuasion is not an effective method for resolving ambivalence.  These tactics generally increase client resistance and diminish the probability of change.  

The counseling style is generally a quiet and eliciting one. Direct persuasion, aggressive confrontation, and argumentation are the conceptual opposite of motivational interviewing and are explicitly proscribed in this approach. To a counselor accustomed to confronting and giving advice, motivational interviewing can appear to be a hopelessly slow and passive process. The proof is in the outcome. More aggressive strategies, sometimes guided by a desire to “confront client denial,” easily slip into pushing clients to make changes for which they are not ready.  

The counselor is directive in helping the client to examine and resolve ambivalence. Motivational interviewing involves no training of clients in behavioral coping skills, although the two approaches are not incompatible. The operational assumption in motivational interviewing is that ambivalence or lack of resolve is the principal obstacle to be overcome in triggering change. Once that has been accomplished, there may or may not be a need for further intervention such as skill training. The specific strategies of motivational interviewing are designed to elicit, clarify, and resolve ambivalence in a client-centered and respectful counseling atmosphere.

Resistance and “denial” are seen not as client traits, but as feedback regarding therapist behavior. Client resistance is often a signal that the counselor is assuming greater readiness to change than is the case, and it is a cue that the therapist needs to modify motivational strategies.

The therapeutic relationship is more like a partnership or companionship than expert/recipient roles. The therapist respects the client’s autonomy and freedom of choice (and consequences) regarding his or her own behavior. Viewed in this way, it is inappropriate to think of motivational interviewing as a technique or set of techniques that are applied to or (worse) “used on” people. Rather, it is an interpersonal style, not at all restricted to formal counseling settings. It is a subtle balance of directive and client-centered components shaped by a guiding philosophy and understanding of what triggers change.

The motivational interviewing style includes:

  • Seeking to understand the person’s frame of reference, particularly via reflective listening
    Expressing acceptance and affirmation
  • Eliciting and selectively reinforcing the client’s own self-motivational statements and expressions of problem recognition, concern, desire and intention to change, and ability to change
  • Monitoring the client’s degree of readiness to change and ensuring that resistance is not generated by jumping ahead of the client.
  • Affirming the client’s freedom of choice and self-direction. The point is that it is the spirit of motivational interviewing that gives rise to these and other specific strategies and informs their use.


In early treatment sessions, a counselor should determine the client’s readiness to change by asking open-ended questions.  Open-ended questions help a counselor understand the clients’ point of view and elicits their feelings about a given topic or situation. Open-ended questions facilitate dialog; they cannot be answered with a single word or phrase and do not require any particular response. They are a means to solicit additional information in a neutral way. Open-ended questions encourage the client to do most of the talking, they help the counselor to avoid making premature judgments, and they keep communication moving forward.

Reflective listening, summarizing, affirming, eliciting self-motivational statements can all help the client move to new behaviors that better serve their values and goals.

Components of successful Motivational Interviewing:

  • Empathy– the ability to understand and identify another person’s experience and communicate that perception back to the person is one of the main components of establishing rapport. Empathy and Hope are the most important components of good counseling.
  • Active Listening– involves attending skills and reflective listening. This helps counselors connect with the client by reflecting what the client’s underlying thoughts and feelings are back to the client.  The counselor can also provide useful feedback to the client that may include observations that the client had not considered.
  • Concreteness– the counselor will translate the vague aspects of the client’s statements and experiences into specific concrete terms in order to help the client develop more effective coping skills.
  • Paraphrasing– includes the therapeutic qualities of empathy and warmth. Comprises the counselor’s verbal responses that rephrase the content of the client’s statements into a meaningful conclusion. It allows the client to hear what he or she has just said and applies added clarity of meaning for the client.  This helps increase trust and reduces the client’s resistance.
  • Reflecting– This occurs when the counselor rephrases content that generated emotion in the client. It reflects feeling.  Reflection captures the essence of what a client is feeling and states it back to the client. This helps the client be aware of his or her own expressed emotions and how the counselor understood the client’s emotional message.  Counselors are warned not to interpret their clients’ feelings.  Do not offer opinions, judgments or advice at this point.
  • Simplifying– includes reflection and restatement of what the client is trying to convey in a concise and clear way. It removes confusion and avoids intellectualization. Simplifying helps clients stay focused on specific problems in the here and now.”
  • Summarizing– involves tying together the main points, themes and issues.
  • Attending– refers to how the counselor pays attention to the client using cues.
  • Probing– consists of asking open-ended questions in order to clarify information and help the client gains an insightful understanding.
  • Reframing– involves offering a different perspective on a problem or circumstance the client is facing.
  • Exploring Alternatives– helping the client develop and consider various options.
  • Self-disclosure– this is when the counselor shares something personal about himself or herself that is beneficial to the client.
  • Confrontation– this is when a counselor raises a point to challenge a discrepancy that the client presented.
  • Immediacy– this involves interpersonal counseling, where the clinician discusses issues between himself or herself and the client in the present.

Motivational interviewing has been shown to be a useful clinical intervention and is an effective, efficient, and adaptive therapeutic style.

Motivational interviewing has the following benefits:

  • Low cost. Motivational interviewing was designed from the outset to be a brief intervention and is normally delivered in two to four outpatient sessions.
  • Efficacy. There is strong evidence that motivational interviewing triggers change in high-risk lifestyle behaviors.
  • Effectiveness. Large effects from brief motivational counseling have held up across a wide variety of real-life clinical settings.
  • Mobilizing client resources. Motivational interviewing focuses on mobilizing the client’s own resources for change.
  • Compatibility with health care delivery. Motivational interviewing does not assume a long-term client-therapist relationship. Even a single session has been found to invoke behavior change, and motivational interviewing can be delivered within the context of larger health care delivery systems.
  • Emphasizing client motivation. Client motivation is a strong predictor of change, and this approach puts primary emphasis on first building client motivation for change. Thus, even if clients do not stay for a long course of treatment (as is often the case with substance abuse), they have been given something that is likely to help them within the first few sessions.
  • Enhancing adherence. Motivational interviewing is also a sensible prelude to other health care interventions because it has been shown to increase adherence, which in turn improves treatment outcomes.

Motivational interviewing is non-judgmental, non-confrontational and non-adversarial. The approach attempts to increase the client’s awareness of the potential problems caused, consequences experienced, and risks faced as a result of the behavior in question. Therapists help clients envision a better future and become increasingly motivated to achieve it.  The strategy seeks to help clients think differently about their behavior and ultimately to consider what might be gained through change.  



Someone once said “an unexamined life is not worth living”, however, it is sometimes easier to buy into the concept of ignorance is bliss. Denial works to block out that which does not serve our reality as we see it. This denial, all positive intention aside, does not always serve us well. The ability to examine our actions and see them for what they are can sometimes be the only true way to bliss.\

In my research on the subject of denial, I have encountered many interesting works. For example, the following excerpt from the Columbia Encyclopedia, Sixth Edition (2001) helped me to realize that denial was recognized as a defense mechanism by early psychologists, in psychology, an ego defense mechanism operates unconsciously to resolve emotional conflict, and to allay anxiety by refusing to perceive the more unpleasant aspects of external reality. In the psychoanalytic theory of Sigmund Freud, denial is described as a primitive defense mechanism. Anna Freud studied the widespread occurrence of denial among small children and explained that the mature ego does not continue to make extensive use of denial, because it conflicts with the capacity to recognize and critically test reality. Most people employ denial at some time in their lives when coping with stressful situations, such as the death of a loved one. Elisabeth Kubler-Ross’s influential theory describes denial as the first stage of a dying persons progress in coming to terms with a terminal illness. In such instances, denial may be considered adaptive. It is considered maladaptive, however, when it becomes delusional. In recent years, the term is used more generally, to describe the suppression of reality rather than a particular defense mechanism in the Freudian sense.

The modern use of denial has a much broader application than was previously conceived. Denial has been described in various ways by many different people. I personally think Webster’s Dictionary’s definition of denial more adequately reflects its current use: an assertion that an allegation is false disbelief in the existence or reality of a thing; self-denial and the reduction of anxiety by the unconscious exclusion from the mind of intolerable thoughts, feelings or facts.   I think also if denial is expressed in a slightly different way it can be more easily understood by individuals who are chemically dependent. For this application, denial is a psychological process typically used to protect or shield the individual from things or situations that threaten or would be painful if encountered by blocking or by masking awareness of these things. Consequently, it is a psychological defense mechanism that distorts reality and shields the individual from the pain and anxiety related to acceptance or acknowledgment of an item or situation. Denial can function as a buffer against experiences we may not be able to accept (at a given time) in our consciousness. It then enables an individual to psychologically adjust to the situation and to mobilize other less radical defenses. From this perspective, one can conclude that denial is a defense mechanism and as such is a very valuable tool to help one cope with situations that would otherwise be beyond his/her ability to deal with. In many cases denial allows a person to cope with situations or to delay the actual encounter until he/she is ready and until it is time for the individual to face what it is that they had previously avoided.


How Big is the Problem of Denial?

The National Household Survey on drug use and abuse revealed that many users who meet criteria for needing substance abuse treatment do not personally recognize that they have a problem. The survey estimated that more than 4.6 million substance-using individuals are in denial regarding their use; consequently, there are approximately 4.6 million individuals in need of professional help that is not likely seeking help because they deny the existence of a problem. As a matter of fact, this situation is believed to account for the high rate of unsuccessful treatment programs as its very difficult to help someone who does not think they have a problem (ergo denial).

Mr. John Walters, Director of National Drug Control Policy states: we have a large and growing denial gap when it comes to drug abuse and dependency in this country. He went on to state, we have a responsibility as family members, employers, physicians, educators, religious leaders, neighbors, colleagues, friends, and counselors to reach out to help these people. Sometimes it requires a helping individual to apply a tough love concept that focuses on an intervention that will guide the individual toward the help that is needed as opposed to enabling the individual to continue with his or her destructive behavior. While I was in private practice, I had a personal experience with a family that was faced with a complex dilemma. Their teenage son was deeply into hard drugs. The father said his son left home several times and only returned after he had exhausted his money, gotten ill, and was destitute. The father said he and his wife always welcomed their son home, helped to restore him to health and hoped he would never return to drugs. After the parents exhausted all hope they finally realized they were helping (enabling) their son to continue to use by providing a safe place for him to recover after an episode. The parents finally refused to accept their son when he was involved with drugs. Eventually, the son left and the parents had no contact with him for over two years. This story ends on a good note, as so many don’t. The son finally searched and found the help he needed. Through a very comprehensive treatment program, he was able to recover from drugs and learn to live a drug-free life and become a valued member of his family and the community. One will never know how this story would have ended if the parents had continued to enable their son to continue his involvement with drugs. The simple message is that a repetitive cycle of abuse/enabling/denial/abuse can often extend individuals involved with drugs. Sometimes, if not often, when this cycle is disrupted it opens a door to effective treatment. I think one of the most important challenges for the 21st century is to find ways to reach out to help in situations such as this. We must discover better and more effective treatment options to help lead individuals to productive and drug-free lives. Obviously, the earlier in the use-enable cycle an intervention can be made the earlier they are reached, the greater is the likelihood of success.

Types of Denial

Denial is generally accepted as a psychological process that is automatically invoked when an individual faces a threatening and/or frightful situation. It is used to protect an individual by masking their awareness of a pending calamity or by diverting attention toward other things. Therefore, it is a psychological defense mechanism that distorts reality and helps an individual to avoid the feeling of acute pain associated with the situation. It is common for most individuals to experience denial. For example, an individual will often reject unfavorable medical diagnosis, family issues, dysfunctional relationships or negative behavioral indicators. The tendency is to report that everything is fine when in reality their life may be very chaotic.

There are also unique applications of denial in the chemically dependent sub-population. It appears they have taken a basic, natural process and perfected it for their personal benefit. In other words, they become professionals at denial and use it to the determent of themselves, to the frustration of their counselors and to the harm of those around them. The end result for many addicted individuals is that they need to hang-on to denial as it enables them to continue their use and abuse of alcohol and/or other drugs. It is also interesting to note the progressive nature of denial (small lies to larger lies and so on) and to recognize that the progression of denial parallels the progression of the disease of addiction (more on this later).

Individuals also develop methods, tendencies and creative ways of retaining their denial or to avoid even having to admit (to others) that they use various forms of denial on a regular basis. The following are common types of denial that are used by the chemically dependent individual, as well as other persons. It should be noted that most forms of denial are not necessarily unhealthy nor do they (in themselves) reflect an out of control personality. However, for most chemically dependent individuals it is a fairly accurate indicator of the severity of his/her problem.

  1. SIMPLE DENIAL: characterized by an individual stating views that are in opposition to the obvious; denying addiction when all indicators are positive for dependency.
  2. MINIMIZING: comparing one’s self to others who may have a more serious problem “I’m okay compared to John who drinks to excess on a daily basis.”  The individual may admit to a problem, but in such a way that it appears less serious than it actually is. An example is to admit to drinking but generally concludes with not that much or “I’m okay to drive”.
  3. RATIONALIZING: making excuses to justify behavior. Example: I have trouble getting to sleep, so I drink or use other drugs; I usually don’t drink and drive but a co-worker needed a ride home. The key to rationalization is that the behavior is not denied, but generally, a fabricated or enhanced explanation as to the cause is given.
  4. INTELLECTUALIZING: avoiding emotional and personal awareness of a problem by explaining away the generally accepted criteria for defining chemical dependency. Challenging the establishment with statements like everyone drinks wine with dinner; my father was an alcoholic; consequently, I don’t have a choice but to drink; my childhood was so bad, it helps me cope with my emotions and feelings.
  5. PROJECTING: placing the blame for a behavior somewhere else. Statements like: if you were married to him/her, you would drink also; I was laid off, that makes me drink. Again, the behavior is not denied, but its cause is placed on something or someone else.
  6. DIVERSION: changing the focus away from a subject that is threatening. An example of diversion is to respond with a jovial remark such as, if you think I was drunk you should have seen the others.
  7. BARGAINING: making deals or setting conditions such as I’ll stop drinking if you stop smoking.
  8. PASSIVITY: ignoring the situation or developing a cant win attitude. An example of this is, there is nothing I can do because the urge to use is stronger than I am. The individual is a victim of the situation.
  9. HOSTILITY: becoming angry and exhibiting threatening behaviors when the subject of drinking or using is mentioned. A chemically dependent individual will generally go to whatever level of anger it takes (verbal, emotional, physical, domestic violence, etc.) to convince other parties to avoid talking about that subject. The chemically dependent individual typically views a discussion of his/her problem as a personal attack and reacts accordingly.

Denial may be automatic in most situations, however, it may not be a matter of deliberate lying or willful deception. Unfortunately, most chemically dependent individuals are out of touch with reality to the point where they do not know what is true or false concerning their drinking or drug use and its consequences. The denial system in conjunction with excessive use distorts their perceptions of reality and impairs their judgment to the point that they become self-deluded and virtually incapable of accurate self-awareness. Needless to say, its truly sad when an individual represses the truth even from themselves and destroys their life rather than undergoing treatment and following a prescribed recovery plan.

As noted earlier, denial is generally progressive. Specifically, as the illness of chemical dependency progresses, the denial system becomes increasingly more pronounced and entrenched. In the early stages of alcoholism, for example, it is frequently minimal, and with proper treatment, most people can view their problem objectively and fairly realistically. Unfortunately, by the time an individuals illness is sufficiently advanced that the problem is serious in the perception of others, an elaborate system of defenses shields him or her from being aware of what is really happening. I am reminded of a gentleman in one of my outpatient groups. He had received 6 driving under the influence charges over his lifetime. He had been abusive to his wife while under the influence of alcohol numerous times throughout his 22-year marriage. Even still, he was court-ordered to attend the group! He stated in the group, “mandating me to treatment was the best thing the law ever did for me. I never saw a problem.”



Most addicted persons have assembled around them those who will enable, in some ways support, their destructive behavior. These enablers will help the individual escape the consequences of their actions. In some cases, an enabler will be so proficient they pretend that destructive behavior is not occurring. In this environment with an efficient and dependable protective shield around the addictive individual, he/she is much less likely to accept his/her substance-related problem and to seek and accept treatment. Typical behaviors of the enabling persons include

>Enablers deny that the individual is an alcoholic or addict-they insist the user should be able to control his/her use.

>Socializing (using) with the alcoholic or addict projecting a positive social image and an everything is an okay picture.

>Making excuses for the user’s behavior providing alibis for them when

he/she misses work, school or other commitments.

>Acting on behalf of the alcoholic or taking over their responsibilities.

>Minimizing he/she only drinks at home, he/she will be better when he/she gets a good job.

>Agreeing and rationalization that everybody drinks

>Avoiding crisis protecting and controlling the environment; keep the

peace; cushion the fall.

>Protecting the alcoholic most enablers are proficient in making excuses for the alcoholic’s behavior. For example, calling the boss and reporting an illness or accepting blame for an incident that otherwise would result in a legal problem for the alcoholic.

Through the team of enablers, the addict can continue to drink without ever having to accept the consequences of his/her own behavior. He/she does not have to feel the pain that is caused by drinking. The enabler always rushes in to cushion the addict from the consequences of his/her use; consequently, the addict never experiences the pain of his/her involvement with drugs. It is obvious from most people around the alcoholic that his/her drinking or other drug use has placed him/her in a dependent and helpless situation, however, the addict can continue to believe he/she is independent because he/she has been rescued from the entanglements by his well-meaning enabling team (family, friends, employer, co-worker and possibly counselors).

It should be noted that the relationship between an enabler and the alcoholic is often a two-way street. Often a spouse with low self-esteem can feel useful and also feel that their life is meaningful through his/her helping their spouse. In situations like this the enabler is sometimes in denial regarding their situation and on some level frequently needs the alcoholic to continue to drink so that she will have a purpose in life.

In this environment and with their support system in place, the alcoholic may continue in the progression of the disease of alcoholism until he/she hits bottom. When this occurs even the most dedicated drinker must admit they have a problem. Typically they begin a relapsing phase where they abstain for varying periods of time and then they resume drinking or using. Most enabling teams are quickly regrouped and also resume this prior activity. This relapsing process can continue until the alcoholic or addict finally accepts his/her illness and is willing to accept help. In many cases, the choice is to either accept help or death.


Attributes of Denial

It has been noted by many researchers that denial is progressive. It begins with small, insignificant falsehoods and progresses to where an individual is totally immersed into a lifestyle of misrepresentation and lies. It has been suggested that some individuals progress to the level that they are unable to discern between truth and falsehoods. Many have also hypothesized that denial progresses in direct proportion to the progression of the disease of alcoholism/addiction. Moreover, to better understand the attributes of denial we will look at the disease concept of addiction and then look at the corresponding aspect of denial with regard to the stages of the progression of alcoholism/addiction.

Which came first the chicken or the egg? This has been debated since the beginning of time and we are no closer to an answer today than when we first posed the question. Is it possible that both chicken and the egg are universal in that if you have either you can get the other (assuming the egg has been fertilized)? The argument can be carried over into the addiction versus denial arena. Again, which came first, the addiction or the denial? I will say, based on my own counseling experiences, that I have known some dishonest people who were not substance abusers; however, I have never met an addict whose integrity hadn’t been flexed over the years. Getting closer to the question of how to break the cycle of addiction, it can be stated that addiction and denial are so closely related that both must be worked simultaneously to help the addict get into an effective treatment program and learn how to live a happy and successful life free of drugs.   Program outcome studies reveal that it does very little good to force an alcoholic/addict into treatment prior to his/her acceptance of a substance abuse problem. I will present an overview of the cycle of addiction and then relate to the areas where it may be possible to attack denial.

The cycle of addiction begins with an individual’s set of values surrounding his/her convictions, opinions, persuasions and/or sentiments. In essence, it is one’s belief system and represents the perception one holds toward relationships, values (what’s good/what’s bad; what’s right/what’s wrong, ect.), religion, jobs, ect.. Most professionals in the mental health field agree that most individuals have a very well defined belief system at an early age and this will be further defined by their experiences throughout their lifetime. This belief system will guide their decisions made around most subjects throughout their life. It should be noted this system also includes a set of values or judgments regarding the use and abuse of alcohol and will become the set parameters by which one will judge if they have a problem with drinking or not. For example, if an individual believes that an alcoholic is a falling-down drunk and he or she never falls down while drinking then that person concludes (internally) that he/she does not have a problem with alcohol. Consequently, there is a very close relationship between a faulty belief system and denial. As a matter of fact, most counselors would agree that one of the root causes of denial is because the individual has a flawed concept of alcoholism.

An abnormal or misconceived notion or belief system results in an individual making poor decisions. They seldom conceive the truth or the reality of an action or activity. It is very easy to bridge from the concept of impaired thinking to the world of denial for an alcoholic/addict. The main form of denial (rationalizing, minimizing and blaming) are all mental exercises to mask the reality of alcoholism or addiction.

The final element of the cycle of addiction is an out-of-control lifestyle the consequence of which is pain. The good news is that when the pain becomes severe enough, the individual may seek help.

The consequences of an out-of-control lifestyle are increased health problems, more accidents as well as emotional problems such as feelings of shame, guilt, and depression. Again, this relates very well to the attributes of denial during this dependency phase.

The aforementioned concepts help to enhance the understanding of relationships between alcoholism/addiction and denial it goes back to the chicken versus the egg they are universal in that with one an individual almost always has the other. How does one break through denial? I don’t think there is one solution to this problem as we have found out (the hard way) that one treatment modality does not work for everyone. The following is a generalized plan that has proven effective with many substance-abusing clients:

Problem Recognition: The identified patient must be brought to recognize and accept his or her problem. This can be accomplished via an intervention where the family and friends confront the individual with the facts of how his/her behavior is impacting the people around them. This is sometimes more effective concurrent with or immediately after a family crisis. The intervention generally addresses the physical, material and spiritual ramifications of the individuals use. The intervention also results in a disbanding of the enabling team and outlines a plan of care that is aimed at helping the individual accept responsibility for his/her actions, ultimately, the goal is total abstinence.

Another aspect of an effective intervention is to educate the identified patient on the disease of alcoholism/addiction and to increase his/her awareness of the increased health, safety and family risks associated with continued use. The reasons for using substances vary somewhat from person to person but in general, they relate to physical, psychological and social needs of the individual. In an open discussion type environment, such as an intervention, the reasons or layers can be discussed in detail. After all plausible reasons have been discussed and discarded, the intervention team leaders can present a final and sometimes shocking reason and that is one of selfishness. The major theme is that the individual chooses a behavior without concern or caring about what impact his/her behavior may have on others. This can get fairly detailed and deal with safety (driving under the influence with his family in the vehicle), family unity (always absent from family activities), financial support (family income used to purchase alcohol and/or other drugs in lieu of helping meet the needs of the family). 

In conjunction with the intervention, the identified patient should be examined by an addictionologist to determine if medication would ease the withdrawal symptoms. In many cases, medications can also help to reduce the desire or craving for a particular substance. The doctor may also prescribe an anti-anxiety medication and/or other medication that will help calm emotions and help the patient rest and recover more quickly. This is a critical step as much progress has been made in the field of pharmacology and new medications are becoming available on a regular basis.

Concurrent with intervention and medical support is individual counseling and support groups. They are aimed at helping the individual develop additional coping skills and stress management techniques and also to help educate the individuals regarding addictions. The support groups help the individual to relate to other individuals who have had similar problems and have found a way to recover.


Exercises to Break Denial:

If we say that reality is what each of us perceives it to be, then how can we expect to change an addicts perception because that is his/her reality? Again, it relates back to their perception of an alcoholic or addict. If he/she believes that an addict is someone who lives under a bridge and they don t then they are not an addict, how do you as a professional help them to help themselves?

One exercise used with a client with multiple charges of underage drinking and DUI, although on the abrupt side follows: the client was asked about her most recent DUI and she said it was no big deal she wasn’t hurt and the other guy was released from the hospital with just a broken leg. She stated she drank because all of her friends were older than her and that was the only way to hang out with them. She expressed that she was going to continue her drinking despite the past and current consequences. In a measure of desperation, the counselor asked her to close her eyes and describe the man she was in an accident with. She said I don’t really know that much about him. The counselor said create it; give him a name, a family and so on. The counselor asked what he looked like, what his name was, how many kids he had and what their names were, what their ages were, what his wife was like, what their family did together on the weekends. They really got to know this created personality. Then the counselor asked the client to change the accident and have him been killed. The counselor asked the client to describe the family’s reaction, the funeral, etc.. The client was disturbed by the exercise. The point of counseling is not to upset your client with scenarios that didn’t even happen, but the exercise did help the client grow in a very necessary direction. She agreed this could have been the result and felt differently leaving the office.

Another exercise is to have a client write a story about what their life would be like if their drinking or drug abuse was out of control. Then go back and look at how the story parallels what they have heard their family, friends, and co-workers complain about in reality. In what ways does it sound familiar to what they have already or very nearly gone through?

It can be helpful for a client to list any and all of the consequence they have endured at the hands of others due to their own drinking. The consequences, in the beginning, are the fault of the others, but none the less they can see the negative impact using has had on their life.

The use of tests such as the SASSI can often help individuals see in black and white so to speak that the medical field would classify them as problematic users and caution them regarding continued use.

Group treatment can also be effective at helping individuals see through their own denial. In hearing stories from others who they can clearly see have issues with abuse and dependency they can see similarities in themselves without it being forced upon them. Being told something or coming to their own conclusion can make a world of difference.

The net result inherent in this process is that denial is broken down concurrent with breaking the addiction cycle. I seriously doubt if breaking through denial would be effective without addressing the problem of chemical dependency. In summary, the issues must be addressed concurrently.




Across the U.S., many families struggle with teen alcohol and other drug (AOD) use or misuse. Results from a recent survey show that by the 8th grade about 36% of teens in the U.S. have used alcohol at some point in their life; this number increases to 71% by the 12th. As for use of any illegal drugs, about 21% of teens have used some form of illegal drug by 8th grade, with the number increasing to just over 48%by the 12th grade. Although the number of teens who report that they have used AODs has gone down over the past ten years, there are still many teens that are using drugs and alcohol regularly and in unsafe ways.

Risk Factors1

Why Do Teens Use Alcohol and Other Drugs (AODs)?

Even though it is illegal for anyone in the U.S. under age 21 to buy or be caught with alcohol or illegal drugs, many teens are still using. Alcohol use and the abuse of prescription drugs are common among teens. The most common drugs teens report using include alcohol, tobacco, caffeine, pot or weed (marijuana), and pills that were not prescribed to them. Other less used drugs include opiates, cocaine, amphetamines, hallucinogens, depressants, inhalants, club drugs, and performance-enhancing drugs.

Experts believe there are a number of reasons youth use AODs. First, recent research shows that the brain does not fully develop until around a person’s mid-twenties. The area of the brain that is last to develop is the pre-frontal cortex, which is in charge of judgment and decision making. This is thought to be one reason why risky behaviors among teens is so common and why adults always puzzle over poor decisions teens make.

Researchers have found that teens start using drugs and alcohol for four main reasons:

Risk Factors2(1) to improve their mood;

(2) to receive social rewards;

(3) to reduce negative feelings; and

(4) to avoid social rejection.

Teens who reported social reasons for drinking were more likely to report moderate drinking. Those who wanted to improve their mood reported heavy alcohol use while those looking to reduceRisk Factors6 negative feelings showed problematic drinking patterns. Experts point to peer pressure and other social reasons for initial use of substances during teen years. Teens will sometimes copy what their friends do to feel accepted, and some are curious about the effects of drugs on their mood and behavior.


What Are the Problems with Teen Drug and Alcohol Use?

Drug and alcohol use during the teen and young adult years can lead to many problems for teens and their families. Teen AOD misuse can lead to skipping school, bad grades, conflict in relationships with friends and peers, rocky family relationships, and can cause poor brain function, concentration, and other areas of brain development. Some teens also get in trouble with the law and end up in court, involved with police and Social Services, and may spend time in juvenile detention. Teens that begin using AODs earlier are more likely to be heavy users and may become chemically dependent on substances later. These problems have a negative impact on the life of the teen and on their future work life, family relationships, friendships, and overall health.



The rapid decline of health and appearance is evident in the faces of the pictures of young adults who use drugs.  








Is Teen AOD Misuse a Family Issue?

Many experts have pointed to AOD misuse as a family issue, not an individual problem. When it comes to teens, it becomes even clearer. Teens copy what they see the adults in their lives doing, and will use AODs to feel more grown-up or to rebel against adults. AOD use is something teens frequently learn to do from their parents and other adults who misuse alcohol and drugs. It is helpful for parents to give clear messages about the dangers of teen AOD use and pair those messages with rules and consequences that are firm but fair. Following their own rules in the home as an example of responsible, legal, and safe use of alcohol is another important hint for parents. Modeling what you want your child or teen to do in terms of drug and alcohol use is key. Researchers also have found a genetic link that puts people at higher risk for addiction, but they also now know that there is no single “alcoholism gene” that causes addiction. We now know that many risk factors act together to add to a person’s risk of becoming addicted.


What Are the Risk and Preventive Factors for Adolescent Alcohol and Other Drug (AOD) Use and Misuse?

Experts have found that there are a number of risk factors that make a teen more likely to have problems with AOD use in the future. These include individual, family, and community risk factors. Individual risk factors including being male, having an untreated mental health issue (especially ADHD, mood disorders, learning disorders, and PTSD), having low self-esteem, poor grades in school, and poor social and coping skills. Family risk factors include a family history of AOD abuse, poor modeling from parents, chaos at home, and poor communication between parents and children. Community risk factors include a high incidence of AOD abuse and availability of drugs in the community. Obviously, if a teen never encounters AODs, they have no opportunity to use, thereby reducing their risk of addiction to zero. For this reason, experts believe limiting teens’ access to AODs and individuals who use AODs is the very best protective factor for long-term health. While this “abstinence” approach makes sense, it is not likely that teens’ exposure to substances will be extinguished entirely.

Risk Factors4Experts also focus on the factors that protect teens from AOD abuse. These include factors involving parents, peers, community, and school. Parents who model positive behaviors, have good communication skills, set limits, and supervise their teens can improve the chances that their children will avoid AOD use. Having friends who do not abuse AODs helps protects kids, as does having a zero-tolerance policy in the local community. Schools help by providing after school activities, sports, teachers and coaches who are good role models, and quality education.

Marijuana is one of the first drugs teens are often introduced to. Here are some signs of teen marijuana use.

  1. Visine – Healthy teens don’t often need eye-strain medication, red-eyed marijuana smokers concealing their use do need this.
  2. Rolling papers, pipes, a bong, roach clips etc. – Drug paraphernalia is a pretty good indicator of a problem, and once a person acquires marijuana accessories, you can be sure they’ve passed the initial experimentation stage of use. They are not holding these things for friends.
  3. Incense – Incense hides marijuana smells. Incense in the bedroom or a sweet/perfumed smell on clothes can be a warning sign of drug use.
  4. Mouth wash, air fresheners etc. – Like with incense, if your teen suddenly wants or buys scent masking agents this could indicate drug use.
  5. Small burns on the thumb and forefinger – A characteristic injury caused by smoking a joint down to the very end. Nothing else causes this type of burn.
  6. Marijuana stickers or posters – A lot of teens identify with marijuana culture and advertise their association with stickers, pins on school bags and books, or through posters in the bedroom. A marijuana poster above the bed is a pretty good sign of an unhealthy interest in the drug! Code 420 refers to marijuana smoking, and you can often see 420 stickers on school bags.
  7. Talking in code or in a secretive manner with friends while you are in earshot.
  8. A sudden change in friends, especially if long-held good friends get discarded for a new group of seemingly less savory friends.
  9. A sudden need for more money without much to show for it – A marijuana habit can get expensive.
  10. Signs of depression or isolation from the family – Teens crave independence and autonomy, but an unusual demand for isolation in the bedroom and a refusal or strong reluctance to participate in family activities may indicate a problem.
  11. A sudden drop in academic performance – When your previously A and B teen becomes a C and D teen, something is going on.
  12. Your teen no longer participates in activities they used to find very enjoyable and rewarding – Suddenly abandoning sports, music or clubs without replacing these activities with anything other than “hanging out with friends” is not a good sign.
  13. Appearing stoned – An obvious one, but it’s easy to explain-away odd behaviors with wishful thinking. If your teen seems confused, slow and lethargic, they may be high.
  14. A sudden willingness to take the dog for a late-night walk may be an excuse to get out of the house to smoke a joint.
  15. They don’t seem motivated to accomplish any worthwhile goals – Normal teens will have interests, passions, and desires. These desires may not be academic, and they may not be interests that you approve of, but most teens have interests and activities.


What is Available to Help Teens Who Are Using AODs?

images-7AOD intervention programs are useful after a teen has been found to be using or abusing AODs. To decide which program is best for a teen who is drinking or using drugs, a doctor or therapist should meet with the teen to decide how far along their drug use is.

It is important to remember is that AOD use is on a scale from no use to heavy use. A small portion of teens fall on the high end of that scale (drug or alcohol dependence). While teen misuse of AODs calls for some type of intervention, adults should remember that very little use, while still a risk factor, may not need intervention at all. Research tells us, however, that the earlier a teen begins AOD use, the higher at risk they are of future problems. When deciding what programs a teen needs to help them quit drinking or using drugs, the first step is to figure out how much of what the teen is using. While teen use of AODs calls for some form type of program, adults should remember that very little use, while still a risk factor, may not need intervention at all. Health care workers are the best people to decide the need for programs for teens.

Once a healthcare professional has recommended a program for a teen and their family, there are many options that have been found to be helpful. Most teens who have been abusing substances for a short period go into an outpatient program that involves group therapy, individual therapy, and drug education. Most larger communities provide these services. Because teens who are in these types of programs stay where they are living, experts think having the family involved gives the best results for short and long term success.Risk Factors5

Teens who have been assessed and found to be chemically addicted or dependent on AODs most likely will be referred for inpatient treatment. Most major cities have an inpatient treatment program that is either privately owned or run through the county mental health services department. Inpatient treatment may begin with a medical detoxification process for some teens who are at risk of medical complications as the drugs or alcohol leave their system. Others enter inpatient treatment directly where they will experience daily individual and group therapy sessions and academic tutoring. All of their medical, emotional, and mental health issues are addressed in inpatient treatment. Programs that pay attention to all parts of the teen’s health and lifestyle are most helpful, and research has shown that the longer the teen is in the program, the better they do in the long run. Because these programs are usually less than 30 days, many teens are then sent to outpatient programs to continue to learn how to live drug and alcohol-free.

There are many kinds of therapy that are used with teens to help them learn how to cope without drugs and alcohol. Studies show that it is not as important what kind of program a teen attends, but that they feel supported and safe while learning a new skill set. Family therapy is also helpful for many teens who are trying to live without drugs and alcohol.

Another type of program that some teens and families find useful in dealing with AOD use and misuse are self-help groups. These include Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), and are also known as 12-Step groups. These groups are run by other people recovering from addictions and give support to those who are learning to live drug-free lives. These should not be used in place of good treatment programs but as an addition to the support needed for recovery.

While about 80% of teens begin AOD use early in their teen years, only some end up having serious problems because of AOD use. For these teens, professionally run programs can help them stop using and help guard against long-term health and social problems. A brief meeting with a trained professional can help determine the amount and type of AOD misuse so that the teen and his or her family can get the right type of help, whether it is outpatient counseling or inpatient programs. Teens in college now have more options for treatment as well if their AOD use becomes a problem on or off-campus.



All people are different when it comes to their experience with addiction and mental illness. Some begin to experience mental health issues during childhood or adolescence and experiment with drugs and alcohol soon after, developing both an addiction problem and a serious mental illness at the same time.

Others may seek out drugs and alcohol in an attempt to “self-medicate” a mental health issue that develops in early adulthood or that develops out of an injury or trauma later in life.

Still others may first develop an addiction problem that grows so severe that it causes mental health issues or triggers the onset of symptoms that may otherwise have remained dormant.

Formerly known as dual diagnosis or dual disorder, co-occurring disorders describes the presence of both a mental health and a substance-use disorder.

People with mental health disorders are more likely than people without mental health disorders to experience alcohol or substance use disorder. Co-occurring disorders can be difficult to diagnose due to the complexity of symptoms, as both may vary in severity. In many cases, people receive treatment for one disorder while the other disorder remains untreated. This may occur because both mental and substance use disorders can have biological, psychological, and social components. Other reasons may be inadequate provider training or screening, an overlap of symptoms, or that other health issues need to be addressed first. In any case, the consequences of undiagnosed untreated, or under-treated co-occurring disorders can lead to a higher likelihood of experiencing homelessness, incarceration, medical illnesses, suicide, or even early death.

People with co-occurring disorders are best served through integrated treatment. With integrated treatment, practitioners can address mental and substance use disorders at the same time, often lowering costs and creating better outcomes. Increasing awareness and building capacity in service systems are important in helping identify and treat co-occurring disorders. Early detection and treatment can improve treatment outcomes and the quality of life for those who need these services.

The term co-occurring disorder replaces the terms dual disorder and dual diagnosis when referring to an individual who has a co-existing mental illness and a substance-use disorder. While commonly used to refer to the combination of substance use and mental disorders, the term also refers to other combinations of disorders (such as mental disorders and intellectual disability).

Clients with co-occurring disorders (COD) typically have one or more disorders relating to the use of alcohol and/or other drugs as well as one or more mental disorders. A client can be described as having co-occurring disorders when at least one disorder of each type can be established independent of the other and is not simply a cluster of symptoms resulting from another disorder.

Common examples of co-occurring disorders include the combinations of major depression with cocaine addiction, alcohol addiction with panic disorder, alcoholism and poly-drug addiction with schizophrenia, and borderline personality disorder with episodic poly-drug abuse. Thus, there is no single combination of co-occurring disorders; in fact, there is great variability among them.

The combination of a substance use disorder and a psychiatric disorder varies along important dimensions, such as severity, chronicity, disability, and degree of impairment in functioning. For example, the two disorders may each be severe or mild, or one may be more severe than the other. Additionally, the severity of both disorders may change over time. Levels of disability and impairment in functioning may also vary.

People with co-occurring disorders often experience more severe and chronic medical, social, and emotional problems than people experiencing a mental health condition or substance-use disorder alone. Because they have two disorders, they are vulnerable to both relapse and a worsening of the psychiatric disorder. Further, addiction relapse often leads to psychiatric distress, and worsening of psychiatric problems often leads to addiction relapse. Thus, relapse prevention must be specifically designed for the unique needs of people with co-occurring disorders. Compared to patients who have a single disorder, patients with co-existing conditions often require longer treatment, have more crises, and progress more gradually in treatment.



Over time, numerous terms have been used to describe co-occurring disorders and their treatment.

Substance Abuse, Substance Dependence, and Substance-Induced Disorders

In the DSM-IVTR substance-related disorders are divided into substance use disorders and substance-induced disorders.

Substance use disorders are further divided into substance abuse and substance dependence.

There are 11 categories of substance use disorders (e.g., disorders related to alcohol, cannabis, cocaine, opioids, nicotine), which are separated by criteria into abuse and dependence. The term “substance abuse” has come to be used informally to refer to both abuse and dependence. By and large, the terms “substance dependence” and “addiction” have come to mean the same thing, though debate exists about the interchangeable use of these terms.

Finally, the system of care for substance-related disorders is usually referred to as the substance abuse treatment system.

Substance-induced disorders are important to consider in a discussion of co-occurring disorders. Although they actually represent the direct result of substance use, their presentation can be clinically identical to other mental disorders. Therefore, individuals with substance-induced disorders must be included in co-occurring disorder planning and service delivery.

Substance abuse, as defined in the DSM-IV-TR, is a “maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances.

Classes of Substance Use Disorders

-Amphetamine or similarly acting sympathomimetics
-Phencyclidine (PCP) or similarly acting arylcyclohexylamines
-Sedatives, hypnotics, or anxiolytics


Substance dependence is “a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues the of the substance despite significant substance-related problems.   This maladaptive pattern of substance use includes all the features of abuse and additionally such features as:

  • Increased tolerance for the drug, resulting in the need for ever greater amounts of the substance to achieve the intended effect.
  • An obsession with securing the drug and with its use
  • Persistence in using the drug in the face of serious physical or psychological problems

Substance-induced disorders include substance intoxication, substance withdrawal, and groups of symptoms that are “in excess of those usually associated with the intoxication or withdrawal that is characteristic of the particular substance and are sufficiently severe to warrant independent clinical attention.

Substance-induced disorders present as a wide variety of symptoms that are characteristic of other mental disorders such as delirium, dementia, amnesia, psychosis, mood disturbance, anxiety, sleep disorders, and sexual dysfunction.

To meet diagnostic criteria, there must be evidence of substance intoxication or withdrawal, maladaptive behavior, and a temporal relationship between the symptoms and the substance use must be established. Clients will seek care for substance-induced disorders, such as cocaine-induced psychosis, and co-occurring disorder systems must be able to address these conditions.


Mental Disorders

The standard use of terms for non–substance-related mental disorders also derives from the DSM-IV-TR. These terms are used throughout the medical, social service, and behavioral health fields.

The major relevant disorders for co-occurring disorders include schizophrenia and other psychotic disorders, mood disorders, anxiety disorders, and personality disorders.

The major relevant categories of mental disorders that frequently occur with substance abuse issues include:

  • Schizophrenia and other psychotic disorders
  • Mood disorders
  • Anxiety disorders
  • Somatoform disorders
  • Factitious disorders
  • Dissociative disorders
  • Sexual and gender identity disorders
  • Eating disorders
  • Sleep disorders
  • Impulse-control disorders
  • Adjustment disorders
  • Personality disorders
  • Disorders usually first diagnosed in infancy, childhood, or adolescence


5 Most Common Mental Disorders Associated with Specific Addictions

Some conditions seem destined to come in pairs. Heart disease often follows a diagnosis of diabetes, for example, and allergies often come hand in hand with asthma. The same sort of joining effect sometimes takes hold when an addiction is in play. In fact, it’s quite common for certain drugs of abuse to be entangled with specific mental health disorders.  

These are five of the most common mental health/addiction combinations in play today.


Alcoholism and Anti-Social Personality Disorder

Alcohol abuse is associated with a number of mental health concerns, including:

  • Mania
  • Dementia
  • Schizophrenia
  • Drug addiction

According to the National Institute on Alcoholism (NIAAA), antisocial personality disorder (ASPD) has the closest link with alcoholism, as people who drink to excess on a regular basis are 21 times more likely to deal with ASPD when compared to people who don’t have alcoholism. Often, the two disorders develop early in life, the NIAAA says, but alcoholism can make the underlying mental illness worse, as people who are intoxicated might have lowered inhibitions, which makes their antisocial behaviors more prevalent.  


Marijuana Addiction and Schizophrenia

It’s not unusual for people who have schizophrenia to develop addictions. In fact, a study in the American Journal of Psychiatry suggests that about half of all people with schizophrenia also have a substance abuse disorder. However, there’s a particularly striking association between marijuana abuse and schizophrenia. It’s unclear why people with schizophrenia would abuse this drug, as it seems to produce many of the same symptoms these people experience when in the midst of a schizophrenic episode, but it is clear that marijuana abuse is at least somewhat common in those who have schizophrenia.


Cocaine Addiction and Anxiety Disorders

People who abuse cocaine often take the drug because it makes them feel euphoric and powerful. However, continued use seems to lead to symptoms that are more indicative of an anxiety disorder, including:

  • Paranoia
  • Hallucinations
  • Suspiciousness
  • Insomnia
  • Violence

These symptoms may fade away in people, who achieve a long-lasting sobriety, but sometimes the damage lingers and the unusual thoughts and behaviors stick around even when sobriety has taken hold.


Opioid Addiction and PTSD

Post-traumatic stress disorder (PTSD) is a mental illness that takes hold in the aftermath of a very serious episode in which the person was either facing death or watching someone else die. Often, people who survive these episodes emerge with very serious physical injuries, and often, those injuries are treated with prescription painkillers. These drugs can also boost feelings of pleasure and calm inside the brain, and sometimes people who have PTSD are moved to abuse their drugs in order to experience euphoria. While people in physical pain do need help to overcome that pain, blending PTSD with painkillers can lead to tragic outcomes that no one wants.


Heroin Addiction and Depression

While heroin can make users feel remarkably pleasant in the short term, long-time users can burn out the portions of the brain responsible for producing signals of pleasure. In time, they may have a form of brain damage that leads to depression. They’re physically incapable of feeling happiness unless the drug is present. This drug/mental illness partnership is remarkably common, but thankfully, it can be amended with treatment and sobriety.



The symptoms of co-occurring disorders include those associated with the particular substance abuse and mental health conditions a person has. Co-occurring disorders can be difficult to diagnose because the symptoms of substance abuse or dependence can mask the symptoms of mental illness, and vice versa.

As stated, substance abuse is a maladaptive pattern of substance use that occurs despite the individual’s experiencing significant substance-related problems. Individuals who abuse substances may experience such harmful consequences of substance use as repeated failure to fulfill roles for which they are responsible, legal difficulties, or social and interpersonal problems. It is important to note that the chronic use of an illicit drug still constitutes a significant issue for treatment even when it does not meet the criteria for substance abuse.

For individuals with more severe or disabling mental disorders, as well as for those with developmental disabilities and traumatic brain injuries, substance use at lower levels might be more harmful (and therefore defined as abuse) than for individuals without such disorders.

People with co-occurring disorders are at high risk for many additional problems such as symptomatic relapses, hospitalizations, financial problems, social isolation, family problems, homelessness, suicide, violence, sexual and physical victimization, incarceration, serious medical illnesses such as HIV and hepatitis B and C, and early death. Anyone of these problems complicates the treatment of co-occurring disorders.



Mental health and substance abuse disorders often occur as a result of biological and environmental factors. Mental disorders and addiction are each a dynamic process, with varying degrees of severity, rate of progression, and symptom manifestation. Both types of disorders are greatly influenced by several factors, including genetic susceptibility, environment, and pharmacologic influences. Certain people have a high risk for these disorders (genetic risk); some situations can evoke or help to sustain these disorders (environmental risk), and some drugs are more likely than others to cause psychiatric or substance use disorder problems (pharmacologic risk).

People with mental health disorders are more likely than people without mental health disorders to experience alcohol or substance-use disorder. Mental illness can lead people to use alcohol or drugs to make themselves feel better temporarily. In other cases, a substance-abuse disorder triggers or in some other way leads to severe emotional and mental distress.



To provide appropriate treatment for co-occurring disorders, the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services recommends an integrated treatment approach. Integrated treatment is a means of coordinating substance abuse and mental health interventions, rather than treating each disorder separately and without consideration for the other.

Integrated treatment occurs when a person receives combined treatment for mental illness and substance use from the same clinician or treatment team. It helps people develop hope, knowledge, skills, and the support they need to manage their problems and to pursue meaningful life goals. Integrated treatment may include the following:

  • Help patients think about the role that alcohol and other drugs play in their life. People feel freer to discuss these issues when the discussion is confidential, nonjudgmental, and not tied to legal consequences.
  • Offer patients a chance to learn more about alcohol and drugs—how they interact with mental illnesses and with other medications—and to discuss their own use of alcohol and drugs.
  • Help patients become involved with supportive employment and other services that may help the process of recovery.
  • Help patients identify and develop recovery goals. If a person decides that the use of alcohol or drugs may be a problem, a counselor trained in integrated treatment can help that person identify and develop personalized recovery goals. This process includes learning about steps toward recovery from both illnesses.
  • Provide counseling specifically designed for people with co-occurring disorders. This can be done individually, with a group of peers, with family members, or with a combination of these.

Successful strategies with important implications for clients with COD include interventions based on addiction work in contingency management, cognitive-behavioral therapy (CBT), relapse prevention, and motivational interviewing.

All substance-abuse treatment programs should have in place appropriate procedures for screening, assessing, and referring clients with CODs. It is the responsibility of each provider to identify clients with both mental and substance use disorders and to assure them that they have access to the care needed for each disorder.

A comprehensive assessment serves as the basis for an individualized treatment plan. Appropriate treatment plans and treatment interventions can be quite complex, depending on what might be discovered in each domain. This leads to another fundamental principle: There is no single, correct intervention or program for individuals with COD’s. Rather, the appropriate treatment plan must be matched to individual needs according to these multiple considerations.

An onsite addiction treatment psychiatrist can improve treatment retention and decrease substance use among patients. The onsite psychiatrist brings diagnostic, medication, and psychiatric counseling services directly to the location where clients are based for the major part of their treatment. This approach often is the most effective way to overcome barriers presented by offsite referral, including distance and travel limitations, the inconvenience of enrolling in another agency and of the separation of clinical services (more “red tape”), client fears of being seen as mentally ill (if referred to a mental health agency), cost, and the difficulty of becoming comfortable with different staff.

The National Dialogue on Co-Occurring Mental Health and Substance Abuse Disorders created a conceptual framework that classifies clients into four quadrants of care based on relative symptom severity, not diagnosis. The four quadrants are

I.  low addiction/low mental illness severity
II.  low addiction/high mental illness
III. high addiction/low mental illness
IV.  high addiction/high mental illness

The four-quadrant model provides a structure for moving beyond minimal coordination to foster consultation, collaboration, and integration among systems and providers in order to deliver appropriate care to every client with co-occurring disorders.



Many clients with COD require medication to control their psychiatric symptoms. Pharmacological advances over the past decade have produced antipsychotic, antidepressant, anticonvulsant, and other medications with greater effectiveness and fewer side effects. With the support available from better medication regimens, many people who once would have been too unstable for substance abuse treatment, or institutionalized with a poor prognosis, have been able to lead more functional lives.


Psychoeducational Classes

Psychoeducational classes on mental and substance use disorders are important elements in basic COD programs. These classes typically focus on the signs and symptoms of mental disorders, medication, and the effects of mental disorders on substance-abuse problems. Psychoeducational classes of this kind increase client awareness of their specific problems and do so in a safe and positive context.

Relapse-prevention education presents strategies designed to help clients become aware of cues or “triggers” that make them more likely to abuse substances and help them develop alternative coping responses to those cues. Some providers suggest the use of “mood logs” that clients can use to increase their consciousness of the situational factors that underlie the urge to use drugs or drink.


Group Therapy

Group therapy provides a forum for discussion of the interrelated problems of mental disorders and substance abuse, helping participants to identify triggers for relapse. Clients describe their psychiatric symptoms (such as hearing voices) and their urges to use drugs. They are encouraged to discuss, rather than to act on, these impulses. Groups also can be used to monitor medication adherence, psychiatric symptoms, substance use, and adherence to scheduled activities. These groups can provide a constant framework for assessment, analysis, and planning. Through participation, the individual with COD develops a perspective on the interrelated nature of mental disorders and substance abuse and becomes better able to view his or her behavior within this framework.


Outpatient Substance Abuse Treatment Programs for Clients with COD

Treatment for substance abuse occurs most frequently in outpatient settings. Some offer several hours of weekly treatment, which can include mental health and other support services as well as individual and group counseling for substance abuse. Others provide minimal services, such as one or two brief sessions to give clients information and refer them elsewhere. Some agencies offer intensive outpatient programs that provide services several hours per day and several days per week. Typically, treatment includes individual and group counseling, with referrals to appropriate community services.

Individuals with COD often need a range of services besides substance-abuse treatment and mental health services. Generally, important needs include housing and case management services to establish access to community health and social services. These can be essential to the successful recovery of the person with COD.

It is imperative that discharge planning for the client with COD ensures continuity of psychiatric assessment and medication management, without which client stability and recovery will be severely compromised. Relapse-prevention interventions after outpatient treatment need to be modified so that clients can recognize symptoms of psychiatric or substance abuse relapse on their own and can call on a learned repertoire of symptom management techniques (such as self-monitoring, reporting to a “buddy,” and group monitoring). This also includes the ability to access assessment services rapidly, since the return of psychiatric symptoms can often trigger a bstance-abuse relapse.

The Medical System

Although not substance-abuse treatment settings per se, acute care and other medical settings are included here because important substance abuse and mental health interventions do occur in medical units. Acute care refers to short-term care provided by intensive-care units, brief hospital stays, and emergency rooms (ERs). Providers in acute-care settings are not usually concerned with treating substance-use disorders beyond detoxification, stabilization, and/or referral.

In other medical settings, such as primary care offices, providers generally lack the resources to provide any kind of extensive substance-abuse treatment but may be able to provide brief interventions and treatment referrals.

Primary health care providers (physicians and nurses) have historically been the largest single point of contact for patients seeking help with co-occurring disorders. Physicians and nurses are uniquely qualified to manage life-threatening crises and to treat medical problems related and unrelated to psychiatric and substance use disorders. Because they are in contact with such large numbers of patients, they have an exceptional opportunity to screen and identify patients with co-occurring disorders. At that point, the person with COD can




A drug test is an analysis of a biological sample used to determine the presence of specific substances. These tests do not usually indicate whether the subject is impaired at the time they are administered, just if the person has used any of the substances being tested for in a set period. Drug tests are a way to determine if a person is using illicit drugs, which may indicate a problem with substance abuse.

Drug testing is done pre-employment, randomly by employers, after an accident on the job, during probation, by the police, in the prison system, in recovery programs, in hospitals, and by parents.  There are various types of tests including urine, saliva, breath, blood, hair, nails and perspiration. Tests can be done in a lab, in an office, by mail or in a home.

In this section will we explore the types of drug tests, what each screens for, the collection procedure and the need for consent.



There is not a standard for all drug testing, although the Substance Abuse and Mental Health Services Administration, SAMHSA, along with the U.S. Department of Health and Human Services (DHHS) and the Department of Transportation have standardized procedures that federal agencies must follow. Private employers who drug test are not usually required to follow federal guidelines, although many do so for legal reasons.  We will look at these standardized procedures later in the course.

Drug testing accuracy depends in part on the type of test used and standards observed. Drug tests use biological samples from the body in order to check for the presence of drugs and sometimes alcohol. Drug tests may test one’s:

  • Urine
  • Blood
  • Sweat
  • Breath
  • Saliva or oral fluids
  • Nails
  • Hair

The most common and least expensive drug tests involve urinalysis. For these tests, a urine sample is collected by the subject urinating into a specimen cup.  Levels of antigen-antibody complexes that the body produces when drugs are present are counted in nanograms per milliliter, ng/mL. Drugs can be detected through a urine drug test for anywhere from one day to one month after use, depending on the type of drug abused, duration of abuse, and amount of drug abused.

There are two levels of urinalysis drug tests: immunoassay and gas chromatography or mass spectrometry. The first is the most cost-effective, produces immediate results, and generally is used as an initial test, although it may not be as accurate as other methods. False positives are possible, and certain types of drugs may be missed. Often, a secondary gas chromatography or mass spectrometer test is ordered that also tests urine. It is more accurate, but also more expensive, and it takes longer to complete.

Federal drug tests use a split sample, meaning they take the urine sample, split it in two and first test with immunoassay methods and then gas chromatography or mass spectrometer methods if the first test was positive. This is called a confirmation test after the initial screening test. All federal drug tests are required to be performed at SAMHSA-certified labs and follow strict guidelines and chain of custody procedures, ensuring the samples are handled correctly, thus reducing the margin for error.

At-home, or portable, drug test kits can be purchased online and over the counter for as little as $10-$20. These kits are typically urine tests that check for the presence of illegal or prescription drugs. Depending on the kit, the presence of different drugs may be tested.

The U.S. Food and Drug Administration (FDA) reports that these tests are accurate in determining a preliminary presence of illicit drugs if used correctly. If an initial positive result is found, the sample is then supposed to be sent to a laboratory for further testing, which will cost additional money but provide more accurate and detailed results.

Urine drug testing may be the most common form of drug testing, but saliva testing is becoming more popular simply because it is less invasive. However, it seems that saliva drug tests should only be used to detect very recent drug use to ensure accurate results. One study, for instance, reports that saliva testing can only detect cannabinoids when the subjects have smoked cannabis only 4-10 hours beforehand.

The most expensive and invasive of all drug testing methods also happens to be the most accurate. It detects right at the time of testing the presence of the substance and its metabolites in the blood. The actual amount of drugs in the blood at the time of the test can also be measured by a blood drug test. However, its cost and invasiveness make blood drug testing used less frequently.

Hair tests probably provide the most detailed insights possible into one’s history with drugs. These tests can tell you whether a person was using drugs recreationally or quite frequently. They can tell you the type of drugs that were being abused, among many other types of details. The idea of hair drug testing is based on the premise that drug metabolites enter the blood vessels of the scalp, and the hair will filter them and keep them as a permanent record of a person’s drug use. Many people, however, object to hair testing because it does not measure current drug use. A person could have last used, say, cannabis a few months before, and still be found positive today because residues of the substance will remain in the hair for months afterward, and no amount of shampooing can take them away. For an accurate test, most labs require anywhere from 40 to 50 strands of hair. The drugs will be detectable in the hair approximately 4 to 5 days after ingestion and will remain in the hair until the hair gets shed off from the body. There is also a considerable cost and a lengthy process with the hair sample testing.

Fingernail, a keratinized protein like hair, is emerging as a popular specimen type for drug testing.  Drugs can be identified in nail clippings two weeks to four weeks following ingestion. A 3-millimeter specimen of fingernail represents up to eight months of the collective history of drug exposure.  Toenail clippings show over one year of drug use. 

Perspiration drug testing works through a sweat patch affixed to the skin for a period of 14 days. The patch is worn to detect the presence of drugs that a person excretes through perspiration. However, this method is more commonly used to monitor people on probation or those involved in child custody cases.

Breath is the standard matrix for alcohol testing because alcohol is volatile and substantially excreted through the lungs.  Breath expelled into a Breathalyzer-style collection device can also identify amphetamine, methamphetamine, cannabis, cocaine and heroin use up to two hours after use.

Urine drug tests most commonly screen for:

  • amphetamines
  • methamphetamines
  • benzodiazepines
  • barbiturates
  • marijuana
  • cocaine
  • PCP
  • methadone
  • opioids (narcotics)

Blood drug tests most commonly screen for:

  • Amphetamines
  • Cocaine
  • Opiates
  • Nicotine
  • Marijuana
  • Methamphetamines
  • Alcohol

Hair drug tests most commonly screen for:

  • Cocaine
  • Marijuana
  • Opiates
  • Methamphetamine
  • Phencyclidine

Nail clipping drug tests most commonly screen for:

  • Amphetamines
  • Methamphetamines
  • Cannabinoids
  • Cocaine
  • Opiates
  • Phencyclidine
  • Benzodiazepines
  • Barbiturates
  • Methadone
  • Propoxyphene

Saliva drug tests most commonly screen for:

  • Alcohol
  • Marijuana
  • Cocaine
  • Amphetamines
  • Methamphetamines

Perspiration drug test most commonly screen for:

  • Marijuana
  • Cocaine
  • Opiates
  • Amphetamines
  • Methamphetamines
  • PCP

Breath drug test most commonly screen for:

  • Alcohol
  • Amphetamine
  • Methamphetamines
  • Cannabis
  • Cocaine
  • Heroin


Drug Testing Timelines

  • THC: Casual use 3-4 days, chronic use 6-11 weeks
  • Benzodiazepines: Up to 6 weeks
  • Barbiturates: Up to 6 weeks
  • Cocaine: Up to 22 days
  • PCP: Casual use up to 8 days, chronic use up to 30 days
  • Methadone: 2-3 days
  • Amphetamines: 2 days
  • Ecstasy: Up to 2 days
  • Codeine: 1-2 days
  • Heroin: 1-2 days
  • Hydromorphone: 1-2 days
  • Morphine: 1-2 days
  • Propizepine: Between 6 and 48 hours
  • LSD: 8 hours
  • Alcohol: 5 hours (1 ounce)

The size of the dose of any given drug, a person’s metabolism and body mass, as well as fat content, how active a person is, and age may all effect the drug testing timelines. 


Performing Drug Tests

Drug tests are given in many different settings.  In 1991, the U.S. Congress passed the Omnibus Transportation Employee Testing Act when they recognized the need for a drug and alcohol-free transportation industry. The DOT’s drug screening rules and procedures are listed within Title 49 of the Code of Federal Regulations (CFR) Part 40, commonly known as “Part 40.” These rules are published by an office within the DOT: The Office of Drug & Alcohol Policy & Compliance (ODAPC).  This standard has been adopted by other industries.  All DOT drug tests use the same 5-panal tests.  It tests for marijuana metabolites, cocaine metabolites, amphetamines, opioids, and phencyclidine.

The procedures can be found at:

The Division of Workplace Programs that perform forensic drug testing for federal agencies and federally regulated industries.  The have created mandatory guidelines for workplace testing. 

The Mandatory Guidelines can be found at:

SAMHSA has created a Specimen Collection Handbook for use in federal agency workplace testing.

The Specimen Collection Handbook can be found at:

Many others beyond federal agencies also follow these guidelines and collection policies. 

Specimen collection, a crucial component of drug testing, must be carefully designed and actively managed to ensure that valid results are generated. Additionally, the storage of samples, particularly urine, may be challenging if testing is delayed for several days. If the delay between collection and testing is substantial, appropriate storage is needed to help prevent drug degradation. Many recovery program staff members are untrained in collection and storage procedures, exacerbating the opportunity for patient donors to adulterate or substitute specimens or for drug degradation.

A brief overview of the collection method created in CFR Part 40 includes the requirements of restrooms where collections are received having no running water and commodes have bluing agents (so specimens cannot be diluted). Ceilings must be of a height and/or composition that doesn’t allow for “hiding” of additional specimens. Patients are instructed to not flush after the collection (or specimens are collected with a remote-flushing commode).

Collection Procedures: (Suggested guidelines only, for full procedures please reference the SAMHSA Specimen Collection Handbook)

Prior to any specimen collection procedure, secure the collection facility and if necessary, perform a thorough search for hidden adulterants or substitute urine specimens. Place bluing agent in the toilet bowl or tank, remove or secure all chemicals (soaps, cleaning supplies, etc.) and secure or eliminate all water sources.

Check the identity of donor (e.g. social security number or driver’s license number and photo I.D.). If using a drug screen test request form, note the identity on the form.

  1. Ask the donor to remove any unnecessary outer clothing. All personal belongings (the subject may retain a wallet) should be placed in a secure location outside the stall or partitioned area
  2. Do not ask the donor to remove articles of clothing such as shirts, pants, dresses, etc. If a collector notices any unusual behavior that indicates a donor may attempt to tamper with or adulterate a specimen (e.g., bulging pockets), the collector may request that the donor empty his/her pockets and explain the need for such items during collection
  3. Prior to collection, ask the donor to wash his/her hands to eliminate any possible adulterating or contaminating substances from under the donor’s fingernails
  4. Place the following information on the bottle label:
    • Date of collection,
    • Donor’s name and/or identification numbers
    • Collector’s initials
  5. Provide the donor with a clean, unused urine specimen collection container and instruct the donor to fill the container at least half full (a minimum of 30 mL’s).
  6. Unobserved Collection: Allow the donor to enter and maintain privacy within the stall or partitioned area. The collector will wait outside the collection area until the donor is finished urinating. Complete the remainder of the test request form while the donor is collecting the specimen.
  7. Observed Collection: Inform the donor that collection will occur under direct observation. Accompany the donor into the collection facility (the collector must be the same gender). Instruct the donor to urinate into the sample container with the witness observing urination. Complete the remainder of the test request form after the donor has completed collecting the specimen.
  8. Accept the specimen from the donor. The use of disposable gloves is recommended when handling specimens, so prior to accepting the specimen from the donor, be sure to wear gloves.
  9. Upon receipt of the specimen from the donor, immediately apply the temperature strip (if applicable) to the outside of the bottle. If using a drug screen test request form, record the urine temperature on the form.

NOTE: Urine temperature should be measured within (4) four minutes of collection and should read between 90-100°F.

The SAMHSA Specimen Collection Handbook identifies who is qualified to be an observer for a direct observed urine specimen collection, as well as what training is required. There are also limits to when direct observation methods can be used and what must be done prior to using this method.


Cheating on a Drug Test

There are three primary ways to attempt to fool a drug test:  dilution, substitution, and adulteration. 

A “dilute specimen” is a urine sample that has a higher than average water content. The goal when diluting a sample is to minimize the drug levels visible in the urine. Laboratories have specific cut-off points where, even if the drug is detected, it will not be marked as a positive result because it is very little in the sample.

Unintentional dilution is common. When a test applicant consumes excessive amounts of fluid, the concentration of urine will subsequently become dilute. This can be abused by intentionally over-consuming large amounts of water prior to a drug test. This will lower drug ratios in the urine. Unfortunately for cheaters, this does not guarantee a negative result, and the laboratory will immediately detect the diluted sample.

The malicious form of dilution is adding pure water directly to the urine sample. This is the reason testing laboratories add dye to their toilets and shut off faucets. This is also very easy to detect.

Some people attempt to cheat drug tests by submitting a urine sample that did not come from their bodies. Individuals who try this method may use liquid urine, synthetic urine, or urine that belongs to someone or something else, such as an animal, just to pass the test. Those who are diligent about going undetected may buy powdered urine packets online and then mix the contents with water.

It is difficult to keep substitute urine samples at the right temperature. However, those determined to do so may use devices to keep the specimen warm. They may also keep the sample warm by holding it close to their bodies in an armpit or the groin area.

Urine samples that have been tampered with are called “adulterated specimen.” Some would-be drug testers attempt to pass off a sample that contains chemicals that have been added to either hide the presence of drugs or affect the equipment used in laboratory drug testing. Some of these chemicals include bleach, salt, soap, eye drops, peroxide, among others.  Both collection sites and laboratories have at their disposal several mechanisms to detect potentially invalid specimens.

Some who are up for a drug screening may just try to wait it out and delay taking the test until the drug leaves their systems. Many factors come into play here, including the kind of drug that was taken and how much of it was taken. Some substances clear the system faster than others. However, body height, weight, age, metabolism, and family history, among other factors, also affect how long a substance hangs around and whether a drug test will detect it in a person’s urine. Signs of past drug use can last for a few days or a few weeks.

Other attempts to cheat drug tests include taking various products and foods and before turning over the urine for examination. The list of “home remedies” runs long and includes everything from eating fiber and certain herbs, such as red clover and burdock root, to drinking detox herbal teas or liquids that act as diuretics to flush out toxins left behind after drug use. These include apple cider vinegar and cranberry juice among others.

Some people opt to use “commercial screens to “clean” their urine sample, but if these are found, the sample will be flagged.


Drug Testing in Recovery Programs

Drug testing is not a treatment method, but rather a tool that can be used in a recovery program.  With relapse being a typical phenomenon in the recovery process, 40% to 60% relapse rate, drug testing is not only an effective way to detect use but also to offer a deterrence. Many addiction treatment programs require regular drug testing or require clients to submit to random drug tests. In a program drug testing can be used in three phases of addiction treatment:

  • Screening and diagnostic evaluation
  • Formal Treatment
  • Long-term monitoring after initial intensive phases of addiction treatment

Without drug screens, patients who are serious about their recovery are at risk from those who play at the concept of sobriety just to fulfill a temporary obligation. This practice is somewhat controversial, but it’s often used to protect clients from temptation and being triggered. 

Drug testing policies differ from program to program and often depend on whether clients have access to substances. For example, residential or inpatient programs in which clients are required to stay in the facility 24 hours per day, with some exceptions, don’t typically need to do drug tests unless they have reason to suspect that drug use has occurred. On the other hand, outpatient programs that let clients stay at home and come into the treatment program a couple of times per week often perform regular drug tests.

When a drug-testing plan is carried out as part of a drug or alcohol rehabilitation, clinical specialists should take actions to guarantee that clients see the treatment as a favorable tool on their recovery journey and not an infraction of trust accelerated in the therapeutic relationship.

Although programs do not always penalize clients for positive tests, some programs need the patient and therapist to prepare a list of pre-determined consequences in case of a positive drug test. Depending on the treatment strategy, a positive test might trigger a patient to be negatively affected at home or work. In other scenarios, reporting might be needed by an employer or court. For example, in order to keep his job, a patient has the consent to allow the center to inform his employer if he tests positive for drug or alcohol usage, a positive test reported to the company might cause him to lose his job.  In some cases, a dirty screen will change someone’s level of care or even end their place in a program, but consequences should be discussed early in treatment.

A fundamental goal of addiction treatment is for patients to achieve abstinence from the use of alcohol and other drugs of abuse. In this context, an unexpected positive test result signals continued the use of non-prescribed drugs of abuse by tested patients.

Discharging a patient from treatment for an initial positive test is seldom, if ever, appropriate. Positive test results signal the need to intensify or alter current care. There are many options to consider in response to positive test results, including more frequent testing and specialized interventions for non-compliant patients.

Continued positive test results, after the intensification of treatment, raise the question of the value of treatment and may justify discharging the patient from treatment. Each patient’s situation should be considered as a clinician determines what changes should be made to the treatment plan in the patient’s best interests in response to positive test results.  A “therapeutic discharge” often can set the stage for the patient’s later return to treatment with more determination to meet the program’s expectations.

The level of care is a determining factor for the use of drug screens.  Just as new information about disease severity in the treatment of another chronic medical or psychiatric illness would lead to treatment plan adjustments, usually intensification and addition of new elements, positive drug test results are a manifestation of the severity of illness, or the inadequacy of treatment, and signals the need to reevaluate and readjust treatment plans.

In residential primary treatment, drug testing helps to ensure that the integrity of the drug-free therapeutic environment has not been compromised by smuggled contraband. Most patients who use unauthorized substances in treatment do not volunteer this information to staff, so drug testing is necessary to detect such events.

In outpatient primary treatment settings, the opportunities for the use of alcohol or other drugs are much greater. Therefore, the need for frequent random drug testing is greater than for patients in residential treatment. The detection of substance use in an outpatient setting should be used to revise treatment plans, including using additional strategies to help the patient establish and maintain a drug-free state.

In outpatient OTPs, after an initial period of adjustment to the prescribed medicine (e.g. methadone or buprenorphine), drug test results are commonly used to determine the gain or loss of take-home medication privileges.

Additional responses to positive drug tests may include more frequent visits with counselors, including more intensive group or individual counseling, revising treatment plans, increased engagement in 12-step recovery programs, and increasing the frequency of drug testing. All these responses help patients work toward establishing and maintaining abstinence.

When drug testing is used in addiction treatment settings, it is best to use random, rather than scheduled, testing and to set the frequency of the random testing higher at the start of treatment, when patients are known to more frequently engage in continued drug use. When the patient has attained a substantial period of stable abstinence from drug use, the frequency of random drug testing can be lowered; however, random testing less frequently than once a month in addiction treatment is seldom wise, even for patients with established abstinence. It is important that the testing be unpredictable, even if it is infrequent, so the patient can be tested at any time, even the day after the prior test.

Even though drug testing is a central component of years-long monitoring programs for licensed health professionals, there is no agreed-to standard among states regarding frequency or duration of testing in such programs. This lack of standardization is, in part, a reflection of the reality that most Partial Hospitalization Programs (PHP) have some connection with state regulatory and licensing authorities and professional licensure is a state-based function under specific oversight with substantial variation among the states. In general, most PHPs set the frequency of random testing at once a week early in their monitoring. The frequency of testing is reduced to twice a month and then once a month after long-term sobriety is achieved. It is essential to recognize that in random testing a donor who is tested today can be tested again tomorrow – even if the random testing is set for only once a month. This means that donors who are being monitored cannot predict when they will be tested, regardless of the nominal frequency of the drug and alcohol testing.


Legal Issues

Although drug testing can be a beneficial recovery tool, in order to protect a patient’s privacy and individual rights under the law, any effect for unfavorable drug or alcohol tests need to be prepared under the standards supplied by the National Institute of Drug Abuse and the Clinical Laboratory Improvement Act.

Consent for drug testing and how the results are handled are important legal issues. The concern about the adverse effects that social stigma and discrimination have on patients in recovery and how those adverse effects might deter people from entering treatment led the Congress to pass legislation and the Department of Health and Human Services (DHHS) to issue a set of regulations to protect information about patients’ substance abuse. The law is codified at 42 U.S.C. §290dd-2. The implementing Federal regulations, “Confidentiality of Alcohol and Drug Abuse Patient Records,” are contained in 42 CFR Part 2 (Vol. 42 of the Code of Federal Regulations, Part 2).


Controversies Surrounding Drug Testing

Drug testing is an invasion of privacy and sets a foundation of distrust.  It is not always accurate, and false positives are common. Drug tests may also be expensive to follow up on if you have gotten a false positive and require a confirmation test. Non-standardized procedures and regulations may lead to improper testing techniques and reliability issues. Not to mention drug tests can be beaten, and many methods are used in order to obtain false negative results.

It is imperative that drug-testing procedures be followed up with correctly. If a positive result is obtained, for example, there needs to be a policy in place that permits necessary treatment plans. Substance abuse may indicate a larger problem, including mental health issues or addiction, which is a treatable chronic brain disease.


Drug testing is not the only way to identify drug use, misuse, diversion or a suspected substance use disorder or relapse.  Valuable information can be obtained by asking individuals about their drug use. Interviewing collateral sources of information such as family members. with patient consent, can also provide important information about drug use. However, because it is common for drug users to minimize or deny drug use, it can be important to use drug testing as an objective assessment tool and patient advocacy/support tool.

Urine testing is generally the most popular method of testing for illicit drugs, while testing breath is usually the most common way to determine the presence of alcohol. Not all the testing methods test for all types of substances, and each has different accuracy levels. The different types of tests will detect the presence of different substances depending on the half-life of the substance, type of test administered, and duration of abuse. Substances are detectable for longer periods in chronic substance users.



Internet use is currently accepted as part of the social structure in the USA and in many other countries, as well.   Operation, oversight, and control of the Internet is difficult to administer as it is multi-national, relatively new and broad-based in its applications; consequently, it is left to the user to determine his or her own boundaries and to decide what is enough or too much. It should be noted that certain aspects of Internet use is “somewhat” controlled. For example, legalized gambling has an age restriction and frequently posts warnings regarding the potential for addiction.


Internet use is a controversial subject at the present time. Some choose to define excessive use as an “addiction” whereas others strongly disagree. I will not attempt to resolve this debate as I think excessive use of the Internet is a problem regardless of what we call it.   For example, a survey of 18,000 Internet users found that approximately 5.7 percent of this sample could be considered compulsive Internet users. (Greenfield, 1998). The results of this survey compare favorably with other surveys that indicate the range of compulsive users to be between 5 and 15 percent of those who regularly use the Internet.   Internet use is widespread today with usage estimates as high as 70 percent of the total US population. It follows that over 20 million Americans are potentially impacted by the excessive use of the Internet.


Problematic use of the Internet may consist of any or all of the following:

  • Too much time on-line
  • Excessive and anonymous socialization
  • Pornography
  • Excessive on-line shopping and e-mail
  • Use to escape life circumstances
  • Use to escape depression and boredom


The general problems associated with Internet use increases significantly when Internet gaming is considered. The Internet is generally home based and in most cases, gaming websites originate from a foreign country that is favorable toward gambling. Consequently, it is more difficult to manage and control this application as other countries often have more liberal gaming laws than those found in the USA. Gambling is a special case and social acceptance or rejection will eventually decide its fate…with a permissive/favorable attitude, it will increase, and when public opinion turns negative, it will decrease. At the present time, it appears to be on an upswing, as evidenced by the successes in Nevada, NJ, media (TV programs that televise poker games), other gaming outlets (horse racing, dog racing, lotto, scratch cards, bingo and a multitude of others) and the Internet.  


If society attempts to limit Internet use or to stop Internet gaming, if history tells the future, the outcome would be similar to the attempt at the prohibition of the use of alcohol. In that case, Americans chose to consume alcohol, regardless of the legal ramifications. Many have noted that more alcohol was consumed during prohibition (1920-1933) than either before or immediately after it was repealed. In essence, Americans chose to drink, Many choose to use the Internet to shop, socialize and gamble. In essence, we have never been able to successfully legislate morality or to impose limits on social activities, and will probably fail again if we attempt that approach on the Internet.   Our best approach is to educate the general public, focus on control of the Internet and to develop effective treatment modalities for those who become compulsive users and need professional help.


Intenet Exposure

As in other types of addiction, compulsive Internet use is progressive (increases over time). It is more challenging to detect, as many of the physical attributes associated with other addictions (such as alcoholism) are not present with Internet use. However, the absence of physical symptoms does not infer that Internet addiction has a lesser impact on individuals and society than any other addiction.

As with alcoholism, there are phases associated with the progression of use. The generalized phases along with a brief description of each are as follows:

  •  Social Phase: Typically a new user is in awe of the amount of information on the Internet and the ease at which it may be accessed. Most users are also pleased that it is home based, available 24/7 and is relatively inexpensive (if one can limit their on-line shopping and stays away from gambling).
  •  Use/Excessive Use Phase: The transition from social use to excessive use can be quick, exciting and destructive.   The user experiences heightened emotional states such as joy, excitement, anxiety, aggression, and depression, et al. The user often undergoes personal/social/value/lifestyle changes and began to let the Internet control their lives. For example, ending a social relationship that began in the chat room can be psychologically devastating (almost to the level of loosing one of the family).   The user is generally aware of the problem (at this phase) but he or she has difficulty controlling the impulse to use; consequently, relationships with family and friends deteriorate.
  •  Compulsive Phase: The progression to the compulsive phase is slow and usually occurs over a few years (typically 3 to 5). The behavioral patterns of people who have progressed to this phase is similar to people who get hooked on soap operas to the point they will forgo other social activities and family outings in order use the internet. In chat experiences, the individuals that become regulars become part of the extended family. At times, the user can no longer maintain normal social or family relationships. He or she may begin to recognize their problem and will often seek help from friends or other users. The compulsive user generally feels remorse and hopelessness after concluding a long session.   Loss of former lifestyle and relationships may be accompanied by suicidal ideations.


Often professional counselors may suspect that one or more of their clients are overly involved with the Internet. In such cases, the counselor may need diagnostic tools to help determine if a client has an Internet-related problem and if so, to what severity.   A twenty-question questionnaire (similar to Gamblers Anonymous (GA) 20-question questionnaire) has been developed to provide a counselor with some indication of the client disorder related to the Internet. This questionnaire should be used for information purposes only as it does not relate to diagnostic criteria in the DSM-V.   Problem Internet users generally answer “yes” to seven (7) or more of the questions. Should this be the case, professional counseling related to impulse control is strongly recommended.

Table 1 presents the twenty questions – the client should answer each one carefully and honestly as the earlier a problem is identified the earlier treatment can begin (early intervention increases success rate of treatment).


Internet Questionnaire – 20 Questions






Do you lose time from work due to Internet use?




Does Internet use make your home life unhappy?




Do you ever gamble on the Internet?




Do you ever feel remorse after a late night session in the chat room?




Do you escape from personal problems by retreating to the Internet?




Does Internet use cause a decrease in you ambition or efficiency?




After a session in the chat room, do you feel you must return as soon as possible to find out what happened to the other person(s)?




After a session, do you have a strong urge to return and continue the dialogue?



Do you often stay on the Internet until you are exhausted?




Are you ever tardy or miss work due to late night sessions on the Internet?




Do you ever miss family functions to spend time on the Internet?




Do you plan your daily activities to allow time for the Internet?




Does the Internet make you careless about the welfare of your family?




Do you ever stay on the Internet longer than you planned?




Do you ever stay on the Internet to escape worry or trouble?




Have you ever caused a family financial crisis by excessive on-line shopping or gambling?




Does Internet use cause you to have difficulty sleeping?




Do arguments, disappointments, or frustrations create within you an urge to use the Internet?




Do you have an urge to celebrate good fortune by a few hours on the Internet?




Do you ever consider self-destruction as a result of your Internet use?








Clinical Diagnosis

Internet addiction is not included in the latest Diagnostic and Statistical Manual of Mental Disorders (DSM-5) used by health professionals for diagnosis. The only behavioral addiction (as opposed to substance addiction) included in the latest DSMis gambling disorder.

Internet addiction appears to be a common disorder that very well might merit inclusion in DSM-V in the future. Conceptually, the diagnosis is a compulsive-impulsive spectrum disorder that involves online and/or offline computer usage and if in order with other criteria would consist of at least three subtypes: excessive gaming, sexual preoccupations, and e-mail/text messaging.

Any of the variants should include the four components of 1) excessive use, often associated with a loss of sense of time or a neglect of basic drives, 2) withdrawal, including feelings of anger, tension, and/or depression when the computer is inaccessible, 3) tolerance, including the need for better computer equipment, more software, or more hours of use, and 4) negative repercussions, including arguments, lying, poor achievement, social isolation, and fatigue.

In kind, the International Classification of Diseases 11th Revision (ICD-11) also does not have a specific code for internet abuse, addiction or disorder yet.  Reports by expert committee members show a discussion around the terms “addiction” and “abuse,” and the possibility of dropping the terms in favor of less pejorative and stigmatizing identifiers such as “dependence” and “harmful use,” according to the thirty-fifth report of the WHO committee.  There is speculation that Internet Use and Gaming Disorder will be included in the ICD-11 in future editions.  Currently, the code most frequently accepted for such criteria would be the Impulse Control Disorder.


Types of Internet Users

As in substance abuse, with its three types or levels of users (recreational/social, abuse, and dependency/addiction) there are also different types or levels of Internet use. The following paragraphs identify the generalized types and present a brief description of the individuals who fit into each type:

  •  Social Internet user: Individuals who use the Internet socially; generally use for business and entertainment. They typically use with control (limit how frequently they use and how much time is involved) and usually use infrequently except for business use.   The social user will often conceal infrequent late night sessions from family or friends. A social user may remain at this level throughout a lifetime and ‘enjoy’ the Internet without the detrimental impacts that are common with more advanced types.
  •  Serious Social Internet User: Internet use is a major source of entertainment and most of his daily activities are planned around use. He/she typically has a daily routine with planned sessions. His or her intensity and absorption increases over time and the user may experience strong emotional swings with an attendant attitude of, “I’m okay” after a positive experience and/or “I’m not okay” after a negative session. However, for this classification, Internet use is still under control and he/she could stop but they would miss it.   This type is often disassociated from family activities.
  •  Relief or Escape User: Internet use is a significant element in this individual’s life. Emotionally, the user equates use as being as important as family, career and/or education. However, there is generally little impaired functioning with regards to family, job and/or education. Internet use is typically more than a pastime; however, the user can stop but experiences some difficulty.   Also, emotional swings are heightened during this level over that of previous levels. Progression to the next level may occur and can be associated with a traumatic experience such as loss of job. The most important criteria for this classification is that the user does not generally compromise life areas (family, career, financial status, etc.)
  •  Antisocial Personality: Users often avoid interaction with family or friends with an attendant strong urge to use much like a cocaine addict who forsakes all others or commits criminal acts to continue his/her addiction (this is a psychological comparison only and is not intended to equate Internet use to Cocaine use). The individual with an antisocial personality disorder may use the Internet as an escape mechanism.
  •  Problem Use: The Internet is increasing in importance in the individual life and it has begun to cause impairment in family, job, school, and other normal social functioning.   Consequently, it is no longer just a form of fun or entertainment.  
  •  Compulsive User: A compulsive user has characteristics similar to the following criteria. This criterion is NOT defined in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (commonly referred to as the DSM-IV) and should be used as information and not for clinical diagnosis. A compulsive Internet user may be characterized by persistence and recurrence behavior, indicated by the presence of at least five (5) of the following items:
  1. Is preoccupied with Internet use (e.g., preoccupied with reliving past episodes or ways to gain additional access to the Internet.
  1. Needs to use with increasing amounts of time to achieve the desired excitement.
  1. Has repeated unsuccessful efforts to control, cut back or stop using the Internet.
  1. Is restless or irritable when attempting to cut down, or stopping using the Internet.
  1. Uses as a way of escaping from problems or from relieving a desperate mood (e.g., feelings of hopelessness, guilt, anxiety, depression).
  1. Strong urge to return another day to find out what happened in the chat room or to specific individuals.
  1. Lies to family members or others to conceal the amount of time or level of involvement with the Internet
  1. Has neglected family or job obligations due to the use of the Internet.
  1. Has jeopardized or lost a significant relationship, or educational or career opportunity because of Internet use,
  1. Relies on others to provide money to relieve a desperate financial situation caused by excessive shopping or gambling on the Internet.


An individual who suspects they have an impulse control problems should be exposed to these criteria carefully and openly (under the guidance of a professional counselor). As with any “excess situation”, it is common for an individual to deny their exposure and to blame everything and everyone except themselves. It also makes treatment more difficult (if an individual is in denial), as it’s hard to help someone who doesn’t think they have a problem. Again, a compulsive Internet user may need professional help if he/she wants to overcome his/her condition and to resume normal social functioning.


Warning Signs / Diagnostic Tools

I doubt if anyone ever starts using the Internet with the intent of becoming a compulsive user. For example, early users typically begin with a low level of involvement that increases gradually over time. Many individuals never progress beyond this phase; however, for some who progress to the compulsive use phase, it can be totally devastating.

Compulsive use is not easy to detect, as most individuals will attempt to hide their problem from themselves (self-denial) as well as from family and friends.   However, there are warning signs that if properly interpreted and acted upon can help the individual to accept his/her problem and also help to accurately diagnose the problem.   Some of the indicators that an individual may have a problem include:

  •  High absenteeism from family functions
  •  Inability to stop or control the use
  •  Going into debt due to excessive on-line shopping or gambling
  •  Using the Internet as an escape from stressful situations, worry or trouble
  •  Neglecting self or family
  •  Providing false information regarding the amount o time spent on the Internet
  •  Abnormal emotional swings. Feelings of guilt, shame, hopelessness, depression, as a result of excessive use (in some severe cases suicidal ideations may occur).
  •  Financial crisis – indebtedness.
  •  Refusing to discuss time and money involved with Internet use
  •  Secrecy and avoidance – only interested in Internet activities.

From a behavioral viewpoint and overall characteristics are that an individual with an Internet problem may begin to make high-risk time decisions that could lead to disruption of normal family relations and may also lead to anti-social behavior.   Also, an Internet abuser may continue to believe that they can handle the situation, keep the family happy and still use the Internet. However, if/when things improve, he or she generally continue to use until they are again in another family or financial crisis. In essence, the using cycle continues until the compulsive user enters treatment.


Cycle of Internet Use (Overview)

The “Cycle of Use” is presented to help the Internet user or a professional counselor working with an Internet user to better understand problematic use of the Internet and also to help the therapist structure an effective treatment program (help the addicted individual break the cycle of use). The objectives are for the individual and the professional involved with treatment to recognize the special needs of this sub-population and design treatment modalities aimed at their specific needs. For example, as it is beneficial for an insulin dependent diabetic to be educated on all aspects of diabetes, it is equally important for the problematic Internet user to be educated on impulse control, distortive cognitive ability and the consequences of poor decision-making.


Value/Belief System 

An individual’s value/belief system reflects his/her perception of self and represents values, judgments, and myths that he/she believes to be true. A persons value/belief system is fairly well established by an early age and is refined and honed as life’s experiences make us into the person we are at any given time in our lives.   It is a major control and decision-making guide and helps us to choose between right and wrong and things we do versus don’t do. Our value/belief system influences our thinking and decision making throughout our lives. Most individuals have a value/belief system about:

  •  Religion
  •  Alcohol and other drugs
  •  Sexuality
  •  Race
  •  Careers
  •  Age
  •  Personal activates
  •  Time management
  •  Social issues
  •  Community involvement
  •  Family roles

A therapist should explore a client’s value/belief to understand what they believe about various topics including topics related to impulse control.   Questions might include:

  •  Were you exposed to limits or restrictions as a youth
  •  Did your parents have a permissive attitude toward social activities?
  •  Did you have a detailed schedule as a youth?

Obviously, exposure to a permissive attitude/environment will enable a young person to form a positive image of most activities and/or to establish a distorted mental picture of a specific activity (such as games of chance). To give an example of how our belief/values work in the life of an Internet user, let’s suppose a person forms a concept of a problem user as one who is staying on the Internet all night. Now, let’s suppose this individual is a compulsive user but does not meet this pre-programmed characteristic. In this case, the individual would test his situation against his value/belief system and would conclude he does not have an Internet problem. The cycle is repeated until there is a match between his/her behavior and his/her pre-programmed belief/value system. The cycle may also be disrupted by other factors (generally a crisis) in the user’s life.


Distorted Cognitive Ability 

The overall concept is that distorted cognitive ability results in illogical and impaired thinking. Consequently, an individual is unable to comprehend the reality, consequences or truth about events/actions/activities. When an individual cannot see the reality or truth about things, the distorted cognitive activity is generally referred to as denial. The most common forms of denial are:

  • q Rationalizing: Making excuses for Internet use. Example, “I’m restless and it helps me relax”.
  • q Minimizing: Indicating his/her use is less serious than it really is. Example: “Sure I surf the net, but not that much”; “I only go on-line during the day, real users play all night”.
  • q Blaming: I use the Internet because; “everyone else does”. The user admits involvement but the responsibility for it lies with some else. Example.


Distorted cognitive activity or impaired thoughts mask the reality of most situations, and truth (in many cases) ceases to exist. An Internet user who finds them selves in a quagmire can gain insight as to their preconception (thinking) regarding excessive Internet use by answering and analyzing the following questions:

  1. Most frequently used form of denial (with respect to Internet use) is: __________ (rationalizing, minimizing, blaming or others)
  1. Most frequently processed impaired thought:__________________________________________
  1. I’m not a problem user because: ____________________________________________________


If an individual becomes emotionally stressed when asked the aforementioned questions, it is a strong indication that the individual is in denial regarding their involvement with the Internet and they are in need of professional help. The key to any cognitive change is that the individual is open and honest and willing to accept that change is needed. If they have a good attitude, it is easier for them to accept the perils associated with compulsive use. The net is that people can change but in most cases, the change must be initiated at the cognitive level. If one is in denial regarding a problem there is very little that anyone else can do to help that individual.


Continued Internet Use

It is self-evident that distorted cognitive ability enables an individual to continue using the Internet, which leads to behavioral problems or unmanageability of one’s life.




Tobacco use has widely gone hand and hand with other substance abuse and dependence. When discussing comprehensive alcohol and other drug treatment the integration of tobacco education into the service continuum is beneficial for staff and clients as a way to increase knowledge, skills, attitudes, and motivation that contribute to a positive change in substance use behaviors across the board.  

Tobacco use harms nearly every organ of the body. It causes many diseases and reduces the health of those who use in general. Smoking tobacco is the leading preventable cause of premature death and a leading cause of illness and mortality.

Despite the well-known health risks of smoking and tobacco use, cessation continues as one of our biggest public health challenges. Approximately 70% of all smokers say they want to quit, but even the most motivated may try to quit 5 or 6 times before they are able to discontinue. 50 million smokers attempt to quit each year; only 6% of these smokers successfully quit cold turkey, or on their own, all at once, without assistance. Whether with cessation aids or on their own, over 3 million Americans do successfully quit smoking every year and in doing so improve their lifespan, quality of life and positively impact the lives of those around them.

Smoking is the most common method of consuming tobacco, and tobacco is the most common substance smoked. The active substances trigger chemical reactions in nerve endings, which heighten heart rate, memory, alertness, and reaction time. Dopamine and later endorphins are released, which are often associated with pleasure.

Most smokers begin during adolescence or early adulthood. Smoking has elements of risk-taking and rebellion for younger users, which often appeals to this age group. The presence of peers that smoke and media featuring tobacco use may also encourage smoking. Because teenagers are influenced more by their peers than by adults, attempts by parents, schools, and health professionals at preventing people from trying cigarettes are frequently unsuccessful.

Children of smoking parents are more likely to smoke than children with non-smoking parents.

Research has suggested that smokers tend to be sociable, impulsive, risk-taking, and excitement seeking individuals. Although personality and social factors may make people likely to smoke, the actual habit is a function of operant conditioning. During the early stages, smoking provides pleasurable sensations (because of its action on the dopamine system) and thus serves as a source of positive reinforcement.

After an individual has smoked for many years, the avoidance of withdrawal symptoms and negative reinforcement become the key motivations to continue. Tobacco users report their reasons for continued use as:

  •         addictive smoking

  •         pleasure from smoking

  •         tension reduction/relaxation

  •         social smoking

  •         stimulation

  •         habit/automatism

  •         handling (something to do with their hands)


Methods of Tobacco Consumption   

Tobacco is an agricultural product processed from the leaves of plants in the genus Nicotiana. It can be consumed, used as an organic pesticide and, in the form of nicotine tartrate, used in some medicines. It is most commonly used as a recreational drug.

Tobacco is most commonly consumed in the forms of smoking, chewing, snuffing, or dipping tobacco, or snus.

Some forms of smokeless tobacco consumed may be categorized as:

  •      Snus (Scandinavian), a moist Scandinavian form of snuff which is placed under the upper lip which does not result in the need for spitting.

  •      Snus (American), similar to the Scandinavian form of snus. Most American Snus generally have a lower moisture content and lower pH, resulting in a lower bioavailability of nicotine than Swedish varieties

  •      Chewing tobacco, tobacco furnished as long strands which are placed between the cheek and gum or teeth.

  •      Nasal snuff (luktsnus in Swedish and luktesnus in Norwegian), a dry form of snuff which is insufflated or “snuffed” through the nose.

  •      Dipping tobacco a moist and American form of traditional snuff which is placed between the lower lip and the gums and often causes excess saliva while dipping.

Some forms of tobacco consumed in inhalation may be categorized as:

  •         A cigarette is a small roll of finely cut tobacco leaves wrapped in a cylinder of thin paper for smoking.

  •         Beedi is a thin, South Asian cigarette filled with tobacco flake and wrapped in a tendu leaf tied with a string at one end.

  •         Cigars is a tightly-rolled bundle of dried and fermented tobacco that is ignited so that its smoke may be drawn into the mouth.

  •         Electronic cigarette is an alternative to tobacco smoking, although no tobacco is consumed. It is a battery-powered device that provides inhaled doses of nicotine by delivering a vaporized propylene glycol/nicotine solution.

  •         Hookah is a single or multi-stemmed (often glass-based) water pipe for smoking. It can be used for smoking herbal fruits, tobacco, or cannabis.

  •         Kretek is cigarettes made with a complex blend of tobacco, cloves and a flavoring “sauce”.

  •         Passive smoking and/or Second-hand smoke and Third-hand smoke is, the usually involuntary, consumption of smoked tobacco. Second-hand smoke (SHS) is the consumption where the burning end is present, environmental tobacco smoke (ETS) or third-hand smoke is the consumption of the smoke that remains after the burning end has been extinguished.

  •         Pipe smoking involves placing shredded pieces of tobacco into a chamber of a pipe and igniting it.

Negative Effects of Tobacco Use 

Tobacco use leads most commonly to diseases affecting the heart and lungs, with smoking being a major risk factor for heart attacks, strokes, chronic obstructive pulmonary disease (COPD) (including emphysema and chronic bronchitis), and cancer (particularly lung cancer, cancers of the larynx and mouth, and pancreatic cancer). It also causes peripheral vascular disease and hypertension. Cigarette smoke contains more than 4,000 chemicals, including truly nasty things like cyanide, lead, and at least 60 cancer-causing compounds. The effects depend on the number of years that a person smokes and on how much the person smokes. Starting smoking earlier in life and smoking cigarettes higher in tar increases the risk of these diseases.

Tobacco use is responsible for an estimated 7 percent of total U.S. health care costs. It accounts for the 18 percent increase in the incidence of cancer and the 7 percent rise in cancer’s mortality since 1971. Smokers have abnormally high heartbeats, low tolerance for exercise, and an increased risk of damaging arteries from fatty buildups associated with heart disease, according to the American Heart Association’s first report on tobacco-related health problems. In addition, exposure to tobacco smoke exacerbates asthma, decreases lung capacity, and increases the frequency and severity of respiratory infections.

Other consequences of tobacco use include:

  •   Cataracts in the eyes

  •   Thyroid disease

  •   Gum disease

  •   Chronic bronchitis

  •   Emphysema

  •   Asthma

  •   Pneumonia

  •   Degenerative disc disease

  •   Infertility

  •   Leukemia

  •   Weakened immune system

  •   Increased risk for stroke

Tobacco use has obvious health issues. Smoking tobacco also has additional hazards.   The number one cause of deaths from fire is smoking. Most of these deaths occur when somebody falls asleep and drops a cigarette on a piece of furniture or a mattress.  


Smoking During Pregnancy  

Smoking during pregnancy is very dangerous. It may cause up to 7.5% of all miscarriages that occur. As many as 26,000 newborns each year are admitted to intensive care units because of low birth weight caused by smoking.

Tobacco Use and Children/Adolescents

The American health foundation has cited increased cigarette smoking as a factor in the deteriorating health of the nation’s children.   Roughly 3,000 children in the U.S. become addicted to tobacco every day. Although it’s illegal in all states to sell cigarettes to persons younger than 18 years old, teens are able to buy cigarettes over the counter between 70-80% of the time.


Tobacco Use and Alcohol and Other Drug Recovery

Most alcoholics or other drug addicts have several addictions, and smoking is the most common other addiction by far. 

New studies have shed light on cross-addiction between nicotine and alcohol in particular.  Nicotine has been shown to increase the craving for alcohol. For many alcohol and other drug users, smoking is also a behavioral trigger for use, and getting clean from cigarettes is a major step toward reducing cravings for other use.

All of this supports the increased prevalence of tobacco use among people receiving treatment or in recovery. Tobacco use among this population is dramatically higher than the general U.S. adult population rate. Approximately 90% of alcoholic inpatients in the U.S. and 85-90% among substance abuse inpatients report tobacco use.

People with a DSM-IV-TR diagnosis (not including nicotine dependence) consume 44% of all tobacco sold in the U.S. and those with a co-occurring mental health and substance use disorder consume 70% of tobacco products.

Smoking Cessation   

There are two primary approaches to smoking cessation treatment; the first being the pharmacological approach and the second being a behaviorist approach.

The pharmacological approach includes methods of delivering nicotine to the system without smoking, on the theory that the user will gradually wean off. These nicotine replacement therapies include the nicotine patch, nicotine gum, nicotine nasal spray, and the nicotine inhaler. Recent studies show that nicotine replacement therapies can help smokers quit. People using aids are 70% more likely to quit than those using placebos.  

The effectiveness of these nicotine replacement tools is improved if done in combination with some kind of behavioral therapy.  There are numerous behavioral approaches, often used together.  Common ones include tapering or fading, scheduling or timing, motivational enhancements via rewards and punishments of different kinds, relapse prevention, cue exposure, aversion therapy, and others. 

New medications for both nicotine addiction and alcoholism are on the way, now that scientists realize that addictions stem from much more than “an addictive personality” or weak will. The remedies being tested actually target the cascade of neurochemical events at the root of addicts’ cravings.

Within two years after people quit smoking, the risk of death from heart disease declines 24 percent. Quitting for 10 to 14 years produces a risk level almost equal with someone who never smoked.



Tobacco use, including cigarette smoking, cigar-smoking, and smokeless tobacco use, remains the leading preventable cause of death in the United States.

Tobacco is considered an addictive substance because it contains the chemical nicotine. In addition to nicotine, tobacco also contains more than 19 known cancer-causing chemicals (most are collectively known as “tar”) and more than 4,000 other chemicals.

Because of the addictive properties of nicotine, tolerance and dependence develop. Tolerance can be defined as a state of progressively decreased responsiveness to a drug as a result of which a larger dose of the drug is needed to achieve the effect originally obtained by a smaller dose. Dependence can be defined as a state in which there is a compulsive or chronic need.

Tobacco usage is an activity that is practiced by some 1.1 billion people across the world and up to 1/3 of the adult population.

Quitting tobacco use is not easy, but it can be done. The rewards are immeasurable not only to the tobacco user but for all of those around them, their family and for generations to come.