WK4Ch8

8 Substance Abuse Counseling and Co-occurring Disorders

CHAPTER OBJECTIVES

After reading this chapter, you will be able to:

· 1. Recognize substance dependence and substance abuse.

· 2. Know key diagnoses and definitions from the DSM-IV-TR.

· 3. Be aware of the various co-occurring disorders that are common to substance abusers.

· 4. Understand the various screening and assessment tools that are used in the treatment of substance abuse disorders.

· 5. Know the 12 core functions associated with substance abuse treatment.

· 6. Be aware of the impact that denial has on the addicted population’s prognosis.

· 7. Understand the dynamics of relapse prevention.

INTRODUCTION

The prevalence of offenders suffering from substance use and abuse problems currently in the American Criminal Justice System is staggering. The massive increase in the number of convicted offenders suffering from substance abuse began in the 1980s and continues through the present. As Hanser ( 2006 ) points out, any informed discussion of drug offenders in the United States must begin with the war declared on drugs by the U.S. Government. As crack cocaine began to sweep through the nation in the early to mid-1980s an outcry shivered through the fabric of our society. Not only was the drug trade burgeoning and access to illegal substances becoming easier than ever, the violent crime rate was also increasing. A connection was quickly made between the expanding drug culture and the often violent incidents that occurred within its realm. This connection, along with societal upheaval, forced the government to take action in an attempt to rid ourselves from the evils and perils commonly associated with substance abuse and criminal behavior.

The resulting action taken by federal and state lawmakers has been to draft laws aimed at corralling illegal substance–using offenders. And, law enforcement efforts have been somewhat successful—successful at least in its ability to arrest a sufficient amount of drug-related offenders so that nearly every correctional agency in America is at or beyond capacity.

Once drafted these laws are enforced. In order to be enforced assets must be well equipped and mobilized. What is the primary ingredient for equipping and mobilizing assets? Money. As a country we have spent enormous amounts of money in attempt to halt the flow and usage of illegal substances. The money has primarily gone to two components of the criminal justice system: enforcement and corrections. Enforcement efforts are usually aimed at stopping the flow of illegal substances from entering our country; arresting those transporting and distributing illegal substances after they have entered the country; as well as, arresting those found to be using illegal substances. Enforcement efforts are carried out by a multitude of law enforcement agencies ranging from federal to state and local jurisdictions. Once arrested these offenders then become the responsibility of correctional agencies, also operating at local, state, and federal levels. In essence, we have filled every space available within the correctional component of criminal justice with a human inmate.

Closely related to substance use and abuse problems are co-occurring disorders. Co-occurring disorder is a phenomenon whereby individuals are not only suffering from substance abuse issues but they are also afflicted with psychological or emotional impairments that affect their overall health and well-being. For example, co-occurring disorder would be the appropriate concept used to describe an offender suffering from substance use or abuse in conjunction with some other ailment such as anxiety or depression. In fact, it is very rare to observe an offender with substance abuse issues but not also suffering from other psychological or emotional disorders. This is because, in general, substance use and abuse is a method of relieving or adapting to life circumstances that are experienced as unpleasant and troublesome. Psychologically and emotionally healthy human beings are generally not involved with the abuse of illegal substances because of their limiting effects. Humans function best in natural states of existence free of foreign substances. The ingestion of illegal substances by mostly psychologically and emotionally healthy individuals has a tendency to “gum things up” keeping them from functioning at their highest levels.

What we do know is that our correctional system is at full capacity. We also know that our correctional system is filled mostly with offenders suffering from co-occurring disorders. It would be difficult at best to refute these facts. The question then becomes, What do we do? How do we deal with our inmate population that is largely made up of offenders suffering from a multitude of psychological and emotional disorders coupled with the use and abuse of illegal substances?

First, it is important to point out that there are no simple answers or solutions. Our democratic style of government ensures checks and balances that work to limit one ideology from completely dominating policy and procedure. Conservatives may argue that the answer lies in building more prisons. The problems with this approach, however, are robust. How many more prisons would we need to build? Who would assume responsibility for the massive costs? On the other hand, liberals may argue that we need to decriminalize all forms of substance use. In relation to this postulate, the reality is that our society is not yet ready to seriously consider this approach as viable. Therefore, we are left to function somewhere between these two extremes.

Our contention is that we need a strong presence on different fronts. We need law enforcement to work diligently because many offenses, often violent, occur in conjunction with substance use and abuse. In addition, we need to create innovative approaches to address both the substance abuse issue among offenders as well as mental health issues that confront them. Among the innovations that have been incorporated, it is the use of both drug courts and mental health courts that has received widespread support and popularity within the criminal justice system. Students may recall the mention of these types of interventions from  Chapter 1 , noting again that drug courtssynthesize therapeutic treatment and judicial processes to optimize outcomes with the drug-addicted offender population (Watson, Hanrahan, Luchins, & Lurigio,  2001 ), while mental health courts consist of specialized dockets for defendants with mental illnesses (Bureau of Justice Assistance,  2004 ). Over the past two decades, there has been fervent support for drug courts and, upon the common realization that substances induce and correlate with other disorders, mental health course as well.

As can be seen, the trend is, and should be, to bear public resources on treating offenders who suffer from co-occurring disorders while in custody. Recidivism rates speak loudly and aggressively to this last postulate. As Hanser ( 2006 ) points out, recidivism rates are closely related to substance abuse. When considering co-occurring disorders recidivism rates are even higher. However, the complexities in providing the actual intervention for offenders who present with these multiple challenges are great. Therefore, the remaining portions of this chapter are aimed at identifying, describing, and treating those offenders suffering from substance use and abuse as well as co-occurring disorders. To begin, it is useful to define some of the concepts commonly used within the parameters of treating offenders suffering from substance abuse and co-occurring disorders. Many of these terms are commonly used interchangeably but as will be pointed out there are subtle differences that need to be illuminated.

PART ONE: RECOGNIZING SUBSTANCE DEPENDENCE AND SUBSTANCE ABUSE

Important Concepts Defined

The document most relied on to provide official definitions for most psychological and emotional concepts is the Diagnostic Statistical Manual (DSM-IV-TR) published by the American Psychological Association (APA). The latest version being the fourth edition published in 2000.

First, substance-related disorders are divided into substance use disorders and substance-induced disorders (CSAT,  2006 ). Substance use disorders are further divided into substance abuse and substance dependence. Substance use disorders are characterized by 11 categories provided by the APA ( 2000 , p. 191):

· 1. Alcohol

· 2. Amphetamine or similarly acting sympathomimetics

· 3. Caffeine

· 4. Cannabis

· 5. Cocaine

· 6. Hallucinogens

· 7. Inhalants

· 8. Nicotine

· 9. Opioids

· 10. Phencyclidine (PCP) or similarly acting arylcyclohexylamines

· 11. Sedatives, hypnotics, or anxiolytics.

These 11 categories are separated by criteria into abuse and dependence. Substance abuse is often used to refer to both abuse and dependence. Also, substance dependence and addiction are often used interchangeably although there is strong debate as to whether this is appropriate (CSAT,  2006 ). Finally, the system of care responsible for treating substance-related disorders is commonly referred to as the substance abuse treatment system.

Substance Abuse—the DSM-IV-TR defines substance abuse as a “maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances” (APA,  2000 , p. 198). Individuals who abuse substances are likely to experience harmful consequences such as, but not limited to, the following:

· 1. Repeated failure to fulfill roles for which they are responsible

· 2. Use in situations that are physically hazardous

· 3. Legal difficulties

· 4. Social and interpersonal problems.

Substance Dependence—is defined by the APA ( 2000 ) as “a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems” (p. 192). This harmful pattern of behavior includes all of the features of substance abuse as well as such features as:

· 1. “Increased tolerance for the drug, resulting in the need for ever-greater amounts of the substance to achieve the intended effect

· 2. An obsession with securing the drug and with its use

· 3. Persistence in using the drug in the face of serious physical or psychological problems” (CSAT,  2006 , p. 1).

Substance-Induced Disorders—are characterized by three main facets which include substance intoxication, substance withdrawal, and group 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” (APA,  2000 , p. 210). Further exacerbating the problem of substance-induced disorders is the fact that individuals suffering from this ailment often present with a wide variety of symptoms characteristic of various mental disorders including delirium, dementia, amnesia, psychosis, mood disturbance, anxiety, sleep disorders, and sexual dysfunction (CSAT,  2006 ).

Co-occurring Disorders—a condition where individuals suffer from substance-related and mental disorders. Offenders suffering from co-occurring disorders will likely have one or more substance-related disorders operating in conjunction with one or more mental disorders (CSAT,  2006 ). The Center for Substance Abuse Treatment (CSAT) further defines co-occurring disorders, at the individual level, as a phenomenon where “at least one disorder of each type can be established independent of the other and is not simply a cluster of symptoms resulting from a single disorder” (CSAT,  2006 , p. 3).

An important distinction noted by CSAT ( 2006 ) is that some offenders at particular points in time may present with symptoms that do not neatly fit the criteria for diagnoses found in the DSMIV-TRcategories. From a practical standpoint, however, these offenders are suffering from symptoms that are best addressed from a framework which assumes the presence of a co-occurring disorder. To address this distinction CSAT ( 2006 ) created a “service definition of co-occurring disorder.” The definition consists of three postulates:

· 1. “Individuals who are ‘prediagnosis’ in that an established diagnosis in one domain is matched with signs or symptoms of an evolving disorder in the other

· 2. Individuals who are ‘postdiagnosis’ in that either one or both of their substance-related or mental disorders may have resolved for a substantial period of time

· 3. Individuals with a ‘unitary disorder and acute signs and/or symptoms of a co-occurring condition’ who present for services. Suicidal ideation in the context of a diagnosed substance use disorder is an excellent example of a mental health symptom that creates a severity problem, but itself does not necessarily meet criteria for a formal DSM-IV-TR diagnosis. Substance-related suicidal ideation can produce catastrophic consequences. Consequently, some individuals may exhibit symptoms that suggest the existence of co-occurring disorder but could be transitory (e.g., substance-induced mood disorders). While the intoxicated person in the emergency room with a diagnosis of a serious mental illness will not necessarily meet abuse or dependence criteria, he or she will still require co-occurring disorder assessment and treatment services” (p.  3 ).

How Substance Abuse Starts

First, it is important to state clearly that it is impossible to articulate a clear path to substance abuse to capture the path taken by all people. The paths are as complex and varied as human beings themselves. In addition, there has been much debate that still continues to try and place substance abuse within a particular domain. For example, in past years it was believed that substance abuse was primarily a moral issue. Addicts were viewed as morally deficient and corrupt (Dimoff,  2001 ). More recently, debate has shifted to consider substance abuse as a disease. This ideology places the enigma into the medical profession.

Today, it is mostly accepted that the issue of substance abuse is primarily grounded on at least two main components: heredity and environment, and/or a combination of the two. There is strong evidence that heredity is a major factor with powerful influence on the likelihood of some individuals engaging in substance abuse. Some reports claim individuals reared by parents who are substance users and abusers are four times more likely to be involved with substance abuse (Dimoff,  2001 ). Environmentally, the United States comprises of approximately 5–6 % of the world’s population. Americans consume, however, three-quarters of all illegal drugs produced in the world making us the leading consumers of alcohol and prescription drugs.

Important to this discussion is one environmental factor that highlights current emphasis on “feeling good.” With medical advances we now have a variety of medications aimed at soothing almost any ailment. If we do not feel good we turn to substances as a solution. And, this ideology has become big business for drug makers and pharmaceutical companies. This fact is quickly observed by the constant flow of media outlets telling us there is medication for whatever adverse feelings we may experience. Closely related to this phenomenon is the media-advanced depiction of what we should physically look like in order to be accepted and successful. In essence, if you are not thin and attractive you are relegated to the outer fringes of society. This ideology creates enormous social and environmental pressures which are impossible to achieve. There is a constant drive toward perfection. The problem with perfection, however, is that it is a very elusive concept that is usually characterized by such statements as, “If I were only able to be a little more … then I would be perfect.” We mentally create scenarios that are impossible to achieve. And when we are unable to measure up to the impossible circumstances we create the result which is usually a feeling of shame or defectiveness. In order to alleviate the painful feelings of these emotions some turn to substances to dull the effects. A vicious circular cycle is created and rigidly adhered too and unfortunately this cycle is one that is incapable of producing the feelings we truly desire.

An additional component that may be most salient in the origins of substance abuse is the role or influence of parents or guardians. A strong consensus now exists that indicates much of a child’s personality is formed by the age of eight. This includes values, morals, work ethic, and attitude. In most cases, parents will have the greatest influence on their children’s psychological and emotional well-being. Ideally, children need to be given sufficient freedom to explore and learn their ever-expanding world. This freedom needs to be balanced with guidance and support aimed at showing the child what is right and wrong and also what is safe and dangerous. If children are not given sufficient freedom to learn and grow it is likely that deep emotional problems will result such as stress, low self-worth, depression, anxiety, and nervousness. These psychological and emotional disorders often contain negative feelings that are powerful influences on behavior. As children grow to adolescence and early adulthood it becomes very difficult to function in a normal and healthy manner. Not surprisingly, many will turn to substances to relieve the powerful pangs of anxiety, depression, shame, anger, and fear.

External pressures also contribute to the origins of substance use and abuse. External difficulties are commonly characterized by such issues as school problems, work difficulties, family problems, peer pressure, and relationship issues. All of these circumstances or environments are strong causal factors for individuals to experience feelings such as shame and defectiveness, which are described as being at the heart of addiction. As will be covered later in the chapter, substance abuse is really a symptom of psychological and emotional dysfunction. The issue is not so much treating substance abuse as it is treating repressed emotion and the psychological dys-function that accompanies it.

Progressive Stages of Substance Abuse

It is important to recognize the different stages that usually lead to substance abuse. Obviously, these stages may vary for some individuals depending on particular circumstances. However, there is usually observable behavior that would fit the following five categories:

· 1. Compulsion to acquire and use substances and a preoccupation with their acquisition and use

· 2. Loss of control over substance use or substance-induced behavior

· 3. Continued substance use despite adverse consequences

· 4. A tendency toward relapse following periods of abstinence

· 5. Tolerance and or withdrawal symptoms (LASACT,  2004 ).

Compulsive behaviors usually result from users learning that good feelings can be produced by using substances. The individual may start out using substances at parties or on weekends to “take the edge off.” Initially, powerful feelings of euphoria are experienced because of a lack of tolerance. And, generally there are no adverse behavioral effects because the substance has not yet begun to interfere with the user’s lifestyle or obligations. In essence, there is a powerful feeling of euphoria with few consequences (Dimoff,  2001 ).

Due to the euphoric effects and initial lack of consequences, compulsive behaviors become more pronounced as users begin to actively plan both attainment and use of the substance(s). At this point use may still be controlled. For example, the individual may use only at “appropriate” times and places such as, not at work, not before 5:00 P.M. and certainly not in the mornings. Nonetheless, a very important and powerful process is now underway; tolerance is beginning to be developed.

Loss of control over substance use or substance-induced behavior usually becomes evident as the individual becomes more preoccupied with euphoric mood swings. There is generally an increase in the frequency of substance use and some of the self-imposed rules begin to be broken. The individual may engage in solitary use as opposed to only at parties or on the weekends with friends. In addition, more of the substance may be used than originally planned. At this point, the user is quickly approaching the realm of chemical dependency. This is where the individual’s lifestyle begins to change. In fact, individuals who have become chemically dependent on a substance will usually arrange their life so that the substance and its obtainment and use are paramount. Everything else becomes secondary to the substance.

Once the individual has become dependent on a substance(s) a variety of destructive behaviors will usually become evident to the informed observer. Keep in mind that the dependent individual will likely be very clever in disguising his or her substance use and abuse. In fact, cognitive processes of these individuals may now be arranged in such fashion that their very survival is dependent on the substance. The individual begins to shift from using a substance to obtain euphoria to one of coping with negative emotions such as anger, guilt, fear, or anxiety. The individual’s actions may become sneaky and mysterious as more effort is allocated to keeping his or her use a secret. Appreciate, that at this point the concept of control has shifted. The individual is no longer in control; the substance is in control.

Due to the shame that will accompany the loss of control, individuals will usually be irritable or angered easily. The individual will attempt to rationalize his or her behavior to avoid responsibility and become very adept at projecting one’s problems to others. Personal relationships will begin to deteriorate as the substance will command more importance than other people, and also, the individual begins to repeatedly violate his or her own value system. All of these factors contribute to emotional distress perpetuating the circular cycle of what is now chemical dependence/addiction.

The concept of denial, which will be explored in greater detail later in the chapter, begins to take hold within the individual’s methods of coping. In fact, denial is a concept often described as a person’s way of coping with painful situations whereby the denial of the existence of a problem allows the individual not to deal with or assume responsibility for it. At this point, the person’s use of a substance or substances can be described as chronic chemical dependency. Chronic chemical dependency can be described by the following characteristics:

· 1. Individual uses substance to feel normal and avoid pain rather than for achieving euphoria.

· 2. Individual experiences blackouts which progressively become longer and more frequent.

· 3. The desire to use the substance is now the most important factor in the individual’s life.

· 4. The individual experiences complete loss of control.

· 5. The individual experiences paranoid thinking and may fear insanity.

· 6. Individual feels alone and isolated.

· 7. Individual is likely to experience a loss of desire to live.

· 8. Individual begins to experience physical problems (Dimoff,  2001 ).

During this phase of the substance abuse process there is usually a strong tendency toward relapse following periods of abstinence. In fact, some users may begin experimenting with the idea of not using. This is an attempt to show themselves or others that they really are not dependent and that they could halt usage if desired. This period of abstinence, however, is usually short lived and usage quickly resumes, resulting in relapse. It is important to note that relapse is not an isolated event. Relapse is a condition of becoming unable to cope with life without the use of substances. Relapse prevention is a critical strategy that will be given specific attention later in the chapter.

Finally, tolerance levels and withdrawal symptoms are such that the offender needs more of the substance and experiences noticeable difficulties during periods of abstinence. Tolerance is the “need for markedly increased amounts of the substance to achieve intoxication,” or a “markedly diminished effect when using the same amount” (DSM-IV). Withdrawal syndrome is the characteristic group of signs and symptoms that typically develop after a rapid, marked decrease or discontinuation of a substance upon which an individual is dependent. The severity and duration of the withdrawal syndrome depends on several factors including the nature of the substance used, the half-life and duration of action of the substance, the length of time the substance has been used, the amount used, the use of other substances, the presence of other medical and psychiatric conditions, and other individual biopsychosocial variables.

Recognizing Substance Abuse

As a counselor in a correctional setting it is important to be able to recognize certain signs indicative of substance abuse. The proper recognition allows for proper assessment which in turn enables the institution to better provide appropriate services. Many offenders will under-or overreport their substance use and abuse problems. Even if not an intentional attempt at deception, it is rare that offenders will accurately depict their current reality concerning substance use and abuse. The following characteristics, provided by Dimoff ( 2001 ), are meant to provide a guide or framework for some of the more common characteristics displayed by offenders suffering from substance abuse. They are certainly not meant to be all inclusive:

Outward Physical and Mental Signs:

· • Rapid weight loss or gain

· • Discolored fingers

· • Injection marks along veins—due to increased scrutiny of arms and other common injection points many offenders are now injecting substances in more concealed areas of the body including thighs, and over tattoos

· • Wears long sleeve shirts on warm days.

· • Dilated pupils

· • Bloodshot or glassy eyes

· • Poor balance

· • Perspires excessively

· • Health complaints

· • Smells of alcohol or marijuana.

· • Displays droopy eyelids or sleepy appearance.

· • Frequently wears sunglasses at odd times.

· • Uses gum or mints to cover breath.

Source: SACS, 2006.

Mental Impairments:

· • Denial

· • Delusional

· • Paranoia

· • Preoccupation

· • Blackouts

· • Memory impairment

· • Poor judgment

· • Difficulty concentrating

· • Difficulty thinking

Co-occurring Disorders

Currently, there is strong movement on behalf of the federal government to address offenders suffering from co-occurring disorders. As previously stated, co-occurring disorder refers to any psychological or emotional disorder that is operating in conjunction with substance abuse. One such program being funded through SAMHSA is jail diversion. Jail diversion programs are aimed at identifying offenders who are suffering from substance abuse and/or co-occurring disorders. Once identified, those offenders meeting necessary criteria are diverted from jails and placed into comprehensive community service programs aimed at treating the offender’s disorders. The theoretical structure on which jail diversion rests is that if those offenders suffering from co-occurring disorders are not treated then the likelihood of them being released and further acting out in ways that bring them into contact with criminal justice system is enhanced. It is important to note that most offenders, once assessed, will meet necessary criteria for dual diagnosis. “Dual diagnosis” is a term used to describe a phenomenon whereby offenders are suffering from a substance abuse disorder in concert with a mood disorder, anxiety disorder, personality disorder, or a psychotic disorder.

MOOD DISORDER

Mood is a concept that describes a pervasive and sustained emotional state that may affect all aspects of an individual’s life and perceptions (LASACT,  2004 ). Mood disorder describes a pathologically elevated or depressed disturbance of mood and includes full or partial episodes of depression or mania (LASACT,  2004 ). It is important to note the term “pathological” because this denotes the presence of disease. Elevated or depressed mood states are normal adjustments to daily activities and circumstances. In some instances where we are engaged in pleasurable activities it is considered normal and healthy to experience elevated moods. The same is true for circumstances that are experienced as painful such as the loss of a loved one. Moods become pathological when there is a persistence and prolonged nature of being in either a depressed or elevated state. In essence, we are not free to traverse different states of mood based on current life circumstances. The disorder works to keep us trapped so that we experience either depressed or elevated states of being, independent of our surroundings. The term used to describe an elevated mood state is “manic episode.” A manic episode is a period of at least one week where an individual experiences a persistently elevated, euphoric, irritable, or expansive mood (LASACT,  2004 ). A manic episode is usually characterized by such symptoms as hyperactivity, grandiosity, flight of ideas, talkativeness, a decreased need for sleep, and distractibility (LASACT,  2004 ). A depressive episode, or major depressive episode, is used to describe a mood characterized by a depressed state. Major depressive episodes involve feelings of depression that are accompanied by loss of pleasure or indifference to most activities, most of the time for at least two weeks (LASACT,  2004 ). Some common examples of major depressive episodes include feelings of worthlessness and inappropriate guilt. In addition, some individuals may experience recurrent thoughts of death or suicide.

According to the Louisiana Association of Substance Abuse Counselors and Training (LASACT) ( 2004 ), there are four major components that are able to capture a wide range of cognitive and behavioral patterns described by the broad term of “mood disorder.” These components consist of bipolar disorder, cyclothymia, dysthymia, and hypomanic episode and are listed below:

· •  Bipolar disorder —is a condition that entails cycling mood changes from severe highs (mania) to severe lows (depression). In many cases, periods of normal mood levels will be mixed in-between. While clients are in the depression cycle, they will present with any or all of the symptoms of depression. While in the manic cycle, the client will likely be overactive, overtalkative, and will typically have an overabundance of energy. Further, manic states tend to affect thinking and judgment leading to impulsive and disproportionately exuberant social behaviors that can cause serious problems and/or embarrassment. For example, clients experiencing a manic phase may feel elated, engaging in anything from unwise business decisions to romantic sprees that are later regretted (National Institute of Mental Health,  2009 ).

· •  Cyclothymia —is likened to a low-key form of bipolar disorder but, with cyclothymia, mood variability occurs with greater frequency and tends to be more chronic in nature (LASACT,  2004 ). Exhibited episodes of mania and depression are not severe enough to be diagnosed in the major category of severity but they are serious enough to disrupt the client’s ability to lead a balanced and adjusted life (APA,  2000 ; LASACT,  2004 ).

· •  Dysthymia —is described as a chronic mood disturbance that usually entails a loss of interest or pleasure in most day-to-day activities. The mood disturbance, however, is not sufficient to meet the full criteria for a clinical diagnosis of major depressive episode. Dysthymia is a mood disturbance that, while not debilitating to the client’s day-to-day functioning, tends to diminish the client’s ability to enjoy life; these individuals often have pessimistic outlooks and attitudes, regardless of their circumstances. In other words, a person diagnosed with dysthymia is often able to carry out normal duties and functions but there is no “zest” to life.

· •  Hypomanic episode —is a condition described as a period, usually weeks or months, “of pathologically elevated mood that is similar to but less severe than a manic episode” (LASACT,  2004 , p. 41). Similar to dysthymia, hypomanic disorders are usually not severe enough to cause overt and clearly observable impairment in functioning within social or occupational settings (LASACT,  2004 ).

SUBSTANCE-INDUCED MOOD DISORDER

As mentioned, it is important to remember that many offenders will be suffering from more than one disorder. Substance abuse and mood disorder often exist in conjunction with the other. Any variation of mood disorders is sufficient to greatly diminish the joys of life. When people are unable to experience natural joy or pleasure their response will often be to turn to substances in order to change their mood.

A substance-induced mood disorder is described in the DSM-IV-TR as meeting the following criteria:

· A. A prominent and persistent disturbance in mood characterized by either, or both, of the following: 1. Depressed mood or markedly diminished interest or pleasure in all, or almost all activities 2. Elevated, expansive, or irritable mood.

· B. There is evidence from the history, physical examination, or laboratory findings of substance intoxication or withdrawal, and the symptoms in Criterion A developed during, or within a month of, significant substance intoxication or withdrawal.

· C. The disturbance is not better accounted for by a mood disorder that is not substance induced. Evidence that the symptoms are better accounted for by a mood disorder that is not substance induced might include the following: The symptoms precede the onset of the substance abuse or dependence; they persist for a substantial period of time after the cessation of acute withdrawal or severe intoxication; they are substantially in excess of what would be expected given the character, duration, or amount of the substance used; or there is other evidence suggesting the existence of an independent non-substance-induced mood disorder.

· D. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

· E. The disturbance does not occur exclusively during the course of delirium.

In essence, a substance-induced mood disorder can be described as having manic features, depressive features, or mixed features that manifest during intoxication or withdrawal (LASACT,  2004 ).

ANXIETY DISORDERS

Anxiety disorders are commonly noted as being the most common group of psychiatric disorders (LASACT,  2004 ). Fosha ( 2000 ) describes anxiety as being the mother of all pathologies. Anxiety is a concept that describes the sensations of nervousness, tension, apprehension, and fear that are experienced in anticipation of some type of danger. The danger may manifest itself through internal or external mechanisms. It is important to note that anxiety is also described as a normal reaction to stress. Anxiety may function as a motivator to get things done such as studying for an exam, completing necessary assignments in the office, and preparing for a speech. Anxiety becomes a disabling disorder when it grows to an excessive and irrational dread of everyday life and circumstances. Anxiety disorder refers to different clusters of signs and symptoms that may manifest themselves in a variety of ways including anxiety, panic, and phobias (LASACT,  2004 ).

A panic attack is described as a period of intense fear or discomfort that usually develops abruptly and reaches a peak within a few minutes. There is usually a manifestation of both physical and psychological symptoms. Physical symptoms may include hyperventilation, heart palpitations, trembling of body limbs, sweating, dizziness, hot flashes or chills, sensations of numbness or tingling, as well as nausea or choking. Psychological symptoms are mainly rooted in the emotion of fear. Common symptoms include the fear of fainting, dying, losing control, or losing one’s mind. Individuals who suffer from panic attacks often describe the episodes as being extremely frightening. The fear of losing complete control can be so overwhelming that once the attack subsides a persistent fear reemerges with the thought of the recurrence of more panic attacks. In essence, those who experience panic attacks live in a constant state of fear and arousal that reaches climax during the attack and then subsides until the next (LASACT,  2004 ).

A phobia is a type of anxiety disorder where the focus of the anxiety is on an activity, person, or situation that is dreaded, feared, and avoided if at all possible. Phobia can be so powerful that one’s life becomes restricted. For example, someone with a fear driving may only feel comfortable in their own home or places within walking distance. Some of the more common phobias include agoraphobia, social phobia, and simple or specific phobia (LASACT,  2004 ).

Agoraphobia is the fear of being caught in a situation or environment from which an exit would be impossible, difficult, or embarrassing. Embarrassment in this sense is usually in relation to the idea of being seen losing control in public. Typical situations in which agoraphobia may present include driving, standing in line, being in an auditorium, or just simply being outside of one’s home. Agoraphobia will usually result in a pattern of avoidant behaviors, particularly avoidance of places or situations where an attack was experienced (LASACT,  2004 ).

Social phobia refers to persistent and irrational fear of embarrassment and humiliation in social situations. Often the fear is recognized as being irrational; however, the feelings are so powerful that one’s cognitions are completely consumed. Individuals suffering from social phobia often view others as being much more competent and greatly exaggerate the effects of small or common mistakes. The most common social phobia is public speaking. However, symptoms of social phobias may also present when being around anyone other than those closest to the individual (LASACT,  2004 ).

Specific phobias are sometimes called single or simple phobias. Specific phobia is an intense, excessive, or unreasonable fear triggered by the presence or anticipation of a specific object or situation. Naturally occurring specific phobias may consist of rain, lightening, or spiders, whereas situational specific phobias have been known to manifest when one is faced with heights or riding in elevators (LASACT,  2004 ).

Another form of anxiety disorder is obsessive compulsive disorder (OCD). Obsessions are described as repetitive and intrusive thoughts, impulses, or images that trigger feelings of anxiety. Compulsions are described as repetitive rituals and acts that people are driven to perform, often reluctantly, in order to prevent or reduce stress. Oftentimes the obsessions or compulsions or both consist of thoughts and actions that are contrary to social norms. Some examples of OCD include harming others, becoming contaminated, excessive hand-washing, and silently counting and repeating words. Manifestations of OCD are extremely time consuming and significantly interfere with daily functioning (LASACT,  2004 ).

Post-traumatic stress disorder (PTSD) is a disorder where an individual experiences a psychologically traumatic stressor. In most cases PTSD is thought of in relation to severely traumatic events such as war, witnessing a death, experiencing a near-death situation, as well as sexual abuse. And, though these instances are more than sufficient to provide the necessary framework for PTSD, it is important to note that PTSD may result from situations and circumstances that are much less severe. Whether a person experiences the effects of PTSD depends on how they process the effects of certain circumstances. For example, the witnessing of a deadly automobile accident may leave permanent psychological scars for one individual thus inhibiting this individual from ever driving again. The same accident, however, witnessed by another person operating from a different cognitive structure may experience the wreck as tragic but is able to effectively move on and experiences little residual effects (LASACT,  2004 ).

PTSD consists of a persistent reexperiencing of a traumatic event through recurrent and intrusive images and thoughts (LASACT,  2004 ). These recurrent images may also manifest themselves in the form of dreams where the trauma is relived. Some of the symptoms experienced by people suffering from PTSD include insomnia, irritability, hypervigilance, and exaggerated startle responses. In addition, sufferers from PTSD will often avoid stimuli associated with the trauma including certain activities, feelings, and thoughts (LASACT,  2004 ).

PERSONALITY DISORDERS

Personality refers to deeply ingrained patterns of thought and behavior that affect the way individuals perceive, relate to, and think about themselves and their world (LASACT,  2004 ). A personality disorder is generally described as a cluster of behaviors that are considered rigid, inflexible, and maladaptive. These behaviors are usually of sufficient severity to cause significant impairment in functioning or significant internal stress (LASACT,  2004 ). Additionally, personality disorders are enduring and persistent styles of behavior and thought; they are not atypical episodes that are uncommon behavior in certain circumstances.

Four personality disorders that present some of the greatest challenges to treatment providers include:

· • Antisocial personality disorder

· • Borderline personality disorder

· • Narcissistic personality disorder

· • Passive-aggressive personality disorder.

For an individual to be diagnosed with antisocial personality disorder there is usually a history of chronic antisocial behavior that begins before the age of 15 and continues into adulthood. Certain behaviors common to antisocial disorder include academic failure, poor job performance, illegal activities, recklessness, and impulsive behavior. Some of the symptoms common to antisocial personality disorder include dysphoria or an inability to tolerate boredom, feeling victimized, and a diminished capacity for experiencing intimacy (LASACT,  2004 ). Oftentimes offenders will describe their feelings just prior to committing an offense for which they were caught as being bored. They will make such statements as “there was nothing else to do,” or “I was looking for some excitement and wanted to see if I could get away with it.”

Borderline personality disorder is usually characterized by unstable moods and self images. These individuals will sometimes display extreme mannerisms of overidealization and devaluation along with drastic shifts from baseline to extreme moods or anxiety states. In addition, they are usually very impulsive. Offenders suffering from borderline personality disorder will usually be involved in very intense and unstable interpersonal relationships (LASACT,  2004 ). These relationships are often volatile and include periods of euphoria followed by extreme disruption that will often culminate in violence.

Narcissistic personality disorder is a concept that describes a pattern of grandiosity, lack of empathy, and hypersensitivity to evaluation of others. The pattern is pervasive and rigid (LASACT,  2004 ). Offenders suffering from narcissistic personality disorder will usually blame everyone but themselves for their circumstances. They lack empathy and are usually unable to experience compassion for others. In essence, a narcissistic individual will usually conclude that they are more intelligent than others and that their problems are due to the faults of those around them. In addition, they become extremely rigid when receiving feedback that is not positive.

The concept of passive-aggressive personality disorder describes a behavior that reflects hostility and aggression in passive ways. Offenders suffering from passive-aggressive personality disorder usually lack adaptive or assertive social skills, especially in relation to authority figures. These individuals likely endured strict control during formative years and have adapted by learning to substitute passive resistance for active resistance. This is because active resistance in the presence of a controlling authority figure was perceived as dangerous. Some common symptoms of passive-aggressive behavior include purposefully being late with social or job tasks, failing to do one’s share of the work, criticizing authority figures in subtle ways, and having a constant negative attitude.

PSYCHOTIC DISORDERS

Psychosis refers to a disintegration of the thinking process, involving the inability to distinguish external reality from internal fantasy (LASACT,  2004 ). A psychotic disorder is described as a mental disorder in which a person’s personality is seriously disorganized and contact with reality is impaired. Some of the characteristics commonly associated with psychotic disorders include, but are not limited too, delusions, hallucinations, bizarre behavior, incoherent or disorganized speech, and disorganized behavior (LASACT,  2004 ). One of the most salient characteristics in the identification of psychosis will be the offender’s inability to differentiate between information that originates from the external world and information that originates from the inner world of the mind (LASACT,  2004 ). In the following, some of the more common psychotic disorders are discussed along with attendant characteristics.

Schizophrenia is a formidable psychotic disorder where symptoms usually persist for at least six months resulting in deterioration of occupational and social functioning. Schizophrenia is best understood as a group of disorders with similar clinical profiles. Common characteristic symptoms include hallucinations, delusions, bizarre behaviors, and deterioration in general levels of functioning. In addition, one may experience severe disturbances in relation to language and communication, content of the thought processes, as well as perceptions, affect, and relationship to the external world. Schizophrenia can also be divided into subtypes that generally consist of the following:

· • Paranoid type—usually characterized by delusions or hallucinations

· • Disorganized type—usually characterized by speech and behavior problems

· • Catatonic type—usually characterized by catalepsy or stupor, meaning a trance-like state with loss of sensation or consciousness, as well as extreme agitation or extreme negativism.

· • Undifferentiated type—here there is no single clinical presentation that predominates. Usually consists of a cluster of characteristics with no one characteristic that is diagnosable within a particular subgroup.

· • Residual type—at this point there are no predominant characteristics or psychotic symptoms. The disorder may have been successfully treated or the symptoms dormant.

Additional psychotic disorders that offenders may present with include brief reactive psychosis. “Brief reactive psychosis” is a term used to describe psychotic symptoms that result from being confronted by overwhelming stress. Delusional disorders describe prominent and often well-organized delusions but generally absent of hallucinations. Additional symptoms may include disorganized thought and behavior as well as abnormal affect. Induced psychotic disorder is a disorder in which psychotic behaviors or thoughts result from the acceptance of one person of the delusional beliefs of another. In essence, a dominant partner suffers from delusional psychosis and these delusions are believed and accepted by a more passive partner. Finally, alcohol and other drug-induced psychotic disorder (AOD) is a condition where individuals suffer conditions characterized by delusions or hallucinations as a result of psychoactive drug use.

SECTION SUMMARY

It is important to recognize that a large portion of offenders will be suffering from substance abuse problems. In addition, the literature is clear regarding the fact that most offenders suffering from substance abuse will also be suffering from various other psychological and emotional disorders. Therefore correctional counselors should anticipate the likelihood of having to address multiple issues stemming from a variety of sources. In fact, it is important that counselors understand that oftentimes substance abuse is a symptom of repressed emotion. In essence, the real task is to help guide offenders through the process of reconnecting with their repressed emotion and fully identify and express what they are feeling.

LEARNING CHECK

1 .

What does Fosha describe as the “mother of all pathology”?

· a.Depression

· b.Bipolar disorder

· c.Fear

· d.Anxiety

2 .

Common characteristics of schizophrenia include which of the following.

· a.Delusions

· b.Bizarre behaviors

· c.Hallucinations

· d.All of the above

3 .

Psychosis describes the process of being unable to distinguish between external reality and internal fantasy.

· a.True

· b.False

4 .

Common signs of substance abuse include which of the following.

· a.Rapid weight loss or gain

· b.Poor hygiene

· c.Blood shot or glassy eyes

· d.All of the above

5 .

Personality disorders generally describe behaviors that are inflexible, rigid, and maladaptive.

· a.True

· b.False

PART TWO: SCREENING, DIAGNOSIS, AND ASSESSMENT

Screening, diagnosis, and assessment are critical components in the process of deciding the depth and nature of services appropriate for offenders suffering from substance abuse and co-occurring disorders. In criminal justice settings, substance use and mental health disorders are often under-diagnosed which ultimately leads to misdiagnosis (Peters,  1992 ). When offenders are misdiagnosed it becomes difficult at best to employ proper interventions aimed at treating substance abuse and mental health disorders. It is for this reason that the proper assessment of substance abusers is critical to the ultimate prognosis. However, as noted before, it can be difficult to accurately assess the substance-abusing correctional client. Several reasons for nondetection of substance abuse and mental health disorders are commonplace. First, there is often a negative consequence associated with disclosure of symptoms; second, there is usually a lack of training on behalf of the staff concerning the diagnosis and management of substance abuse and co-occurring disorders (Peters & Bartoi,  1997 ).

Further adding to the enigma is the fact that mental health, substance abuse, and criminal justice systems often operate independently and do not adequately share critical information. In essence, each entity has a different, or at least slightly different, mission. This inadequate sharing of information often results in the nondetection of substance abuse and mental health disorders thereby stymieing the offender’s opportunity to access integrated services (Peters & Bartoi,  1997 ). Kofoed, Dania, Walsh, and Atkinson ( 1986 ) suggest that integrated screening and assessment approaches are commonly found to produce more favorable outcomes. This is because there are very few, if any, validated single instruments capable of assessing co-occurring disorders inside or outside the criminal justice system (Peters & Bartoi,  1997 ). Therefore, for the purposes of screening and assessment the combination of specialized substance abuse and mental health instruments used in conjunction is most desired.

Definitions of Screening, Diagnosis, and Assessment

Screening is a concept used to describe the process of detecting mental health and substance abuse disorders along with indicators that reflect the need for treatment (Peters & Bartoi,  1997 ). Drake and Mercer-McFadden ( 1995 ) point out that screening is usually conducted early in the process of gathering information and usually precedes diagnosis and assessment. Common goals of the screening usually include the following:

· • Detect current mental health and substance use disorders

· • Identify individuals with a history of violence and/or severe medical problems

· • Identify individuals suffering from severe cognitive deficits

· • Identify individuals who would not be suitable for treatment of co-occurring disorders (Peters & Bartoi,  1997 ).

Diagnosis describes the process of reviewing symptoms related to DSM-IV-TR mental health and substance use disorders. Diagnosis is usually a more detailed description of the types of disorders detected in an offender. Diagnosis usually involves an interview, psychological assessment, review of archival records, as well as other types of testing (Peters & Bartoi,  1997 ). Diagnosis usually helps determine the primary focus of treatment and whether the focus will be substance abuse disorders, mental health disorders, or both. Some of the common goals of diagnosis include the following:

· • Identify the presence of specific DSM-IV-TR mental health and substance use disorders.

· • Develop hypotheses for psychosocial assessment (Peters & Bartoi,  1997 ).

Assessment is a concept describing a comprehensive examination of psychosocial needs and problems including the severity of disorders, the conditions associated with the occurrence and maintenance of the disorders, problems related to the disorders that may affect treatment, the offender’s motivation for treatment, and specific areas for treatment interventions (Peters & Bartoi,  1997 ). Assessments are commonly conducted through interviews and/or specialized instruments and consist of the following goals:

· • Examine the scope of mental health and substance abuse problems

· • Assess the full spectrum of psychosocial problems that need to be addressed in treatment

· • Provide a comprehensive foundation for treatment planning (Peters & Bartoi,  1997 ).

Selection of Screening, Diagnosis, and Assessment Instruments

In the following sections detailed information is provided concerning different instruments used to screen, diagnose, and assess offenders. Appreciate that the concepts of screening, diagnosing, and assessing offenders represent different stages in the process of identifying disorders in need of treatment, and to some degree represent different goals. It should also be noted that the following instruments presented in this discussion are not meant to be all inclusive. A cursory glance at the literature will yield hundreds of psychometric instruments designed to measure a wide range of psychiatric, psychological, emotional, and substance abuse disorders. Therefore, when reviewing the different instruments and deciding which to include in this discussion three important concepts were considered:

· 1. Reliability—a concept used to describe the accuracy of a measure. In other words, is the instrument accurately measuring a variable regardless of what the variable may be?

· 2. Validity—a concept used to describe whether an instrument is actually measuring what it is intended to measure. In other words, if the intended variable to be measured is depression, is the instrument truly measuring depression and not anxiety?

· 3. Has the instrument been used in a criminal justice setting (Peters & Bartoi,  1997 )?

In addition, we include positive features as well as concerns for each of the instruments listed in order to assist practitioners and students in the selection of instruments most suitable for a particular agency.

Screening Instruments

A possible combination of screening instruments suggested by Peters and Bartoi ( 1997 ) include the following:

· 1. The Brief Symptoms Inventory (BSI) (Derogatis & Melisaratos,  1983 ) or the Referral Decision Scale (RDS) (Teplin & Schwartz,  1989 ) to measure mental health symptoms; and

· 2. Either the TCU Drug Dependence Screen (DDS) (Simpson,  1993 ), Simple Screening Instrument (SSI) (CSAT,  1994 ), or the combination of the Alcohol Dependence Scale (ADS) (Skinner & Horn,  1984 ) and the Addiction Survey Index (ASI) (McLellan et al.,  1992 ) to measure substance abuse symptoms. These instruments have been found to be the most effective in identifying inmates with substance dependence problems (Peters & Greenbaum,  1996 ).

The BSI is comprised of 53 items and consists of three global indices of psychopathology and nine primary psychiatric dimensions.

Positive Features

· • Brief to administer and requires no significant training.

· • Only a sixth-grade reading level is required.

· • Has adequate internal consistency and test-retest reliability.

· • Adequate convergent validity with the Minnesota Multiphasic Personality Inventory (MMPI) (Hathaway & McKinley,  1989 ).

Concerns

· • The BSI has poor discriminant validity.

· • Has low construct validity and may be most useful as a general indicator of psychopathology (Boulet & Boss,  1991 ).

The RDS is a 14-item measure of mental health symptoms that was designed to identify individuals entering jails with significant mental health problems requiring treatment while in jail.

Positive Features

· • Developed and validated in a criminal justice setting.

· • Requires no training to administer.

· • Can be self-administered.

Concerns

· • Its validity has not been examined among offenders with co-occurring disorders.

· • Examines only a few mental health disorders (depression, bipolar disorder, schizophrenia), however, in criminal justice settings these disorders are commonly the most problematic.

The DDS is a 19-item screen that examines diagnostic symptoms of drug use developed at the Texas Christian University, Institute of Behavioral Research.

Positive Features

· • One of three screening instruments found to be most effective in identifying substance dependant inmates (Peters & Greenbaum,  1996 ).

· • One of two screening instruments found to be most effective in identifying substance using inmates who were nondependent (Peters & Greenbaum,  1996 ).

· • DDS is brief to administer.

· • Because the DDS is a public domain instrument it is available at no cost.

Concerns

· • The validity of the DDS has not been examined among offenders suffering from co-occurring disorders.

· • The DDS does not examine quantity or frequency of recent or past substance use.

The SSI is a 16-item screening instrument that examines symptoms of alcohol and drug dependence. The SSI examines five different domains related to substance dependence including: (1) alcohol and/or drug consumption, (2) preoccupation and loss of control, (3) adverse consequences, (4) problem recognition, and (5) tolerance and withdrawal.

Positive Features

· • The SSI was one of three screening instruments found to be most effective in identifying inmates considered to be substance dependent.

· • The SSI had the highest sensitivity of all screening instruments in a study conducted by Peters and Greenbaum ( 1996 ).

· • The SSI is brief to administer.

· • The SSI is a public domain instrument available at no cost.

Concerns

· • Validity has not been examined among offenders with co-occurring disorders.

· • The SSI does not examine quantity or frequency of recent or past substance use.

The ADS is a 25-item instrument developed to screen for alcohol dependence symptoms. The instrument was developed and published by the Addiction Research Foundation in Toronto, Canada.

Positive Features

· • The ADS, when used in conjunction with the ASI, was found to be one of three instruments most effective in substance dependent inmates (Peters & Greenbaum,  1996 ).

· • The ADS, when used in conjunction with the ASI, was found to be very effective in identifying nondependent inmates.

· • The ADS is brief to administer and easy to score.

Concerns

· • The ADS is limited to screening for alcohol abuse.

· • Although the cost is modest, the ADS is a commercial product and would need to be purchased.

The ASI is described as the most widely used substance abuse instrument and is commonly used for screening, assessment, and treatment planning (Peters & Bartoi,  1997 ). In addition, the ASI is commonly used in criminal justice settings. Seven areas of functioning commonly related to substance abuse are measured. These areas include drug or alcohol use, family or social relationships, employment or support status, and mental health status (Peters & Bartoi,  1997 ).

Positive Features

· • In combination with the ADS, the ASI was found to be very effective in identifying substance dependent inmates.

· • In combination with the ADS, the ASI was found to be very effective in identifying nondependent inmates.

· • The ASI measures different psychosocial components related to substance abuse.

· • The ASI is capable of capturing the history of substance abuse as well as recent and current use.

· • Normative data are available for criminal justice populations (McLellan et al.,  1992 ).

· • The ASI is a public domain instrument and available at no cost.

Concerns

· • The ASI requires significant training to administer and score.

· • Administration of the entire ASI requires up to 75 minutes.

Aside from the suggestions of Peters and Bartoi ( 1997 ), we strongly recommend the Substance Abuse Subtle Screening Inventory (SASSI) as an alternate instrument for drug abuse screening. This instrument utilizes several criteria to detect personality profiles and/or characteristics that have a strong likelihood for substance abuse problems. In fact, the SASSI is designed to detect likely substance abuse among persons who are either in denial or who deliberately attempt to deceive the clinician. Because of this and because of the SASSI’s effectiveness (substance abuse detection at 93% accuracy), it is a premier assessment tool. The SASSI is a brief and easily administered screening measure that helps identify individuals who probably suffer from a substance use disorder.

The SASSI Institute notes that “interpretations of SASSI profiles also produce hypotheses that clinicians may find useful in understanding clients and their treatment planning” (SASSI Institute presentation). The SASSI has enjoyed widespread popularity and is used in both criminal justice and mental health settings. This means that the SASSI is ideal for correctional counseling objectives, and, as the student may recall from  Chapter 1 , the continual generation of hypotheses augments the scientific method of inquiry and also aids in the refinement of treatment plans (see  Chapter 2 ).

The SASSI consists of face valid items and subtle items that do not directly address substance abuse in a detectable manner. The questions are oblique in nature and instead ask about other lifecourse issues that often are commonplace with the substance-abusing lifestyle. The profiles generated provide several clinical inferences, and among these are the following: (1) indication of defensive responding, (2) level of insight and awareness of the effects of substance misuse, (3) evidence of emotional pain, and (4) likely future risk of involvement with the criminal justice system. It is clear from these other inferences that the SASSI is ideal for correctional treatment programs and that it appeals to both treatment and custodial-related concerns.

In addition, the SASSI can be administered by traditional pencil and paper format, computer and compact disc, or even online. Further, clinicians are given extensive support and guidance by the SASSI Institute, making its use “counselor friendly” and all the more easier to competently implement within the facility setting. Addictions professionals who are trained in a one-day SASSI workshop can effectively implement this screening tool. The SASSI Institute produces newsletters semiannually and provides phone and online support. The reason that we note these positive aspects of SASSI products is not to necessarily solicit our readers (we have no actual profit motive in recommending the SASSI) but to instead demonstrate that clinicians will find this tool both effective and easy to administer. We speak from experience when we note the effectiveness of the SASSI and when we note that the SASSI Institute provides ongoing and effective support to its consumers. It is with this in mind that correctional counselors may find this instrument to be a prudent choice in there drug abuse screening and assessment.

Lastly, one additional component of a comprehensive screening process includes measuring offenders’ motivation and readiness for treatment. Motivational screening instruments are primarily designed to identify those offenders not suitable for treatment (Peters & Bartoi,  1997 ) and are able to predict dropout, as well as treatment outcome. In addition, those offenders who are not found to be ready for treatment can be diverted to other programs aimed at educating the offender regarding the effects of substance abuse and co-occurring disorders. One motivational screening instrument commonly used in correctional settings is the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). The SOCRATES consists of a personal drinking questionnaire and a personal drug use questionnaire. Both instruments consist of 19 items and capture data in relation to three scales: ambivalence, recognition, and taking action. These scales reflect stages of offenders’ motivation and readiness for treatment (Peters & Bartoi,  1997 ).

Positive Features

· • According to Peters and Greenbaum ( 1996 ), the SOCRATES has been found to be highly reliable among correctional settings.

· • The instrument is brief to administer and easily scored.

· • It is a public domain document and free of charge.

Concerns

· • Validity has not been determined among populations suffering from co-occurring disorders.

· • The SOCRATES has not been validated for use in treatment matching in criminal justice settings.

Diagnostic Instruments

Diagnostic instruments are useful in identifying key questions or issues that will need to be addressed in the assessment stage as well as in the development of individual treatment plans (Drake & Mercer-McFadden,  1995 ). Diagnostic instruments are primarily used to examine symptoms of substance abuse and mental health disorders within the framework of the DSM-IV-TR. In essence, diagnostic instruments build on the information obtained during the initial assessment and provide a more in-depth look into the offender’s psychosocial characteristics.

The Diagnostic Interview Schedule (DIS) (Robins, Helzer, Croughan, & Ratcliff,  1981 ) is a fully structured diagnostic instrument. The DIS measures such constructs as mood, anxiety, schizophrenia, eating, somatization, psychoactive substance abuse, and antisocial personality disorder (Peters & Bartoi,  1997 ).

Positive Features

· • The DIS is able to measure antisocial personality disorder which is often associated with substance abuse.

· • The DIS requires little training and can be administered by nonclinicians.

Concerns

· • Structured instruments sometimes fail to detect up to 25% of those individuals abusing alcohol and it is possible that even a larger percentage of substance abusers go undetected (Drake et al.,  1990 ; Stone, Greenstein, Gamble, & McLellan,  1993 ).

· • According to Hasin and Grant ( 1987 ) the DIS may not be best suited to detect depression among offenders suffering from co-occurring disorders.

A second diagnostic instrument that may be useful is the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) (First, Spitzer, Gibbon, & Williams,  1996 ). The SCID examines 32 different Axis I diagnoses and includes major mental health and substance use disorders.

Positive Features

· • Interrater reliability of the SCID is mostly good (0.64–0.72) among individuals suffering from co-occurring disorders (Corty, Lehman, & Myers,  1993 ).

· • Peters and Greenbaum ( 1996 ) note the SCID has good test-retest reliability (77–100%) among male, prison inmates.

Concerns

· • Similar to the DIS, the SCID also suffers from an inability to detect up to 25% of alcohol abusers and possibly even a higher number of substance abusers (Drake et al.,  1990 ; Stone et al.,  1993 ).

· • The SCID requires clinical expertise to determine if symptoms meet the criteria of a particular disorder (Corty et al.,  1993 ).

· • Significant training is required for administration and scoring.

Assessment Instruments

The assessment of an offender usually entails a detailed and personalized gathering of information that is relied upon to develop a specific treatment plan. The assessment usually takes place after screening and diagnosis and once the offender has been referred to treatment services. One note important to the concept of assessment is that sufficient time should be given prior to an assessment to ensure the offender has been detoxified, is sober, and that any mental health symptoms are not the result of withdrawal (Weiss & Mirin,  1989 ). Some of the key components of a thorough assessment include examining skill deficits, the need for psychotropic medication, as well as the types of treatment and support services that will be needed to properly attend to the various disorders of a particular offender (Peters & Bartoi,  1997 ). In addition, Peters and Bartoi ( 1997 ) suggest the following types of information should be included in the assessment of co-occurring disorders:

· • Criminal justice history and status

· • Mental health history, current symptoms, and level of functioning

· • Substance abuse history, current symptoms, and level of functioning

· • History of interaction between mental health and substance use disorders

· • Family history of mental health and substance use disorders

· • Medical and health status

· • Social/family relationships

· • Interpersonal coping strategies, problem-solving abilities, and communication skills

· • Employment/vocational status

· • Educational history and status

· • Literacy, IQ, and developmental disabilities

· • Treatment history and response to treatment

· • Prior experience with peer support groups

· • Cognitive appraisal of treatment and recovery

· • Motivation and readiness for treatment

· • Self-efficacy in adopting lifestyle changes

· • Expectancies related to substance use

· • Participant conceptualization of treatment needs

· • Resources and limitations affecting the ability to participate in treatment.

When deciding on which instruments are most appropriate for assessment it is important to understand that an integrated approach is critical to success. There should be a comprehensive assessment of mental health and substance use disorders as well as an in-depth examination of criminal justice history and current status. Based on information provided by Peters and Bartoi ( 1997 ) the following combination of instruments may be best suited for assessing offenders’ suffering from substance abuse and/or co-occurring disorders:

· 1. Either the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) (Hathaway & McKinley,  1989 ), the Millon Clinical Multiaxial Inventory-III (MCMI-III) (Millon,  1992 ), or the Personality Assessment Inventory (PAI) (Morey,  1991 ).

· 2. The Addiction Severity Index (ASI) to examine substance abuse–related areas.

All three personality inventories (MMPI-2, MCMI-III, and PAI) are self-report measures that have undergone intense research and proven to be mostly reliable and valid instruments. The MMPI is a very robust instrument that is now used in a multitude of correctional settings. Students may recall that the MMPI-2 was discussed extensively in  Chapter 2 . The MCMI-III is useful in assessing personality disorders that may affect involvement in treatment. The MCMI-III also includes a drug abuse scale aimed at measuring personality characteristics associated with drug abuse. In addition to personality constructs, the PAI also includes measures of alcohol and drug problems (Peters & Bartoi,  1997 ). When used in conjunction with the ASI, previously described, this combination should yield mostly accurate depictions of offenders’ current state regarding substance abuse and co-occurring disorders.

Threats to Accurate Screening, Diagnosis, and Assessment

It can be very difficult to obtain reliable and valid information from offenders suffering from substance abuse and co-occurring disorders. Many offenders vested in a criminal lifestyle will be hesitant to provide accurate and truthful information. There is often a lack of trust on behalf of offenders for anyone working in the various components of the justice and mental health system. As a result, screening, diagnosing, and assessing should be conducted on an ongoing basis throughout the duration of the offender’s involvement with the justice system. It is important to note that in addition to the various psychometric instruments it is also important to engage offenders in interpersonal conversation aimed at assessing their overall mental and physical status. Some of the more common threats include the following:

· • Inadequate staff training and poor familiarity with mental health and/or substance use disorders

· • Inadequate amounts of time for proper screening and assessment

· • Previous clinicians who may have avoided, or neglected, to provide screening for co-occurring disorders

· • Incomplete or misleading records

· • Extreme variation in the expression of co-occurring disorders

· • An offender may be in temporary remission at the time of screening

· • Considerable symptom interaction between co-occurring disorders

· • Individuals suffering from co-occurring disorders may have difficulty providing accurate histories due to cognitive impairment, mental health symptoms, and confusion

· • Individuals in the criminal justice system may anticipate negative consequences related to disclosure

· • Symptoms may be feigned or exaggerated if an individual believes that this will lead to more favorable placement or disposition.

SECTION SUMMARY

Screening, diagnosing, and properly assessing offenders is a critical component of being able to effectively render appropriate services. The essence of each of these steps is to ascertain what types of services an offender needs. There are a variety of instruments available to help counselors properly screen, diagnose, and assess offenders. It is important that the counselor carefully identify certain instruments based on their reliability and validity. Also, it is important that counselors identify instruments that are capable of assessing both psychological and emotional disorders as well as substance abuse. This process usually consists of using several instruments because of the lack of single instruments able to capture the necessary components salient to the criminal justice system. Finally, it is important that counselors thoroughly familiarize themselves with the types of information produced by the instruments they use in order to maximize their utility.

LEARNING CHECK

1 .

Diagnosing describes the process of detecting mental health and substance abuse disorders that need to be treated.

· a.True

· b.False

2 .

Assessments are commonly conducted through interviews and/or specialized instruments.

· a.True

· b.False

3 .

A common threat to accurate screening, diagnosis, and assessment is the fact that many offenders distrust the criminal justice system and are hesitant to provide truthful information.

· a.True

· b.False

4 .

Motivational screening instruments are primarily used to identify offenders who are

· a.most suitable for treatment

· b.highly motivated

· c.not sure if they need treatment

· d.not suited for treatment

5 .

When choosing a particular instrument, it is not important to consider whether the instrument has been used in a criminal justice setting

· a.True

· b.False

PART THREE: TREATING ALCOHOL/SUBSTANCE ABUSE AND CO-OCCURRING DISORDERS

Treating offenders suffering from alcohol and/or substance abuse requires an informed and comprehensive approach that targets each area of the offender’s life circumstance that may be contributing to the continued use. An informed treatment approach must be able to identify psychological and emotional characteristics, dynamics of interpersonal relationships, as well as the offender’s physical surroundings that may be contributing to or causing the use of alcohol and/or other drugs. It is important to note that there are many different treatment paradigms that can be effective in treating alcohol and substance abuse as well as co-occurring disorders. The specifics of a particular treatment modality usually depend on the emphasis of a particular service provider as well as the training undergone by a particular counselor or mental health professional. The 12 core functions that are presented below have been widely adopted by service providers throughout the world in treating alcohol and substance abuse. Each function is critical to the success of treating offenders. For the purposes of this text, we suggest these functions as a guide to be implemented according to the specific protocols of individual mental health and substance abuse providers.

· 1.  Screening —as mentioned above, this is usually the point at which the offender is determined to be eligible for admission to a particular program. During the screening an initial evaluation is conducted aimed at gathering information regarding psychological, social, and physiological signs and symptoms of substance abuse and co-occurring disorders.

· 2.  Intake —consists of administrative and initial diagnosis procedures for admission to a program. Clients are usually expected to fill out and complete necessary forms and documents including informed consents.

· 3.  Orientation —generally consists of describing to the client the general nature and goals of the program as well as rules governing client conduct and infractions that could lead to disciplinary actions or discharge from the program.

· 4.  Assessment —procedures consisting of an in-depth evaluation of a client’s strengths, weaknesses, problems, and needs in order to develop a particular treatment plan. The assessment should consist of gathering relevant history including, but not limited to, alcohol and drug use; identifying methods and procedures for corroborating the client’s history from significant secondary sources; identifying appropriate assessment tools; explaining to the client the rationale for using the assessment techniques; and finally, developing a comprehensive diagnostic evaluation of the client’s substance abuse and/or co-occurring disorders in order to provide an integrated approach to treatment based on the client’s strengths, weaknesses, and identified problems and needs. The results of the assessment should suggest the focus of the treatment.

· 5.  Treatment planning —the process by which the counselor and client, through collaboration, identify and rank problems needing resolution. In addition, the counselor and client establish immediate and long-term goals and decide on the appropriate treatment process and the resources to be utilized.

· 6.  Counseling —the process of using special skills to assist individuals, families, or groups in achieving objectives through exploring problems and their ramifications; examining attitudes and feelings; and consideration of alternative solutions and decision-making skills. In essence, counseling is the relationship whereby the counselor helps mobilize the client’s resources to resolve problems and/or modify attitudes and values. Counselors need to have a working knowledge of various counseling theories. These theories may include reality therapy, transactional analysis, strategic family therapy, client-centered therapy, existential therapy, and so on.

· 7.  Case management —the process of bringing services, agencies, resources, and/or people together within a planned and coordinated framework with the goal of achieving identified goals. Case managers may perform counseling, however, the bulk of their responsibilities usually entail the coordination of multiple services needed to address specific needs of the offender. In addition, it is very important that case managers assume an active role in the treatment process where they are able to closely monitor the offender’s progress or lack thereof.

· 8.  Crisis intervention —describes the process of delivering services that respond to an offend-er’s needs during acute emotional and/or physical distress. A crisis is a decisive event in the course of treatment that threatens to compromise or destroy the rehabilitation effort. A crisis may consist of overdose or relapse as well as indirect circumstances such as the death of a loved one or divorce. It is critical that the counselor identify the crisis as quickly as possible and take immediate action to begin mitigating or resolving the salient problems.

· 9.  Client education —educating offenders is an important part of the overall treatment process. Education can be provided in a variety of ways including relevant psychosocial concepts, dangers and risks associate with certain behaviors, as well as describing self-help groups and other resources that may be available.

· 10.  Referral —the process of identifying the needs of an offender that cannot be met by the counselor and then following up by assisting the client in obtaining support and resources from other professionals that are able to provide appropriate services. It is important that counselors be aware of the referral process as well as the different community resources and their deliverables.

· 11.  Report and record keeping —the process of accurately recording the results of the assessment and treatment plan usually through writing reports, progress notes, discharge summaries, and other offender-related data. If performed properly, the process of reporting and record keeping will enhance the offender’s entire treatment experience. Accurate reporting facilitates communication, timely feedback from supervisors, assists other programs that may provide services, and enhances the accountability of the program that may be necessary for licensing and funding.

· 12.  Consultation with other professionals —usually consists of communicating with in-house staff or outside professionals to ensure the best care possible for the offender. Consultations provide a good opportunity for professionals to gather in order to generate and share ideas regarding the treatment process of an offender.

In addition to the 12 core functions in treating alcohol and substance abuse, the Center for Substance Abuse Treatment ( 2006 ) provides 12 principles to address the needs of persons with co-occurring disorders. These principles were generated from the accumulated experience of mental health professionals over many decades of practice. Some of the information provided in the following principles may overlap with information already provided. We go forward, however, based on the belief that these areas of overlap cannot be emphasized enough.

· •  Principle 1 —Co-occurring disorders are to be expected in all behavioral health settings. In other words, it should be assumed that many offenders will be suffering from a multitude of disorders. Based on this assumption, all policies, regulations, funding mechanisms, and programming should reflect the need to serve people with co-occurring disorders.

· •  Principle 2 —An integrated system of mental health and addiction services that emphasizes continuity and quality is in the best interest of consumers, providers, programs, funders, and systems. This principle cannot be emphasized enough. A variety of services must be available and need to be matched with the specific needs of offenders.

· •  Principle 3 —The integrated system of care must be accessible from multiple points of entry and be perceived by the offender as caring and accepting. Many offenders suffering from substance abuse and co-occurring disorders lack the capacity to traverse complicated service systems and their attendant bureaucracy. In addition, a variety of barriers such as financial limitations, inadequate transportation, and so on may prevent some offenders from accessing or even seeking treatment. These barriers need to be removed whenever possible to avoid discouraging offenders from seeking treatment and continuing down the path of the untreated waiting for the next crisis.

· •  Principle 4 —The system of care for co-occurring disorders should not be limited to a single “correct” model or approach. Every individual is different, and what works for one may not work for the other. Systems of care need to be diversified and able to adapt to the specific needs and learning styles of particular offenders.

· •  Principle 5 —The system of care must reflect the importance of the partnership between science and service, and support both the application of evidence- and consensus-based practices for persons with co-occurring disorders and evaluation of the efforts of existing programs and services. In essence, there needs to be a constant effort aimed at enhancing services based on scientifically grounded evidence.

· •  Principle 6 —Behavioral health systems must collaborate with professionals in primary care, human services, housing, criminal justice, and education and related fields in order to meet the complex needs of persons with co-occurring disorders. This breadth of need is based on the fact that offenders suffering from co-occurring disorders are often among the most disadvantaged and impoverished members of society.

· •  Principle 7 —Co-occurring disorders must be expected when evaluating any offender, and clinical services should incorporate this assumption into all screening, diagnostic, assessment, and treatment planning.

· •  Principle 8 —Within the treatment context, both co-occurring disorders are considered primary. For offenders with co-occurring disorders, symptoms of either disorder may vary over time. One set of symptoms may be managed at a particular time while the other set causes impairment. This interactive nature requires each disorder to be continually assessed. This principle is based on the assumption that there is always a relationship between the disorders.

· •  Principle 9 —Empathy, respect, and belief in the individual’s capacity for recovery are fundamental provider attitudes. Many offenders suffering from co-occurring disorders have experienced significant let-downs and disappointment throughout the course of their life. They are often very keen to any form of judgmentalism on behalf of the counselor and will likely feel demoralized, rejected, or disappointed once again. When faced with judgmentalism, whether real or perceived, many offenders will instinctively employ the defense mechanism of shutting down, which is an attempt at reducing emotional pain. Once cognitively and emotionally shut down real therapeutic progress is all but impossible.

· •  Principle 10 —Treatment should be individualized to accommodate the specific needs, personal goals, and cultural perspectives of unique individuals in different states of change. The concept of cultural competency on behalf of the service provider must be adhered to. Cultural differences must be learned, respected, and incorporated into all aspects of the treatment plan.

· •  Principle 11 —The special needs of children and adolescents must be explicitly recognized and addressed in all phases of assessment, treatment planning, and service delivery.

· •  Principle 12 —The contribution of the community to the course of recovery for consumers with co-occurring disorders and the contribution of consumers with co-occurring disorders to the community must be explicitly recognized in program policy, treatment planning, and consumer advocacy.

Denial as Clinical Treatment Issue

Counseling criminal justice offenders with substance abuse and/or co-occurring disorders is challenging work for a myriad of reasons. Often offenders will be resistant due to a lack of trust in the system; their only motivation for attending counseling sessions will be because they have been ordered to do so by the court; and the thought of getting in touch with emotion may be considered a weakness to be taken advantage of by others. In essence, many offenders will be unable to express and feel emotion. Their emotional landscape is barren due to past experiences that have left them feeling hurt and rejected. As a result, the thought of trying to reconnect with emotion and feeling, a critical part of the recovery process, will often provoke powerful feelings of anxiety.

One defense mechanism often employed to reduce the unpleasant feelings of anxiety, and particularly salient to offenders suffering from substance abuse and/or co-occurring disorders, is the concept of denial. Often offenders will deny the fact that they have a problem with the use of substances. This denial serves as an internal mechanism aimed at staving off powerful pangs of anxiety induced by the thought of living one’s life without alcohol and/or drugs. Offenders seriously addicted to substances may be unable or unwilling to imagine their existence sober. The paradox, however, is that denial as a defense is only effective in the short term. As long as an offender is using denial as a coping mechanism he or she will be unable to experience or truly participate in lasting therapeutic change. Therefore, the goal is to assist and accompany offenders through the frightening process of rejecting the concept of denial as a defense mechanism and replacing it with acceptance and a true desire to recover their natural self.

There are a variety of strategies that can be effective in helping the offender move from denial to acceptance. The following strategies are meant to serve as guide that may be useful in assisting some offenders dismantle the concept of denial as a viable defense mechanism.

· •  Confront —At some point the offender’s use of denial as a defense mechanism will have to be confronted. In other words, it will have to be clearly articulated, in a manner in which the offender is able to comprehend, that the continued use of denial is counterproductive to the healing process. Even though the client may not be ready to accept the alternative, the counselor may be well served by further articulating that what needs to replace denial is acceptance of self; accepting the fact that he or she is a flawed but worthy human being deserving of love and freedom.

· •  Empathy/Compassion —When offenders are using denial as a coping mechanism, they will often be resistant to much of the information being provided by a counselor. This resistance can trigger the counselors own negative emotions. For example, when an offender resists or rejects what the counselor is saying many counselors will begin to feel confused, panic, hurt, and even rejected (Egan,  2007 ). Based on these negative feelings counselors may react in ways that are counterproductive such as: becoming impatient and hostile; blaming the client and entering into a power struggle; or simply giving up (Egan,  2007 ). It is critical that counselors be aware of their own issues related to denial, resistance, and reluctance. In other words, how would you, the counselor, feel if you were being coerced or encouraged to do something that involved significant change? Or, as Egan ( 2007 ) points out, how do you avoid personal growth and development? By exploring these issues, counselors are better equipped to appreciate the fear and anxiety being experienced by the offender. The ability to understand the offender’s plight allows the counselor to genuinely express empathy and compassion free of judgmentalism.

· •  Understand that some reluctance on the part of the offender is normal —Appreciate that many offenders will be heavily vested in the use of substances as a coping mechanism. Denial may be the only construct available that is strong enough to keep them from having to immediately face the realities of their destructive behaviors.

· •  Educate the offender as to why the concept of denial is so powerful —Help the offender understand the underlying structure that is supporting the continued use of denial as a coping mechanism. For example, a counselor may suggest that the offender talk to his or her denial. The counselor may prompt the offender to complete this statement, “Denial, I am so glad I have you in my life. If it were not for you, denial, I would have to …” The likely completion of the aforementioned sentence would probably be something like, “Denial, if it were not for you I would have to admit that I have a drug or alcohol problem and it is destroying my life.”

· •  Be realistic, it is ultimately up to the offender —Try to remember that there are limits to what a counselor can do (Egan,  2007 ). Unrealistic expectations can lead to a power struggle that is counterproductive. Some clients may choose to reject help and continue on with their current lifestyle. As unfortunate as this may sound it is a reality that must accepted by the counselor.

· •  Strategies to remember :

· • Show deep respect.

· • Relate with empathy and compassion.

· • Be genuine.

· • Maintain a sense of humor.

· • Be honest—admit when you are confused or do not understand.

· • Always try to relate to an offender in a nonjudgmental fashion. Judgmentalism will quickly erode any connection between the counselor and offender (Egan,  2007 ).

Alcoholics Anonymous (AA) and 12 Step Groups

Alcoholics Anonymous (AA) is a process carried out by self-help groups whose members suffer from alcoholism. AA was founded in the 1930s by Dr. Robert Smith and William Wilson (Alexander,  2000 ) and has been very successful in helping scores of individuals recover from alcoholism. AA is predicated on 12 steps that are to be followed by members in chronological order. A complete breakdown of the 12 steps can be found at  http://www.aa.org .

Because AA and its 12 steps have been so successful it has served as a prototype for the treatment of other problems including Narcotics Anonymous, Al-Anon Family Groups, Gamblers Anonymous, Alateen, Adult Children of Alcoholics, Co-Dependents Anonymous, and others (Alexander,  2000 ).

There are several components of self-help groups that make them extremely effective for many people. First, usually everyone in the group is suffering from similar circumstances ranging from addiction, co-dependency, or living with family members who are drug addicts or alcoholics. This is an extremely powerful component and lets the individual know that they are not alone. Oftentimes people suffering from addiction or emotional/psychological disorders come to believe that they are the only ones suffering from these ailments. In addition, because they feel alone in their suffering they begin to feel as though they are defective which usually results in powerful feelings of shame. The group works to alleviate these negative emotions by providing an atmosphere of caring individuals suffering the same afflictions. Second, by working the 12 steps individuals are able to share their stories and circumstances and be heard. For some addicts, they may not have ever had the experience of truly being heard by others. They may not have had the opportunity to receive empathy and compassion unconditionally. In addition, the group may provide their first experience at being able to share their feelings and not be judged. These are powerful therapeutic forces that greatly enhance recovery efforts. Third, because members are addicts themselves they are able to provide practical guidance and support that has worked for them. Members are able to provide advice to others in regard to how they have traversed each of the steps.

SECTION SUMMARY

When attempting to treat offenders suffering from co-occurring disorders, it is important to recognize that an integrated system of care is necessary. Treatment should be individualized based on a specific offender’s needs. It is important to avoid a “one-size–fits-all” mentality when working with offenders due to the myriad of factors that will be contributing to their problems. These factors are likely to be very specific to the individual and though some may appear to be common to most offenders the underlying characteristics are likely to be different. The primary reason for the differences is the fact that individuals have different cognitive processes for interpreting and responding to their environments. Counselors should always provide services with empathy and respect. Finally, it is important to recognize different cultural values and how they impact the offender’s methods of reasoning.

LEARNING CHECK

1 .

A counselor should never admit to being confused or not understanding. This would reduce the counselor’s credibility and hinder the ability to provide services.

· a.True

· b.False

2 .

In most circumstances where an offender is suffering from co-occurring disorders, the substance abuse problem should be considered primary.

· a.True

· b.False

3 .

Denial is a powerful defense mechanism primarily because of which of the following.

· a.Its ability to stave off powerful feelings of shame.

· b.Its ability to allow the offender to justify his or her actions.

· c.Its ability to allow the offender to pretend as though he or she does not have a problem.

· d.All of the above.

4 .

The primary concept that needs to replace the offender’s denial is the acceptance of

· a.the situation

· b.oneself

· c.the fact that they will never change

· d.none of the above

· e.all of the above

5 .

One of the most powerful components of self-help groups is the fact that all of the members are suffering from similar circumstances.

· a.True

· b.False

PART FOUR: RELAPSE PREVENTION

Unfortunately, many offenders who undergo treatment while in the criminal justice system will go back to old environments and return to using alcohol and/or drugs. The recidivism statistics clearly show this to be a fact. For some, there is nothing really that can be done. In order to stay sober the offender must be fully committed to maintaining a substance-free life and willing to work diligently at maintaining an environment that is conducive to this success. The final segment of this chapter is aimed at those offenders who have successfully gotten clean and are committed to maintaining a life free of drugs and/or alcohol. Much of the information presented is drawn from the Counselor’s Manual for Relapse Prevention with Chemically Dependent Criminal Offenders. The manual is part of the Technical Assistance Publication Series funded by SAMHSA.

Relapse prevention is the process of helping recovering addicts recognize and manage internal and external life circumstances that may lead to relapse. Relapse, in this context, is the process of becoming dysfunctional in recovery, which leads to a chemical use, physical or emotional collapse, or suicide. There are typically observable warning signs that precede episodes of relapse. Relapse usually progresses from bio/psycho/social stability through a period of distress that culminates with physical and/or emotional collapse. The symptoms intensify and the offender turns to substances for relief. Understanding and identifying the warning signs is a critical component in helping offenders stay clean. In essence, relapse occurs when offenders reverse the basic components of the recovery process. Therefore, it is possible to articulate a relapse process by first identifying the recovery process.

Process of Recovery:

· 1. Abstaining from alcohol and other drugs

· 2. Separating from people, places, and things that promote the use of alcohol or drugs, and establishing a social network that supports recovery

· 3. Stopping self-defeating behaviors that prevent awareness of painful feelings and irrational thoughts

· 4. Learning how to manage feelings and emotions responsibly without resorting to compulsive behavior or the use of alcohol or drugs

· 5. Learning to change addictive thinking patterns that create painful feelings and self-defeating behaviors

· 6. Identifying and changing the mistaken core beliefs about oneself, others, and the world that promote dysfunctional thinking.

Relapse Process:

· 1. Have a mistaken belief that causes dysfunctional thoughts

· 2. Begin to return to addictive thinking patterns that cause painful feelings

· 3. Engage in compulsive, self-defeating behaviors as a way to avoid the feelings

· 4. Seek out situation involving people who use alcohol and drugs

· 5. Find themselves in more pain, thinking less rationally, and behaving less responsibly

· 6. Find themselves in a situation where drug or alcohol use seems like a logical escape from their pain and as a result they use alcohol or drugs.

Based on the idea of being able to identify the relapse process a number of principles have been constructed specifically geared toward relapse prevention therapy. These principles are geared toward helping relapse-prone offenders maintain abstinence.

Principle 1: Self-Regulation

The risk of relapse decreases as the offender’s capacity to self-regulate thinking, feeling, memory, judgment, and behavior increases. In essence, when the offender experiences disruptive stress he or she needs to be stabilized. The stabilization process often involves:

· • Solving the immediate crises that threaten continued abstinence

· • Learning skills to identify and manage withdrawal

· • Establishing a daily structure that includes proper diet, exercise, stress management, and regular contact with treatment personnel and self-help groups.

Principle 2: Integration

The risk of relapse will decrease as the level of conscious understanding and acceptance of situations and events that have led to past relapses increase. The offender needs to become aware of critical issues that are capable of triggering relapse through a critical self-assessment. Identifying these critical issues allows the counselor to develop intervention plans, in conjunction with the offender, that enable the offender to work through crises before relapse occurs.

Principle 3: Understanding

The risk of relapse will decrease as the offender’s awareness of the general factors that cause relapse increases. Oftentimes this process is carried out in structured education sessions and reading assignments. In addition, it is important to test offenders to ensure adequate comprehension and retention of the material.

Principle 4: Self-Knowledge

The risk of relapse will decrease as the offender’s ability to recognize personal relapse warning signs increases. The offender should create a personalized warning sign list which includes circumstances and feelings that have led to past relapses. It is important that the list be developed and constantly revised as new problems arise.

Principle 5: Coping Skills

The risk of relapse will decrease as the ability to manage relapse warning signs increases. Once warning signs have been identified coping skills must be in place to help offenders deal with the problems that arise in a manner that fosters their ability to stay in recovery. First, offenders are taught to modify their behavioral responses in situations or circumstances that trigger warning signs. Second, through a cognitive behavioral approach offenders are taught to challenge dysfunctional thoughts. Third, offenders are taught to identify the core addictive and psychological issues that initially create the warning signs.

Principle 6: Change

The risk of relapse will decrease as the relationship between relapse warning signs and recovery program recommendations increases. The primary task is to identify a recovery activity for each warning sign on the offender’s personalized list.

Principle 7: Awareness

The risk of relapse will decrease as the use of daily inventory techniques designed to identify relapse warning signs increases. The offender is taught to identify primary goals for each day, create a to-do list, and then carry out the necessary tasks for achieving the goals. At the end of the day the offender should review his or her warning sign list and recovery plan and determine whether any warning signs were present while carrying out the tasks.

Principle 8: Significant Others

The risk of relapse will decrease as the responsible involvement of significant others in recovery and in relapse prevention planning increases. Relapse-prone individuals are not likely to recover alone. They need help. A counselor should encourage significant others to be involved in the recovery process whenever possible.

Principle 9: Maintenance

The risk of relapse decreases if the relapse prevention is regularly updated during the first three years of sobriety. It is important to note that nearly two-thirds of all relapses occur within the first six months of recovery. In addition, less than one quarter of the variables that actually cause relapse can be predicted during the initial treatment phase. In essence, ongoing outpatient treatment is necessary for effective relapse prevention.

CONCLUSION

A lot of information has been presented in this chapter. We began by discussing substance abuse issues and some of the common issues concerning this disorder. As a counselor working with offenders it is important to be able to identify the common signs and symptoms that will usually be present among substance abusers. This is particularly salient when considering that many offenders will not freely admit their substance abuse problems. Oftentimes, this is because they are untrusting of the criminal justice system and will not want to get into further trouble. A detailed discussion was provided concerning common occurring mood, anxiety, personality, and psychiatric disorders. Appreciate that many offenders, once assessed, will be determined to be suffering from co-occurring disorders. If an offender is suffering from substance abuse problems it is extremely likely that they will also have another co-occurring disorder. Both disorders must be treated and both should be considered primary when attempting to devise a treatment plan.

The process of screening, diagnosing, and assessing offenders is the process whereby counselors and other professionals determine what disorders are present as well as the severity of each. Each step in the process builds upon the previous. Several psychometric instruments were presented in order to assist counselors with accurately identifying the various disorders from which offenders may be suffering. It is through each of these three components that we ultimately create an individualized treatment plan for each offender. The treatment plan serves as a roadmap for providing offenders with necessary counseling and information aimed at treating their disorders.

Many offenders suffering from co-occurring disorders require substantial counseling to modify or completely change old patterns of thinking and behaving. Counseling offenders is sometimes difficult due to their lack of trust as well as being heavily vested in ways and patterns of living. In addition, those offenders suffering from substance abuse issues will often be in denial regarding the seriousness of the disorder. Denial is a very common concept among populations of substance abusers. It will be critical to work with these offenders in a manner in which they are able to be guided through and out of the process of denial and begin to take ownership of their circumstances. This takes skill and vigilance on the part of the counselor. It is also important for the counselor to be intimately aware of his or her own emotions and vulnerabilities so as to avoid getting into power struggles and psychological games with offenders.

The importance and value of self-help groups cannot be overstated. One combination that may be particular beneficial is the use of self-groups in conjunction with counseling. Self-help groups provide support for many offenders and consist of others who are suffering the same symptoms and problems. Through sharing and support, offenders are able to learn that they are not alone and are also able to receive valuable feedback and guidance from their peers. Finally, relapse prevention must be considered a critical component to any mental health service provider attempting to treat offenders suffering from substance abuse and co-occurring disorders. Through relapse prevention techniques offenders are taught skills aimed at identifying situations in which they may be vulnerable and the ability to exercise new and better behaviors rather than drug use.

Essay Questions

· 1. Is there a difference between substance dependence and substance abuse? Is one more difficult to treat than other? Why or why not?

· 2. Define the concept of co-occurring disorders. Among the offender population, identify two of the most common co-occurring disorders. Why is it so important that counselors be familiar with and able to treat co-occurring disorders?

· 3. Discuss some of the key factors usually associated with how substance abuse starts. If you had to choose one, which factor would you identify as most important? Why?

· 4. What is the difference between a psychotic disorder and a personality disorder? Provide at least one example of each.

· 5. What is the primary purpose of denial? How does this concept affect the counselor’s ability to effectively work with an offender? Discuss two methods of reducing or eliminating an offender’s use of denial in relation to co-occurring disorders.

Treatment Planning Exercise

The case vignette presented below addresses substance abuse issues but also adds a twist for students; the client has co-occurring disorders. This makes the clinical case much more complicated but this is precisely the issue that confronts correctional counselors on a daily basis. It is seldom that counselors have clients with a singular issue. Rather, in many cases, the problems are multivariate and one clinical issue tends to compound the other. It is with this in mind that we present this case for students to address. Providing challenging treatment cases ensures that students understand the complexities with the treatment process and also ensures that material is not presented in an elementary or topical fashion. Further, co-occurring disorders tend to require the implementation of information from various chapters, thereby integrating the information that students acquire throughout the text and providing interlocking learning process where information is applied rather than being memorized. With this in mind, the student must do the following:

· 1. Refer back to  Chapter 4  and explain how you would go about developing an effective therapeutic alliance with Mike? What challenges are you likely to encounter? How would you work to overcome these challenges?

· 2. What defense mechanisms and/or behaviors does Mike exhibit that is common to substance abusers? How can you determine if this is a dimension of Mike’s addiction or more a dimension of his potential for Narcissistic personality disorder?

· 3. What would you treat first, the drug abuse or the potential personality disorder? Would you treat them simultaneously?

· 4. How likely do you think it is that Mike will refrain from further drug use? How likely do you think it is that Mike will refrain from engaging in further criminal activity?

· 5. How would you motivate Mike to address his substance abuse issues? Explain some of the first initial processes that you might use when implementing the treatment planning process with Mike (some suggestions might come from  Chapters 2  and  4 ).

The Case of Mike

Mike is a 20-year-old male who has just recently been released from jail. Mike is technically on probation for car theft, though he has been involved in crime to a much greater extent. Mike has been identified as a cocaine user and has been suspected, though not convicted, for dealing cocaine. Mike has been tested for drugs by his probation department and was found positive for cocaine. The county has mandated that Mike receive drug counseling, but as you continue counseling with Mike, you notice that he is very resistant to treatment. In fact, he denies issues with the severity of his drug use and blames either environmental circumstances or the behaviors of other people. When looking through his case file, you notice that at one time Mike was diagnosed by a psychologist to have Narcissistic personality disorder. This would then mean that he has comorbid issues that would need to be addressed.

Mike seems to have little regard for the feelings of others. Coupled with this is his extreme sensitivity to the comments of others. In fact, his prior fiancée has broken off her relationship with him due to what she calls his “constant need for admiration and attention. He is completely self-centered.” After talking with Mike, you quickly find that he has no close friends. As he talks about people who have been close to him, he discounts them for one imperfection or another. These imperfections are all considered severe enough to warrant dismissing the person entirely. Mike makes a point of noting how many have betrayed their loyalty to him or have otherwise failed to give him the credit that he deserves.

When asked about getting caught in the auto theft, he remarks that “well my dumb partner got me out of a hot situation by driving me out in a stolen get-a-way car, we got nabbed only because the cop recognized the vehicle.” (Word on the street has it that Mike was involved in a sour drug deal and was unlikely to have made it out alive if not for his partner.) Mike adds, “You know, I plan everything out perfectly, but you just cannot rely on anybody … if you want it done right, do it yourself.” During this crime, Mike was high on a variety of stimulant drugs, including methamphetamine. In one group counseling session, he noted that his clarity is better with stimulants even though other members pointed out that his use of stimulants may actually be the reason that he finds himself in continual “bad luck” situations.

Mike recently has been involved with another woman (unknown to his prior fiancée) who has become pregnant. When she told Mike he said “Tough, you can go get an abortion or something, it isn't like we were in love or something.” Then he laughed at her and told her to go find some other guy who would shack up with her.

Incidentally, Mike is a very attractive man and he likes to point that out on occasion. “Yeah, I was going to be a male model in L.A., but my agent did not know what he was doing … could never get things settled out right … so I had to fire him.” Mike is very popular with women and has had a constant string of failed relationships due to what he calls “their inability to keep things exciting.”

As Mike puts it “hey, I am too smart for this stuff. These people around me, they don't deserve the good life cause they're a bunch of dummies. But me, well I know how to run things and get over on people. And I am not about to let these dummies get in my way. I got it all figured out … see?”

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