Substance Abuse in Brief
April 2003, Volume 2 Issue 1
What You Should Know About Alcohol Problems
Alcohol use is legal for persons age 21 and older, and the majority of people who drink do so without incident. However, there is a continuum of potential problems associated with alcohol consumption. Alcohol is the most used intoxicating substance in the United States—82 percent of people age 12 and older have used alcohol at least once in their lifetimes. And nearly half of all Americans age 12 and older—an estimated 109 million people—have used alcohol in the past month (Substance Abuse and Mental Health Services Administration 2002).
How Do We Define “Alcohol Problem”? The term alcohol problem refers to any problem related to alcohol use that may require some type of intervention or treatment. Alcohol problems vary in duration (that is, they are acute, intermittent, or chronic) and severity (that is, ranging from mild to severe). People who drink may, on occasion, consume alcohol at levels that pose a risk for alcohol-related problems. Such risky drinkers typically experience mild or moderate intermittent alcohol problems. More severe chronic problems may be experienced by persons clinically diagnosed with alcohol abuse or alcohol dependence (Institute of Medicine 1990). Some characteristics that may affect a client’s development of alcohol problems or treatment of these problems include his or her age, cultural background, and mental or physical health, including disabilities.
Risky Drinking A significant proportion of problems related to alcohol use occur in persons who are not alcohol dependent but who engage in risky drinking (Institute of Medicine 1990; National Institute on Alcohol Abuse and Alcoholism 2000). Although risky drinking is not a clinically defined condition with quantifiable symptoms, it is typically defined as consuming alcohol in a way that may pose a risk of physical or emotional harm to the drinker or others but has not produced effects that would result in a diagnosis of alcohol abuse or dependence problems (Babor and Higgins-Biddle 2000). Risky drinking includes heavy or excessive drinking, such as binge drinking Inside (drinking four or more drinks on a single occasion for females and five or more drinks for males) (National Institute on Alcohol Abuse and Alcoholism 2000). It also includes 2 Alcohol Dependence drinking in situations that increase the risk of harm, such as before or while driving, while 2 Factors That May pregnant, or while taking certain prescription medications (e.g., certain sedatives) (Fiellin et Contribute to Alcohol al. 2000). Identifying risky drinking behavior may lead to the early detection and prevention Dependence of the more serious problems of alcohol abuse and dependence. 3 Consequences of Problem Alcohol Use Alcohol Abuse 4 Detection and A person who frequently engages in risky drinking may have a more severe alcohol Treatment of Alcohol problem—alcohol abuse. A recognized medical condition, alcohol abuse is the regular use Use Problems of alcohol despite recurrent adverse consequences. A diagnosis of alcohol abuse is made when someone exhibits one or more of the following within a 12-month period: 5 References n Recurrent alcohol use resulting in a failure to fulfill obligations at work, school, or home 6 Providing Treatment n Referrals Recurrent alcohol use in situations in which it is physically hazardous (e.g., driving an automobile when impaired by alcohol use) 6 What You Can Do n Recurrent alcohol-related legal problems To Raise Awareness n Continued alcohol use despite having persistent or recurrent social or interpersonal 6 National Alcohol problems caused or exacerbated by alcohol use (American Psychiatric Association 1994). Screening Day
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April 2003
Alcohol abuse, although problematic, usually does not progress to dependence. In fact, a recent study found that 5 years after being diagnosed with alcohol abuse, only 3.5 percent of abusers met the criteria for alcohol dependence (Schuckit et al. 2001).
Alcohol Dependence The most severe problem is alcohol dependence, also referred to as alcoholism or alcohol addiction. In 2001 an estimated 5.4 million people age 12 and older were dependent on alcohol (Substance Abuse and Mental Health Services Administration 2002). Alcohol dependence is a chronic disease with discrete definable symptoms. An individual has become alcohol dependent when he or she experiences three or more of the following in a 12-month period: n Tolerance: the need for increasing amounts of alcohol to reach intoxication. n Withdrawal: the occurrence of physical symptoms when heavy alcohol use is reduced or stopped. Its symptoms may include tremors, sweating, a high pulse rate, nausea or vomiting, insomnia, and anxiety. Severe withdrawal may induce transient hallucinations or grand mal seizures. n Drinking larger amounts or drinking over a longer period than was intended. n A persistent desire or unsuccessful efforts to cut down on or control alcohol use. n Spending a great deal of time obtaining, using, or recovering from the effects of alcohol use. n Giving up or reducing social, occupational, or recreational activities because of alcohol use. n Using despite having knowledge of persistent or recurring physical or psychological problems that were caused or exacerbated by alcohol use (American Psychiatric Association 1994).
Alcohol dependence is a persistent condition. Approximately two-thirds of persons who are alcohol dependent will still be dependent in 5 years (Schuckit et al. 2001).
Factors That May Contribute to Alcohol Dependence Alcohol dependence is influenced by both genetic and environmental factors. Persons with a family history of dependence have a higher chance of lifetime dependence than those without such a history (U.S. Department of Health and Human Services 2000). In addition, researchers have identified genes that influence people’s susceptibility to alcohol dependence; however, hereditary influences alone do not predict a future of alcohol dependence. Environmental factors also play a significant role. For example, the child of a parent who is dependent on alcohol may be genetically predisposed to alcohol dependence but may effectively thwart it through education, self-monitoring, and social support (National Institute on Alcohol Abuse and Alcoholism 1995). Conversely, neurochemical changes in the brain caused by repeated abuse of substances such as alcohol can lead to neurological substance dependence, even if the individual has no genetic vulnerability to addiction disorders (Center for Substance Abuse Treatment 1999).
Preventing drinking among youth is important, not only because drinking alcohol is illegal for persons younger than age 21, but also because postponing the onset of alcohol use decreases the likelihood of developing dependence later in life. About 40 percent of those who start drinking at age 15 or younger develop alcohol dependence at some point; for those who start drinking at age 21 or older, the figure is approximately 10 percent (see figure 1) (Grant and Dawson 1997). Several factors may help discourage or at least postpone alcohol use. Parental support, communication, and monitoring are significantly related to whether adolescents drink, the amount they drink, and the frequency of their drinking. Adolescents’ drinking behavior is also related to their friends’ acceptance or rejection of drinking and whether their friends drink (National Institute on Alcohol Abuse and Alcoholism 1997).
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April 2003
Figure 1. Percentage of Adults Diagnosed With Lifetime Alcohol Dependence by Age at First Alcohol Use Percent
Age at First Alcohol Use
Source: Grant and Dawson 1997.
Consequences of Problem Alcohol Use Identifying and eliminating problem drinking behaviors are important for many reasons. Problem alcohol use of any degree of severity may disrupt family and social relationships and lead to psychological problems, violence and aggression, and legal problems. Problem alcohol use is also linked to an increased risk of injuries, including those resulting from automobile crashes, falls, and fires. Not only does the risk of injury increase with the amount of alcohol consumed, but this risk begins to rise at relatively low levels of consumption. Problem drinking may also contribute to unsafe sex practices leading to an increased incidence of HIV/AIDS, hepatitis, and other sexually transmitted diseases. Finally, higher levels of alcohol consumption are associated with a greater risk of negative health effects, including a weakened immune system, tuberculosis, coronary heart disease, stroke, liver cirrhosis, and cancer (National Institute on Alcohol Abuse and Alcoholism 2000).
The most recent calculation of the overall economic costs of alcohol problems was estimated by the National Institute on Alcohol Abuse and Alcoholism at more than $184 billion in 1998 (see figure 2). More than 70 percent of these costs were attributed to productivity losses ($134.2 billion) caused by impaired workplace and household productivity related to alcohol use, worktime lost by incarcerated offenders and victims of alcohol-related crime, and alcohol-related premature death. Other economic costs of alcohol problems include healthcare expenditures related to the prevention and treatment of alcohol abuse and dependence and the medical consequences of alcohol consumption ($26.3 billion), administrative and property damage costs from alcohol-related motor vehicle crashes ($15.7 billion), criminal justice system costs stemming from alcohol-related crime ($6.3 billion), fire destruction attributable to alcohol use ($1.5 billion), and alcohol-related social welfare expenditures ($0.5 billion) (National Institute on Alcohol Abuse and Alcoholism 2000).
3 Substance Abuse in Brief
April 2003
Figure 2. Estimated Econonic Costs of Alcohol Abuse in the United States, 1998 (in billions of dollars)
Healthcare Expenditures 14% ($26.3) Motor Vehicle Crashes Productivity Losses 9% ($15.7) 73% ($134.2) Crime 3% ($6.3)
Other 1% ($2.0)
Source: National Institute on Alcohol Abuse and Alcoholism 2000.
Detection and Treatment of Alcohol Use Problems Prevention of and early intervention in alcohol problems are important to reduce their consequences and related social and economic costs. Alcohol screening attempts to identify both risky drinkers and drinkers who are experiencing symptoms of alcohol abuse or dependence. Screening tools range from brief self-administered questionnaires to lengthy clinician-administered interviews. Screening for co-occurring mental disorders is also essential for planning an effective intervention.
Once an alcohol problem has been identified, it should be treated appropriately. Not only do affected individuals experience different types of alcohol problems; each individual has different characteristics, strengths, and weaknesses that should be considered when assessing what treatment methods are most appropriate. A comprehensive and effective assessment should provide a detailed description of the kind of alcohol problem experienced by a particular individual at a specific time (Institute of Medicine 1990).
In general, persons identified as risky drinkers—those experiencing mild or moderate alcohol problems—may benefit most from brief interventions, which usually incorporate counseling and education sessions that provide practical advice and build skills (Babor and Higgins-Biddle 2000; Institute of Medicine 1990). Typically used by a primary care provider, brief interventions are designed to reduce alcohol use, thus minimizing the risk of developing alcohol-related problems (Fleming and Manwell 1999). Research has shown that brief interventions are effective in reducing drinking and related problems (Babor and Higgins-Biddle 2000).
Brief interventions are insufficient for persons diagnosed with alcohol dependence. These persons may benefit more from intensive treatment approaches, which can include psychological, pharmacological, social, and medical services. The primary goal of all treatment programs should be to eliminate alcohol use as a factor contributing to physical, emotional, and social problems (Institute of Medicine 1990).
4 Substance Abuse in Brief
April 2003
References American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association, 1994. Babor, T.F., and Higgins-Biddle, J.C. Alcohol screening and brief intervention: Dissemination strategies for medical practice and public health. Addiction 95(5):677–686, 2000. Center for Substance Abuse Treatment. The science of addiction: Simplified. Substance Abuse in Brief. Rockville, MD: Substance Abuse and Mental Health Services Administration, July 1999. Fiellin, D.A.; Reid, M.C.; and O’Connor, P.G. Screening for alcohol problems in primary care: A systematic review. Archives of Internal Medicine 160(13):1977–1989, 2000. Fleming, M., and Manwell, L.B. Brief intervention in primary care settings: A primary treatment method for at-risk, problem, and dependent drinkers. Alcohol Research & Health 23(2):128–137, 1999. Grant, B.F., and Dawson, D.A. Age at onset of alcohol use and its association with DSM-IV alcohol abuse and dependence: Results from the National Longitudinal Alcohol Epidemiologic Survey. Journal of Substance Abuse 9:103–110, 1997. Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: National Academy Press, 1990. National Institute on Alcohol Abuse and Alcoholism. The Genetics of Alcoholism, Alcohol Alert 18. Bethesda, MD: National Institutes of Health, 1995. Substance Abuse in Brief National Institute on Alcohol Abuse and Alcoholism. Youth Drinking: Substance Abuse in Brief is produced under Risk Factors and Consequences, Alcohol Alert 37. Bethesda, MD: contract number 270-99-7072 by Johnson, National Institutes of Health, 1997. Bassin & Shaw, Inc., and The CDM Group, Inc., for the Substance Abuse and Mental National Institute on Alcohol Abuse and Alcoholism. 10th Special Health Services Administration’s (SAMHSA’s) Report to the U.S. Congress on Alcohol and Health. Bethesda, MD: Center for Substance Abuse Treatment (CSAT). National Institutes of Health, 2000. This publication transmits information about substance abuse and its treatment to health Schuckit, M.A.; Smith, T.L.; Danko, G.P.; Bucholz, K.K.; Reich, T.; and and human service professionals whose work Bierut, L. Five-year clinical course associated with DSM-IV alcohol is affected by alcohol and illicit drug use. abuse or dependence in a large group of men and women. American Edwin M. Craft, Dr.P.H., LCPC, is the Journal of Psychiatry 158(7):1084–1090, 2001. alternate Government Project Officer and Substance Abuse and Mental Health Services Administration. Results the SAMHSA editor of this publication. From the 2001 National Household Survey on Drug Abuse: Volume II, Technical Appendices and Selected Data Tables. Rockville, MD: U.S. An electronic version of Substance Abuse in Brief is available online at www.csat.samhsa.gov Department of Health and Human Services, 2002. Available at www.samhsa.gov/oas/nhsda/2k1nhsda/PDF/vol2cover.pdf [accessed under publications. If you wish to reference November 26, 2002]. or reproduce this issue, citation of this publication is appreciated. Recommended U.S. Department of Health and Human Services. Healthy People 2010, Citation: Center for Substance Abuse Volume I. Washington, DC: U.S. Government Printing Office, Treatment. What You Should Know About November 2000. Alcohol Problems. Substance Abuse in Brief, April 2003, Volume 2 Issue 1. 5 SubstanceSubstance Abuse Abuse inin BriefBrief April 2003
Providing Treatment What You Can Do To Raise Awareness Referrals n Employers: Provide educational materials about potential alcohol use problems and institute employee assistance programs. Visit www.workplace.samhsa.gov for The Substance Abuse and more information. Mental Health Services n Faith-Based Communities: Provide training to clergy so that they understand the Administration provides nature and signs of potential alcohol use problems and can provide referrals to information about local community treatment resources. The Substance Abuse Resource Guide: Faith treatment programs Communities (available online at www.ncadi.samhsa.gov) provides additional (1–800–662–HELP). In resources. addition, the Substance n Educators: Provide parents and students with information on drinking. Lesson Abuse Treatment Facility plans, activities, and parent information for fifth graders are available online at Locator (www.findtreatment. www.ncadi.samhsa.gov. The publication Keeping Your Kids Drug-Free (available samhsa.gov) provides a online at www.ncadi.samhsa.gov/govpubs/phd884/default.pdf) also provides searchable directory of valuable information for parents. more than 11,000 alcohol and drug treatment programs. National Alcohol Screening Day The National Alcohol Screening Day (NASD) program, the Nation’s only large-scale screening and early intervention program for alcohol problems, has screened more than 50,000 individuals since its inception in 1999. Screenings are conducted at community- based healthcare facilities, primary care offices, and colleges. NASD is held annually in April and is organized by the nonprofit organization Screening for Mental Health, Inc., with major support from the National Institute on Alcohol Abuse and Alcoholism, the Center for Substance Abuse Treatment, and the Center for Substance Abuse Prevention.
For more information, visit www.mentalhealthscreening.org or contact Screening for Mental Health, Inc., at 781–239–0071 or [email protected].
6 Substance Abuse in Brief
Winter 2004, Volume 3, Issue 1 Treating Alcohol Problems
Most people who drink do so without adverse consequences. However, some may develop alcohol problems that require some type of intervention or treatment. In 2002, nearly two-thirds of the 3.5 million persons who received treatment for a substance use disorder in the past year received treatment for alcohol problems—an estimated 2.4 million persons (Substance Abuse and Mental Health Services Administration [SAMHSA] 2003). Problem alcohol use can lead to various physical, psychological, and social consequences. Early detection and treatment of alcohol problems can minimize or prevent these consequences and related costs. This issue of Substance Abuse in Brief discusses several aspects of treatment, including identifying problem alcohol use, applying brief interventions, introducing behavioral treatment approaches, and providing supportive services and appropriate treatments.
Identifying Alcohol Problems Identifying risky drinking behavior, alcohol abuse, or alcohol dependence can be difficult. Related health, social, and personal problems often develop slowly and may not be detected without a precipitating event such as a workplace crisis, an incident involving the police, or an alcohol-related automobile crash. In addition, people often are reluctant to acknowledge or discuss alcohol-related problems, even with their doctors. One study found that approximately half of those with alcohol use disorders never mentioned the problem to their doctors and, of those who did, only half were diagnosed as a result (Commander et al. 1999). Studies such as this point to the importance of routine screening and assessment by primary care providers to detect and identify problems with alcohol consumption (Center for Substance Abuse Treatment [CSAT] 1997).
Health care providers have a unique opportunity to identify individuals in their care with substance use disorders at an early stage. Health care providers should screen all patients routinely for problems with alcohol by asking questions to learn how much alcohol they drink and how often. They also should ask whether patients’ use of alcohol creates problems in their daily lives and relationships, such as frequent absences from work or arguments with family members about alcohol use.
Various screening tests for alcohol use are available for use by the trained health care clinician, including Alcohol Use Disorders Identification Test (AUDIT) questionnaires and the CAGE instrument. Regardless of length or type, screening instruments have the same goal—to identify individuals who are or may become problem drinkers (CSAT 1997).
Inside When health care providers ask specific questions about alcohol use, patients have an opportunity to share their concerns and reportedly are two to three times more likely to speak again about their alcohol use with a health care professional. In addition, when such 2 Brief Interventions discussions include other health topics such as exercise, diet, weight control, and 2 Treatment Approaches medications, both providers and patients may feel more comfortable discussing problems with alcohol or other substance use (CSAT 1997). 3 Supportive Services 4 Treatments Using Once an alcohol problem is identified, finding appropriate treatment for the individual is the Medications next step. The level of treatment required depends on the type and severity of alcohol use 4 Treatment and any associated problems the person may have. For example, a person with mild alcohol Effectiveness problems usually can benefit from a brief intervention; someone with more severe alcohol problems may require specialized treatment services (Fleming and Manwell 1999). To guide 6 What You Can Do To treatment planning further, a substance abuse treatment specialist or a physician trained in Increase Awareness addiction medicine also can assess the person’s mental and behavioral status.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration ...continued on page 2 Center for Substance Abuse Treatment www.samhsa.gov Substance Abuse in Brief
Brief Interventions Individuals identified with mild-to-moderate drinking problems may benefit most from a brief intervention, a time-limited, client-centered counseling strategy focused on changing behavior and improving compliance with therapy. Brief interventions typically include five components:
1. A statement of medical concern from the counselor or health care provider about the client’s alcohol use 2. Screening and assessment to determine the nature of the alcohol problem 3. Feedback and advice on how to abstain from or reduce alcohol use 4. A course of action that sets specific goals for abstaining from drinking or reducing alcohol consumption 5. A summary of the discussion and the agreed-on course of action and the scheduling of a followup appointment. Brief interventions usually can be conducted in less than half an hour, making them especially useful in settings in which health care providers have limited time, such as hospitals, primary care clinics, and urgent care facilities. For information on conducting brief interventions in primary care settings, see Treatment Improvement Protocol (TIP) 24, A Guide to Substance Abuse Services for Primary Care Clinicians (CSAT 1997).
Brief interventions often succeed in reducing clients’ alcohol consumption and related problems as well as their use of health care services for alcohol-related medical conditions and trauma (Fleming et al. 2002; Fuller and Hiller-Sturmhofel 1999). An estimated 15 to 20 million heavy drinkers potentially could be helped by brief interventions that might prevent adverse alcohol-related consequences, such as accidents and emergency room visits (CSAT 1997).
Brief interventions have been found to be more effective than no intervention and often are as effective as a more extensive treatment. Brief interventions also can be cost effective. A recent study found that every $10,000 a physician invested in brief alcohol intervention reduced potential health care costs by an estimated $43,000 (Fleming et al. 2002).
Treatment Approaches People with mild-to-moderate alcohol use problems often respond well to brief interventions. However, those diagnosed with alcohol use disorders or dependence require more intensive behavioral treatment approaches, such as cognitive behavioral therapy and motivational enhancement therapy.
Cognitive behavioral approaches to alcohol treatment help clients identify high-risk, relapse situations; learn and rehearse strategies for coping with these situations; and recognize and cope with their cravings for alcohol and its effects (Kadden 2001). Clients participate in role-playing activities and are assigned homework to help develop behavioral and cognitive skills that enable them to cope better with situations that might tempt them to resume former alcohol habits.
Locating Screening and Motivational enhancement therapy encourages clients to use their own Assessment Tools resources to change their behavior. Based on a therapist’s assessment of the type and severity of clients’ drinking-associated problems, clients receive Numerous screening and assessment structured feedback to stimulate their motivation to change (Fuller and Hiller- tools, including several for specific Sturmhofel 1999). Research has shown that cognitive behavioral and populations such as youth, can be motivational therapies have comparable long-term success rates. According to obtained from SAMHSA’s National one study, 24 percent of clients in cognitive behavioral therapy and 27 percent in Clearinghouse for Alcohol and Drug motivational enhancement therapy were abstinent three years after treatment Information (NCADI) at (Project MATCH Research Group 1998). www.ncadi.samhsa.gov or by calling toll free 1-800-729-6686, Hablamos Another approach, known as 12-Step facilitation, adapts traditional 12-Step Español 1-877-767-8432, or TDD methods to behavioral therapy. (hearing impaired) 1-800-487-4889. 2 Substance Abuse in Brief
Outpatient or Inpatient Treatment? Depending on their circumstances, clients may receive inpatient treatment, outpatient treatment, or a combination of both. Long-term treatment outcomes of inpatient and outpatient clients appear similar (Fuller and Hiller-Sturmhofel 1999; National Institute on Alcohol Abuse and Alcoholism [NIAAA] 2000), yet individual client characteristics and the nature of the alcohol problem may make one type of treatment more appropriate than the other.
Outpatient programs Inpatient programs n May range from counseling once or twice a week to n May last from a few weeks to more than 6 months an all-day or evening program n Eliminate the need for transportation to and from n Enable clients to maintain family and social treatment relationships while receiving treatment n Provide around-the-clock professional help for n Typically cost less than inpatient treatment managing clients’ medical and psychological problems n May be appropriate for people with adequate social n Are appropriate for people who live in disruptive support whose withdrawal symptoms are mild to environments, have difficult work situations, are at risk moderate and who do not have co-occurring medical for life-threatening withdrawal symptoms, or require or psychiatric impairments care for additional medical or psychiatric conditions
Supportive Services Programs that provide services for people dependent on or addicted to alcohol can be much more effective when they also address clients’ social, family, and practical needs. Supportive services can be crucial in keeping clients in treatment and preventing relapse. Self-help approaches, such as the 12-Step Alcoholics Anonymous program, provide support through the recovery process. Clients attend regular meetings and often maintain a close relationship with a sponsor who is an experienced member of the group (Fuller and Hiller-Sturmhofel 1999). Self-help programs commonly are used in conjunction with formal alcohol treatment programs. There is a strong correlation between attending self-help meetings during and after treatment and successful recovery from Know Your Treatment Community alcohol use disorders (NIAAA 2000). Professionals working in health care, social Clients also experience better outcomes when they receive additional service, criminal justice, and mental health services that help them stay in treatment, such as childcare, family fields should be familiar with available counseling, and training in interpersonal and parenting skills. Services resources for patients with alcohol use that address clients’ needs for practical help with education, job disorders. Each State has a drug and training, and legal, housing, and transportation issues also have a alcohol authority that can provide positive effect on treatment outcomes (CSAT 2000). For example, one information about licensed treatment SAMHSA study found that clients in residential treatment programs programs (for additional information, visit were six times more likely to stay in treatment for 90 days or longer if www.findtreatment.samhsa.gov/ufds/ they also were enrolled in educational training (Simpson et al. 1997). abusedirectors). CSAT’s Substance Abuse Another SAMHSA study found that clients who received vocational Treatment Facility Locator also can help training services were nearly three times more likely to complete identify treatment centers and support treatment (CSAT 1999a). groups in local communities (visit www.findtreatment.samhsa.gov or call 1-800-662-HELP).
3 Substance Abuse in Brief
Treatments Using Medications People in treatment for alcohol dependence also can benefit from appropriate medications. Today, two prescription drugs approved by the Food and Drug Administration are used to treat alcohol dependence.
Disulfiram, an aversive medication, provides a powerful incentive to avoid alcohol by causing severe physical symptoms (e.g., nausea, vomiting, cardiovascular changes) when a client drinks. However, this medication does not eliminate the craving for alcohol. Patients—particularly those with low motivation to abstain—may stop taking the medication and relapse (West et al. 1999).
Naltrexone, which suppresses alcohol craving, was approved for use in 1995. It works by diminishing alcohol’s pleasurable stimulant effects, while magnifying negative effects such as grogginess and lack of energy (NIAAA 2000). Naltrexone’s adverse side effects may include liver toxicity, so this drug should not be given to patients with acute hepatitis or liver failure. Before treatment with naltrexone, patients should be tested for liver function, with periodic tests during treatment. Naltrexone may cause or aggravate withdrawal in people who are physiologically dependent on opioids (CSAT 1998).
Treatment Effectiveness Numerous studies have demonstrated that people can be treated effectively for alcohol dependence. A nationally representative study of treatment outcomes found that the number of days per month that alcohol was consumed by clients in treatment decreased from 17 days before treatment to 10 days after treatment (SAMHSA 1998). SAMHSA’s National Treatment Improvement Evaluation Study found that the percentage of clients in treatment who reported getting drunk decreased from 33 percent in the month before the study to 24 percent following treatment (CSAT 1999a).
Treatment not only reduces alcohol use, but also has been shown to reduce other alcohol-related problems (Figure 1). For example, in one study, posttreatment clients committed fewer crimes (down from 24 to 11 percent) and experienced an increase in employment (up from 29 to 54 percent) (CSAT 1999b). Another study found that clients used fewer health services after alcohol treatment, particularly more expensive ones such as inhospital stays and Figure 1. Comparison of Five Pretreatment and emergency room services (Armstrong Posttreatment Variables et al. 2001). in Treatment Clients
Posttreatment improvements like these benefit the health care system and society at large, as well as the individuals who are helped, their families, and their communities. Preliminary findings of the Persistent Effects of Treatment Studies indicate that 2 years after treatment, each dollar spent on alcohol and drug treatment resulted in a saving of $6.40 per patient to society due to lower costs for health care and criminal justice services and increased earnings (Harwood et al. 2001).
4 Substance Abuse in Brief
References Armstrong, M.; Midanik, L.; Klatsky, A.; and Lazere, A. Utilization of health services among patients referred to an alcohol treatment program. Substance Use & Misuse 36(13):1781-1793, 2001.
Commander, M.; Odell, S.; Williams, K.; Sashidharan, S.; and Surtees, P. Pathways to care for alcohol use disorders. Journal of Public Health Medicine 21(1):65-69, 1999.
CSAT. A Guide to Substance Abuse Services for Primary Care Clinicians. Treatment Improvement Protocol (TIP) Series 24. DHHS Publication No. (SMA) 00-3405. Rockville, MD: SAMHSA, 1997, reprinted 2000. www.ncadi.samhsa.gov/govpubs/BKD234 [accessed May 16, 2003].
CSAT. Naltrexone and Alcoholism Treatment. TIP Series 28. DHHS Publication No. (SMA) 98-3206. Rockville, MD: SAMHSA, 1998.
CSAT. The National Treatment Improvement Evaluation Study: Retention Analysis. Rockville, MD: SAMHSA, 1999a.
CSAT. A Profile of Clients Entering Treatment for Alcohol Problems. Rockville, MD: SAMHSA, 1999b.
CSAT. Treatment Components and Their Relationships With Drug and Alcohol Abstinence. Rockville, MD: SAMHSA, 2000.
Fleming, M., and Manwell, L.B. Brief intervention in primary care settings: A primary treatment method for at-risk, problem, and dependent drinkers. Alcohol Research & Health 23(2):128-137, 1999.
Fleming, M.; Mundt, M.; French, M.T.; Manwell, L.B.; Stauffacher, E.A.; and Barry, K.L. Brief physician advice for problem drinkers: Long-term efficacy and benefit-cost analysis. Alcoholism: Clinical and Experimental Research 26(1):36-43, 2002.
Fuller, R.K., and Hiller-Sturmhofel, S. Alcoholism treatment in the United States. Alcohol Research & Health 23(2):69-77, 1999.
Harwood, R.; Koenig, L.; Siegel, J.; Gilani, J.; and Chen, Y.-J. Economic benefits of treatment: Preliminary findings from the Persistent Effects of Treatment Studies (PETS)-Cuyahoga. Paper presented at the meeting of the College on Problems of Drug Dependence, Scottsdale, AZ, June 18, 2001.
Kadden, R.M. Behavioral and cognitive-behavioral treatments for alcoholism: Research opportunities. Addictive Behaviors 26:489-507, 2001.
NIAAA. 10th Special Report to the U.S. Congress on Alcohol and Health. Bethesda, MD: U.S. Department of Health and Human Services, 2000.
Project MATCH Research Group. Matching alcoholism treatments to client heterogeneity: Project MATCH three-year drinking outcomes. Alcoholism: Clinical and Experimental Research 22(6):1300-1311, 1998.
SAMHSA. Services Research Outcomes Study. Rockville, MD: U.S. Department of Health and Human Services, 1998.
SAMHSA. Results From the 2002 National Survey on Drug Use and Health: National Findings. Rockville, MD: U.S. Department of Health and Human Services, 2003.
Simpson, D.S.; Joe, G.W.; and Brown, B.S. Treatment retention and followup outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors 11(4):294–307, 1997.
West, S.L.; Garbutt, J.C.; Carey, T.S.; Lux, L.J.; Jackman, A.M.; Tolleson-Rinehart, S.; Lohr, K.N.; and Crews, F.T. Pharmacotherapy for Alcohol Dependence. Evidence Report No. 3. AHCPR Publication No. 99-E004. Rockville, MD: Agency for Health Care Policy and Research, January 1999.
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Substance Abuse in Brief is produced under contract n Health Care Providers: Routinely ask patients about number 270-99-7072 by Johnson, Bassin & Shaw, Inc., alcohol use, screen for alcohol-related problems, and and The CDM Group, Inc., for the Substance Abuse and conduct brief interventions when appropriate. For practical Mental Health Services Administration’s (SAMHSA’s) information on the role of health care providers in the Center for Substance Abuse Treatment (CSAT). Edwin M. Craft, Dr.P.H., LCPC, is the SAMHSA editor for this treatment process, consult CSAT’s TIP 24, A Guide to publication. Substance Abuse Services for Primary Care Clinicians (CSAT 1997). An electronic version of Substance Abuse in Brief is available on line at www.csat.samhsa.gov under publications. If you n Faith-Based and Community Organizations: Work wish to reference or reproduce this issue, citation of this together to provide integrated education and support to publication is appreciated. those with alcohol problems. For additional information on faith-based and community partnerships, visit HHS- Recommended Citation: Center for Substance Abuse SAMHSA’s Faith-Based and Community Initiative’s Web Treatment. Treating Alcohol Problems. Substance Abuse in site at www.samhsa.gov/faithbased. Brief, Winter 2004. Volume 3, Issue 1.
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AHCPR Archived reports, Put Prevention Into Practice and Minnesota Health Technology Advisory Committee SAMHSA/CSAT Treatment Improvement Protocols 31. TIP 31: Screening and Assessing Adolescents for Substance Use Disorders
Chapter 2—Preliminary Screening of Adolescents
The Consensus Panel recommends that all adolescents who exhibit signs of substance use receive appropriate, valid, and sensitive screening. Health service providers, juvenile justice workers, educators, and other professionals who work with adolescents at risk should be able to screen and refer for further assessment.
When screening turns up "red flags" that indicate that the adolescent may have a substance use disorder, the youth should be referred for a comprehensive assessment (Winters, 1994). For adolescents at high risk for substance use disorders, a negative screening result should be followed up with a re-evaluation, perhaps after 6 months. In recognition of the importance of early detection and intervention, it is appropriate to be inclusive when screening youth for substance use problems. The goal of screening is to identify accurately youth who will benefit from a full and complete assessment, at which time a determination of a substance use disorder can be made and recommendations for intervention developed.
Of course, just because an adolescent shows warning signs of substance use, this does not confirm that he has a problem severe enough to warrant a formal diagnosis or referral to intensive drug treatment. Some adolescents' substance involvement is temporary (Newcomb and Bentler, 1989), and most young substance users do not develop serious problems as they get older (Shedler and Block, 1990). Thus, professionals conducting screenings for substance use disorders must also be sensitive to the potential danger of stigmatizing the youth with a label of a substance abuse or substance dependence diagnosis or as having a "disease."
Screening
Screening determines the need for a comprehensive assessment; it does not establish definitive information about diagnosis and possible treatment needs. The process should take no longer than 30 minutes and ideally will be shorter. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), the hallmarks of a screening program are (1) its ability to be administered in about 10--15 minutes and (2) its broad applicability across diverse populations (SAMHSA, 1994). A screen should be simple enough that a wide range of health professionals can administer it. It should focus on the adolescent's substance use severity (primarily consumption patterns) and a core group of associated factors such as legal problems, mental health status, educational functioning, and living situation. The client's awareness of her problem, her thoughts on it, and her motivation for changing her behavior should also be solicited.
During a 30-minute screening, there may be enough time to gather information from both the adolescent and a parent or guardian and to administer a brief standardized screening questionnaire to supplement the interview. A 10- to 15-minute screening process would involve the adolescent and one method of data collection (either brief questionnaire or structured interview). The shorter screening procedure may be the only feasible strategy in facilities that must process large numbers of at-risk youth and where staff is overburdened with other tasks. Some believe that behavioral histories obtained using interactive computer software are more accurate than those done by interview or written survey, but other experts debate this (Turner et al., 1998).
Who Should Screen
Community organizations (e.g., schools, health care delivery systems, the judiciary, vocational rehabilitation, religious organizations) and individuals associated with adolescents at risk must be able to screen and detect substance use. Thus many health and judicial professionals should have screening expertise, including school counselors, street youth workers, probation officers, and pediatricians.
Who Should Be Screened
Obviously, juvenile justice systems should screen all adolescents at the time of arrest or detention. "Status offenders" do not go through these processes, but they should also be screened. Adolescent offenders clearly form an at-risk population, and the base rate of substance use is sufficiently high among them to justify universal screening (Dembo et al., 1993a). Given the high correlation between psychological difficulty and substance use disorders, all teens receiving mental health assessment should also be systematically screened. Within other service delivery systems, runaway youth (e.g., at shelters), teens entering the child welfare system, teens who dropped out of school (e.g., in vocational/job corps programs), and other high risk populations (e.g., special education students) should also be screened.
Adolescents who present with substantial behavioral changes or emergency medical services for trauma, or who suddenly begin experiencing medical problems such as accidents, injury, or gastrointestinal disturbance should also be screened. In addition, schools should screen youth who show increased oppositional behavior, significant changes in grade point average, and a great number of unexcused school absences.
Components of the Screening Process
Naturally, an appropriate screening procedure must consider several variables pertaining to the client, such as age, ethnicity, culture, gender, sexual orientation, socioeconomic status, and literacy level. Before using standardized interviews and questionnaires, it is incumbent on the assessor to review the instrument manual to gauge how sensitive it is to differences in adolescents' backgrounds. For example, many instruments will have different norms for boys and girls and for younger and older children. Collecting normative data for representative populations of different cultural groups can confuse the assessment of substance use disorders among individuals across cultural groups. If the norm for a particular group is high substance use, high substance use will "score" as normal when compared with a standardization sample made up exclusively of members of that group. What is important is that the content of the test is appropriate for clients from a variety of backgrounds and cultural experiences. Responses to potentially culture-insensitive items should be reviewed with the individual for clarification.
There are three primary components to preliminary screening: (1) content domains, (2) screening methods, and (3) information sources.
Content
The screening procedure focuses on empirically verified "red flags," or indicators of serious substance-related problems among adolescents (Rahdert, 1991). The indicators tend to fall into two broad categories: those that indicate substance use problem severity and those that are psychosocial factors. While more research is needed to validate red flags of adolescent substance use disorders, a growing body of empirical literature identifies salient markers. Figure 2-1 provides a list of such markers prepared by the Panel. There is no definitive rule as to how many uncovered red flags dictate a referral for a comprehensive assessment. Many screening questionnaires provide empirically validated cut scores to assist with this decision. Nevertheless, any time there are several red flags or a few that appear to be meaningful, it is advisable to refer the adolescent for a comprehensive assessment.
HIV/AIDS risk behaviors
Current public health concerns require that screenings for substance use disorders place a high priority on the issue of substance use as a contributor to risky sexual activity and to other HIV/AIDS risk behaviors (Leigh and Stall, 1993). According to the Youth Risk Behavior Survey, in 1995 over half of students in grades 9-12 had already engaged in sexual intercourse. Almost one-fifth reported that they had more than four sex partners, and only half of all sexually active high schoolers reported using a condom the last time they had intercourse. Drug use also appears to encourage risky sexual behavior: One-fourth of the sexually active students said they used substances the last time they had intercourse (Centers for Disease Control and Prevention, 1998; Jainchill et al., in press).
This issue highlights the importance that workers dealing with youth receive adequate training on HIV/AIDS prevention, education, and referral. Because confidentiality is essential in this area, agencies and service providers should have clear policies and procedures for recording, providing, and disclosing information on HIV counseling and testing. State laws vary concerning the confidentiality rights of youth and the right of parents to know about the HIV status of their child. Thus, it is important that local policies and procedures be consistent with State regulations. If a program receives funds from Federal sources, it may have to consider Federal laws as well.
Screening methods
Interviews and questionnaires
A model screening instrument is short, simple, and appropriate to the youth's age. The instrument should give the "big picture" of the youth's situation, not a lot of specific, detailed information. However, the instrument should be of sufficient scope to cover the "red flag" areas of substance use disorders and psychosocial functioning noted above. The tool should not require sophisticated knowledge in test administration or interpretation; it must have high utility for a broad range of professionals and paraprofessionals.
The most commonly used screening method is the interview. Not only is a screening interview an efficient means to gathering information on the essential red flags, it also offers an opportunity to observe the client's nonverbal behaviors and to gauge his verbal skills.
When structured screening interviews are used, it is important that the interviewer follow the administration structure provided in the interview booklet. Unstructured interviews pose special administration problems that contribute to measurement error. The Panel strongly recommends that structured or semistructured interviews be used in this field. Interviews should not be performed with parents present.
When using paper-and-pencil questionnaires, administration procedures should have the client read aloud the instructions that accompany the test to ensure that the client understands what is expected of him and to judge whether the client's reading ability is appropriate for the testing situation.
The Consensus Panel and Revision Panel reviewed available screening instruments for adolescent substance use (see Appendix B). Many of these screening instruments can be administered in 15 minutes and require only a few more minutes to score. Others ("mid-range screeners" such as Dembo's Prototype Screening/Triage Form) are quite lengthy and will require more administration, training, and scoring time (Dembo et al., 1990a). Furthermore, the group of screening tools varies considerably in how many red flags each tool covers. The Problem- Oriented Screening Instrument for Teenagers (POSIT), recently developed by the National Institute on Drug Abuse (NIDA) (Rahdert, 1991), covers 10 domains, while others are quite narrow in scope. Naturally, choosing a screening tool requires other considerations, including cost (some are not public domain) and its long-range value for agencies wanting to develop clinical databases. The reader is encouraged to contact the authors of instruments to obtain additional information about their applicability and utility.
Drug monitoring
Laboratory methods to monitor substance use can be conducted in the preliminary screening to supplement information gathered through screening tools and additional sources. Drug testing is an important addition to most screens and assessments; it is particularly useful at intake to juvenile assessment centers, other juvenile detention facilities, and crisis stabilization units. Drug monitoring should be conducted at an appropriate point during screening and in a manner consistent with accepted standards and guidelines. NIDA-certified laboratories are generally available in most communities and are equipped to provide agencies with the necessary training in collecting urine and blood samples.
Drug testing should always be conducted with the knowledge and consent of the adolescent. Surreptitious testing (e.g., asking for a sample for "medical" reasons and then testing it for drugs) is never advisable. Assessors should always report the results of testing to a youth and discuss their implications. Drawbacks to drug testing include the fact that lab tests yield a narrow range of information. Severity of use and the consequences of that use cannot be obtained from testing for the presence of drugs in urine and blood. Since adolescents may adulterate or replace their urine sample, collection should probably be observed. Appendix C provides additional information about laboratory testing procedures.
Other sources of information
Although it is a luxury in most screening situations, supplemental and corroborative information is useful during a screening evaluation. In most instances, obtaining it will involve interviewing a knowledgeable parent or guardian. Other logical sources at this level may be other family members, or the youth's caseworker, probation officer, or teacher. Getting information from other sources helps the assessor guard against developing an incorrect picture based solely on the young person's self-report. There is evidence that knowledgeable parents generally provide valid information about their child's "externalizing" problems, such as conduct problems, delinquency, and attention deficits, while they provide less valid and corroborating information with respect to the child's "internalizing" concerns, such as mood distress and self-view (Ivens and Rehm, 1988). Parents also can report on signs of use such as paper bags with inhalable substances in them, beer cans in a car, or drug-seeking behaviors such as stealing money from family members. Clinical wisdom suggests that parents' knowledge of their child's substance use is probably based on observation of its consequences (e.g., physical effects of intoxication).
After getting the teenager's consent, the assessor should also collect information about family life, including substance use behaviors and attitudes in the home, and whether physical, sexual, or emotional abuse is present. It is wise to collect the information when the youth is not present in the interview room and to tell the parents that what they say may be shared with the adolescent in the summary of the screening.
The Need for Community Coordination
At-risk behavior among youth is often viewed solely as a disciplinary problem rather than a signal that intervention is needed. Community-based training and community involvement in the screening process can go a long way toward enhancing effective community responses to substance-using adolescents. The Consensus Panel recommends that everyone who works with youth use the same instruments. One way to accomplish this would be for schools, child welfare agencies, human service agencies, and juvenile justice systems to establish an areawide coordinating committee for adolescent screening and assessment. The committee could review and select reliable, standardized screening and assessment tools from among the instruments presented in Appendix B so that all agencies serving the local adolescents and their families will use the same standardized measures. The use of these measures can be refined from feedback gained from focus groups.
When substance use disorder treatment, mental health, and related service providers and other community agencies specifically designed to serve at-risk youth agree to use the same screening instruments and follow similar procedures, the community is most able to apply consistent referral criteria. This process can be facilitated by communities agreeing on definitions of "high- risk" behavior for their particular community and thresholds for referring young persons for additional comprehensive assessment and treatment. If possible, local communities should ascertain the instruments' reliability and validity for that community. It is also important for local agencies to maintain their own databases on local drug testing results for the particular purposes of need assessment. For example, it helps to have data on the frequencies of abuse of various drugs and to document what are the most prevalent problems that coexist with the substance use disorder.
Administrative considerations regarding preliminary screening include cost, ease of use, flexibility of use in different settings among different populations, analyses of screening data, and preparation of relevant reports. To address these considerations, agencies throughout the community or local area must coordinate their screening policies. A communitywide interagency mechanism should be put in place to coordinate and implement screening, management of information systems (MIS), and training of screeners and other relevant professionals. Any such mechanism would have to conform to confidentiality regulations (see below).
The establishment of an areawide coordinating body for screening and assessing adolescents for substance use disorders could greatly facilitate administrative effectiveness on all levels. Such centers can coordinate intake, screening, referral, and MIS activities. The Treatment Alternatives for Safe Communities (TASC) program offers one example of effective interagency collaboration. TASC programs have been successful in identifying a large number of offenders in need of substance use disorder services (Cook, 1992). The TASC evaluation conducted in 1976 stated that various programs had achieved success in identifying a large number of offenders who qualified for TASC services and that self-reports, urinalysis, and referrals from lawyers and judges seemed to increase client flow (Toborg et al., 1976). This type of structured case management between the criminal justice and treatment systems has facilitated the traditional goals of each system.
Funding for grassroots training and implementation is necessary to support communitywide collaboration. Training should take place within a particular agency, among different agencies, and areawide. These efforts will help to identify the service providers most likely to conduct preliminary screening (such as protective service and intake workers, guidance counselors, and nurses). Training should focus on the advantages and cautions when using standardized measures (e.g., advantage of reducing error associated with subjective judgment versus inherent limitation of tests to address the unique situation of an individual).
After client-identifying information has been stripped, screening results can be made available to a large repository that can track data through on-line computer and database systems. A number- identifying system is one way to share data and yet ensure confidentiality. MIS tracking based on compiled data can provide information critical to future planning. (Some communities will not have the resources to conduct these efforts.) Electronic case reporting and instrument scoring are easing the inevitable move to paperless recordkeeping and electronic data communication, and they provide aggregate data for population descriptions, internal accountability, and reports to funding and licensing agencies. In addition, aggregate case data can sometimes persuade funding and governmental agencies responsible for resource allocation that a serious need exists for expanded local resources for adolescents.
How information is stated and stored in the files is critical, especially in today's world of computerized recordkeeping. Computerization of records greatly complicates efforts to ensure security. Once a file is created, it can "follow" a client for the rest of her life. Wording can lead to misinterpretation, creating future problems. Labeling of the adolescent must be avoided. One way to avoid labeling is to report facts, not opinions, and only information that is necessary for meeting the client's treatment needs. (For a brief discussion of some of the issues computerization raises, see TIP 23, Treatment Drug Courts: Integrating Substance Abuse Treatment With Legal Case Processing[CSAT, 1996], pp. 52-53.)
Protocols developed by community agencies to govern screening and assessment must be clear about consent and patient notice, confidentiality and privacy, State and Federal regulations (including those regarding child abuse reporting), and duty-to-warn requirements. Programs must establish and follow guidelines on confidentiality and privacy, including policies for administrative procedures and training. In other words, confidentiality and privacy must be highlighted as priorities in every aspect of the program. Training must be provided so that protocols and instruments are clearly understood. Interviewers must remind clients in a clear, realistic, and understandable manner about their rights concerning informed consent and privacy. See Chapter 4 for a more detailed discussion of confidentiality and other legal concerns.
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Chapter 3—Comprehensive Assessment of Adolescents for Referral and Treatment
Comprehensive assessment follows a positive screening for a substance use disorder and may lead to long-term intervention efforts such as treatment. Screening procedures identify that a youth may have a significant substance use problem. The comprehensive assessment confirms the presence of a problem and helps illuminate other problems connected with the adolescent's substance use disorder. Comprehensive information can be used to develop an appropriate set of interventions.
The comprehensive assessment has several purposes:
1. To document in more detail the presence, nature, and complexity of substance use reported during a screening, including whether the adolescent meets diagnostic criteria for abuse or dependence 2. To determine the specific treatment needs of the client if substance abuse or substance dependence is confirmed, so that limited resources are not misdirected 3. To permit the evaluator to learn more about the nature, correlates, and consequences of the youth's substance-using behavior 4. To ensure that related problems not flagged in the screening process (e.g., problems in medical status, psychological status, social functioning, family relations, educational performance, delinquent behavior) are identified 5. To examine the extent to which the youth's family (as defined earlier) can be involved not only in comprehensive assessment but also in possible subsequent interventions 6. To identify specific strengths of the adolescent, family, and other social supports (e.g., coping skills) that can be used in developing an appropriate treatment plan (financial information is relevant here as well) 7. To develop a written report that o Identifies and accurately diagnoses the severity of the use o Identifies factors that contribute to or are related to the substance use disorder o Identifies a corrective treatment plan to address these problem areas o Details a plan to ensure that the treatment plan is implemented and monitored to its conclusion o Makes recommendations for referral to agencies or services
In addition, the assessment begins a process of responding creatively to the youth's denial and resistance and can be seen as an initial phase of the treatment experience. Although an adolescent who has been referred for a substance use disorder assessment is likely to have a substance use problem, a counselor should not presuppose the presence of a problem. Assessment must go to the depth necessary to rule out the possibility of a substance use disorder. If a substance use disorder cannot be excluded from consideration, then the probe should continue.
The Assessor
The assessor should be a well-trained professional experienced with adolescent substance use issues, such as a psychologist or mental health professional, school counselor, social worker, or a substance abuse counselor. The assessor might work in private practice, a public clinic, a nonprofit organization, or a juvenile justice setting. Naturally, the assessor should have sufficient training in psychological assessment, use of standardized measures, developmental psychology, and substance use disorders. The assessor should also be familiar with the local slang terms for particular drugs.
It is advisable for one individual to take the lead in the assessment process, especially for gathering, summarizing, and interpreting the assessment data. If the responsibility is spread out, the adolescent may "fall through the cracks," or tasks may be duplicated unnecessarily. The process of coordinating the activities of different people and agencies working with a young person can be difficult and often creates interagency turf problems. These potential tensions can be reduced if all involved agencies are clear about expectations and responsibilities.
The skill level of the assessor should be appropriate to the tasks required by the assessment process and the particular training needed to use the specific instruments. For example, an unlicensed but trained technician may administer an objective assessment instrument such as one summarized in Appendix B, the results of which may need to be interpreted and confirmed by a licensed professional. Many diagnostic interviews need to be administered by a licensed professional because advanced training in descriptive psychopathology is required to assess the complexity of behavioral and mental disorders. However, many standardized and highly structured instruments to assess psychiatric disorders can now be administered by lay personnel with appropriate training and scored by a computer.
Note that the training, education, accreditation, sensitivity, and skill level of the assessor can limit the scope and outcome of the assessment. For example, an assessor not licensed to make mental health diagnoses should refer an adolescent who needs a formal mental health workup to an appropriate professional. Professional qualification of an assessor may affect eligibility for reimbursement for the assessment and, in some cases, authorization for treatment.
The assessor should not be a passive link in the chain from assessment to treatment. By accepting responsibility for the assessment of an adolescent and her family, the assessor also accepts responsibility for assisting in the treatment planning process. Linkages with various local agencies and programs should be established to guarantee that the adolescent will be properly transferred from assessment to the recommended referral or service agency and receive the services she needs.
To ensure that the youth obtains needed services, the assessor sometimes must become the young person's advocate. This often includes overcoming challenges in the treatment referral process and in obtaining needed services. The barriers include limited family financial resources, a shortage of slots in treatment programs, agency turf issues, and lack of appropriate services for specific treatment needs. These issues can be addressed by community networking, comprehensive case management, interagency communication and collaboration, and systematic data gathering to document adolescent treatment needs.
Setting
The assessment should be conducted in an office or other site where confidentiality can be ensured and where the adolescent can feel comfortable, private, and secure. The validity of information provided by the youth may depend on the setting (especially if the setting is seen by the youth as adversarial or threatening), the level of trust between the adolescent and the assessor, and the adolescent's understanding of the potential use and audience for the information he is about to divulge.
If the adolescent feels that he will be overheard by others in the assessor's office or that providing information will result in punishment, he is unlikely to tell the full truth. If an interview is conducted in a detention center, the juvenile should be assured that no one in authority at the center can overhear the interview. Screening and assessment should not take place in a cell (see Chapter 5).
If other people, such as the youth's family, are involved in the assessment process, the assessor should determine the order of the interviewing process. For example, it may be advisable to first interview the young person in private, then the parent(s) in private, then with the group as a whole, being sure to tell each person that no information given in confidence will be shared with the entire group unless prior permission is granted. This strategy will maximize comfort and confidentiality.
The Multiple Assessment Approach
As described in Chapter 1, the Panel recommends the use of the multiple assessment approach whereby different content issues are measured with methods from several sources. Because no single factor causes substance use disorders, and given that its effects extend to multiple areas of a youth's life (Children's Defense Fund, 1991), it is necessary to measure a wide range of personal and environmental factors.
Furthermore, the measurement challenges require that the assessor evaluate substance use disorders using multiple strategies and several sources of information (Winters, 1990). Thus, assessors should collect information through interview, observation, and specialized testing (discussed in detail below), and attempt, with the adolescent's consent, to gather information from well-informed parents, other family members (e.g., siblings), and adults and peers important to the youth. Of course, the evaluation needs to be conducted according to local, State, and Federal laws and guidelines regarding confidentiality and child abuse reporting (see Chapter 4). See Figure 3-1 for a schematic representation of the multiple assessment approach.
Content Domains To Be Assessed
Listed below are the domains that should be assessed in order to arrive at an accurate picture of the adolescent's problems. The comprehensive instruments reviewed in Appendix B measure them or subsets of them.
History of use of substances, including over-the-counter and prescription drugs, tobacco, and inhalants--the history notes age of first use; frequency, length, and pattern of use; mode of ingestion; treatment history; and signs and symptoms of substance use disorders, including loss of control, preoccupation, and social and legal consequences Strengths and resources to build on, including self-esteem, family, other community supports, coping skills, and motivation for treatment Medical health history and physical examination, noting, for example, previous illnesses, ulcers or other gastrointestinal symptoms, chronic fatigue, recurring fever or weight loss, nutritional status, recurrent nosebleeds, infectious diseases, medical trauma, and pregnancies Sexual history, including sexual orientation, sexual activity, sexual abuse, sexually transmitted diseases (STDs), and STD/HIV risk behavior status (e.g., past or present use of injecting drugs, past or present practice of unsafe sex, selling sex for drugs or food) Developmental issues, including possible presence of attention deficit disorders, learning problems, and influences of traumatic events (such as physical or sexual abuse) Mental health history, with a focus on depression, suicidal ideation or attempts, attention- deficit disorders, anxiety disorders, and behavioral disorders, as well as details about prior evaluation and treatment for mental health problems. Family history, including the parents', guardians', and extended family's history of substance use, mental and physical health problems and treatment, chronic illnesses, incarceration or illegal activity, child management concerns, and the family's ethnic and socioeconomic background and degree of acculturation (The description of the home environment should note substandard housing, homelessness, proportion of time the young person spends in shelters or on the streets, and any pattern of running away from home. Issues regarding the youth's history of child abuse or neglect, involvement with the child welfare agency, and foster care placements are also key considerations. The family's strengths should be noted as they will be important in intervention efforts.) School history, including academic and behavioral performance, and attendance problems Vocational history, including paid and volunteer work Peer relationships, interpersonal skills, gang involvement, and neighborhood environment Juvenile justice involvement and delinquency, including types and incidence of behavior and attitudes toward that behavior Social service agency program involvement, child welfare agency involvement (number and duration of foster home placements), and residential treatment Leisure-time activities, including recreational activities, hobbies, and interests
Involvement of Other Sources
The adolescent's family is an important factor in the adolescent's involvement in and treatment for substance use disorders. Therefore, it is critical to form a therapeutic alliance with the family to the fullest extent possible and to involve the family in the assessment process. If there is evidence that the adolescent is being abused at home, the family should still be questioned about the matter. It is important to pursue what is known about possible abuse from the parents, even the abusing parent, as well as other family members (e.g., siblings). Of course, the reporting requirements for professionals regarding evidence of abuse must be disclosed to each individual being interviewed (see Chapter 4 for details).
The assessment should not be considered complete until there has been time to assess the traditionally defined family and others identified by the court as legal custodians who can speak for the best interests of the adolescent, as well as the family that is defined by the young person. The assessor must determine who the "family" is as perceived by the adolescent and by legal considerations (that is, the person or entity able to legally represent the interests of the adolescent).
The assessment of an entire family requires a specific set of skills in addition to those needed to assess an individual (Szapocznik et al., 1988). Such assessments require people who are highly skilled and trained to interpret family dynamics, strengths, weaknesses, and social support systems. Assessors must also be able to identify key family structures and interrelationship patterns in which the adolescent's substance use disorder is enmeshed. It is also essential for the assessor to elicit previous treatment experiences, as well as previous attempts by the family to address the substance use problem and to ascertain the family's feelings about the adolescent. Do the family's responses to questions about this indicate the desire to help the adolescent, or do they suggest that the family sees the adolescent as "the problem?" These responses are useful in determining how to best proceed in working with the adolescent and the family.
Of course, the absence of a traditional family can be a barrier for adolescents seeking treatment. At-risk adolescents may be homeless or on the verge of homelessness. Some youth may go from shelter to shelter and have no address. In some States, a minor cannot gain access to any services unless an adult signs for her. Potential assistance can be obtained by initiating procedures to help the adolescent achieve emancipation or become a temporary ward of the State.
Key sources other than family members include adult friends, school officials, surrogate parent advocates in school-related issues, court officials, Court Appointed Special Advocates, social service workers (especially when the youth has been involved with the child welfare system), previous treatment providers, and previous assessors. Contacting these additional sources of information, with the client's consent, may be necessary to support or supplement the information that the adolescent provides in the comprehensive assessment.
Assessment Instruments
The Panel emphasized the importance of two methods for use when assessing adolescent substance use disorders: self-report questionnaires, and structured and unstructured interviews. (Laboratory testing, described in detail in Appendix C, is considered more relevant to the screening procedure.)
The use of well-designed questionnaires and interviews can yield an accurate, realistic understanding of the teenager and the problems he is experiencing. The information derived can also provide important insights into the young person's motivation and readiness to make use of and benefit from treatment.
Appendix B describes recommended instruments and their purpose, content, administration, time required for completion, training needed by the assessor, how to obtain them, their cost, and persons to contact for further guidance. All the instruments met the two most important criteria in the evaluation of any measurement instrument: reliability and validity. It is important to briefly discuss these psychometric concepts.
Reliability
Reliability refers to the relative freedom of a measure from error. One indicator of favorable reliability in a test is high consistency of item responses. Two types of consistency are involved: internal consistency and temporal stability. Internal consistency represents the expectation that the client's responses to various items are congruent to each other. For example, if the response to one question is that drugs are used "daily," it would be consistent for the client to say, in response to another question, that he uses drugs frequently. Temporal or "test-retest" consistency is based on repeated use of the measurement and refers to how the person's responses compare over a short time period, that is, from day to day or even from week to week. Thus, if the instrument is administered a second time to the individual shortly after the initial administration and the results for the two occasions correlate highly with each other, then evidence for the instrument's "test-retest" consistency is demonstrated.
Validity
Validity refers to the extent or degree to which the assessment instrument measures what it is intended to measure. Of course, a test can be valid only to the degree that it is reliable--a result with a wide amount of error cannot measure exactly what it is intended to measure. Good reliability, however, does not guarantee validity. Descriptions of assessment instruments often mention four kinds of validity.
One is content (or face) validity. This is, based on logical reasoning, the extent to which the test items are judged, "on the face of it," to deal with information, questions, or problems related to the stated objectives of the test. Content validity is often assessed by developing in advance a table of specifications that describes all the domains and characteristics that should be included in a test, and then having experienced judges rate their content relevance. A drug abuse test might gather evidence for face validity by obtaining ratings of relevance of test items from experts in the field. Some effective tests eschew content validity because they seek items whose content cannot be recognized by the subjects.
Concurrent or criterion validity is the extent to which the results of an instrument are statistically consistent with a measure intended to address the same trait or domain. The concurrent validity of a test being developed can be measured by comparing it to an already established test. For example, the Wechsler Adult Intelligence Scale has been demonstrated to be effective in assessing the thinking, memory, and learning capabilities of adults, and it has established validity as a test of intelligence. If a group of researchers developed another instrument, such as one that requires a person to solve linguistic and graphic puzzles, they might administer the two tests to a group of adults. The group would have evidence that the new test reflects intelligence if each individual scored at about the same level on both tests. That is, there would be evidence that the new test measures the same construct of intelligence that is measured by the Wechsler test by virtue of it concurring with the validity evidence associated with the established scale.
Predictive validity deals with the effectiveness with which an assessment instrument predicts how people will function or behave in the future. Thus, a criminality instrument could be used on a group of people to predict whether they will actually become criminals. In this regard, they would be followed for several years after completing the questionnaire and checked for evidence of criminality. The instrument would be considered to have predictive validity if a high correlation (for example, a correlation of .50 or higher) was determined between the results on the instrument and the later incidence of illegal behavior.
A complex type of validity is construct validity. This refers to whether the results derived from a test are consistent with and reflect the underlying theoretical notion it is intended to measure. This can be determined by assessing the extent to which the results obtained are in line with what the theory claims. For example, the developer of an assessment instrument may theorize that people who are likely to commit crimes are without clear-cut values of honesty, social conformity, or sympathy for other people and are not thoughtful about their actions. The developer then organizes a questionnaire containing items related to these traits. The questionnaire is administered to a group of known criminals and to a group known not to be criminals. When the questionnaires are scored, construct validity is present if the criminals and noncriminals are successfully distinguished from each other to a statistically significant degree.
Validity evidence can be reported in the form of correlations. Generally, validity coefficients tend to be lower than reliability coefficients. They may range between .30 and .80 or even higher, depending on whether they refer to concurrent validity (in which case coefficients tend to be higher) or to predictive validity (in which case coefficients tend to be lower). Also, as the complexity of what is being evaluated is great, as in the assessment of personality makeup, the validity coefficients are likely to be lower. Another form of reporting validity evidence is with between-group difference tests. The user of the instrument should examine the data available on validity to determine whether they represent the type of validity that fits the purposes for which the test is to be used.
Other Test Features
Norms, which are provided by the author of an assessment instrument, represent the scores or results that the types of people who are to be assessed by the instrument tend to obtain. No psychological instrument is useful for all people. Therefore, the author of the instrument reports the types of individuals for whom its use is appropriate. This report should refer to such client characteristics as the age, sex, ethnicity, educational achievement, socioeconomic level, and medical and psychological status of the population on which the original measurements were made.
Norms are often provided as tables that show how the scores are distributed for key characteristics, such as the sex or age of the population. The central tendency, or the average, of the scores is shown, along with the range from highest to lowest scores. These normative tables can be very useful to the counselor in determining the extent to which a client's functioning is within normal or abnormal limits. Often, as a test is used more extensively, norms are expanded, and the instrument becomes appropriate for increasingly larger and differing types of client populations.
Conditions for administration of any test or assessment instrument should be clearly spelled out in a manual prepared by the author of the instrument. The manual for the instrument should describe how the test was constructed and should reportavailable information on its reliability, validity, and norms. It should also describe the content and structure of the instrument, as well as how it relates to similar instruments.
Of great importance to the user is the author's description of how the instrument is to be administered, scored, and interpreted. Specific statements should include
1. The purpose or aim of the test 2. For whom the test is and is not appropriate 3. Whether the test can be administered in a group or only on an individual basis 4. Whether it can be self-administered or if it must be given by an examiner 5. Whether training is required for the assessor, and, if so, what kind, how much, and how and where it can be obtained 6. Where the test can be obtained and what it costs
Consideration of the above practical issues and of the conditions for administration should enable program staff to select the instruments that are most applicable and useful for its program and clients. Once selected, the tests should be administered in the manner recommended by the authors. No substitutions should be made for any test items and no items should be eliminated or modified. For structured interviews, the interview format and item wording should be strictly followed. If this rule is not followed, the results obtained from the test cannot legitimately be interpreted in terms of the norms provided in the test manual. Changing the test in any way makes it, in effect, a different test, so that the reliability, validity, and norms reported for the test no longer apply, thus making it difficult to know how to interpret the results. However, not all assessment tools are tests. The more descriptive instruments may have more flexibility in terms of adaptation to the individual and the situation.
Written Report
Depending on the setting, the assessor should prepare a detailed report based on information gathered using assessment instruments and personal observation. The complexity of adolescence requires that the individual being assessed never be reduced to a test score. A child's range of strengths and problems can best be evaluated with both quantitative and qualitative procedures. The aim is to assess the strengths and competence, as well as the limitations, of the child (see Figure 3-2). After the information from the different sources has been assembled, the assessor writes a report of what he has learned about the adolescent in terms that can be understood by all concerned, including the adolescent. The written report captures the adolescent's range of problems, strengths, and sources of support, as well as those of the youth's family.
To maintain continuity with previous workups and interventions, to make efficient use of all information available, and to spare the adolescent (and the party paying for the assessment) unnecessary duplication of effort, the assessor should be actively involved in determining if organized, accurate information on the adolescent already exists. When appropriate, that information should be integrated into the current written report. In particular, historical information can provide an indication of the progression of symptoms and problem severity. However, the assessor's report, along with providing immediate direction for treatment and other interventions, has the potential to follow the young person for years and be a central factor in shaping decisions about the adolescent. Therefore, it is important not to include opinions and descriptions from previous reports unless that information is currently accurate. The report should deal with such issues as (1) the way the adolescent processes information most effectively and how this will affect treatment, (2) how the adolescent's past experiences will affect his reaction to certain treatment interventions, (3) specific treatment placement recommendations and justifications, and (4) counselor recommendations. As the field has many different levels of professionals, it is important that these reports be written with specific treatment recommendations that can be understood by all.
The report should be distributed on a need-to-know basis to those service providers who will be working with the adolescent. Adolescents and their parents or guardians often request reports or assessment findings. One practice is to write the report to the parents of a youth under 18 years of age and directly to the young adult if he is over 18, with a copy to the parents who may be paying for the assessment. However, in keeping with the requirements regarding confidentiality, information often cannot be released without the young person's approval and signature on the proper consent forms. Refer to Chapter 4 for further elaboration on the laws regarding release of information.
The report should specify recommendations for treatment placement and posttreatment support services, although the latter issue may require knowledge of treatment progress. The report should also contain a plan for use by a case manager or other responsible party for monitoring services provided to the youth.
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AHCPR Archived reports, Put Prevention Into Practice and Minnesota Health Technology Advisory Committee SAMHSA/CSAT Treatment Improvement Protocols 31. TIP 31: Screening and Assessing Adolescents for Substance Use Disorders
Chapter 4 --Legal Issues in the Screening And Assessment of Adolescents by Margaret K. Brooks, Esq. 1
Staff of substance use disorder treatment programs serving adolescents need to be aware of legal issues that affect program operation. Of top concern among these issues is confidentiality: the protection of the adolescent's right to privacy.
For example, staff members of a program that assesses adolescents and tries to place them in appropriate treatment are often interested in seeking information from other sources, such as parents and schools, about the adolescents they screen. How can the program approach these sources and, at the same time, protect the adolescents' right to privacy? Can the program contact a parent or guardian without the adolescent's consent? If the adolescent tells program staff that she has been abused, can the program report it? If the adolescent is threatening harm to herself or another, can the program call the authorities? Are there special rules regarding confidentiality for programs operating in the juvenile justice system or for child welfare programs?
This chapter will attempt to answer these questions over five sections. First is an overview of the Federal law protecting a youth's right to privacy when seeking or receiving treatment services for substance use disorders. Next is a detailed discussion of the rules regarding the use of consent forms to get a youth's permission to release information about his seeking or receiving substance use disorder services. The third reviews the rules for communicating with others about various issues concerning a youth who is involved with treatment services (including rules for communicating with parents, guardians, and other sources; reporting child abuse; warning others of an adolescent's threats to harm; and special rules for use within the juvenile justice system). The next section discusses a number of exceptions to the general rules preventing disclosure of information, such as medical emergencies. The chapter ends with a few additional points concerning a youth's right to confidential services and the need for programs to obtain legal assistance.
Federal Law Protects Youths' Right to Privacy
Federal law and a set of regulations guarantee the strict confidentiality of information about persons--including adolescents--receiving substance use prevention and substance use disorder treatment services. The legal citations for these laws and regulations are 42 U.S.C. §290dd-2 as well as 42 Code of Federal Regulations (C.F.R.) Part 2.
These laws and regulations are designed to protect clients' privacy rights in order to attract people into treatment. The regulations restrict communications more tightly in many instances than, for example, either the doctor--client or the attorney--client privilege. Violating the regulations is punishable by a fine of up to $500 for a first offense and up to $5,000 for each subsequent offense (§2.4). 2
Some may view these Federal regulations governing communication about the adolescent and protecting clients' privacy rights as an irritation or a barrier to achieving program goals. However, most of the nettlesome problems that may crop up under the regulations can easily be avoided through planning ahead. Familiarity with the regulations' requirements will assist communication. It can also reduce confidentiality-related conflicts among the program, client, and an outside agency so that they occur only in a few relatively rare situations.
What Types of Programs Are Covered by the Regulations?
Any program that specializes, in whole or in part, in providing treatment, counseling, and/or assessment and referral services for adolescents with substance use disorders must comply with the Federal confidentiality regulations (42 C.F.R. §2.12(e)). Although the Federal regulations apply only to programs that receive Federal assistance, this includes indirect forms of Federal aid such as tax-exempt status or State or local government funding coming (in whole or in part) from the Federal government.
Coverage under the Federal regulations does not depend on how a program labels its services. Calling itself a "prevention program" does not excuse a program from adhering to the confidentiality rules. It is the kind of services, not the label, that determines whether the program must comply with the Federal law.
The General Rule: Overview of Federal Confidentiality Laws
The Federal confidentiality laws and regulations protect any information about an adolescent if the adolescent has applied for or received any treatment related to her substance use disorder or referral services from a program that is covered under the laws. Services applied for or received can include assessment, diagnosis, individual counseling, group counseling, treatment, or referral for treatment. 3 The restrictions on disclosure (the act of making information known to another) apply to any information that would identify the adolescent as having a substance use disorder either directly or by implication. The general rule applies from the time the adolescent makes an appointment, and it also applies to former clients. The rule applies whether or not the person making an inquiry already has the information, has other ways of getting it, has some form of official status, is authorized by State law, or comes armed with a subpoena or search warrant.
When May Confidential Information Be Shared With Others?
Information that is protected by the Federal confidentiality regulations may always be disclosed after the adolescent has signed a proper consent form. (As explained below, parental consent must also be obtained in some States.) The regulations also permit disclosure without the adolescent's consent in several situations, including medical emergencies, child abuse reports, program evaluations, and communications among staff.
The most commonly used exception to the general rules prohibiting disclosure is for a program to obtain the adolescent's consent. The regulations' requirements regarding consent are strict and somewhat unusual and must be carefully followed.
Consent To Disclose Information
Most disclosures are permissible if an adolescent has signed a valid consent form that has not expired or been revoked (§2.31). 4 A proper consent form must be in writing and must contain each of the items specified in §2.31:
1. The name or general description of the program(s) making the disclosure 2. The name or title of the individual or organization that will receive the disclosure 3. The name of the client who is the subject of the disclosure 4. The purpose or need for the disclosure 5. How much and what kind of information will be disclosed 6. A statement that the client may revoke (take back) the consent at any time, except to the extent that the program has already acted on it 7. The date, event, or condition upon which the consent expires if not previously revoked 8. The signature of the client (and, in some States, his parent) 9. The date on which the consent is signed (§2.31(a))
A general medical release form, or any consent form that does not contain all of the elements listed above, is not acceptable. (See sample consent form in Figure 4-1.) A number of items on this list deserve further explanation and are discussed under the subheadings below: the purpose of the disclosure and how much and what kind of information will be disclosed, the youth's right to revoke the consent statement, expiration of the consent form, the adolescent's signature and parental consent, required notice against rereleasing information, and agency use of the consent form.
The Purpose of the Disclosure and What Information Will Be Disclosed
These two items are closely related. All disclosures, and especially those made pursuant to a consent form, must be limited to information that is necessary to accomplish the need or purpose for the disclosure (§2.13(a)). It would be improper to disclose everything in an adolescent's file if the recipient of the information needs only one specific piece of information. In completing a consent form, it is important to determine the purpose or need for the communication of information. Once this has been identified, it is easier to determine how much and what kind of information will be disclosed, tailoring it to what is essential to accomplish the need or purpose that has been identified.
As an illustration, if an adolescent needs to have her participation in counseling verified in order to be excused from school early, the purpose of the disclosure would be "to verify treatment status so that the school will permit early release," and the amount and kind of information to be disclosed would be "time and dates of appointments." The disclosure would then be limited to a statement that "Susan Jones (the client) is receiving counseling at XYZ Program on Tuesday afternoons at 2 p.m."
Youth's Right To Revoke Consent
The adolescent may revoke consent at any time, and the consent form must include a statement to this effect. Revocation need not be in writing. If a program has already made a disclosure prior to the revocation, the program has acted in reliance on the consent--in other words, the program was relying on the consent form when it made the disclosure. Therefore, the program is not required to try to retrieve the information it has already disclosed.
The regulations state that "acting in reliance" includes the provision of services while relying on the consent form to permit disclosures to a third party payor. (Third party payors are health insurance companies, Medicaid, or any party that pays the bills other than the client's family or the treatment agency.) Thus, a program can bill the third party payor for services provided before the consent was revoked. However, a program that continues to provide services after a client has revoked a consent authorizing disclosure to a third party payor does so at its own financial risk.
Expiration of Consent Form
The form must also contain a date, event, or condition on which it will expire if not previously revoked. A consent must last "no longer than reasonably necessary to serve the purpose for which it is given" (§2.31(a)(9)). If the purpose of the disclosure can be expected to be accomplished in 5 or 10 days, it is better to fill in that amount of time rather than a longer period.
This is better than the practice of having all consent forms within an agency expire in 60 to 90 days. When uniform expiration dates are used, agencies can find themselves in a situation where there is a need for disclosure, but the client's consent form has expired. This means at the least that the client must come to the agency again to sign a consent form. At worst, the client has left or is unavailable, and the agency will not be able to make the disclosure.
The consent form does not have to contain a specific expiration date, but may instead specify an event or condition. For example, if an adolescent has been placed on probation at school on the condition that he attend counseling at the program, a consent form should be used that does not expire until the completion of the probation period. Or, if an adolescent is being referred to a specialist for a single appointment, the consent form should stipulate that consent will expire after he has seen that doctor.
The Signature of the Adolescent And Parental Consent
The adolescent must always sign the consent form in order for a program to release information even to her parent or guardian. The program must get the parent's signature in addition to the adolescent's signature only if the program is required by State law to obtain parental permission before providing treatment to the adolescent (§ 2.14). ("Parent" includes parent, guardian, or other person legally responsible for the minor.)
In other words, if State law does not require the program to get parental consent in order to provide services to the adolescent, then parental consent is not required to make disclosures (§ 2.14(b)). If State law requires parental consent to provide services to the adolescent, then parental consent is required to make any disclosures. The program must always obtain the adolescent's consent for disclosures, and cannot rely on the parent's signature alone.
There is one very limited exception to this rule, which is discussed below in the section, "Communicating With Parents or Guardians."
Required Notice Against Redisclosing Information
Once the consent form has been properly completed, there remains one last formal requirement. Any disclosure made with written client consent must be accompanied by a written statement that the information disclosed is protected by Federal law and that the person receiving the information cannot make any further disclosure of such information unless permitted by the regulations (§2.32). This statement, not the consent form itself, should be delivered and explained to the recipient of the information at the time of disclosure or earlier.
The prohibition on redisclosure is clear and strict. Those who receive the notice are prohibited from rereleasing information except as permitted by the regulations. (Of course, an adolescent may sign a consent form authorizing such a redisclosure.)
Note on Agency Use of Consent Forms
The fact that an adolescent has signed a proper consent form authorizing the release of information does not force a program to make the proposed disclosure, unless the program has also received a subpoena or court order (§§2.3(b)(1); 2.61(a)(b)). The program's only obligation is to refuse to honor a consent that is expired, deficient, or otherwise known to be revoked, false, or incorrect (§2.31(c)).
In most cases, the decision whether to make a disclosure pursuant to a consent form is up to the program to decide unless State law requires or prohibits disclosure once consent is given. In general, it is best to follow this rule: Disclose only what is necessary, for only as long as is necessary, keeping in mind the purpose for requesting the desired information. Communicating With Others About Adolescents
Now that the rules regarding consent are clear, attention can turn to the other questions introduced at the beginning of this chapter:
How can programs seek information from collateral sources about adolescents they are screening? How can programs communicate with parents? Can programs report child abuse? Do programs have a duty to warn others of threats by adolescents, and if so, how do they communicate the warning? Are there special rules for adolescents who are involved in the juvenile justice system?
Seeking Information From Collateral Sources
Making an inquiry of schools, doctors, and other health care providers might, at first glance, seem to pose no risk to an adolescent's right to confidentiality. But it does.
When a program that screens, assesses, or treats adolescents asks a school, doctor, or parent to verify information it has obtained from the adolescent, it is making a client-identifying disclosure that the adolescent has sought its services. In other words, when program staff seek information from other sources, they are letting these sources know that the youth has asked for substance use disorder services. The Federal regulations generally prohibit this kind of disclosure unless the adolescent consents.
How then is a screening or assessment program to proceed? The easiest way is to get the adolescent's consent to contact the school or health care facility.
Another method involves the program's asking the client to sign a consent form that permits it to make a disclosure for purposes of seeking information from collateral sources to any one of a number of entities or persons listed on the consent form. Note that this combination form must still include "the name or title of the individual or name of the organization" for each collateral source the program may contact. Whichever method the program chooses, it must use the consent form required by the regulations, not a general medical release form.
Communicating With Parents or Guardians
As noted above, programs may not communicate with the parents of an adolescent unless they get the adolescent's written consent.
In getting the adolescent's consent, the program should discuss with the adolescent wheth the purpose of the disclosure (which must be stated on the consent form) would be "to obtain information from Mary's parents in order to assist in the screening (or assessment) process." The kind of information to be disclosed (which must also be stated on the consent form) would be "Mary's application for services." The expiration date should be keyed to the date by which the counselor thinks screening or assessment will have been completed.
If the program and Mary decide they want the program's counselor to be free to talk to Mary's parents or guardians over a longer period of time, the program would fill out the consent form differently. The purpose of the disclosure would be "to provide periodic reports to Mary's parents" and the kind of information to be disclosed would be "Mary's progress in treatment." The expiration of this kind of open-ended consent form might be set at the date the program and Mary foresee her counseling ending or even "when Mary's participation in the program ends." (However, Mary can revoke the consent any time she wishes to.)
What if Mary refuses to consent? Since the Federal confidentiality regulations forbid disclosures without Mary's consent, the program cannot confer with her parents.
One special situation deserves mention. The Federal regulations contain an exception permitting a program director to communicate with a minor's parents when the following conditions are met:
1. An adolescent has applied for services. 2. The program director believes that the adolescent, because of an extreme substance use disorder or a medical condition, does not have the capacity to decide rationally whether to consent to the notification of his guardians. 3. The program director believes the disclosure is necessary to cope with a substantial threat to the life or well-being of the adolescent or someone else.
Thus, if an adolescent applies for services in a State where parental consent is required to provide services but the adolescent applying for services refuses to consent to the program's notifying his parents or guardians, the regulations permit the program to contact a parent without his consent only if those two conditions are met. Otherwise, the program must explain to the adolescent that while he has the right to refuse to consent to any communication with a parent, the program can provide no services without such communication and parental consent (§2.14(d)). 5
Section 2.14(d) applies only to applicants for services. It does not apply to minors who are already clients. Thus, programs cannot contact parents of clients without consent even if the programs are concerned about the behavior of the children.
Reporting Child Abuse and Neglect
All 50 States and the District of Columbia have statutes requiring reporting when there is reasonable cause to believe or suspect child abuse or neglect. While many State statutes are similar, each has different rules about what kinds of conditions must be reported, who must report, and when and how reports must be made.
Most States now require not only physicians but also educators and social service workers to report child abuse. Most States require an immediate oral (spoken) report, and many now have toll-free numbers to facilitate reporting. (Half of the States require that both oral and written reports be made.) All States extend immunity from prosecution to persons reporting child abuse and neglect. Most States provide penalties for failure to report.
Program staff will often need some form of training to review the State's child abuse and neglect laws and to clearly explain what the terms "abuse" and "neglect" really mean according to the law. A lay person's--or a professional's--idea of child neglect may differ greatly from the legal definition. For example, a child living with a parent involved in extensive alcohol or drug use, perhaps surrounded by a culture of drugs and alcohol, is often not considered to be "abused" or "neglected" unless certain additional conditions are met. Such legal definitions may go against the grain of what some staff members consider to be in the best interest of the child, but these are safeguards that have developed over time to protect the child, the parent, and the family unit.
Because of the variation in State law, programs should consult an attorney familiar with State law to ensure that their reporting practices are in compliance. 6 Since many State statutes require that staff report instances of abuse to administrators, who are then required to make an official report, programs should establish reporting protocols to bring suspected child abuse to the attention of program administrators. Administrators, in turn, should shoulder the responsibility to make the required reports. However, some States require that an individual aware of child neglect or abuse must report the situation directly to the child protection authority. Alerting the situation to an administrator alone does not exempt the individual from making the report.
The Federal confidentiality regulations permit programs to comply with State laws that require the reporting of child abuse and neglect. However, this exception to the general rule prohibiting disclosure of any information about a client applies only to initial reports of child abuse or neglect. Programs may not respond to followup requests for information or to subpoenas for additional information, even if the records are sought for use in civil or criminal proceedings resulting from the program's initial report. The only situation in which a program may respond to requests for followup information is when the adolescent consents or the appropriate court issues an order under subpart E of the regulations.
There are clinical considerations as well. There is a need, on the one hand, to guarantee the immediate safety of the adolescent or other children in the home and to comply with the legal reporting requirements of child abuse. On the other hand, assessors need to be sensitive to the potential strain on the trust between assessor and youth that may arise from initiating a report of suspected child abuse. Assessors must handle their obligations with sensitivity.
Duty To Warn
For most treatment professionals, the issue of reporting a patient's threat to harm another or commit a crime is a troubling one. Many professionals believe that they have an ethical, professional, or moral obligation to prevent a crime when they are in a position to do so, particularly when the crime is a serious one.
There has been a developing trend in the law to require psychiatrists and other therapists to take "reasonable steps" to protect an intended victim when they learn that a patient presents a "serious danger of violence to another." This trend started with the case of Tarasoff v. Regents of the University of California, 17 Cal.3d 425 (1976). In that case, the California Supreme Court held a psychologist liable for monetary damages because he failed to warn a potential victim that his patient threatened to, and then did, kill. The court ruled that if a psychologist knows that a patient poses a serious risk of violence to a particular person, the psychologist has a duty "to warn the intended victim or others likely to apprise the victim of the danger, to notify the police, or to take whatever other steps are reasonably necessary under the circumstances."
While the Tarasoff ruling, strictly speaking, applies only in California, courts and legislatures in other States have adopted Tarasoff's reasoning to hold therapists liable for monetary damages when they have failed to warn someone threatened by a patient. In most instances, liability is limited to situations where a patient threatens violence to a specific identifiable victim; liability does not usually apply where a patient makes a general threat without identifying the intended target.
If an adolescent's counselor thinks she poses a serious risk of violence to someone, there are at least two--and sometimes three--questions that need to be answered:
Does a State statute or court decision impose a duty to warn in this particular situation? Even if there is no State legal requirement that the program warn an intended victim or the police, does the counselor feel a moral obligation to warn someone?
The first question can only be answered by an attorney familiar with the law in the State in which the program operates. If the answer to the first question is "no," it is advisable to discuss the second question with a knowledgeable lawyer, too.
If the answer to question 1 or 2 is "yes," how can the program warn the victim or someone able to take preventive action without violating the Federal confidentiality regulations?
The problem is that there is a conflict between the Federal confidentiality requirements and the "duty to warn" imposed by States that have adopted the Tarasoff rule. Simply put, the Federal confidentiality law and regulations appear to prohibit the type of disclosure that the Tarasoff rule requires. Moreover, the Federal regulations make it clear that Federal law overrides any State law that conflicts with the regulations (§2.20). In the only case, as of this writing, that addresses this conflict between Federal and State law (Hansenie v. United States, 541 F. Supp. 999 (D. Md. 1982)), the court ruled that the Federal confidentiality law prohibited any report.
When an adolescent makes a threat to harm himself or another and the program is confronted with conflicting moral and legal obligations, it can proceed in one of the following ways:
The program can go to court and request a court order authorizing the disclosure. The program must take care that the court abides by the requirements of the Federal confidentiality regulations (discussed below in detail). The program can make a disclosure that does not identify the adolescent who has threatened to harm another as a patient. This can be accomplished either by making an anonymous report or--for a program that is part of a larger nonsubstance use disorder treatment facility--by making the report in the larger facility's name. For example, a counselor employed by a drug program that is part of a mental health facility could phone the police or the potential target of an attack, identify herself as "a counselor at the New City Mental Health Clinic" and explain the risk. This would convey the vital information without identifying the adolescent as someone in treatment for a substance use disorder. Counselors at free-standing alcohol or drug programs cannot give the name of the program. (The "nonpatient-identifying disclosure" exception is discussed more fully below.) If the adolescent has been mandated into treatment by the criminal justice system (CJS) or the juvenile justice system (JJS), the program can make a report to the mandating CJS or JJS agency, so long as it has a CJS consent form signed by the adolescent that has been worded broadly enough to allow this sort of information to be disclosed. (For a discussion of the criminal justice system consent form, see the next section.) The CJS or JJS agency can then act on the information to avert harm to the adolescent or the potential victim. However, the regulations limit what the justice agency can do with the information. Section 2.35(d) states that anyone receiving information pursuant to a criminal justice system consent "may redisclose and use it only to carry out that person's official duties with regard to the patient's conditional release or other action in connection with which the consent was given." Thus, the referring justice agency can use the disclosure to revoke the adolescent's conditional release or probation or parole. If the justice agency wants to warn the victim or notify another law enforcement agency of the threat, it must be careful that it does not mention that the source of the tip was someone at a substance use disorder treatment program or that the adolescent making the threat is in treatment for a substance use disorder. However, the disclosure most likely cannot be used to prosecute the adolescent for a separate offense (such as making the threat). The only way to prosecute an adolescent based on information obtained from a program is to obtain a special court order in accordance with §2.65 of the regulations (discussed below). The program can make a report to medical personnel if the threat presents a medical emergency that poses an immediate threat to the health of any individual and requires medical intervention. (See the discussion of the medical emergency exception below.) The program can obtain the patient's consent. This may be unlikely, unless the patient is suicidal.
If none of these options is practical, and a counselor believes there is a clear and imminent danger to an adolescent patient or another identified person, it is probably wiser to err on the side of making an effective report about the danger to the authorities or to the threatened individual.
While each case presents different questions, it is doubtful that any prosecution (or successful civil lawsuit) under the confidentiality regulations would be brought against a counselor who warned about potential violence when he believed in good faith that there was real danger to a particular individual. On the other hand, a civil lawsuit for failure to warn may well result if the threat is actually carried out. In any event, the counselor should at least try to make the warning in a manner that does not identify the individual as having a substance use disorder. "Duty to warn" issues represent an area in which staff training, as well as a staff review process, may be helpful. For example, a troubled youth may engage in verbal threats as a way of "blowing off steam." Such threats may be the adolescent's cry for additional support services. Program training and discussions can help staff sort out what should be done in each particular situation.
Adolescents in the Juvenile Justice System
Programs screening and assessing adolescents who are involved in the JJS (such as family court or juvenile court) must also follow the confidentiality rules that generally apply to treatment programs. However, some special rules apply when an adolescent comes for screening or assessment as an official condition of probation, sentence, dismissal of charges, release from detention, or other disposition of any criminal proceeding. A consent form (or court order) is still required before any disclosure can be made about an adolescent who is the subject of JJS referral. 7 However, the rules concerning the length of time that a consent is valid and the process for revoking the consent are different (§2.35). Specifically, the regulations require that the following factors be considered in determining how long the consent involving an adolescent who is the subject of a criminal justice system referral will remain in effect:
The anticipated duration of treatment The type of criminal proceeding in which the juvenile is involved The need for treatment information in dealing with the proceeding When the final disposition will occur Anything else the client, program, or juvenile justice agency believes is relevant
These rules allow programs to continue to use a traditional expiration condition for a consent form that once was the only one allowed--"when there is a substantial change in the client's justice system status." This formulation appears to work well. A substantial change in status occurs whenever the adolescent moves from one phase of the JJS to the next. For example, if an adolescent is on probation, there would be a change in JJS status when the probation ends, either by successful completion or revocation. Thus, the program could provide an assessment or periodic reports to the probation officer monitoring the adolescent and could even testify at a probation revocation hearing if it so desired, since no change in criminal justice status would occur until after that hearing.
As for the revocability of the consent (the rules under which the youth can take back his consent), the regulations provide that the consent form can state that consent cannot be revoked until a certain specified date or condition occurs. The regulations permit the JJS consent form to be irrevocable so that an adolescent who has agreed to enter treatment in lieu of prosecution or punishment cannot then prevent the court probation department or other agency from monitoring her progress. Note that although a JJS consent may be made irrevocable for a specified period of time, its irrevocability must end no later than the final disposition of the criminal proceeding. Thereafter, the client may freely revoke consent.
Other Exceptions to the General Rule Other exceptions to the Federal confidentiality rules prohibiting disclosure regarding youth seeking or receiving services for a substance use disorder are
Disclosures that do not reveal the fact that the client has a substance use disorder Disclosure authorized by court order Disclosures made during medical emergencies Disclosure of information regarding a crime on program premises or against program personnel Disclosures to an outside agency that provides services to the program Disclosures to other staff within the program Disclosures to researchers, auditors, and evaluators with appropriate institutional review to ensure the protection of program participants
Communications That Do Not Disclose "Client-Identifying" Information
Federal regulations permit programs to disclose information about an adolescent if the program reveals no client-identifying information. "Client-identifying" information is information that identifies someone as having a substance use disorder. Thus, a program may disclose information about an adolescent if that information does not identify him as having a substance use disorder or support anyone else's identification of the adolescent as such.
There are two basic ways a program may make a disclosure that does not identify a client. The first way is obvious: A program can report aggregate data about its population (summing up information that gives an overview of the clients served in the program) or some portion of its populations. Thus, for example, a program could tell a newspaper that, in the last 6 months, it screened 43 adolescent clients--10 female and 33 male.
The second way is trickier: A program can communicate information about an adolescent in a way that does not reveal the adolescent's status as a substance use disorder client (§2.12(a)(i)). For example, a program that provides services to adolescents with other problems or illnesses as well as substance use disorders may disclose information about a particular client as long as the fact that the client has a substance use disorder is not revealed. An even more specific example: A program that is part of a general hospital could have a counselor call the police about a threat an adolescent made, so long as the counselor does not disclose that the adolescent has a substance use problem or is a client of the treatment program.
Programs that provide only substance use disorder services cannot disclose information that identifies a client under this exception, since letting someone know a counselor is calling from the "XYZ Treatment Program" will automatically identify the adolescent as someone in the program. However, a freestanding program can sometimes make "anonymous" disclosures, that is, disclosures that do not mention the name of the program or otherwise reveal the adolescent's status as having a substance use disorder.
Court-Ordered Disclosures A State or Federal court may issue an order that will permit a program to make a disclosure about an adolescent that would otherwise be forbidden. A court may issue one of these authorizing orders, however, only after it follows certain special procedures and makes particular determinations required by the regulations. A subpoena, search warrant, or arrest warrant, even when signed by a judge, is not sufficient, standing alone, to require or even to permit a program to disclose information (§2.61). 8
Before a court can issue an order authorizing a disclosure about a youth that is otherwise forbidden, the program and any adolescents whose records are sought must be given notice of the application for the order and some opportunity to make an oral or written statement to the court. Generally, the application and any court order must use fictitious names for any known adolescent, not the real name of a particular youth. All court proceedings in connection with the application must remain confidential unless the adolescent requests otherwise (§§2.64(a), (b), 2.65, 2.66).
Before issuing an authorizing order, the court must find that there is "good cause" for the disclosure. A court can find "good cause" only if it determines that the public interest and the need for disclosure outweigh any negative effect that the disclosure will have on the client or the doctor--client or counselor--client relationship and the effectiveness of the program's treatment services. Before it may issue an order, the court must also find that other ways of obtaining the information are not available or would be ineffective (§2.64(d)). 9 The judge may examine the records before making a decision (§2.64(c)).
There are also limits on the scope of the disclosure that a court may authorize, even when it finds good cause. The disclosure must be limited to information essential to fulfill the purpose of the order, and it must be restricted to those persons who need the information for that purpose. The court should also take any other steps that are necessary to protect the adolescent's confidentiality, including sealing court records from public scrutiny (§2.64(e)).
The court may order disclosure of "confidential communications" by an adolescent to the program only if the disclosure:
Is necessary to protect against a threat to life or of serious bodily injury Is necessary to investigate or prosecute an extremely serious crime (including child abuse) Is in connection with a proceeding at which the adolescent has already presented evidence concerning confidential communications (for example, "I told my counselor ...") (§2.63) 10
Medical Emergencies
A program may make disclosures to public or private medical personnel "who have a need for information about [an adolescent] for the purpose of treating a condition which poses an immediate threat to the health" of the adolescent or any other individual. The regulations define "medical emergency" as a situation that poses an immediate threat to health and requires immediate medical intervention (§2.51).
The medical emergency exception permits disclosure only to medical personnel. This means that the exception cannot be used as the basis for a disclosure to the police or other nonmedical personnel, including parents.
Under this exception, however, a program could notify a private physician or school nurse about a suicidal adolescent so that medical intervention can be arranged. The physician or nurse could, in turn, notify the adolescent's parents, so long as no mention is made of the adolescent's substance use disorder. Whenever a disclosure is made to cope with a medical emergency, the program must document all of the following in the adolescent's records:
The name and affiliation of the recipient of the information The name of the individual making the disclosure The date and time of the disclosure The nature of the emergency
Crimes on Program Premises or Against Program Personnel
When an adolescent patient has committed or threatens to commit a crime on program premises or against program personnel, the regulations permit the program to report the crime to a law enforcement agency or to seek its assistance. In such a situation, without any special authorization, the program can disclose the circumstances of the incident, including the suspect's name, address, last known whereabouts, and status as a patient at the program (§2.12(c)(5)).
Drugs brought into the program by patients. One crime that an adolescent might well commit on program premises is drug possession--bringing drugs into the program either on his person or (if the program is residential) in his luggage. When a program finds drugs on a patient or in a patient's personal property, what should it do? Should the program call the police? And what should it do with the drugs?
The answer to the first question has already been discussed above in the section dealing with reporting criminal activity. Generally, State law does not require programs to make such a report. As for the second question, State regulations often govern how a program may dispose of drugs, sometimes requiring that they be flushed down a toilet. Programs should check with their Single State Agency if they are unsure about State mandates.
Qualified Service Organization Agreements (QSOAs)
If a program routinely needs to share certain information with an outside agency that provides services to the program, it can enter into what is known as a qualified service organization agreement (QSOA).
A QSOA is a written agreement between a program and a person providing services to the program, in which that person
1. Acknowledges that in receiving, storing, processing, or otherwise dealing with any client records from the program she is fully bound by the Federal confidentiality regulations 2. Promises that, if necessary, she will resist in judicial proceedings any efforts to obtain access to client records except as permitted by these regulations (§§2.11, 2.12(c)(4))
A sample QSOA is provided in Figure 4-2.
A QSOA should be used only when an agency or official outside the program is providing a service to the program itself. An example is when laboratory analyses or data processing are performed for the program by an outside agency.
A QSOA is not a substitute for individual consent in other situations. Disclosures under a QSOA must be limited to information that is needed by others so that the program can function effectively. A QSOA may not be used between different programs providing substance use disorder treatment and other services.
Internal Program Communications
The Federal regulations permit some information to be disclosed to individuals within the same program.
The restrictions on disclosure in these regulations do not apply to communications of information among personnel having a need for the information in connection with their duties that arise out of the provision of diagnosis, treatment, or referral for treatment of substance abuse if the communications are (i) within a program or (ii) between a program and an entity that has direct administrative control over that program (§2.12(c)(3)).
In other words, staff members who have access to client records because they work for or administratively direct the program--including full- or part-time employees and unpaid volunteers--may consult among themselves or otherwise share information if their substance use disorder work so requires (§2.12(c)(3)).
A question that frequently arises is whether this exception allows a program that assesses or treats adolescents and that is part of a larger entity--such as a school--to share confidential information with others who are not part of the assessment or treatment unit itself. The answer to this question is among the most complicated in this area. In brief, there are circumstances under which the assessment unit can share information with other units. However, before such an internal communication system is set up within a large institution, it is essential that an expert in the area be consulted for assistance.
Research, Audit, or Evaluation
The confidentiality regulations also permit programs to disclose client-identifying information to researchers, auditors, and evaluators without client consent, provided certain safeguards are met (§§2.52, 2.53). 11
Other Rules About Confidentiality
Client Notice and Access to Records
The Federal confidentiality regulations require programs to notify clients of their right to confidentiality and to give them a written summary of the regulations' requirements. The notice and summary should be handed to adolescents when they begin participating in the program or soon thereafter (§2.22(a)). The regulations contain a sample notice.
Programs can use their own judgment to decide when to permit adolescents to view or obtain copies of their records, unless State law allows clients or students the right of access to records. The Federal regulations do not require programs to obtain written consent from clients before permitting them to see their own records.
Security of Records
The Federal regulations require programs to keep written records in a secure room, a locked file cabinet, a safe, or other similar container. 12 The program should establish written procedures that regulate access to and use of adolescents' records. Either the program director or a single staff person should be designated to process inquiries and requests for information (§2.16).
A Final Note
Drug abuse treatment programs should try to find a lawyer familiar with local laws affecting their problems.
As has already been mentioned, State law governs many concerns relating to screening and assessing adolescents. A practicing lawyer with an expertise in adolescent substance use and abuse concerns is the best source for advice on such issues. Moreover, when it comes to certain issues, the law is still developing. For example, programs' "duty to warn" of clients' threats to harm others is constantly changing as courts in different States consider cases brought against a variety of different kinds of care providers. Programs trying to decide how to handle such a situation need up-to-the minute advice on their legal responsibilities.
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AHCPR Archived reports, Put Prevention Into Practice and Minnesota Health Technology Advisory Committee SAMHSA/CSAT Treatment Improvement Protocols 26 . TIP 26: Substance Abuse Among Older Adults
Appendix A - Legal and Ethical Issues by Margaret K. Brooks, Esq. 1a
Screening any population for substance abuse raises key legal and ethical concerns: how one can inquire about an individual's alcohol and drug use while continuing to respect that person's autonomy and privacy. Screening of older adults for substance abuse brings these concerns into particularly sharp focus - whether the person screening is a clinician, a staff member at a senior center, a member of the clergy, an adult protective service worker, a Meals-On-Wheels volunteer, a pharmacist, a community health worker, an adult day care worker, or staff member at a long-term care facility.
This appendix examines how the issues of autonomy and privacy (or confidentiality) affect the way providers working with older adults may screen for substance use problems. The first section discusses the relationship between patient or client autonomy and the provider's obligation to inform and counsel the older individual about the health risks of alcohol or other drug use. The second section concerns privacy of information about substance use problems: How can a provider keep accurate records and communicate with others concerned about the older individual's welfare without disclosing information that may subject the individual to scorn or create problems with family or third-party payers?
Autonomy and the Provider's Mission: A Dilemma
Americans attach extraordinary importance to being left alone. We pride ourselves on having perfected a social and political system that limits how far the government - and others - can control what we do. The principle of autonomy is enshrined in our Constitution, and our courts have repeatedly confirmed our right to make our own decisions for ourselves.
Most of us cherish our autonomy and fear its loss, particularly as we age. Although providers who screen or assess for substance abuse do so because they are genuinely concerned about an individual's health or functioning, screening means seeking very personal information - an unavoidable intrusion on a person's autonomy and privacy. Alert to suggestions that their judgment or abilities are impaired, older adults may not always see a provider's effort to "help" as benign. Performed insensitively, screening or assessment may intensify denial. A person of any age who is "in denial" may not realize, or want to realize, that he has to cut back on or give up his intake of alcohol or prescription medications; an older person may view the provider's questions and suggestions as intrusive, threatening, and offensive. Suggestions that an older individual's complaint has an emotional basis may tap an underlying reluctance to acknowledge an emotional component to any problem and reinforce the individual's resistance. Because the substance abuse label carries a powerful stigma, an older individual may become alarmed if a provider intimates that alcohol or drug abuse may be involved. It will be tempting for the older individual to point to the "normal" infirmities of old age as the source of his difficulty rather than acknowledge a problem with alcohol or other drugs.
How can the provider raise the question of alcohol and drug use constructively, without eliciting a defensive response? Should she raise the issue and then drop it at the slightest hint of resistance on the part of the older individual? Or should she intervene more forcefully - with argument or by involving the family?
To fulfill her ethical responsibility, the provider should do more than simply raise the issue. As the Consensus Panel suggests, most older adults are unaware that their metabolism of alcohol and prescription drugs changes as they age and that lower amounts of alcohol and medicines may incapacitate them. Respect for a person's autonomy means informing him of all relevant medical facts and engaging him in a discussion about his alternatives. If there is a substance abuse problem, the provider can supply the information and encouragement, but only the person with the problem has the power to change what he is doing. Respecting the patient's autonomy - his right to make choices - is central to encouraging that change.
Privacy and Confidentiality
Aside from perceived threats to autonomy, an older person may also be concerned about the practical consequences of admitting a substance use problem. Such patients may find it difficult or impossible to obtain coverage for hospitalization costs if an insurer or health maintenance organization (HMO) learns that their traumatic injuries were related to alcoholism. Relationships with a spouse, children, grandchildren, or friends may suffer. Adverse consequences such as these may discourage patients with substance use problems from seeking treatment.
Concern about privacy and confidentiality is fueled by the widespread perception that people with substance use disorders are weak and/or morally impaired. For an older person, this concern may well be compounded by an apprehension that others may view acknowledgment of a substance use disorder as a sign of inability to continue living independently. If the individual is having family problems - with a spouse or with children - information about substance use could have an adverse impact on resolution of those problems. Or the individual may experience difficulties with health insurance.
Federal Law
The concern about the adverse effects that social stigma and discrimination have on patients in recovery (and how those adverse effects might deter people from entering treatment) led the Congress to pass legislation and the U.S. Department of Health and Human Services to issue a set of regulations to protect information about individuals' substance abuse. The law is codified at 42 U.S.C.§ 290dd-2. The implementing Federal regulations, "Confidentiality of Alcohol and Drug Abuse Patient Records," are contained in 42 CFR Part 2 (Vol. 42 of the Code of Federal Regulations, Part 2).
The Federal law and regulations severely restrict communications about identifiable individuals by "programs" providing substance use diagnosis, treatment, or referral for treatment (42 CFR§ 2.11). The purpose of the law and regulations is to decrease the risk that information about individuals in recovery will be disseminated and that they will be subjected to discrimination and to encourage people to seek treatment for substance use disorders.
In most settings where older adults receive care or services, Federal confidentiality laws and regulations do not apply. 1b Providers should be aware, however, that if a health care practice or social service organization includes someone whose primary function is to provide substance abuse assessment or treatment and if the practice or organization benefits from "Federal assistance," 2 that practice or organization must comply with the Federal law and regulations and implement special rules for handling information about patients who may have substance abuse problems. 3
Moreover, the fact that most providers for older adults are not subject to the Federal rules does not mean that they can handle information about their clients' substance use problems in a cavalier manner. Because of the potential for damage, providers should always handle such information with great care.
State Law
Although Federal rules do not restrict how most providers gather and handle information about an older individual's substance abuse, there are other rules that may limit how such information may be handled. State laws offer some protection to medical and mental health information about patients and clients. Most doctors, social service workers, and clients think of these laws as the "doctor- patient privilege" or "social worker-client privilege" or "psychotherapist-patient privilege."
Strictly speaking, these privileges are rules of evidence that govern whether a professional provider can be asked or compelled to testify in a court case about a patient or client. In many States, however, laws offer wider protection. Some States have special confidentiality laws that explicitly prohibit physicians, social workers, psychologists, and others from divulging information about patients or clients without consent. States often include such prohibitions in professional licensing laws; such laws generally prohibit licensed professionals from divulging information about patients or clients, and they make unauthorized disclosures grounds for disciplinary action, including license revocation.
Each State has its own set of rules, which means that the scope of protection offered by State law varies widely. Whether a communication is "privileged" or "protected" may depend on a number of factors:
1. The type of professional provider holding the information and whether he or she is licensed or certified by the State 2. The context in which the information was communicated 3. The context in which the information will be or was disclosed 4. Exceptions to any general rule protecting information, and 5. How the protection is enforced.
Professionals covered by the "doctor-patient" or "therapist-client" privilege
Which professions and which practitioners within each profession are covered depends on the State where the professional practices. California, which grants its citizens "an inalienable right to privacy" in its Constitution, has what may be the most extensive protections for medical (including mental health) information. California law protects communications with a wide variety of professionals, including licensed physicians, nurses, and psychotherapists (which includes clinical social workers, psychologists, marriage and family counselors), as well as many communications with trainees practicing under the supervision of a number of these professionals. A California court has held that information given to an unlicensed professional by an uneducated patient may be privileged if the patient reasonably believes the professional is authorized to practice medicine. 4
Other States' laws cover fewer kinds of professionals. In Missouri, for example, protection is limited to communications with State-licensed psychologists, clinical social workers, professional counselors, and physicians.
Depending on their professional training (and licensing), primary care physicians, physician assistants, nurse-practitioners, nurses, psychologists, social workers, and others may be covered by State prohibitions on divulging information about patients or clients. Note that even within a single State, the kind of protection afforded information may vary from profession to profession. Professional providers should learn whether any confidentiality law in the State where they practice applies to their profession.
The context in which the information was communicated
State laws vary tremendously in this area, too. Some States protect only the information that a patient or client communicates to a professional in private, in the course of the medical or mental health consultation. Information disclosed to a clinician in the presence of a third party (like a spouse) is not protected. Other States, such as California, protect all information the patient or client tells the professional or the professional gains during examination. 5 California also protects other information acquired by the professional about the patient's mental or physical condition, as well as the advice the professional gives the patient. 6 When California courts are called upon to decide whether a particular communication of information is privileged, State law requires them to presume that it is.
California affords great protection to communications between patients and psychotherapists, a term that covers a wide range of professions. Not only are communications by and to the patient protected, information communicated by a patient's intimate family members to therapists and psychiatric personnel 7 is also protected. California also protects information the patient discloses in the presence of a third party or in a group setting. Understanding what medical information is protected requires professional providers to know whether State law recognizes the confidentiality of information in the many contexts in which the professional acquires it.
Circumstances in which "confidential" information is protected from disclosure
Some States protect medical or mental health information only when that information is sought in a court proceeding. If a professional divulges information about a patient or client in any other setting, the law in those States will not recognize that there has been a violation of the individual's right to privacy. Other States protect information in many different contexts and may discipline professionals who violate their patients' privacy, allow patients to sue them for damages, or criminalize behavior that violates patients' privacy. The diversity of State rules in this area compounds the difficulty professionals face in becoming knowledgeable about what rules apply to them.
Exceptions to State laws protecting medical and mental health information
Consent
All States permit health, mental health, and social service professionals to disclose information if the patient or client consents. However, each State has different requirements regarding consent. In some States, consent can be oral; in others, it must be written. States that require written consent sometimes require that certain elements be included in the consent form or that everyone use a State-mandated form. Some States have different consent forms with different requirements for particular diseases.
Other exceptions
Consent is not the only exception. All States also require the reporting of certain infectious diseases to public health authorities and some require the reporting of elder abuse to protective service agencies, although definitions of "infectious disease" and "elder abuse" vary. And most States require health care professionals and mental health counselors to report to the authorities threats patients make to inflict harm on others. There are States that permit or require health care professionals to share information about patients with other health care professionals without the patients' consent, but some limit the range of disclosure for certain diseases, like HIV. Most States make some provision for communicating information to health insurance or managed care companies.
Many of the situations that physicians and social service workers face daily - processing health claims or public benefit applications, for example - are covered by one of these exceptions. To fully understand the "rules" regarding privacy of medical and mental health information, professionals must also know about the exceptions to those rules. Those exceptions are generally in the statute books - in either the sections on evidence or the professional licensing sections, or both. The state licensing authority as well as professional associations can usually help answer questions about State rules and the exceptions to those rules.
Enforcing confidentiality protections
The role of the courts
To determine the "law" - that is, the rule one must follow - in any particular area, an attorney will search for statutes, regulations, administrative rulings, and court decisions. There is no question that in this country, the courts play a large role in "making" law - particularly in an area like privacy, which involves human behavior, shades of meaning, and intent. No legislator drafting a statute (or bureaucrat drafting a regulation) can foresee all the circumstances under which it may be applied. When one party sues another, a court is forced to decide whether a provider's disclosure of medical information was appropriate or whether such information should be disclosed during the lawsuit itself.
For example, after a car crash, the drivers may sue each other and ask the court to order the disclosure of medical records. Or the victim of an assault by an adolescent may sue the parents and seek disclosure of medical records to prove they knew their child was dangerous. How a court decides whether to order disclosure in such cases will depend on a variety of factors, including State law and regulation, court rules, and the relevance of the information sought to the dispute at hand. Similarly, when a patient or client sues a professional for releasing information to someone without her consent, the court will be called upon to weigh a variety of factors to decide whether the disclosure violated what the State recognizes as the patient's privacy.
Over time, court decisions like these add flesh to the bare statutory and regulatory rules and suggest how those rules will be applied the next time. When a difficult case arises that does not fit neatly within the rule of law as understood, it may be helpful to consult with an attorney familiar with the rules and how the State's courts are likely to interpret them.
Penalties for violations
States differ in the ways they discipline professionals for violations of patients' or clients' privacy. In some States, violation of confidentiality is a misdemeanor, punishable by a fine or short jail term. In many States, the professional licensing agency has the power to bring disciplinary charges against a professional who violates a client's privacy. Such charges may result in censure or license suspension or revocation. Finally, the State may permit the aggrieved patient or client to sue the professional for damages caused by the violation of his right to confidentiality.
The reality is, these enforcement mechanisms are rarely used. States rarely prosecute privacy violation offenses and professional disciplinary committees in most States are more concerned with other kinds of professional infractions. That is not to say that violation of a patient's privacy is cost- free. A patient or client who thinks he has been hurt by a professional's indiscretion is free to sue; while such cases are difficult for clients to win, they can cause the professional and the organization employing her a good deal of grief - financial, emotional, and professional. Even short of litigation, no professional wants to acquire the reputation of being thoughtless or indiscreet.
Strategies for Dealing With Common Situations
Charting substance use information One way for a professional to safeguard clients' privacy and avoid breaking the rules is to develop a charting, or record-keeping, system that is accurate but still protects clients' rights to privacy and confidentiality. It is important to remember how many people could see a client's medical, mental health, or social service record. A medical chart, for example, will be seen by the medical office staff, the insurance company (or HMO or managed care organization [MCO]), and in the event of a referral, another set of clinicians, nurses, clerical workers, and insurers. If the patient is involved in litigation and his medical or mental health is in issue, the court will most likely order disclosure of his chart or file in response to a subpoena.
When a provider documents the results of substance abuse screening or assessment or flags an issue to be raised the next time he sees the client, he should use neutral notations or reminders that do not identify the problem as being substance-use-related. Following are three record-keeping systems that comply with the stringent Federal confidentiality regulations, protect clients' autonomy and privacy, and can be used in a wide variety of settings (TIP 16, Alcohol- and Other-Drug Screening of Hospitalized Trauma Patients, CSAT, 1995):
The "minimalist" approach, which relies on the provider to enter only that information in the chart that is required for accuracy and to use neutral terms wherever possible. The "rubber band" approach, which segregates substance abuse information in a separate "confidential" section in the chart. Information in this section would be shared with other providers only on a need-to-know basis, without being open to the view of every staff person who picked up the chart. The "separate location" approach, which keeps sensitive information separate from the rest of the client's chart. The other place might be a locked cabinet or other similarly secure area. A "gatekeeper" familiar with the provider's record-keeping system and the reasons for the extra security would be responsible for deciding when others - within or outside the office - will have access to this information. This approach provides, in effect, a stronger "rubber band" than that described in the second approach. 8
The push toward computerization of medical records will complicate the problem of keeping sensitive information in medical records private. Currently, there is protection afforded by the cumbersome and inefficient way many, if not most, medical, mental health, and social service records make their way from one provider to another. When records are stored in computers, retrieval can be far more efficient. Computerized records may allow anyone with a disc and access to the computer in which the information is stored to instantly copy and carry away vast amounts of information without anyone's knowledge. Modems that allow communication about patients among different components of a managed care network extend the possibility of unauthorized access to anyone with a modem, the password(s), and the necessary software. The ease with which computerized information can be accessed can lead to "casual gossip" about a client, particularly one of importance in a community, making privacy difficult to preserve.
Communicating with others
One of the trickiest issues is whether and how providers of older adults health care should communicate with others about their clients' substance use problems. Communications with others concerned about the client may confirm the provider's judgment that the client has a substance use problem or may be useful in persuading a reluctant client that treatment is necessary.
Before a provider attempts to gather information from other sources or enlist help for a patient or client struggling with recovery, he should ask the older client's permission to do so. Speaking with relatives (including children), doctors, or other health and mental health professionals not only intrudes on the client's autonomy, it also poses a risk to her right to privacy. Gathering information (or responding to questions about a client's problems) from a spouse, child, or other provider can involve an explicit or implicit disclosure that the provider believes the client or patient has a substance use problem. And the provider making such a disclosure may be inadvertently stepping on a land mine.
Making inquiries or answering questions behind the client's back may seriously jeopardize the trust that has developed between the provider and the client and undermine his attempt to offer help. The professional who talks to the client's son and then confronts her with their joint conclusions runs the risk that he will damage his relationship with the client. Feeling she can no longer trust the provider and angry that he has shown little respect for her autonomy or privacy, the client may refuse to participate in any further discussions about her problems.
Dealing with questions of incapacity
Most older clients or patients are fully capable of comprehending the information and weighing the alternatives offered by a provider and making and articulating decisions. A small percentage of older patients or clients are clearly incapable of participating in a decision-making process. In such cases, the older person may have signed a health care proxy or may have a court-appointed guardian to make decisions in his stead.
The real difficulty arises when a provider is screening or assessing an older person whose mental capacity lies between those two extremes. The client or patient may have fluctuating capacity, with "good days" and "bad days" or periods of greater or lesser alertness depending upon the time of day. His condition may be transient or deteriorating. His diminished capacity may affect some parts of his ability to comprehend information but not others.
How can the provider determine whether the patient or client understands the information she is presenting, appreciates the implication of each alternative, and is able to make a "rational" decision, based on his own best interests? There is no easy answer to this question. One can, however, suggest several approaches.
Maximizing autonomy. The provider can help the patient or client who appears to have diminished capacity through a gradual information-gathering and decisionmaking process. Information the client needs should be presented in a way that allows the patient or client to absorb it gradually. The provider should clarify and restate information as necessary and may find it helpful to summarize the issues already covered at regular intervals. Each alternative and its possible consequences should be laid out and examined separately. Finally, the provider can help the client identify his values and link those values to the alternatives presented. By helping the patient or client narrow his focus and proceed step-by-step, the provider may be able to assure herself that the client, despite his diminished capacity, has understood the decision to be made and acted in his own best interest.
Enlisting the help of a health or mental health professional. If working with the patient or client in a process of gradual information-gathering and decision-making is not making headway, the provider can suggest that together they consult a health or mental health professional. Perhaps there is someone who has known the patient or client for a number of years who has a grasp of the client's history and better understanding of the obstacles to decision-making. Or, the provider may suggest a specialist who can help determine why the patient is having difficulty and whether he has the capacity to make this kind of decision.
Enlisting the help of family or close friends. Another approach is for the provider to suggest to the patient or client that they call in a family member or close friend who can help them organize the information and sort through the alternatives. Asking the client who he thinks would be helpful may win his endorsement of this approach.
When the client cannot grasp the information or come to a decision. If the provider's efforts to inform the patient or client and help him reach a decision are unsuccessful, she might seek his permission to consult a family member or close friend to discuss the problem. If the client consents, the provider should lay out her concerns for the family member or friend. It may be that the client has already planned for the possibility of his incapacity and has signed a durable power of attorney or a health care proxy.
Guardianship. A guardian 9 is a person appointed by a court to manage some or all aspects of another person's life. Anyone seeking appointment of a guardian must show the court (1) that an individual is disabled in some way by disease, illness, or senility, and (2) that the disability prevents him from performing the tasks necessary to manage an area or areas of his life.
Each state handles guardianship proceedings differently, but some principles apply across the board: Guardianship is not an all-or-nothing state. Courts generally require that the person seeking appointment of a guardian prove the individual's incapacity in a variety of tasks or areas. Courts may apply different standards to different life tasks - managing money, managing a household, making health care decisions, entering contracts. A person may be found incompetent to make contracts and manage money but not to make his own health care decisions (or vice versa), and the guardianship will be limited accordingly.
Guardianship diminishes the older adult's autonomy and is an expensive process. It should, therefore, be considered only as a last resort.
Making referrals to substance abuse treatment programs
The provider has persuaded the patient or client to try outpatient treatment and knows the director of an excellent program in the immediate area. Rather than simply picking up the phone and letting the director know she has referred the patient, she should consult the patient about the specific treatment facility. Though it may seem that consent to treatment is the same as consent to referral to a particular facility, it takes very little time to get the patient's consent, demonstrates respect for the client or patient, and protects the provider if, say, the treatment program's director is a relative or has some other connection to the client.
Communications with insurers, HMOs, and other third-party payers
The structure of health, mental health, and ancillary social service care for older adults is changing rapidly. Of course, older adults are covered by Medicare, but many have supplementary insurance or have joined HMOs or are entitled to government-sponsored social services because of particular medical, physical, or mental disabilities. How should the professional provider communicate with these different types of entities?
Traditional health insurance programs offering reimbursement to patients for health care expenditures typically require patients to sign claim forms containing language consenting to the release of information about their care. The patient's signature authorizes the practitioner to release such information. Although HMOs do not require patients to submit claim forms, both practitioners and patients understand that the HMO or MCO can review clinical records at any time and may well review records if it has questions about the patient's or client's care.
Should the provider rely on the patient's signed consent on the health insurance form or the HMO contract and release what she has in her chart (or a neutral version of that information)? Or should she consult the patient?
The better practice is for the provider to frankly discuss with the patient what information she intends to disclose, the alternatives open to the client (disclosure and refusal to disclose), and the likely consequences of those alternatives. Will the information the provider sends explicitly or implicitly reveal the nature of the patient's problem? Does the client's chart contain a substance abuse diagnosis? Once again, the provider confronts the question of how such information should be recorded. Has she balanced the need for accuracy with discretion and a respect for patients' privacy? Finally, even if the chart or file contains explicit information about the client's substance use problem, can the provider characterize the information and her diagnosis in more neutral terms when releasing information to the third-party payer?
Once the client understands what kind and amount of information the provider intends to send a third-party payer, he can decide whether to agree to the disclosure. The provider should explain that if she refuses to comply with the third-party payer's request for information, it is likely that at least some related services will not be covered. If the client expresses concern, she should not mislead him, but confirm that once a third-party payer learns he has had a substance use problem, he could and may lose either some of his insurance coverage or parts of other entitlements and be unable to obtain other coverage. 10
The final decision should be the client's. He may well decide to pay out of pocket. Or he may agree to the limited disclosure and ask the provider to inform him if more information is requested.
As managed care becomes more prevalent throughout the country, medical and mental health providers are finding that third-party payers demand more and more information about patients and about the treatment provided to those patients in order to monitor care and contain costs. Providers need to be sensitive about the amount and kind of information they disclose because there is a risk that this information may be used to deny future benefits to the client. Chart notes may also contain detailed and very personal information about family life that may be unnecessary for a third-party payer to review in order to determine whether and what kind of treatment should be covered.
As in so many other areas involving patients' privacy, it is best to follow two simple rules: First, keep notations and documentation as neutral as possible while maintaining professionally acceptable standards of accuracy. Second, consult the client and let the client decide whether to agree to the disclosure.
Communicating with the legal system
If a doctor, psychologist, social worker, or other provider gets a call from a lawyer asking about a patient or client, or a visit from a law enforcement officer asking to see records, or a subpoena to testify or produce medical records, what should he or she do? As in other matters of privacy and confidentiality, (1) consult the patient, (2) use common sense, and (3) as a last resort, consult State law (or a lawyer familiar with State law).
Responding to lawyers' inquiries. Say a lawyer calls and asks about Emma Bailey's medical, mental health, or social service history or treatment. As a first approach to the question, the provider could tell the lawyer, "I don't know that I have a client with that name. I'd have to check my records" 11 or tell the caller that he must consult with his client before having a conversation about her: "I'm sure you understand that I am professionally obligated to speak with Emma Bailey before I speak with you." It will be hard for any lawyer to disagree with this statement.
The provider should then ask the client if she knows what information the caller is seeking and whether the client wants him to disclose that or any other information. He should leave the conversation with a clear understanding of the client's instructions - whether he should disclose the information, and if so, how much and what kind. It may be that the lawyer is representing the client in a case and the client wants the provider to share all the information he has. On the other hand, the lawyer may represent someone with whom the client has a dispute. There is nothing wrong with refusing to answer a lawyer's questions. 12
If the lawyer represents the client and the client asks the provider to share all information, the provider can speak freely with the lawyer. However, if the provider is answering the questions of a lawyer who does not represent the client (but the client has consented to the disclosure of some information), the provider should listen carefully to each question, choose his words with care, limit each answer to the question asked, and take care not to volunteer information not called for.
Visits by law enforcement. A police officer, detective, or probation officer who asks a provider to disclose medical, mental health, or social service information about a client or a client's case records can usually be handled in a similar manner: 13 The provider can safely tell the officer, as he might a lawyer, "I'm sure you understand that I am professionally obligated to speak with my patient before I speak to you." 14
The provider should then speak with the client to find out whether she knows the subject of the officer's inquiry, whether she wants the provider to disclose information and if so, how much and what kind. The caretaker might end the conversation by asking whether there are any particular areas the client would prefer he not discuss with the officer.
When a law enforcement officer comes armed with a search warrant, the answer is different. In this case, the provider has no choice but to hand over the records listed in the warrant.
Responding to subpoenas. Subpoenas come in two varieties. One is an order requiring a person to testify, either at a deposition out of court or at a trial. The other - known as a subpoena duces tecum - requires a person to appear with the records listed in the subpoena. Depending on the State, a subpoena can be signed by a lawyer or a judge. Unfortunately, it cannot be ignored.
In this instance, the provider's first step should be to call Emma Bailey - the client about whom he is asked to testify or whose records are sought - and ask what the subpoena is about. It may be that the subpoena has been issued by or on behalf of Emma's lawyer, with Emma's consent. However, it is equally possible that the subpoena has been issued by or on behalf of the lawyer for an adverse party. If that is the case, the provider's best option is to consult with Emma's lawyer to find out whether the lawyer will object - ask the court to "quash" the subpoena - or whether the provider should simply get the client's consent to testify or turn over her records. 15 An objection can be based on a number of grounds and can be raised by any party as well as by the person whose medical information is sought. If the provider is covered by a State statutory privilege, he may be able to assert the client's privilege for her.
Conclusion
It is essential for those who work with older adults to respect their clients' autonomy and rights to privacy and confidentiality if they are to be effective in screening and assessing clients for substance use disorders and persuading them to cut down their use or enter treatment. In most situations, providers can follow these simple rules: (1) consult the client, (2) let the client decide, and (3) be sensitive to how information is recorded or disclosed. It is only as a last resort that the provider will have to consult State law or a lawyer.
Endnotes
1a Margaret K. Brooks is an independent consultant in Montclair, New Jersey.
1b For many years, there was confusion about whether general medical care settings such as primary care clinics or hospital emergency rooms were subject to the Federal law and regulations because they provided substance abuse diagnosis, referral, and treatment as part of their services. In 1995, DHHS revised the definition of the kinds of "programs" subject to the regulations that made it clear that the regulations do not generally apply to a general medical care facility unless that facility (or person) holds itself out as providing, and provides, alcohol or drug abuse diagnosis, treatment, or referral for treatment . . . (42 CFR§ 2.11).The full text of § 2.11 now reads:Program means:(a) An individual or entity (other than a general medical care facility) who holds itself out as providing, and provides, alcohol or drug abuse diagnosis, treatment, or referral for treatment; or(b) An identified unit within a general medical facility which holds itself out as providing and provides, alcohol or drug abuse diagnosis, treatment, or referral for treatment; or(c) Medical personnel or other staff in a general medical care facility whose primary function is the provision of alcohol or drug abuse diagnosis, treatment, or referral for treatment and who are identified as such providers. (See § 2.12(e)(1) for examples.)60 Federal Register 22,297 (May 5, 1995).
2 The regulations provide that "federally assisted" programs include:
Programs run directly by or under contract for the Federal government; Programs carried out under a Federal license, certification, registration, or other authorization, including certification under the Medicare Program, authorization to conduct a methadone maintenance treatment program, or registration to dispense a drug that is regulated by the Controlled Substances Act to treat alcohol or drug abuse; Programs supported by any federal department or agency of the United States, even when the federal support does not directly pay for the alcohol or drug abuse diagnosis, treatment, or referral activities; Programs conducted by State or local government units that are supported by Federal funding that could be (but is not necessarily) spent for the substance abuse treatment program; Tax-exempt programs.
42 C.F.R.§ 2.12(b).
3 For a full explanation of the Federal law and regulations, see TIP 8, Intensive Outpatient Treatment for Alcohol and Other Drug Abuse (CSAT, 1994) and TAP 13, Confidentiality of Patient Records for Alcohol and Other Drug Treatment (CSAT, 1994).
4Luhndorff v. The Superior Court of Tulare County, 166 CA 3d 485, 212 Cal. Rptr. 516 (5th District, 1985). Interestingly, Luhndorff was a criminal case in which the prosecution sought the records of an unlicensed social worker who interviewed the defendant, diagnosed his problem, determined the appropriate treatment, and treated him for 3 months. The social worker was working under a licensed individual's supervision. The defendant thought the social worker was a psychiatrist.
5 Section 451 of the California Evidence Code codifies the doctor-patient privilege. See Grosslight v. Superior Court of Los Angeles, 42 CA 3d 502, 140 Cal. Rptr. 278 (1977), in which the court held that information communicated by the parents of a minor psychiatric patient to her doctor and his secretary was privileged, even though the parents were being sued by someone the child injured on the theory that the parents knew their child was a danger to others.
6 Note that the breadth of the protection may vary according to the clinician's profession.
7Grosslight v. Superior Court of Los Angeles, 72 Cal. App. 3d 502, 140 Cal. Rptr. 278 (1977), interpreting Section 451 of the California Evidence Code (see footnote 5).
8 The Consensus Panel for TIP 16 noted: "Physical separation of clinical information is not unusual. Patient charts from past years are generally kept in a separate location. Physicians routinely request charts to be sent to them from this location so that they can review historical clinical information about the patient. In addition, nurses are quite accustomed to keeping some medications locked up and accessible only to designated personnel." (TIP 16, CSAT, 1995, p. 76)
9 In some States, a guardian is referred to as a fiduciary, conservator, or committee. The person who has a guardian is generally called a "ward" or an "incapacitated person."
10 Some States prohibit insurance companies from discriminating against individuals who have received substance abuse treatment; however, these kinds of discriminatory practices continue. Insurance companies routinely share information about applicants for life and disability insurance through the Medical Information Bureau - a data bank maintained by a private organization and supported by the industry.
11 In fact, in some States, depending on the provider's profession, the identity of patients or clients as well as their records are protected. Therefore, professionals should find out whether disclosing a patient's name or acknowledging that the individual about whom the lawyer is inquiring is a client would be considered a violation of the client's right to confidentiality.
12 A firm, but polite, tone is best. If confronted by what could be characterized as "stonewalling," a lawyer may be tempted to subpoena the information he is asking for, and more. The clinician will not want to provoke the lawyer into taking action that will harm the patient.
13 The only exception to this advice would be if the provider knew the patient was a fugitive being sought by law enforcement. In that case, in some States, a refusal to assist or give officers information might be a criminal offense.
14 As noted above, in those States where the identity of clients or patients as well as their medical or mental health records are protected, the professional should give a noncommittal response, such as "I'll have to check my records to see whether I have such a patient."
15 In most instances, the provider is not legally required to notify the client or get his consent to release records that have been subpoenaed. However, notifying the client shows respect for his autonomy and privacy and gives him an opportunity to object to the subpoena.
Copyright and Disclaimer
BLAMEDBLAMED ANDAND ASHAMEDASHAMED
The Treatment Experiences of Youth with Co-occurring Substance Abuse and Mental Health Disorders and Their Families
Federation of Families for Children’s Mental Health and Keys for Networking, Inc.
Federation of Families for Children’s Mental Health BLAMEDBLAMED ANDAND ASHAMEDASHAMED
The Treatment Experiences of Youth with Co-occurring Substance Abuse and Mental Health Disorders and Their Families
Federation of Families for Children’s Mental Health and Keys for Networking, Inc.
Federation of Families for Children’s Mental Health Blamed and Ashamed
Funding for this project was provided by the Substance Abuse and Mental Health Services Administration of the Department of Health and Human Services.
This document is not copyrighted. It is the hope of the Federation of Families for Children’s Mental Health that this information will be useful and that readers will photocopy and disseminate the materials to maximize their use. Please give the Federation credit with the following recommended citation:
Blamed and Ashamed, Federation of Families for Children’s Mental Health. Alexandria, Virginia. 2001
Copies are available from:
Federation of Families for Children’s Mental Health 1101 King Street, Suite 420 Alexandria, Virginia 22314
Phone: 703-684-7710 Fax: 703-836-1040 Email: [email protected] Federation of Families Website: www.ffcmh.org for Children’s Mental Health THE FEDERATION OF FAMILIES FOR CHILDREN’S MENTAL HEALTH
Dear Readers:
It has been both an honor and an adventure for the Federation of Families for Children’s Mental Health to conduct this study with Keys for Networking, Inc., our state- wide organization in Kansas, and a team of outstanding youth researchers. This was a unique project in which youth took the lead and adults provided training and technical support. This fine product is a tribute to the resilience, creativity, energy, and intelligence of the young men and women with co-occurring mental health and substance abuse disorders who designed the study and did the work. Blamed and Ashamed is a wake-up call to every- one concerned with improving services for children and youth who have both substance abuse and mental health problems. We appreciate the cooperation of the Federation state organizations and chapters throughout the country for their assistance in recruiting individuals to participate in the focus groups. Mostly we are deeply indebted to the youth and their families who shared intimate details of their lives so the rest of us would really understand their experience. We are conscious of their trusting us to use their stories with respect and compassion. Blamed and Ashamed was presented as a performance by some of the researchers at the Federation’s Annual Conference in December of 2000. Dr. Bert Pepper, a member of the SAMHSA Advisory Council and an acknowledged expert on youth with co-occuring disorders, provided background information on this problem and commentary on our findings. His valuable remarks are appended to our report. We appreciate Dr. Pepper’s validation of our work and his support of our recommendations. We also gratefully acknowledge Dr. Nelba Chavez, Administrator of the Substance Abuse and Mental Health Services Administration at the time this study was conducted. Her encouragement, leadership, and financial support made this work possible. We thank you for listening.
Sincerely, Barbara Huff, Executive Director Federation of Families for Children’s Mental Health
1101 King Street, Suite 420 ¥ Alexandria, VA 22314 (703) 684-7719 ¥ Fax: (703) 836-1040 E-mail: [email protected] ¥ Web: www.ffcmh.org Keys for Networking, Inc.
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ii Federation of Families for Children’s Mental Health
Table of Contents
Acknowledgements v Executive Summary 1 Introduction 7 How the Study was Conducted 8 Participants 9 Formulating the Questions 9 Training Youth on Interviewing and Focus Group Techniques 9 Gathering Data 10 Recording Responses 11 Analyzing the Data 11 The Questions 13 Responses to the Questions 15 What We Learned — Conclusions 29 Recommendations 29 Providers 29 Family Members 29 Youth 29 SAMHSA 29 Remarks from Dr. Bert Pepper 43
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iv Federation of Families for Children’s Mental Health
Acknowledgements
We are deeply indebted to the youth and their families who shared intimate details of their lives so the rest of us would really understand their experiences. We also appreciate the cooperation of the Federation’s state organizations and chapters for their ongoing support and a their assistance in recruiting individuals to participate in the focus groups. The youth researchers, the Federation of Families for Children’s Mental Health, and Keys for Networking, Inc. wish to acknowledge Dr. Nelba Chavez, Administrator of the Substance Abuse and Mental Health Services Administration. Her encouragement, leadership, and support made this work possible. We thank you for listening.
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vi Federation of Families for Children’s Mental Health
Please feel free to make copies of this Executive Summary for distribution to staff, friends, and colleagues — anyone who cares about youth.
Executive Summary A unique and key This report presents the findings of a two-year project in- feature of the study tended to document and summarize the experiences of youth with was the high co-occurring mental health and substance abuse problems and their ownership of youth families. The purposes of this study were to offer youth and their throughout the families the opportunity to reflect on and give voice to their experi- process. ences, to identify their successes and concerns, and to formulate recommendations so that a national audience might learn from their experience and improve services. The work was funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) in the U.S. Department of Health and Human Services and conducted by two family-run organizations — the Federation of Families for Children’s Mental Health, Alexandria, Virginia, and Keys for Networking, Inc., Topeka, Kansas. A unique and key feature of the study was the high ownership of youth throughout the process. Their control over the study led to a strong sense of power which was key to establishing the trust and comfort necessary for participants to think deeply about and hon- estly share details and feelings about experiences that were very personal — even painful. Between 1997 and 1999, over 150 people from California, Georgia, Illinois, Kansas, Maine, New Mexico, Virginia, West Virginia, and the Washington, D.C. area were interviewed or participated in focus groups. They represent a cross-section of youth with co-occurring mental health and substance abuse prob- lems and their families. Youth participating were from every ethnic group and socio-economic status and ranged in age from 13 to 28. They all shared the experience of having resided in both mental health and substance abuse treatment facilities. Focus groups for youth and parents were held separately. Once the focus groups
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were completed, audiotapes were transcribed and a meeting was held in Kansas City to review and analyze the raw data. The Fed- eration of Families for Children’s Mental Health and Keys for Networking, Inc. wrote the final report. The findings of this study are powerful. Tragically, youth with co-occurring mental health and substance abuse disorders and their families rarely get the kind of help they need at the time they need it. Services and supports are fragmented, isolated, and rigid. These negative experiences, however, direct us to the changes that are necessary to get better outcomes. Peer-to-peer support for both Any change youth and families, really accurate and useful information for both process occurs youth and families, and combined treatment that includes families when individuals are necessary. And most importantly, youth and their families want take responsibility to be heard and respected. They want a say in deciding what and start to do services and supports they will receive, as well as where and how they will be provided. things differently. The report’s recommendations are framed in the spirit of promoting positive change. They focus on how treatment, services, and supports for youth with co-occurring substance abuse and mental health disorders and their families are: ¥ thought about ¥ designed ¥ provided ¥ evaluated The report’s recommendations are intended to stimulate everyone who has an interest in this subject to reflect deeply about what can be done to improve practices and outcomes. Any change process occurs when individuals take responsibility and start to do things differently. Therefore, the recommendations are directed at providers, families, and youth. But they could be applied to a wide variety of individuals, as well as programs and systems. In addi- tion, the report offers SAMHSA suggestions for activities to fund that would begin to address the key information and service needs identified by this study.
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Recommendations for Providers
Listen carefully and attentively and treat youth and families with respect and dignity. ¥ Rely on them to guide you in understanding who they are, what they can do, and what problems they are facing. ¥ Use what you hear to reach your decisions and make your recommendations. Involve youth. ¥ Actively engage youth in designing and evaluating pro- grams. ¥ Offer youth access to information, and a voice in the decisions which get made about their treatment. ¥ Create opportunities for youth to help others in treatment and afterwards. ¥ Create options for youth to use their experience and turn it into positive growth. Help them reclaim self-esteem. Make sure families are included. Invite them into the treatment process. ¥ Provide whole family treatment throughout the length of time a youth is in residential treatment to strengthen the bonds that get broken when children are not living at home. ¥ Provide or link the family to services after the youth returns home from treatment. ¥ Help parents understand the treatment process and help them learn how to notice their child’s progress as well as signs of relapse. ¥ Extend treatment to parents as well as youth. ¥ Work with families to help them set realistic boundaries and enforce the rules they can live with. Offer services and programs that deal with youth in an individualized way, treat each youth as a total person, and include the whole family in the healing process. ¥ Offer choices and include information about the benefits and risks associated with each one. ¥ Promote family-child interaction as core to treatment.
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¥ Focus on the length of time the youth needs treatment instead of the length of time a family is able to pay for services or their insurance is willing to cover it. ¥ Combine substance abuse and mental health treatment— only focus on one before the other if the drug use is so serious that youth cannot function. Deliver usable and helpful information on illness, treatment, after care, and funding to youth as well as to parents. ¥ Have friendly staff available to answer questions at conve- nient times so families can ask their questions. ¥ Provide easy access to information. ¥ Develop information specific to “what to do if/when my child relapses,” so parents, paraprofessionals, and clergy, listen and help them without treating them as failures. ¥ Educate youth and parents on the effects and appropriate recommended dosage for prescription and non-prescription drugs. ¥ Include fathers especially; develop programs to inform and support fathers. ¥ Educate parents about the symptoms of abuse and the effects of drugs so they can provide information to their children and so they will recognize regression when it occurs. Develop public awareness of mental health issues and positive models of treatment to disseminate in schools, to families, and through youth groups. ¥ Develop and disseminate press releases showing good- looking role models taking prescription medication for mental health needs. Recommendations for Family members
Get involved and stay involved. ¥ Listen to what your child is saying. See it from their point of view. Walk a moment in their shoes. ¥ Address substance abuse and mental health issues with your child at the same time. Insist that treatment programs address both. Know the treatment program, visit the pro- gram, and visit your child. Be there and be there often. 4 Federation of Families for Children’s Mental Health
¥ Support your child in treatment and “hear” what they have to say about all their problems. ¥ Praise your son or daughter for making progress and watch for signs of regression, but remember, regression is part of recovery. ¥ Participate in evaluating the program as well as your child’s treatment. Educate, educate, educate. ¥ Tell other parents about mental health/substance abuse issues and treatment. ¥ Offer what you know to other families who need your support and can benefit from your experience. ¥ Offer your child access to information, and assure that he/ she has a voice in the decisions made about treatment issues. ¥ Respect your child’s and your own openness and readiness for disclosure. ¥ Read everything and ask for more. ¥ Ask other parents who have been through this. They know. Recommendations for Youth
Speak up and be heard. ¥ Speak out about getting better: what is helping you, and what you need to make progress. ¥ Ask your parents to be part of your treatment. Ask them to learn about the “treatment.” Get reliable information and share what you know. ¥ Educate yourself on what prompts regression. Know your own weaknesses. ¥ Know whom you can ask for help. ¥ Ask to mentor or help other young people with problems. They can benefit from what you have learned and what you have accomplished. ¥ Offer your expertise to treatment programs and share your observations with staff.
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Recommendations for SAMHSA
Provide peer support ¥ Fund peer-to-peer youth outreach and network develop- ment. ¥ Fund family-to-family outreach and peer support activities. Facilitate information dissemination ¥ Fund a multi-stakeholder process to identify information that is critically needed by youth and families. ¥ Fund family-run organizations to disseminate information in usable formats and use strategies to get it to the people who need it most. Support collaboration and integrated treatment ¥ Fund a multi-stakeholder process to promote collaboration between the substance abuse and mental health systems, agencies, and providers. Fund a multi-stakeholder process to develop and disseminate guidelines for providers to insure services for youth with co- occurring mental health and substance abuse disorders are fully integrated and effective.
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Introduction A unique and key This report presents the findings of a two-year project in- feature of the study tended to document and summarize the experiences of youth with was the high co-occurring mental health and substance abuse problems and their ownership of youth families. The purposes of this study were to offer youth and their throughout. families the opportunity to reflect on and give voice to their experi- ences, to identify their successes and concerns, and to formulate recommendations so that a national audience might learn from their experiences and improve services. The work was funded by the Substance Abuse Mental Health Services Administration in the U.S. Department of Health and Human Services and conducted by two family-run organizations — the Federation of Families for Children’s Mental Health, Alexandria, Virginia and Keys for Networking, Inc., Topeka, Kansas. A unique and key feature of the study was the high ownership of youth throughout. Their control over the study led to a strong sense of ownership which was key to establishing the trust and comfort necessary for participants to think deeply about and honestly share details and feelings about experiences that were very personal — even painful. It was a new experience for youth to do this kind of work and they needed substantial training and support from more experi- enced adults to carry it out. Throughout the project, both the youth researchers and the family members assisting them had to work through the tensions inherent in their different perspectives to develop relationships which, in essence, transformed the traditional ways adults and youth relate to each other. The youth were really in charge. They learned how to exercise this new authority judi- ciously and understand the consequences of their decisions. The adults were really not in charge. They learned how to guide youth
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by providing training and support without the adults having the ‘last say’ about how the study would proceed. A team of youth trained to be researchers designed the ques- tions. They carried out the focus groups and interviews, and they analyzed the data. Keys for Networking, Inc. and the Federation of Families for Children’s Mental Health provided support, training, and guidance, and compiled the information the youth had col- lected. The youth on this research team came from all over the country and did much of their work together via telephone confer- ence calls facilitated by a researcher hired to teach them. Family- Their run organizations from around the country that focus on advocacy recommendations for children with emotional and behavioral issues assisted by ...point the way for setting up focus groups and arranging interviews so youth could policy makers and collect data from their states. practitioners who In the course of doing this study, both the youth and their are committed parents voiced many stressful, painful, and very personal experi- ences related to the topic of addressing the needs of youth with co- to achieving better occurring substance abuse and mental health problems and their outcomes in families. The recommendations made as a result of these disclo- the future. sures cut across class, race, and cultures and are much more than a simple critique of services. They point the way for policy makers and practitioners who are committed to achieving better outcomes in the future. The youth and families who participated in or worked on this study took a risk when exposing themselves with their public testimony. Some youth and their parents were sharing their experi- ences with each other for the first time during this process. Every- one who took these risks did so because they wanted to help shape public policy and improve both the mental health and substance abuse service delivery systems for youth and their families. In Kansas City, small groups of youth and family members met and discussed the raw material separately. The responses and conclu- sions of each group were shared in a manner that protected the identity of the individuals. In other words, parents could not tell which comments or experiences their own children had contributed and youth could not tell what their own family members had said. We learned much. Tragically, youth with co-occurring mental health and substance abuse disorders and their families rarely get the kind of help they need at the time they need it. Services and supports are fragmented, isolated, and rigid. Peer-to-peer support
8 Federation of Families for Children’s Mental Health
for both youth and families, really accurate and useful information intended for both youth and families, and combined treatment that includes families is called for. And mostly, youth and their families want to be heard and respected. They want a say in deciding what services and supports they will receive as well as where and how the services and supports will be provided. How the Study was Conducted The study included a series of activities aimed at: (1) improv- ing the understanding of the needs of youth with co-occurring mental health and substance abuse disorders and their families; and Youth and their (2) providing policy makers and service providers with better families want to information on how to respond to the needs of these youth and be heard and their families. respected. Participants Between 1997 and 1999, over 150 people from California, Georgia, Illinois, Kansas, Maine, New Mexico, Virginia, West Virginia, and the Washington, DC area were interviewed or partici- pated in focus groups. They represent a cross-section of youth with co-occurring mental health and substance abuse problems and their families. Youth participating were from every ethnic group and socio-economic status and ranged in age from 13 to 28. They all shared the experience of having resided in both mental health and substance abuse treatment facilities. Focus groups for youth and parents were held separately. Formulating The Questions The team of youth researchers began with a series of interstate conference calls to design the study process and develop questions. Dr. Melissa Nolte, an independent evaluator and qualitative re- searcher whose specialty is participatory evaluation, worked with the youth researchers. Six conference calls were held with 10 youth and 6 adults to decide how to do the study, what to ask, and how to ask the questions. Questions were phrased differently for youth and for their parents in order to capture their different per- spectives. Yet, the questions for both groups addressed the same broad areas of experience and explored the same three themes. ¥ What really worked to help you? ¥ How were your (or your child’s) substance abuse and/or
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mental health issues addressed in the different treatment centers? ¥ What would you change? Once the questions were developed, pilot focus groups were held under the supervision of Dr. Nolte and Dr. Jane Adams, Executive Director of Keys for Networking, Inc. Audiotapes of the pilot focus groups were reviewed and critiqued by the youth research team. Training youth on interviewing and focus group techniques Confidentiality Drs. Nolte and Adams provided focus group training, eliciting procedures were group responses, and recording information. Ten youth (from provided and Illinois, Kansas, Montana, Ohio, New York, and Virginia) partici- discussed. pated in the focus group training. The training covered six areas: ¥ Each question was reviewed and its rationale discussed including examples of “good” answers to each question and questions to use as probes for additional information. ¥ Instructions were given to manage the logistics including: arriving early, arranging seating, handing out questions, locating restrooms, and other comforts for participants. Procedures were established to go over all the questions first, then solicit answers. Everyone was to be asked to answer, if they elected to “pass” the interviewer was to go back to them. ¥ Confidentiality procedures were provided and discussed. Names would not be used (unless participants specifically requested) and data would be gathered, so that parents would be unable to identify responses from their own child. ¥ Managing problems arising from participant’s discussion and procedures to refer people to professionals were de- tailed. ¥ Instructions for telling participants how data was to be used were reviewed, including how they could request a copy of the final report. ¥ Instruction on the use of tape recorders was provided, including when to turn them on or off if participants re- quested to go ‘off the record.’
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Each youth who was trained as a focus group leader was provided with a focus group kit that included everything needed to conduct the focus group and record the data. The kit included: ¥ Rules for conducting the focus group. ¥ Sign up sheets, which were mailed back to Keys for Net- working, Inc. so participants could get paid. ¥ Audio tapes and tape recorder. ¥ Letter to give to agencies, families, and youth to recruit participants and explain the project. ¥ Permission and consent forms with directions on how to get Family-run these completed. organizations ¥ Confidentiality statements and directions for obtaining across the U.S. informed consent. were invited to ¥ Self-evaluation form for the focus group leader. assist. ¥ Postage to mail everything back to Keys for Networking, Inc. Gathering Data Family-run organizations across the U.S. were invited to assist the youth researchers identify participants and convene focus groups of youth and family members who had the experience of both substance abuse and mental health residential treatments. Trained youth interviewers from this project facilitated the focus groups with the support of staff from Keys for Networking, Inc. and the local family-run organizations. There were 10 participants in each focus group; one third were groups of parents and family members and two thirds were groups of youth. The youth research- ers conducted a total of 15 focus groups, held in California, Geor- 1 Since participants in gia, Illinois, Kansas, Maine, New Mexico, Virginia, West Virginia, the focus groups were and the Washington, DC area. Data from 4 focus groups was recruited by other individu- discarded because the individuals participating in the focus groups als, agencies, and organiza- did not meet the criterion of having both a substance abuse prob- tions, the focus group lem and a mental health disorder.1 In addition to the focus groups, leaders did not necessarily Keys for Networking, Inc. mailed questionnaires to ten parents know in advance who was who couldn’t attend the focus groups themselves but who were attending. This left open the willing to participate because their own child had been in a focus possibility that some partici- group. The questionnaires addressed the same issues that were pants would not have co- discussed in the focus groups. Keys for Networking, Inc. received occurring disorders and the six competed questionnaires. These responses were added to the experience of residential data from the focus groups. treatment.
11 Keys for Networking, Inc.
Recording Responses All the focus group sessions were audio taped. The tapes were transcribed by Dr. Nolte who helped youth researchers at Keys for Networking, Inc. compile all the raw data into lists of responses for each of the questions. Youth and parent responses were compiled separately. Duplicated items were combined. Analyzing the Data The research team felt strongly about who was qualified to analyze the data. They did not want to have some ‘outsider’ or a The participants in person removed from the data analyze it. It was, therefore, decided the Kansas City to hold a conference to examine the data looking for common and meeting were recurring themes. The conference was held in Kansas City in carefully selected in October, 1999. Twenty-nine individuals met for two days to review order to insure that the information that had been collected, make sense of it, and there was a real develop recommendations. ‘member check.’ The participants in the Kansas City meeting were carefully selected in order to insure that there was a real ‘member check.’ Individuals were selected because they had first-hand experience with co-occurring mental health and substance abuse disorders and were astute and courageous enough to speak openly and frankly about it. In addition to this expertise, participant parents and youth were selected to insure: (1) geographic distribution and representa- tion from the sites where the focus groups were held; (2) social and economic mix; and (3) racial and cultural diversity. Youth partici- pants were both in school and out. Some were living with families and some were not. Some of the young people had children of their own and some didn’t. Some of the youth had been incarcerated. Parent participants included an adoptive mother who is a school- teacher, a husband and wife who are cooks, a mother who works for a national policy organization, and a mother who directs a state agency. The group consisted of 12 youth and 17 adults. Among the youth, four had conducted focus groups and three had been partici- pants. Among the adults, nine served as workgroup leaders, facili- tators, recorders, or provided logistical support during the confer- ence. There were five parents (including three who had participated in focus groups), and three adults with the experience, training or skills to provide support and structure for youth when the going got tough for any of them. These three individuals were available round-the-clock. 12 Federation of Families for Children’s Mental Health
Before getting started, this group acknowledged that everyone had strong emotions associated with the subject and that both youth and parents were anxious about talking about it in front of each other. The working conference, therefore, opened with low stress activities to help everyone get acquainted, build trust, and express anxieties and expectations. Youth and parents anonymously posted brief descriptions of their hopes and fears related to sharing this very personal information. These descriptions are summarized below to illustrate the range of emotions associated with the topic. These feelings are likely to be present in any setting with youth and their families where co-occurring mental health and substance abuse disorders are discussed.
Hopes
I hope to: ¥ Keep an open mind about others’ experiences ¥ Hear others’ experiences ¥ I might touch others with my experiences ¥ Start something constructive for my life ¥ Help others feel free to express themselves ¥ Have a real and profound effect on services for children, youth and families ¥ Improve services for other young people who need assistance in dealing with substance abuse and mental health ¥ Affect policies and make the process smoother for other youth facing substance abuse and mental health issues
Fears
I’m afraid: ¥ Of coming forward with all the hurts I’ve experienced ¥ I will be judged ¥ I will be embarrassed, frustrated, or say the wrong thing ¥ I will not touch anyone here. I’m afraid of hurting someone’s feelings.
13 Keys for Networking, Inc.
The Questions 1. Where would you go to get information about substance abuse and mental health services? 2. How would you want information distributed to the com- munity (schools, justice department, etc.) about substance abuse or mental health issues? 3. How has your substance abuse and mental health affected your family and everyday living? 4. Describe your substance abuse and mental health services? What could have made those services better? 5. What was the first residential treatment session you re- ceived like? How did you want it to be? 6. How could the initial residential treatment interview have been changed? 7. What kind of residential treatments have you received for your substance abuse and mental health issues? How were your substance abuse and mental health treatments com- bined? How would you combine them if they weren’t? 8. Do you feel that your substance abuse led to your mental health problems or vice versa? 9. What was your aftercare program like? What did you need for a stronger aftercare program? 10. What was more important to focus on when you started your treatment, substance abuse or mental health issues? 11. How did you get into treatment? How did you want to get there? 12. What decisions would you have liked to have made about your treatment that were different from the choices you were given? 13. How were your parents’ views on your treatment needs different from your own? 14. Which are you more comfortable with, telling people that you have a substance abuse problem or that you have a mental health problem? 15. If you were to relapse, who would you tell and why? 16. Did they allow you/invite you to evaluate the services you received?
14 Federation of Families for Children’s Mental Health
Responses to the Questions There were hundreds of pages of transcripts from the focus groups and interviews. All were filled with powerful statements about individual experiences, and each had features in common with many others. The responses to the questions are summarized below and illustrated with quotations from the transcripts.
Where would you go to get information about substance abuse and mental health services?
Youth Parents Youth identified many sources where Parents did not know where to go other they would seek information. These included than to agencies and programs that provide professionals or service programs such as substance abuse treatment or mental health school counselors, narcotics anonymous, or services. However, they said the information community mental health centers, as well as they got did not help them recognize their son family members and friends. A few did not or daughter was in trouble and needing help. know where they would go. In choosing where “There was essentially no information to go, knowing that the source had experience before our child went to treatment.” with the issues and was reliable and trustwor- “I looked at church, youth groups, recre- thy was important. ational centers, movies, television, and treat- “I’d go to a friend, or someone with ment centers for the right information — experience, a peer. I’d go to a counselor at nothing fit our situation.” school.” “I need someone I can go to as an older role model, someone I can trust, ‘peer advo- cate’ someone who has been through this.”
15 Keys for Networking, Inc.
How would you want information distributed to the community (schools, justice department, etc.) about substance abuse or mental health issues?
Youth Parents All youth thought other youth were the Parents thought parents who have been best source of information and suggested ways through it should educate other parents. their personal strengths and talents could be “There needs to be a group of us, of us used to distribute information (i.e., public normal parents, who have children who were speaking, writing poetry, rapping, youth crisis in trouble so we can relate to each other and and warm lines). They advised that brochures, so we can go out and tell other parents they tapes, public service announcements, and such are not alone.” should be up-to-date and ‘real.’ They stated About half of them also thought the that word of mouth, preferably from peers, is schools had a role to play and suggested using effective and suggested door-to-door cam- “parents who have recovering kids to talk to paigns and personal testimony at rallies and other parents” during drug awareness week school meetings. and other school based opportunities for “I think they just have to listen to my parents to share information. They also recom- story. I can give a lot of information because mended: it’s real. I lost everything and have all these “Classroom resource guides so teachers health problems that follow and all that kind can incorporate discussions.” of stuff.” “Internet, school-based health and “I think they should offer information mental health centers, youth ministries, and about symptoms, services, and programs parent hotlines and information centers.” everywhere, so we can’t, our parents can’t, miss it and will have it when we need it.”
16 Federation of Families for Children’s Mental Health
How has your substance abuse and mental health affected your family and everyday living?
Youth Parents Youth experiences varied. Most reported Parents universally reported dramatic that family life was really bad when they were changes in their family and in relationships using drugs. with their son or daughter. “It basically tore the family apart.” “Ripped it apart.” “It’s crazy around the house, like she “It changes your whole life, it really doesn’t trust me with anything.” does. It changes how you talk to people, who “I’m fighting hurt feelings. My family you associate with, what you do, what plans turned their backs on me. They gave up on me you make, and what plans you don’t make.” because of ignorance, pain, and frustration. I “The house is chaotic all the time. We am angry about that.” have no life.” “I just kind of quit everything.” “It changes every aspect of your life, Some of these young people also ac- emotionally, financially, mentally. We’re all so knowledged that their parent’s efforts at busy with my daughter and running her here supervision didn’t work. and there. There’s no time and no money left.” “They tried locking me up in the house to Some parents stated that their child’s keep me away from guys, keep me off the substance abuse was actually a symptom of streets. It didn’t work, it make me madder, other serious problems in the family and that made me run away.” highlighting the drug problems got them to recognize they all needed help. “She wants to keep me off the streets and it don’t help. I just keep doing it cuz the weed “I can’t say that she tore up the family, has control over me right now and I don’t but she made the loudest noise and so we listen.” started getting some help.” “They’re trying to help me out, you know. Many parents noted the change in their I respect that, but it’s my life.” own social lives. Some youth described parental indiffer- “Because you don’t know what’s going to ence to their substance abuse or complicity happen tonight, you don’t socialize. You don’t with it. have friends over, you don’t go other places.” “My dad does it too and it’s as long as I Many also talked about added activities do what I gotta do, he don’t really care.” and time-consuming responsibilities. “I’m around it everyday, since my mom’s “Balancing caring for the family, caring boyfriend is always getting high downstairs. for this child, and protecting other children She doesn’t really care because she knows from getting it is hard.”
(continued) (continued) 17 Keys for Networking, Inc.
How has your substance abuse and mental health affected your family and everyday living? (cont.)
Youth (continued) Parents (continued) that he gives it to me and my friends some- “There are meetings four nights a week. times.” We eat dinner at eleven o’clock at night.” Youth also expressed specific concern Parents described deterioration in rela- about the impact on schoolwork and especially tionships with their children. on younger siblings. “I just couldn’t trust him anymore, for “It affected our family in huge ways. I am anything. He would lie about the stupidest the bad apple. My mom vows that I will spoil things, whether he actually brushed his teeth my brothers and sisters. I have.” or not. But it seems to be very, very important The few youth who felt there was little or for him to be able to be in control.” no impact on their family attributed it to their Parents recognized the conflict between family not knowing about their problem. letting their son or daughter take responsibil- Youth felt punished and abandoned when they ity for their behavior and doing all they could were sent away. They felt “put away, ” as if to support their recovery. they didn’t belong anymore. “Protecting vs. letting her take responsi- bility is a push and pull thing.” “You try and make it work for them, which we’re not supposed to do, I know. But we’re the moms. You do what you’ve got to do to protect them.” “I know my daughter has to do it on her own, but she’s my kid and I’ve gone this far to keep her alive. It’s hard to just back off.” Parents also mentioned that the financial drain, the stigma and shame “were transferred to the whole family.”
18 Federation of Families for Children’s Mental Health
Describe your substance abuse and mental health services? What could have made those services better?
Youth Parents The youth talked mostly about their Parents described substance abuse and experiences with counseling — individual and mental health treatment programs as oriented group or family sessions. Their descriptions of toward treatment for adults. No program these sessions were very powerful and also successfully involved families in their son’s or very negative. Youth felt ‘talked-at,’ ignored, daughter’s treatment. ‘set-up’, blamed, and disempowered by “The adult substance abuse system is not counselors. Generally it was not helpful. prepared to deal with interested or involved “It really sucked!” parents, let alone parent advocates. Adult “The counselor made it seem like ‘Oh, substance abuse treatments see parents who it’s all your fault. You’re the one starting the are involved as ‘enablers.’” problem with your father’.” “Pure AA systems make individual(s) “All I know is I didn’t like it. My mom responsible for actions and consequences. and me just sat there fighting the whole time.” Young people need support from the family to put it together. We need help to figure this “If your parents were to talk to them out.” beforehand then they make it seem like every- thing is against you. It kind of felt like being Parents also objected to the separation of set-up.” services by the substance abuse and mental health systems. “They talked to me for like a half hour and then the other half hour they talked to my “Substance abuse and mental health mom and that didn’t work for me because my need to be addressed as equally important, mom would have a different story than I inextricably linked. Treatment centers don’t would. So we need to be in the same room so see them as linked due to system division.” like we could talk and she could listen and “We were told we’d have to enroll our understand.” son in one program, finish that, and then send “I guess he was scared of my dad, cuz him away to treatment. Our son was away for every time my dad would jump in, he would let two years and he did not come home recov- my dad take over and say whatever he want. ered from mental illness or substance abuse. He just had everybody in there and it didn’t He was a stranger to us.” work. Everybody would talk at the same time; Parents talked about their need for infor- no one would listen to each other. He didn’t mation: to know about kinds of treatments, to have control of none of us.” know what works, to be involved in planning “They’ll do a family session and they’ll the treatment for their child, to be included, to have everyone go against me. That’s actually learn new ways to relate to a family, to know (continued) (continued) 19 Keys for Networking, Inc.
Describe your substance abuse and mental health services? What could have made those services better? (cont.)
Youth (continued) Parents (continued) a terrible way to counsel somebody. It makes it the signs of relapse, to set boundaries. seem like you’re stupid or you’re bad.” “They treated me like an interloper. They Youth stated that they wanted counselors made me feel like it was my fault.” who listened to them, who could see their “They didn’t even talk to us until our strengths, who were not judgmental, and who insurance ran out. Then he was all ours.” could advise them about strategies for getting along with parents or working on their prob- lems. “I wanted to be listened to. I needed support. I wanted someone who would hear both sides, mine and my parents.” “The thing you don’t want, at first, is to change. You want them to work with you and point out the good points, maybe even be on your side.” “I wanted the first session to be where it was just me and him, he would ask me ques- tions, I would tell him how it went. He could like maybe tell me how I could talk to my parents, or whatever.” “ I needed individual and family counsel- ing to help me explore my problems. Then I needed help working them through with the family.” One youth described a drug abuse class, which she attended for one day. “It was mostly police stuff like what would be different kinds of arrest and what would be a felony and all that stuff about what would happen. It worked but I really didn’t want to go.” Another described an anger management program. “It was boring though, like an hour and half, and I took like ten lessons but I didn’t learn anything.” 20 Federation of Families for Children’s Mental Health
What was the first residential treatment session you received like? How did you want it to be?
Youth Parents Youth emphasized the importance of Parents stated that the whole family neutrality and strength. They want treatment needs help and it is insufficient to focus solely staff to be fair, focus on the positives (rather on one individual — even though that indi- than the negatives which was the general rule), vidual may have very great needs. and be strong enough to keep all sorts of “While the youth is in treatment, the personalities in balance. family should be getting special counseling, “Whoever is facilitating needs to be then everyone should be brought together in someone with a strong personality and “neu- joint counseling. It all works hand-in-hand.” tral” and not give in to the aggressive person “Family must participate because family in the family.” is affected. There needs to be something set up “I want them to make me feel like a for the youth to go into right after treatment.” person, and not look down on me. It is such a Parents also recognize that they need help negative thing and so much focus on the in understanding the treatment. negative aspects.” “Parents need to know how to work with Young people also want the atmosphere their kids, understand them at their level, and to be more welcoming and personal and they understand the treatment.” want their families to participate. As much as parents are committed to full “Youth should be allowed to take some- family involvement, they also recognized that one they are comfortable with to the first sometimes their sons and daughters need some session.” private space. “I was able to continue counseling and “Allow youth to express issues privately therapy that fit my needs. However, my family so treatment is more effective in addressing did not continue their therapy. So it didn’t the issues.” work in the end.”
21 Keys for Networking, Inc.
How could the initial residential treatment interview have been changed?
Youth Parents Youth tended to describe their first Parents characterized half of their initial interviews as a formal event with a profes- interviews as positive and half as negative. sional asking a lot of questions or someone They tended to evaluate the initial interview in filling-in forms that had to be signed. They terms of how the interviewer approached their would have preferred situations that were son or daughter and/or how truthfully their son more personal. or daughter responded. “I felt intimidated, bombarded with “[My daughter] just danced in circles repeated questions by the interviewer.” with them — didn’t give them any information, “I would have [preferred going] one on so they didn’t focus on what they needed to one with someone closer to my own age.” do.” “I got tired of all the questions.” “I was very impressed with him [the interviewer] because he talked on my son’s “They didn’t ask me how I felt about level. He wasn’t judgmental or anything. My being there or if I wanted to be there.” son really related to him.” Young people want to be treated with Parents admitted that they were ‘on respect and dignity. guard’ during the intake fearing they would be “I’d like to be treated like a person not blamed or their child would not be admitted if just a case or money. Start with sensitivity, try they gave ‘wrong’ answers. and get to know us. Be friendly and help.” “My input was based on the agency’s “I was strip searched, psychoanalyzed, perception of me as a parent. I was afraid they and had to take too many tests, too many would say it was my fault.” questions. I want to be treated like a human “Our input was driven by the need to get being.” the child in treatment and safety rather than our real issues. Treatment occurred before they even talked to us.” Parents would have liked the initial interview to be less formal, establish commu- nication, and focus on the real issues that brought them to the facility in the first place. “The interview needs to be more focused on the youth’s needs at the time, instead of just admitting to the treatment program.”
22 Federation of Families for Children’s Mental Health
What kind of residential treatments have you received for your sub- stance abuse and mental health issues? How were your substance abuse and mental health treatments combined? How would you com- bine them if they weren’t? Youth Parents Youth see the inter-relationship between Parents stated that their children needed mental health problems and substance abuse. to be treated holistically as teenagers yet they They reported that substance abuse treatment described a variety of treatment patterns — without mental health treatment doesn’t work. some separate and some combined. These They recommend getting off drugs and com- included counseling, groups, alcoholics bining medication and working on the “real anonymous, self-medication, inpatient treat- issues.” They value programs that help them ment, day programs, private psychologists, find out who they are. and aftercare. Parents talked about the confu- “They worked mainly on substance abuse sion of service fragmentation and how often it and I think they should split the time between was their own efforts that resulted in combin- mental health and substance abuse because I ing treatment. Yet, they get no credit and much really honestly don’t know anyone who has a blame. substance abuse problem who doesn’t have a “We need programs that deal with our mental problem.” child as a whole.” “I’d first get you off of drugs and then try “It was our responsibility as family to figure out what you were covering up with members to put the two together, substance your using and go from there.” abuse and mental health. No one even offered “I didn’t want to hear from someone else, to help us sort this out.” who I was. They basically help you understand. “We need access to funding streams that They really got me to look at myself. The treat- allow us to get services in both areas. We ment I received was pretty sufficient for both don’t know when substance abuse is a prob- mental health issues and substance abuse.” lem or is the problem mental health? How are “When you’re in [substance abuse] we supposed to know!” treatment you should work on also mental All the parents mentioned the lack of health issues because a lot of your mental family participation. health issues have to do with drugs.” Some youth mentioned that lack of family participation was a problem. “When I was ordered to treatment, I was forced to get services. My parents were not.” “When it was over, I was sent back to an unhealthy environment, back with parents who sometimes use, back with parents who knew nothing about how to help me.” 23 Keys for Networking, Inc.
Do you feel that your substance abuse led to your mental health problems or vice-versa?
Youth Parents All youth stated that their mental health Parents generally felt the underlying or emotional problems existed before they got mental health problems, largely untreated or involved with drugs or alcohol. ineffectively treated, led their child to sub- “Ineffective interventions with my mental stance abuse. They saw substance abuse as a health symptoms resulted in my substance form of escape from mental health problems abuse.” their sons and daughters did not understand. They chided the substance abuse system for “My depression led me to using drugs to refusing to deal with mental health issues. try and work my way out of it.” “Untreated mental health problems led to “I used substances to forget my prob- my child’s substance abuse.” lems.” “No one at substance abuse even asked Some also recognized that substance about mental illness.” abuse exacerbated their mental health prob- lems or brought on new ones. “My emotional feelings led to my drug use, but drug use led to a lot of mental health problems down the road, so its like that vi- cious cycle they talk about, one thing leads to another.” “My substance abuse fed my mental health problems and made them much worse than they actually were.”
24 Federation of Families for Children’s Mental Health
What was your aftercare program like? What did you need for a stronger aftercare program?
Youth Parents About a third had no aftercare program. Parents stated that they did not know Comments from those who did were generally what aftercare was. They said there was no positive but for some, “It was the same — I such program and described concerns about hate going.” What works seems to be an getting aftercare started but generally were individualized approach. pleased with the services once they began. “They sent a letter in the mail directly to “Until I find the right one, I’m just kind me rather than my dad or mom, which made of holding my breath that she can maintain me somewhat important. The fact that it was long enough to get started.” personalized was really cool. Or for that They mentioned making new friends and matter, they actually cared enough to write a having ‘clean’ fun as being important for their letter back.” son or daughter. “What I personally do, I go to aftercare “It’s helping more than an intensive once a week, I go to a brief one everyday. And program. It’s getting them involved with I have a sponsor who I talked to everyday on people who’ve been through the program and the phone and all my friends are clean and who are wanting to stay clean. Because that’s they’re from my home group.” the most important thing; they’re going to “The sessions were all right, at least this have to have new friends.” time. The counselor said, ‘Well, you know you “Just the camaraderie seems to be got a real bad temper, your father has a bad helping more than anything.” temper, your sister has a bad temper. I guess it “I’m not sitting in front of a counselor just runs in the family.’ Nothing would have pouring out my guts, I can go have fun.” made them better really, me and my dad just never talk.” In addition, parents mentioned long waiting periods, little or no connection be- “What I needed, they gave me, they gave tween residential treatment and aftercare, and me a psychiatrist. I just wish that he would the adult treatment model that puts full re- talk longer, that’s all. He just asks me common sponsibility on the youth and excludes the questions about how school is and things like family as being obstacles to overcome. that cause he’s on a tight schedule, cause he always synchronizes his watch whenever I “Young people are expected to take full speak to him.” responsibility for themselves. I feel that the service model needs to be revised to support Youth recommendations for stronger the youth in making aftercare a success.” after care include more opportunities to make ‘clean’ friends and to “discuss stuff” related to
(continued) (continued)
25 Keys for Networking, Inc.
What was your aftercare program like? What did you need for a stronger aftercare program? (cont.)
Youth (continued) Parents (continued) their treatment. They also suggested use of “The parent as participant-family in- younger staff and people they could feel volvement — is not considered favorable in comfortable with and trust. aftercare. Youth need support until they can do “I got to two to four meetings a week, it on their own. They are not yet adults.” and just going once to aftercare is not enough.” “It’s easier to talk to people who are around your age.” “Reliable peer or case management would help.” Youth also mentioned that they needed help from their families to get to aftercare services and this was sometimes difficult.
26 Federation of Families for Children’s Mental Health
What was more important to focus on when you started your treatment, substance abuse or mental health issues?
Youth Parents Youth were fairly evenly split on whether Parents had difficulty choosing one their mental health or substance abuse issues problem over the other and for the most part were more important to focus on at the start of described how the two interacted and how treatment. Those who favored treatment for both needed to be addressed. their substance abuse problems focused on the “I kind of thought they went hand in physical danger they were in or their lack of hand, that as they worked on his substance awareness of their mental health problems. abuse, they also worked on his mental health “If I didn’t get off drugs the right way, I side to understand why he’s abusing and how was gonna die.” to quit abusing.” “I wasn’t aware of my emotional prob- About half the parents stated that their lems or anything.” child’s mental health issues were neglected. “Sometimes it’s just overwhelming and “I felt like they focused more on the you feel like you’re just on the verge to do substance abuse, which was a severe problem, something that might damage you or the but I don’t think there was enough focus on others around you.” the mental health issues, to be honest.” Those who favored treatment for mental “She’s got a lot of anger issues and I just health issues attributed their problems to their wish they would have worked more on that.” family background or “going through a stage.” At the same time, they saw that substance abuse had to be brought under control in order for their son or daughter to make progress with the underlying mental health issues. “She has emotional problems but they couldn’t be addressed until she wasn’t on drugs and she was on drugs because she had emotional problems. Keeping her structured and in one place was able at least to keep her clean long enough to get to some of the prob- lems.”
27 Keys for Networking, Inc.
How did you get into treatment? How did you want to get there?
Youth Parents The vast majority of youth were forced Parents reported three ways their sons into treatment by their parents or a court. They and daughters got into treatment: (1) volun- all wished they had gone into treatment tarily (which rarely happened), (2) enrolled by voluntarily. However, they acknowledged that parents, or (3) involuntarily through the courts they were resisting treatment at the time. or social services (sometimes because parents “At the time I didn’t want to get there but called the police). All parents would have since I had to go I wish I could have made the liked their child to enter treatment voluntarily. decision on my own to go.” In addition, parents reported that they did not have sufficient information to recognize or “My mom kept referring and I kept understand the depth of their son’s or putting it off and finally she had me arrested daughter’s problems. This made it difficult to as a runaway.” detect until their child did something that “Once I got in the group and learned caught the attention of some outside agency about why I had problems, I wished I had (such as the police). gone on my own. Being forced into it was a “I had no information about how to good thing for me.” identify the symptoms of substance abuse. I “I would have wanted it to be that they didn’t know there was a problem. When I did were acting upon first detection of behavior get suspicious, there was not enough informa- they couldn’t understand.” tion to handle the problem. I didn’t know what “I wanted to get into treatment on my to do or where to go!” own, but I didn’t. I wanted to go get help with assistance from someone close to me, like my mother. She is always there for me.” Consistently, all parents indicarted that they would have liked their child to voluntarily enter treatment.
28 Federation of Families for Children’s Mental Health
What decisions would you have liked to have made about your treatment that were different from the choices you were given?
Youth Parents The underlying theme in all the youth The underlying theme in all the parent responses was having choices and having a responses was having choices and having a say in decisions. say in decisions. Most of the parents felt they “There was never an alternative or a had not been given any choice of program — choice. Just do it.” this decision was made by some agency with authority (social services or a court). Those “I wanted to be a participant in the who had a choice of programs found it diffi- decision process for my own treatment. My cult to find reliable information about some- parents, probation officer, etc. made all the thing that was likely to work for their family. important decisions. This caused me to go into the program with a negative outlook.” “System information was driven by the provider’s needs and not the youth’s or Youth would have liked to have chosen family’s needs.” where they were going to receive treatment and to have had a say about the length of their One parent suggested that choices might stay and have had more information and not have been a good idea because they were preparation for transitions and entering new so overwhelmed and could not have made one. programs. “I would say the decisions I would have liked to have made were all done before I got to treatment.” “I would have liked to chose to go some- where else or had outpatient treatment.” “It was difficult to deal with a different group of people from different areas. There should be more preparation for that.” Being able decide about taking medica- tion was very important to youth. “I would rather have been given a choice of whether to take medication or not, but no ultimatum, no alternative, they don’t even tell that if you don’t take it you get restrained.” “If I didn’t take, then I’d get restrained. They treated people like crazed dogs or ani- mals. They give you no choice.” (continued) 29 Keys for Networking, Inc.
What decisions would you have liked to have made about your treatment that were different from the choices you were given? (cont.)
Youth (continued) They would also have liked more contact with their families. “My parents could not be involved because of the structure of the treatment. I was told this was my problem.” “Families needed to be involved, be- cause once I was treated I returned to my family.”
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How were your parents’ views on your treatment needs different from your own?
Youth Parents Youth reported that they did not see eye-to- eye with their parents — especially at first. Parents reported that they did not see eye-to-eye with their sons and daughters — “She was more for it and I wasn’t, see.” especially at first. “My parents took my treatment a lot more serious than me and I’m grateful for that be- “In the beginning I think she had an cause I probably wouldn’t be clean if they attitude, then she realized that she had to hadn’t.” cooperate to get through the program and Youth also described their parents as having she accepted it.” expectations that were unrealistic or of being “I, of course, wanted something that over controlling. could save my child, so our views were very “My parents thought that as soon as I came different. I was willing to make her do out I had to be this new person and it obviously anything. She was willing to get out of never worked. By the end of the last treatment doing anything and that’s kind of where we center, I was ready to make a change and my were.” parents really supported it.” “My daughter thought it [treatment] “I can’t even go outside and smoke a was way too long. I thought it [treatment] cigarette without them asking where I’m going, was way too short.” what I’m doing. There’s like, no trust.” “I was there to break down what was “Every time I needed money or something wrong, what was going on in order to figure else it was always up to them to get it. So it just out how to not have it happen any more. He caused big problems.” was of the frame of mind that he didn’t Youth described their parents isolating them want to be there, nothing was wrong, and as ‘the’ problem and denying that there was a he most certainly didn’t want me in his family issue to deal with. Involved and support- face.” ive families were valued and contributed to the Parents described how the treatment youth’s progress and recovery. separated them from their son or daughter “My mom and me agreed on everything and and failed to effectively involve the family. that was one of the biggest factors in getting through my treatment. It helps when someone “There was no attempt to involve agrees with your views.” family, which created a sense of isolation.” “Family support is a strong issue, and they “The program needs to help resolve have to be involved in the treatment.” parent conflict and heal the family.” “There should be some information for the parents to encourage them to want to be involved. If the child gives up, the parent or support needs to want it for them. It’s sad to see the parent give up.”
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Which are you more comfortable with, telling people that you have a substance abuse problem or that you have a mental health problem?
Youth Parents Youth were universally more comfortable Parents said they too were more comfort- telling people about substance abuse prob- able talking about substance abuse problems. lems. They felt that there is a general under- Most said they would let their children take standing of substance abuse and alcoholism the lead. but there is limited understanding and great “I just have a handful of people that I stigma associated with mental health prob- talk about it with, because she is so compli- lems. cated.” “More people understand what using Many parents expressed an active desire drugs is about . . . it is more common than to talk about both mental health and substance mental health issues.” abuse as a way to educate others. All the “They hear better if you say, “I’m a weed parents were willing to reach out to other head, I’m stuck on weed, than “there’s some- families to share their experiences. thing wrong with my head, I’m going crazy.” “I don’t have a problem telling anybody “I’m not really comfortable telling anything because I’m proud of what he did [in people any of those things because to me, treatment] and I would like to be an advocate people stereotype and put people down if they to parents, you know — “Don’t do what I have a problem.” did.” In some cases the youth reported that Parents also mentioned that confidential- they did not understand their mental health ity and legal issues sometimes made it difficult problems well enough to explain them to to talk openly. However, they felt it was a others. family decision — typically led by their son or “Substance abuse would be what I would daughter — whether or not any of them would talk about because I really don’t understand speak publicly about their experience. why I’m depressed.” “The issue is if the child is comfortable Youth who were comfortable talking with talking about their experiences, it be- about mental health issues were getting effec- comes more comfortable for the family.” tive treatment for their problem. “First I would only talk about mental health. But I’m pretty open. I feel I can talk about it because it’s part of my life. I feel I’m getting help with it so it doesn’t need to be hidden.”
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If you were to relapse, who would you tell and why?
Youth Parents Most youth reported they would go to Parents almost universally said they family members or supportive and understand- would go to a professional — typically some- ing friends. The words they used to describe one with whom they and their child already the individual they would seek out showed had a positive and trusting relationship. they recognized the family members who can Parents were looking for advice and guidance be trusted to offer help and support without about what they were “supposed to do first judgement. They emphasized trust. and how to make this curable — how to “It is very important to trust who you are fix it?” talking to: peer advocates, case managers, “I knew Shane was a professional that and counselors.” would know what to do, and I knew that he “If I was real worried about it I’d tell my understood her too.” mom because I know that she would help me A few parents would go to close friends come up with some ideas of things I could do.” mostly for “emotional support.” One parent “My best friend, because he would be was very clear about who NOT to tell. supportive of me . . . he wouldn’t look down “I would not tell my husband’s parents. on me.” They are very close-minded about what you “My grandma, because that’s the only can do to help.” person who really be trying to help me instead But, some families were at a loss as to of going behind my back. She be trying to help where to turn. me, get me to the hospital or something.” “How do you connect with a community Youth also would seek out others who based service when there is no continuing care shared their experience and had constructive and no one to talk to?” advice about making positive change. “I would tell my best friend because he’s been through treatment and he knows what I’ve been through and where I’m coming from.” “I would tell my mom because she would do something and she’s gone through this with me and all that.” Were you allowed/invites to evaluate the services you received?
Youth Parents Never Never
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What We Learned — Conclusions All the youth and family members None of the youth or parents involved in this process had ever been invited, until now, to evaluate the worth of services they did were severely or did not receive. Nor had they ever been asked to make any blamed and recommendations for future services. The participants in the shamed by Kansas City conference took time to carefully review and reflect providers and on the data before identifying several key themes. systems when what All the youth and family members were severely blamed and they needed was shamed by providers and systems when what they needed was nonjudgmental nonjudgmental recognition of their struggle to find caring help and recognition of their support. Both youth and their parents pointed out that blaming one struggle to find another hurts deeply and contributes to the complex array of problems they face (i.e., anger, hurt, frustration, lack of services caring help and and support, isolation, disappointment, conflict, etc.). Youth and support. their families want and need providers, programs, and systems to focus on and reinforce the positive and stress the use of their strengths to overcome or remediate their problems. Youth with co-occurring substance abuse and mental health disorders and their families need and want to be treated with dignity, respect, honesty, and fairness. They want a voice in mak- ing decisions about their care and treatment — whether or not to take medications, where to go for treatment, who to talk with, and how long treatment should last. Many youth want to get better, but react strongly to the inhumane way in which they feel they are treated. They become resistant to participation or, at best, they ‘fake-it’ to get through a program. The result is release from treatment (after the standard period of time) without any real change — often resulting in a relapse. Indeed, recovery begins only after youth and families themselves choose to change their behav- ior and engage in treatment activities or access programs and services that meet their needs.
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Co-occurring substance abuse and mental health disorders are inseparable problems and cannot be effectively addressed in isolation from one other. The current categorical distinctions reflected in the funding streams and administrative structures for physical and mental health services, substance abuse services, social and family services, educational services, and legal services have prevented youth and their families from obtaining the kind of comprehensive and integrated treatment they need. Complex physical, psychological, social, economic, and environmental factors contribute to the substance abuse among youth with mental health problems. All these factors must be considered in order to Early warning signs individually design treatments, services, and supports that will be go unnoticed or are effective for any young person and his or her family. deliberately ignored Co-occurring substance abuse and mental health disorders affect the entire family and cannot be effectively addressed without including everyone who plays a key role in the child’s life. Con- versely, values and attitudes about mental health and substance abuse, as well as behaviors and relationships among family mem- bers, influence how youth and their families seek help and respond to services. The culture and beliefs as well as the strengths and problems within a family must be taken into consideration and should drive the design of intensive treatment and after care ser- vices. Families, regardless of their specific characteristics, are a permanent part of a child’s life while services and providers come and go. Youth and their families rarely see eye-to-eye at the crisis point when they first enter services, however most youth return to their families and communities after treatment. Unless they find improvement, they will quickly relapse. Bonds of affection and trust between youth and families are weakened when they are separated during residential treatment. Families need help to maintain relationships with a young person who is temporarily not living at home, and to create the supportive and structured environ- ment a youth needs to continue or complete their recovery during aftercare. Youth often experience serious legal trouble before treatment for co-occurring substance abuse and mental health disorders become available. This is too late. Early warning signs go unno- ticed or are deliberately ignored leading to escalation in destructive behaviors. Co-occurring substance abuse and mental health disor-
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ders, when ineffectively treated, create great stress in the family, escalate conflicts among parents, children, and siblings; and impair a family’s ability to intervene appropriately or effectively. Currently youth treatment programs for substance abuse and mental health disorders are based on an adult model. The principles upon which they are built are inappropriate for adolescents who are not developmentally ready to take the level of personal responsibil- ity required. Furthermore, adult models intentionally exclude families from treatment planning, implementation, or aftercare. Youth with co-occurring substance abuse and mental health prob- Current treatment lems cannot, and should not, be totally independent of their fami- programs for lies. They are not finished ‘growing up’ and have not learned all substance abuse they need to know about choosing friends, finding and keeping a and mental health job, getting to meetings, and accessing services. Without family involvement and family support (emotional and financial), most disorders are youth cannot follow through with the requirements of a treatment designed for adults. or aftercare program. The principles upon There is a tragic lack of helpful information about substance which they are built abuse and mental health disorders, accompanied by a widespread are inappropriate stigma, prejudice, and misinformation about the disorders. Youth for adolescents. and families from all walks of life need and want access to reliable; straightforward, and current information about early warning signs and symptoms. They want and need effective treatments; access to services; and coping skills training. Youth who are in recovery from co-occurring substance abuse and mental health disorders and their families have been the best source of information and support for others who are facing these problems. Youth and family out- reach and support from peers are greatly needed and sadly lacking. Peer-to-peer networks for youth should be developed and operated by and for the youth themselves.
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Recommendations Change occurs Our recommendations are framed in the spirit of promoting only when positive change in how treatment, services, and supports for youth individuals take with co-occurring substance abuse and mental health disorders and responsibility and their families are designed, provided, and evaluated. The recom- begin to do things mendations are derived from what we have learned and, we hope differently. they will stimulate everyone who has an interest in this subject to reflect deeply about what can be done to improve practices and outcomes. Change occurs only when individuals take responsibility and begin to do things differently. Our recommendations are directed at all those involved — providers, families, youth, and treatment systems. In addition, we offer the Substance Abuse and Mental Health Services Administration (SAMHSA) our sugges- tions for activities to fund that would begin to address the recom- mendations needs identified by this study. Recommendations for Providers
Listen carefully and attentively and treat youth and families with respect and dignity. ¥ Rely on them to guide you in understanding who they are, what they can do, and what problems they are facing. ¥ Use what you hear to reach your decisions and make your recommendations. Involve youth. ¥ Actively engage youth in designing and evaluating pro- grams. ¥ Offer youth access to information, and a voice in their treatment decisions.
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¥ Create opportunities for youth to help others in treatment and aftercare (mentoring). ¥ Create opportunities for youth to use their experience and turn it into positive growth. Help them reclaim self-esteem. Make sure families are included. Invite them into the treatment process. ¥ Provide whole family treatment throughout the length of time the youth is in residential treatment to strengthen the bonds that are broken when children are not living at home. ¥ Provide or link the family to services when the youth returns home from treatment. ¥ Help parents understand the treatment process and help them learn how to notice their child’s progress as well as signs of relapse. ¥ Extend treatment to parents as well as youth. ¥ Work with families to help them set realistic boundaries and enforce the rules they can live with successfully. Offer services and programs that deal with youth in an individualized way and treat each youth as a total person. Include the whole family in the healing process. ¥ Offer choices and include information about the benefits and risks associated with treatment options. ¥ Promote family-child interaction as core to treatment. ¥ Focus on the length of time the youth needs treatment instead of the length of time a family is able to pay for services or their insurance is willing to cover it. ¥ Combine substance abuse and mental health treatment — focus on one before the other only if the drug use is so serious that youth cannot function. Deliver usable and helpful information on illness, treatment, after care, and funding to youth as well as to parents. ¥ Have friendly staff available to answer the families’ questions at convenient times. ¥ Provide easy access to information. ¥ Develop information specific to “what to do if/when my child relapses” so parents, paraprofessionals, and clergy, listen and help them without treating them as failures.
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¥ Educate youth and parents on the effects and appropriate recommended dosage for prescription and non-prescription drugs. ¥ Include fathers especially. Develop programs that inform and support fathers. ¥ Educate parents about the symptoms of abuse and the effects of drug abuse so they can provide information to their children and recognize regression when it occurs. Develop public awareness of mental health issues and encourage positive models of treatment to disseminate in schools, to families, and through youth groups. ¥ Develop and disseminate press releases showing positive role models taking prescription medication for mental health needs. Recommendations for Family members
Get involved and stay involved. ¥ Listen to what your child is saying. See it from their point of view, and try to walk a moment in their shoes. ¥ Address substance abuse and mental health issues with your child at the same time. Insist that treatment programs address both. Know the treatment program, visit the pro- gram, and visit your child. Be there, and be there often. ¥ Support your child in treatment and “hear” what they have to say about all their problems. ¥ Praise your son or daughter for making progress and watch for signs of regression, but remember regression is part of recovery. ¥ Participate in evaluating the program as well as your child’s treatment. Educate, educate, educate. ¥ Tell other parents about mental health/substance abuse issues and treatment. ¥ Offer what you know to other families who need your support and can benefit from your experience. ¥ Offer your child access to information and assure that he/ she has a voice in the decisions that get made about treat- ment issues. 39 Keys for Networking, Inc.
¥ Respect your child’s and your own openness and readiness for disclosure. ¥ Read everything you’re given and ask for more. ¥ Ask other parents who have been through this. They know. Recommendations for Youth
Speak up and be heard. ¥ Speak out about getting better — what is helping you and what you need to make progress. ¥ Ask your parents to be part of your treatment. Ask them to learn about the “treatment.” Get reliable information and share what you know. ¥ Educate yourself on what prompts regression. Know your own weaknesses. ¥ Know whom you can ask for help. ¥ Ask to mentor or help other young people with problems. They can benefit from what you have learned and what you have accomplished. ¥ Offer your expertise to treatment programs and share your observations with staff. Recommendations for SAMHSA
Provide peer support ¥ Fund peer-to-peer youth outreach and network develop- ment. ¥ Fund family-to-family outreach and peer support activities. Facilitate information dissemination ¥ Fund a multi-stakeholder process to identify information that is critically needed by youth and families. ¥ Fund family-run organizations to disseminate information in usable formats and use strategies that will get it to the people who need it most. Support collaboration and integrated treatment ¥ Fund a multi-stakeholder process to promote collaboration between the substance abuse and mental health systems,
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agencies, and providers. ¥ Fund a multi-stakeholder process to develop and dissemi- nate guidelines for providers to insure services for youth with co-occurring mental health and substance abuse disorders are fully integrated and effective.
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— NOTES —
42 Federation of Families for Children’s Mental Health
Blamed and Ashamed: The Treatment Experiences of Youth with Co-occurring Substance Abuse and The material I have gathered from Mental Health Disorders research and And Their Families clinical experience dovetails perfectly with the findings Bert Pepper, MD and TIE, Inc. , 126 N. Main Street, New City, NY 10956 recommendations of the focus groups. As a public health physician and psychiatrist who has described the development of people with co-occurring mental health and sub- stance abuse disorders over the past twenty years, I was honored to participate in the session, Blamed and Ashamed, at the recent Federation’s Annual Conference. The presentation took place in Washington, D.C. on December 2, 2000. I am pleased to recap my remarks for the published report. When I first read the draft report of this project I was aston- ished to find how closely the findings, produced by focus groups of adolescents with co-occurring disorders and their families matched my own work. The material I have gathered from research and clinical experience dovetails perfectly with the findings and recom- mendations of the focus groups. What is the big picture? There are thousands of adolescents and young adults across the United States who, by their behavior, have earned tickets of admission to hospital emergency rooms, homeless shelters, sub- stance abuse treatment programs, psychiatric hospitals, and jails. Many go back and forth in a confusing zigzag, never staying very long in any one place. Despite the best efforts of each agency, not 43 Keys for Networking, Inc.
one of them, working alone, can meet the complex needs of these young people. They live with a mixture of mental health problems, alcohol and other drug abuse problems, health problems, immatu- rities, broken relationships with families, disrupted schooling, and behavior that disturbs the community and is often technically criminal. How many people are affected by co-occurring disorders? The National Co-Morbidity Survey, headed by Dr. Ronald We need to focus Kessler in the early 1990s, indicated that there are about 10 million treatment so that it adults who suffer from at least one mental health and at least one is integrated. substance abuse disorder. Treatment is often unavailable. When it can be found, it is usually uncoordinated. We need to focus treat- ment so that it is integrated: humane, family-inclusive, and clini- cally effective. Treatment of either disorder alone does not work. Treatment integration is essential, because the commonest cause of mental health relapse in this population is continued use of alcohol and other drug abuse. AND, the commonest cause of relapse to the use of alcohol and other drug abuse is untreated mental health problems, such as panic-anxiety and depression. Today, dealing with co-occurring disorders is an every day problem for families, schools, the mental health system, the sub- stance abuse treatment system, the courts and the jails, But it is only recently that the interactive nature of these problems has begun to be recognized. ¥ In the 1960s and 1970s the treating agencies denied that co- occurring mental health and alcohol and other drug abuse problems existed. ¥ By the 1980s there was general acknowledgement that the problem of co-occurring disorders did, indeed, exist. ¥ By the 1990s mental health agencies were referring the problem to substance abuse agencies, while substance abuse agencies were referring the problem to mental health agencies. Troubled youth and their families were getting a runaround. ¥ In this new Millennium we are just beginning to see that providing effective, humane integrated treatment for these interacting disorders is a problem for our whole human
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service system, for our whole society. We have met the problem, and Pogo says it is all of us. What are the problems today? ¥ Agencies receive money from separate sources from mental health and substance abuse agencies, at the federal, state, and local levels. In many cases, conditions attached to the spending of these funds makes it difficult or impossible for treatment to be integrated for the individual with co-occur- ring mental health and alcohol and other drug abuse prob- lems. In many cases, ¥ There are separate agencies for mental health and substance conditions attached abuse at federal, state, and local levels. Their level of to the spending of cooperation and collaboration has been poor, and is only these funds makes now just beginning to improve. it difficult or ¥ The different professional jargons in mental health and in impossible for substance abuse make it difficult for treating clinicians to communicate with each other. This causes each agency to treatment to be want to remain separate, and to avoid responsibility for the integrated. person with multiple problems. ¥ Society stigmatizes people with mental health problems. It separately and differently stigmatizes people with alcohol abuse problems. And society’s stigmatization of people with problems with cocaine and marijuana are yet again different. When the person with co-occurring problems gets pushed into the criminal justice system because of ineffective treatment in the community, an additional stigma is tacked on. The person who has been marked as a criminal has a greater burden to bear, as s/he struggles to find an honorable place in society. ¥ Mental health and substance abuse agencies want to do what they know how to do. Their staffs like to do what they were trained to do. Change is difficult. ¥ As a result of many of the above factors, each agency is likely to reject change because, “We’ve always done it this way!” or, •“We’ve never done it that way.”
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What are administrators doing? In government bureaus and at the service agency level, officials responsible for public policy covering mental health and alcohol and other drug abuse services tend to put forward the following kinds of arguments: •“We know that what is being done now doesn’t work” •“But let’s not set up a new system for co-occurring disor- ders” •“That would be too costly.” but... •“Don’t ask my agency to take on the task.” “We are already •“That would further overburden us.” and doing all we can!” •“We are already doing all we can!” Who gets hurt by current policies and procedures? ¥ Troubled young children who, if their mental health needs are not met promptly and effectively, will probably self- medicate with alcohol and other drugs. ¥ The majority of emotionally troubled adolescents, because in addition to their mental health problem, they are likely to also have an alcohol and other drug abuse problem. ¥ The majority of people with schizophrenia, who also have an alcohol and other drug abuse problem. ¥ The majority of people with manic depression, 60% of whom have an alcohol and other drug abuse problem. ¥ Perhaps 40% of people now in substance abuse treatment, who are at risk of substance abuse relapse because their mental health problems are not being addressed. Who benefits from the current situation? ¥ The prison-industrial complex, as money from government budgets for health, mental health, social services, and education gets sucked out of those budgets, to pay for the construction and staffing of more jails and more prisons.
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What are the facts? What are the numbers? ¥ The mental health treatment system has been radically downsized. In 1955 the nation had 559,000 public mental health hospital beds. By 2000 the nation had only 60,000 beds left. (Figure 1, page 57) ¥ During the past forty years the population of the country has risen by 100,00,000 people. ¥ The few remaining beds must serve many more people. That is why it is hard to get anyone into a hospital, and even harder to keep them there for more than a few days. The mental health ¥ Even if a bed is available, restrictive managed care pay- treatment system ments for hospital care makes it virtually impossible for hospitals to keep patients long enough to treat them. has been radically downsized. ¥ We used to have too many beds and over-hospitalization: now we have too few beds and under-hospitalization. What has happened to our jail and prison capacity? ¥ In 1972 the total capacity of all U.S. incarceration facilities — federal, state, and local jails and prisons - was under 200,000. ¥ In the year 2000 the capacity reached 2,000,000! ¥ And, they are full: ¥ Jails are like sports stadiums: ¥ Build them and they will come! The National Co-Morbidity Survey, and children: As noted before, Dr. Kessler’s survey gives us our best na- tional data regarding mental health and alcohol and other drug abuse disorders. The survey data suggests that: ¥ Between 8 and 11 million persons in the United States have at least one mental health and at least one substance-related disorder today. ¥ The mental disorder developed first in more than 85% of these people.
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¥ The median age of onset for the mental disorder was 11. That is, of these approximately 10 million people, 5 million developed their mental health problem at age 11 or older, and 5 million developed it at age 11 or younger! ¥ The median age of onset for the substance abuse disorder, depending on geography, ethnicity, and gender, was some- where between 17 and 21 years of age. What are the implications of these disturbing numbers? Millions of They tell us that co-occurring disorders usually begin in Americans develop childhood. Whatever the reasons, millions of Americans develop mental health mental health disorders during childhood. The fact that millions go disorders during on to develop an alcohol and other drug abuse disorder some years childhood. later — usually substance abuse — suggests that they are self- medicating their depression, anxiety, confusion, disturbing con- duct, and so on. Would providing adequate early treatment for these children be an effective means of substance abuse preven- tion? It seems likely that if we reached more children with mental health problems early we would do a good deal to reduce problems of alcohol and other drug abuse. Remember, only one in five children with a mental health disorder gets treated today.
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How do the data from the National Co-Morbidity Survey fit with the experience of youth and their families?
Blamed and Ashamed! There are individuals who have no mental health problem and who become involved with the use of alcohol and drugs, because they want to change the way they feel. These single-disorder But for depressed or individuals start out feeling o.k., but want to feel even better. Then anxious, shy, substance abuse and addiction can make them feel much worse. fearful, or But for depressed or anxious, shy, fearful, or hyperactive hyperactive children children and adolescents, the motivation for drug use is very and adolescents, different. They are trying to just feel normal. the motivation for Mental health symptoms can be temporarily relieved by drug use is very ‘medicating’ with alcohol, marijuana, or cocaine. However, as different. They are drug effects wear off, the post-intoxication rebound tends to worsen the original bad feelings, causing a double motivation to trying to just feel use more and more drugs and alcohol. normal. The Continuum of Abuse: The earlier alcohol and other drug abuse starts, the shorter and faster the road to abuse and dependence: ¥ Experimentation: Almost all drug abuse begins this way. Young people are curious, feel invulnerable, and just want to see what it’s like. ¥ Recreational alcohol and other drug abuse: If experimenta- tion progresses, the young person will be using, with friends, once or twice a week... or every day. ¥ Habitual use: With continued recreational use, vulnerable individuals, especially those with a mental health problem, increase the amount and frequency of use. ¥ Drug abuse: When alcohol and other drug abuse becomes so frequent and important that it interferes with school, family life, and personal development, the person has reached this level. ¥ Drug dependence: If the situation grows even more serious, the individual’s body craves the drug, and avoidance of the
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pain of withdrawal becomes an additional motivator for drug use. Now the central focus of the person’s life is the acquisition and use of drugs. Many people who are familiar with the concept of the Con- tinuum of abuse do not know that the length of time it takes to go from one stage to the next varies with the age of first use. ¥ Someone who begins experimenting in their twenties may not become dependent until their fifties, if ever. ¥ Someone who begins recreational use at 16 may become dependent by 20. We should do ¥ A child, beginning to use drugs at 10 or 11, may become everything we can dependent within just two years. to delay children’s This information has been substantiated in study after study, first use of any looking at a wide variety of drugs, from nicotine and alcohol to intoxicating cocaine. That is why, from a public health and family perspective, substance, we should do everything we can to delay children’s first use of any including tobacco. intoxicating substance, including tobacco. (Figure 2, page 58) Do mental health and substance abuse problems in childhood and adolescence affect the maturation of the individual? We often see that the early development of anxiety, depres- sion, thinking problems, behavior problems, when compounded by early use of drugs and alcohol, interfere with the development of a mature, stable, functional personality and sense of self. I have identified several common personality immaturities that may result from childhood and adolescent mental health/alcohol and other drug abuse problems. Each is normal in a young child: ¥ Low frustration tolerance: Trouble working hard, and sticking to it, when gratification is not immediate. ¥ Lying to avoid punishment. ¥ Hostile dependency: A dependent person, unable to do things on their own, may have trouble developing a confi- dent, independent self. Continued dependency may be expressed as hostility toward the very people whose help they need, such as parents. Hostile dependency, although often directed against others, may really be directed against the self. In extreme cases it can lead to a suicide attempt.
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¥ Limit testing: All children test limits; that is a normal part of childhood. It is a troublesome form of immaturity when it persists into later adolescence and adulthood. ¥ Alexithymia. Children and older people with this condition are unable to verbalize their feelings effectively. As a consequence, they may act out their feelings, just as young children do. Rather than verbalizing anger, they may strike out physically. Rather than talking about their fears, they may avoid, run away, and hide. Instead of talking about feelings of hopelessness and depression, they may act out by attempting suicide. People with alexithymia can’t soothe Adolescents who themselves or ask for help. Learning to talk about feelings have no clear is a key step in recovery. sense of past and ¥ Present tense only: Very young children only live in the future can repeat present. They do not have a sense of future, cannot antici- pate consequences of their own behavior, and have not the same mistake become able to learn from past experiences. Adolescents over and over who have no clear sense of past and future can repeat the again. same mistake over and over again. ¥ Rejection sensitivity: Young children, and many people with co-occurring disorders are so eager to please, have friends, and be accepted, that they may agree to do things that they don’t really want to do. They may seek approval by trying too hard to please. If their efforts fail, they may feel terribly rejected, withdraw, and not try again. They can be very thin-skinned. ¥ Dualistic: Young children, when they first learn the differ- ence between right and wrong, put every action into one or the other category: Something is either Right or Wrong. As a consequence, moderation is a problem. A slip - having a glass of wine at a birthday party - may be so wrong that they might as well go ahead and get drunk. Dualism can turn a slip into a relapse. Dualistic judgment toward a counselor or a parent can cause condemnation; that person is now useless and hopeless.
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A model for personality development: The Maze Everyone’s life consists of an unending sequence of conflicts and problems (Figure 3, page 59). The individual whose develop- ment goes along a positive track learns, with the help of parents, to climb the steps and enter the maze: It represents the struggle of learning to resolve conflicts and problems. When the person finally makes it out through the maze, no matter how long it takes, there is an increase in maturity and competence. Every time you make it through you have increased your self-esteem and effective- ness. One reason that we cannot treat these A troubled youth may drop into the drug intoxication evasion loop, and out of the maze. While in the drug-evasion loop there are problems many problems and conflicts, nothing gets resolved. Remember, it separately is that is the resolution of problems and conflicts that leads to maturity. they are interactive within the The interactivity between mental health individual. problems and substance abuse problems: One reason that we cannot treat these problems separately is that they are interactive within the individual. The brain of a person with a mental health problem may be exquisitely sensitive to being disorganized by even tiny amounts of alcohol, marijuana, cocaine, or amphetamines. For all practical purposes, such individuals are ‘allergic’ to drugs, in the sense that a little goes a very long way. What happens to the social life of the person with co-occurring disorders? As can be seen from the sociogram (Figure 4, page 60), a person’s relationships with others vary in type and intensity: ¥ At the fifth level of our social network we have acquaintan- ces. They sell us a cup of coffee in the morning, or cash our paycheck at the bank. ¥ At the fourth level we have casual friends. We do not keep in touch with them on a regular basis, but are glad to see them when we cross paths. ¥ At level three are our good friends. We stay in touch, and they care about us. ¥ The second circle contains those few friends who are our most trusted intimates. These are the individuals who we
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know will never intentionally hurt us, and can be counted on to go out of their way to help us if we are in trouble. You are rich if there are three people, other than family members, in your second circle. ¥ The inner circle shows the private zone. It is shared with no one. The shaded portion refers to the part that is repressed and is not even accessible to the person, while the unshaded portion refers to the part that is suppressed, remembered, but secret; not shared with anyone else. When someone with co-occurring disorders first comes into treatment, often there is no one in their second circle and few if “Addicted or drug any in their third circle. Their social network may be nearly empty abusing individuals until we get to the fourth level; casual friends. with co-existing The person with mental health and alcohol and other drug mental disorders abuse problems may experience their drug of choice as their best should have both friend; it seems to fill the emptiness in their heart. Beginning drug disorders treated in abuse treatment, which requires or involves abstinence, may lead to feeling much worse. The ‘best friend’ is gone, and the emptiness an integrated way.” within is devastating. For this reason, substance abuse programs must address loneliness, sadness, the sense of loss, and the depres- sion that often accompany early recovery. Otherwise, the person may be motivated to leave treatment and rush back to drug or alcohol use, because they cannot bear their depression and loneli- ness. Who says that treatment for co-occurring disorders must be integrated? In 1999 the National Institute of Drug Abuse produced a slender but powerful booklet: Principles of Drug Addiction Treat- ment. We do not have space here to list the 13 principles enumer- ated by NIDA, arising from their vast database of research studies on substance abuse treatment. But item 8 states: “Addicted or drug abusing individuals with co-existing mental disorders should have both disorders treated in an integrated way.” Item 13 of the booklet is equally important: “Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment.”
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How often is treatment for co-occurring disorders integrated in actual practice? Unfortunately, the answer is: rarely. Many young people find themselves trapped in a situation in which there is not even integra- tion between mental health inpatient and outpatient treatment. And, after residential substance abuse treatment they may find that their outpatient program is not integrated with the residential program. Worst of all, it is most difficult to find fully integrated treatment, in which one team deals with all the client’s treatment and support Five distinct needs, and includes the family in the process. problems have There are three distinct approaches to treating individuals been noted with with co-occurring disorders. parallel/ ¥ Sequential treatment: This is the traditional approach, in collaborative which the person is first treated in a mental health or substance abuse agency, and then, presumably after effec- treatment tive treatment has been accomplished, the individual is approaches referred to the other kind of agency. In fact, this doesn’t work. This failed form of treatment, for reasons of tradi- tion, history, and separate funding streams, continues to be common throughout the country. ¥ Parallel treatment treats the person with co-occurring disorders at the same time in two different agencies. If the two agencies attempt to communicate with each other, the treatment is then referred to as collaborative. ¥ Integrated treatment provides treatment for the mental health and alcohol and other drug abuse problems in one place. The treatment team consists of individuals from varied clinical backgrounds who have been cross-trained to work together. The team develops a long-term treatment plan, in which the goals and different modalities of treat- ment are sequenced: Everything cannot be done at once. There is considerable controversy among funding, licensing, and treating agencies as to whether or not integrated treatment is really necessary for all but a few people. Agencies prefer parallel or collaborative treatment, because it requires less change. The Blamed and Ashamed report makes it clear that adolescents and their families prefer/demand integrated treatment. Thus, we have a conflict between the treating agencies and those they serve.
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Five distinct problems have been noted with parallel/collabo- rative treatment approaches: ¥ The young person and their family is caught between the different treatment philosophies and values of the mental health and substance abuse agency. ¥ It is difficult if not impossible to coordinate two different treatment and recovery plans. ¥ Treatment is more expensive because of duplicated ser- vices. ¥ Parallel and collaborative treatment fragments the person, The best approach and is not holistic. to solving the ¥ Dealing with the interactivity of the disorders is virtually impossible when different treatment teams are working problem of with one individual, even if the treaters make a sincere locking up young effort to keep in touch with each other. people with co- occurring disorders The tragedy of the current approach: in jails and prisons Shifting young people with co-occurring would be disorders into the criminal justice system. prevention, early Everyone has to be someplace. When, in today’s society, the intervention, and public mental hospitals have virtually been shut down, when there integrated is no where else for the person with co-occurring disorders to be, treatment. the final ‘three hots and a cot’ are provided by our society in jail. The best approach to solving the problem of locking up young people with co-occurring disorders in jails and prisons would be Prevention, early intervention, and integrated treatment: ¥ Offering early treatment for children with mental health problems. ¥ Offering integrated treatment to adolescents with co- occurring problems. But we are nowhere near that point today. As a stopgap measure, we should be working now to divert young people, before they get to jail. We have three chances. Diversion can be done at: ¥ Arrest ¥ Arraignment ¥ Sentencing
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If diversion-to-treatment has not succeeded in time, and the client ends up in jail, we must insist on ¥ Treatment during incarceration. But treatment during incarceration is not enough. Relapse rates are very high if, after treatment in jail has taken place, the individual is released to the street without adequate supervision, support, housing, educational opportunities, and vocational oppor- tunities. What must be done? A goal for all of us to share: Our wonderful community, the United States of America, must re-invent itself and its systems of services for every citizen, from the infant to the elderly. We must offer support and treatment to every individual, affording that person the opportunity to suc- ceed to the full extent of her or his efforts and abilities. We must provide preventive, supportive, educational treatment and rehabili- tative services. We must also support overburdened families, so that the wonders of our technology, our wealth, and our concern for each other benefit all of us.
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Figure 1 TRANS-INSTITUTIONALIZATION in the USA
1955 2001 550,000 60,000
State Psychiatric Hospital Beds
1972 2001 200,000 2,000,000+
Prison & Jail SQUEEZING THE BALLOON Where Is Treatment?
The Information Exchange, Inc. G-24
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Figure 2
Continuum of Abuse
experimentation
recreational use
+ Dose habitual use + Frequency
abuse *
dependence
The Information Exchange, Inc. ©1994 G-64
58 Federation of Families for Children’s Mental Health
Figure 3
MODEL FOR PERSONALITY DEVELOPMENT
CONFLICT OR PROBLEM MORE MATURE COMPETENT PERSONALITY THE FORCE OF GRAVITY “It is the RESOLUTION of problems and conflicts that leads to maturation drug intoxication of personality.”
EVASION LOOP
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Figure 4
A Sociogram: Intensities of Relationships
1 2 3 4 5 6
6. Strangers 5. Acquaintances 4. Casual friends 3. Good friends 2. Circle of intimacy: trusted intimates 1. Private self
The Information Exchange, Inc. ©1994 G-120
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Phone: 703-684-7710 Fax: 703-836-1040 Email: [email protected]
Website: www.ffcmh.org
Short Contents | Full Contents Other books @ NCBI
AHCPR Archived reports, Put Prevention Into Practice and Minnesota Health Technology Advisory Committee SAMHSA/CSAT Treatment Improvement Protocols 50. TIP 50. Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment: Treatment Improvement Protocol (TIP) Series 50
Part 1, Chapter 1, Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment: Information You Need To Know
Overview of Part 1
Chapter 1: Information You Need To Know
Introduction (pp. 3–4)
Getting Ready To Address Suicidality provides basic principles about your role in working with clients who are suicidal (pp. 4–9)
Background Information concerning substance abuse and suicidality (pp. 9–14)
GATE, a four-step process (Gather information, Access supervision, Take responsible action, Extend the action) for addressing suicidal thoughts and behaviors in substance abuse treatment (pp. 14–25)
Competencies for working with clients with suicidal thoughts and behaviors (pp. 25–31)
Introduction
Did You Know?
• Suicide is a leading cause of death among people who abuse alcohol and drugs (Wilcox, Conner, & Caine, 2004). • Compared to the general population, individuals treated for alcohol abuse or dependence are at about 10 times greater risk to eventually die by suicide compared with the general population, and people who inject drugs are at about 14 times greater risk for eventual suicide (Wilcox et al., 2004). • Individuals with substance use disorders are also at elevated risk for suicidal ideation and suicide attempts (Kessler, Borges, & Walters, 1999). • People with substance use disorders who are in treatment are at especially high risk of suicidal behavior for many reasons, including: They enter treatment at a point when their substance abuse is out of control, increasing a variety of risk factors for suicide (Ross, Teesson, Darke, Lynskey, Ali, Ritter, et al., 2005).
They enter treatment when a number of co-occurring life crises may be occurring (e.g., marital, legal, job) (Ross et al., 2005).
They enter treatment at peaks in depressive symptoms (Ross et al., 2005).
Mental health problems (e.g., depression, posttraumatic stress disorder [PTSD], anxiety disorders, some personality disorders) associated with suicidality often co-occur among people who have been treated for substance use disorders.
Crises that are known to increase suicide risk sometimes occur during treatment (e.g., relapse and treatment transitions).
Who Should Read This Chapter?
Suicide risk is a problem that every frontline substance abuse counselor must be able to address. This chapter is written for you if you are a frontline counselor in a substance abuse treatment program and/or if you work with individuals who have both a substance abuse and mental health disorder and/or if you provide supervision or consultation to frontline counselors. While the information in this TIP is specific to clients with a substance use disorder diagnosis who exhibit suicidal thoughts and behaviors, the content can be generalized for counselors addressing all people with suicidal ideation or behavior.
Why a TIP on Suicide for Substance Abuse Counselors and Supervisors?
Research consistently shows a high prevalence of suicidal thoughts and suicide attempts among persons with substance abuse problems who are in treatment (Ilgen, Harris, Moos, & Tiet, 2007) and a significant prevalence of death-by-suicide among those who have at one time been in substance abuse treatment when compared with those who do not have a diagnosis of substance use disorder (Wilcox et al., 2004). As a result, substance abuse treatment providers must be prepared to gather information routinely from, refer, and participate in the treatment of clients at risk for suicidal behavior. Suicidal thoughts and behaviors are also a significant indicator of other co-occurring disorders (such as major depression, bipolar disorder, PTSD, schizophrenia, and some personality disorders) that will need to be explored, diagnosed, and addressed to improve outcomes of substance abuse treatment.
You Can Do This!
Your clinical training in substance abuse counseling puts you in a solid position to perform the tasks outlined in this TIP. As you will learn, the first step in addressing suicidality is to “gather information,” or to perform exactly the same kind of information-gathering tasks you do every day. For example, if a client were having trouble with craving, you would first want to know more about it. Think about the types of questions you would ask. They might include “Tell me about your craving. How often do you have it? How strong is it? What makes it worse?” These questions are precisely the type you would ask about suicidal thoughts: “Tell me about your suicidal thoughts. How often do you have them? How strong are they? What makes them worse?” In other words, even though some content areas may be less familiar to you, your training and experience in substance abuse counseling provides you with the foundation you need to address suicidal behaviors with your clients.
Consensus Panel Recommendations
You are a trained substance abuse treatment professional or an integrated treatment specialist who works with persons with co-occurring substance use and mental disorders, but most likely, your background does not include detailed training in addressing your clients' suicidal thoughts and behaviors. This TIP is designed to fill that gap and increase your understanding of relevant mental disorders.
In particular, the consensus panel recommends the following:
• Clients in substance abuse treatment should be screened for suicidal thoughts and behaviors routinely at intake and at specific points in the course of treatment (see pp. 15– 18). Screening for clients with high risk factors should occur regularly throughout treatment. • Counselors should be prepared to develop and implement a treatment plan to address suicidality and coordinate the plan with other providers. • If a referral is made, counselors should check that referral appointments are kept and continue to monitor clients after crises have passed, through ongoing coordination with mental health providers and other practitioners, family members, and community resources, as appropriate. • Counselors should acquire basic knowledge about the role of warning signs, risk factors, and protective factors as they relate to suicide risk. • Counselors should be empathic and nonjudgmental with people who experience suicidal thoughts and behaviors. • Counselors should understand the impact of their own attitudes and experiences with suicidality on their counseling work with clients. • Substance abuse counselors should understand the ethical and legal principles and potential areas of conflict that exist in working with clients who have suicidal thoughts and behaviors.
Getting Ready To Address Suicidality
It is important for you to be comfortable and competent when asking your clients questions about suicidal ideation and behavior. It may be challenging to balance your own comfort level with your need to obtain accurate and clear information in order to best help the client. Suggestions made by the consensus panel to ease the process follow.
Be Direct
Talking with clients about their thoughts of suicide and death is uncomfortable. However, you must overcome this discomfort, as it may lead a counselor to ask a guaranteed conversation- ending question, such as “You don't have thoughts about killing yourself, do you?” Discomfort can also lead counselors to avoid asking directly about suicidality, which may convey uneasiness to the patient, imply that the topic is taboo, or result in confusion or lack of clarity. Instead, counselors can learn to ask, “Are you thinking about killing yourself?” Of course, death and suicide are just two examples of taboo topics for many people. The same observations can be made in addressing issues of sexuality and sexual orientation, money and finances, and relationship fantasies and behaviors. The difference is that asking about suicidal thoughts can actually save a life, as it allows a client to feel safe and understood enough to raise concerns and beliefs with you, the counselor. It is important to note that there is no empirical evidence to suggest that talking to a person about suicide will make them suicidal.
Increase Your Knowledge About Suicidality
One of the best ways to become more comfortable with any topic is to learn more about it. Suicide is no exception. Knowing some of the circumstances in which people become suicidal, how suicidality manifests, what warning signs might indicate possible suicidal behavior, what questions to ask to identify suicidality, and, perhaps most important, what the effective interventions are, can increase your competence, and as a result, your comfort in addressing this issue with clients.
Do What You Already Do Well
Good counselors are empathic, warm, and supportive, and trust their experience and intuition. However, on encountering suicidal thoughts and behaviors, counselors sometimes unwittingly employ countertherapeutic practices, such as aggressively questioning the client about his or her thoughts and feelings, demanding assurance of safety when a client cannot provide such assurance, becoming autocratic and failing to collaborate with the client, and/or avoiding sensitive topics so as not to engender sadness. These countertherapeutic practices can be the consequence of anxiety and unfamiliarity with the issue, along with fear of litigation if the client does make a suicidal act. Given these fears and issues, it is easy to see how otherwise highly skilled counselors can fall into the trap of becoming “the suicide interrogator.” Your option? Deliberately choose another path. Stay grounded and make use of your therapeutic skills when dealing with suicidal behaviors, as that is the most important time to fall back on (and not veer away from) your therapeutic abilities, experience, and training. Collect objective data, just as you would collect objective data about a client's substance use, but don't lose your empathy or concern in the process.
Practice, Practice, Practice Remember the first substance abuse client you interviewed? Do you remember your internal reaction to that interview? Now, you're a lot more comfortable talking with clients about their drug history, their current symptoms, and their plans for recovery. Nothing reduces anxiety more than practice. The same holds true about talking with your clients about suicidal thoughts and behaviors. If you need to reduce your initial discomfort on the topic, practice with another counselor or your clinical supervisor. Get feedback about how you are coming across. Start asking every one of your clients about suicidality. The more experience you have, the more comfortable you will become. You may also consider attending a workshop or getting additional training specific to the topic of suicidality.
Get Good Clinical Supervision and Consultation
Getting clinical supervision is a great way to learn and practice new skills. Contract with your clinical supervisor to integrate skill development about suicidality into your Individual Development Plan for clinical supervision. Get feedback from your supervisor about your attitudes toward clients who are suicidal and your skills in interviewing clients. Working with a treatment team almost always increases the quality of information gathering, decisionmaking, and taking action.
Work Collaboratively With Suicidal Clients
Just as you involve clients in developing a treatment plan for recovery, so too should you involve them in suicide prevention planning. You will be most effective if you ask them about suicide with concern (but not alarm), just as you would with any other area of concern. Explain the reason(s) for your concern and any action(s) that you take, elicit their input as to what may help them be safe, and (with your supervisor), consider their input as much as possible in determining the actions that you take. Most often, the client will be willing to work collaboratively with you, particularly if you take the time to listen and to explain your actions. Informed consent should be part of collaboration with your client. Inform the client about the steps that might be taken to reduce suicide risk, steps for referral if needed, and confidentiality issues that might arise. Of course, there may be times when you and your supervisor will need to take an action over a client's objections (e.g., arrange for an immediate evaluation at a hospital), but even in these relatively rare circumstances, you can still seek your client's input, and make efforts to work collaboratively.
Realize Limitations of Confidentiality and Be Open With Your Clients About Such Limits
You should understand existing ethical and legal principles and potential areas of conflict (including the possible limits of confidentiality) because safety and protection of the client trumps confidentiality in certain crisis situations. When you first meet clients and as appropriate during the course of treatment, explain that, in the event of suicide risk, you may take steps to promote the client's safety (including the potential for breaking confidentiality, arranging for an emergency evaluation over the client's objections, and involving emergency personnel). Clients should not be given the false impression that everything is confidential or that all types of treatment are always voluntary.
Ten Points To Keep You on Track
Point 1: Almost all of your clients who are suicidal are ambivalent about living or not living.
Explanation: Wishing both to die and to live is typical of most individuals who are suicidal, even those who are seriously suicidal (see, e.g., Brown, Steer, Henniques, & Beck, 2005). For example, hesitation wounds are commonly seen on individuals who have died by suicide (e.g., hesitation scratches before a lethal cut, bruises on a temple indicating that a gun had been placed there several times before pulling the trigger). It has even been argued that the struggle between wanting to die and wanting to live is at the core of a suicidal crisis (Shneidman, 1985). Take suicidal thinking seriously and think about ways to reinforce realistic hope. Do everything you can to support the side of the client that wants to live, but do not trivialize or ignore signs of wanting to die.
Point 2: Suicidal crises can be overcome.
Explanation: Fortunately, acute suicidality is a transient state (Shneidman, 1985). Even individuals at high, long-term risk spend more time being nonsuicidal than being suicidal. Moreover, the majority of individuals who have made serious suicide attempts are relieved that they did not die after receiving acute medical and/or psychiatric care. The challenge is to help clients survive the acute, suicidal crisis period until such time as they want to live again. Moreover, treatments for suicidal clients, many with substance use disorders, including cognitive-behavioral treatment (CBT; Brown, et al., 2005) and dialectical behavioral therapy (DBT; Linehan, Schmidt, Dimeff, Craft, Kanter, & Comtois, 1999) have shown positive results in reducing repeated suicide attempts. Interventions that successfully address major risk factors such as severe substance use, depression, and marital strife also have the potential to reduce suicidal behavior. Although data are limited, other specific interventions have been shown to prevent suicide deaths (Mann, Apter, Bertolote, Beautrais, Currier, Haas, et al., 2005).
Point 3: Although suicide cannot be predicted with certainty, suicide risk assessment is a valuable clinical tool.
Explanation: Substance abuse counselors work with many high-risk clients. Determining with accuracy who will die by suicide using tests or clinical judgment is extremely difficult, if not impossible (Pokorny, 1983). Although precisely who may die by suicide cannot be known, suicide risk assessment is a valuable clinical tool because it can ensure that those requiring more services get the help that they need. In other words, it is not necessary to have a crystal ball if the assessment information shows that a client fits the profile of an individual at significant risk. In such instances, appropriate actions should be taken.
Point 4: Suicide prevention actions should extend beyond the immediate crisis.
Explanation: Clients in substance abuse treatment who have long-term risk factors for suicide (e.g., depression, child sexual abuse history, marital problems, repeated substance abuse relapse) require treatment of these issues, whether or not they show any indication of current risk for suicide. Individuals with a history of serious suicidal thoughts or suicide attempts, but with no recent suicidal thoughts or behaviors, may be monitored to identify any recurrence of suicidality.
Point 5: Suicide contracts are not recommended and are never sufficient.
Explanation: Contracts for safety are often used as a stand-alone intervention, but they are never sufficient to ensure the client's safety. Contracts for safety are widely used to reduce legal liability, but the consensus panel is aware of no significant evidence that such contracts offer any protection from litigation. They may, in fact, make litigation more likely if suicide prevention efforts appear to be hinged on the contract or if they provide the counselor with a false sense of security. It is misguided to predicate decisions on whether the client “can” or “can't” or “will” or “won't” contract for safety. Use this TIP and choose from among the many other strategies to promote safety. Use contracts sparingly, if at all.
Point 6: Some clients will be at risk of suicide, even after getting clean and sober.
Explanation: Abstinence should be a primary goal of any client with a substance use disorder and suicidal thoughts and/or behaviors (Weiss & Hufford, 1999). Indeed, risk will diminish for most clients when they achieve abstinence. Nonetheless, some individuals remain at risk even after achieving abstinence (Conner, Duberstein, Conwell, Herrmann, Jr., Cox, Barrington, et al., 2000). For example, clients with an independent depression (one that does not resolve with abstinence or is not substance induced), those who have unresolved difficulties that promote suicidal thoughts (e.g., a deteriorating partner relationship, ongoing domestic violence, victimization, impending legal sentencing), those who have a marked personality disturbance (e.g., borderline personality disorder), those with trauma histories (e.g., sexual abuse history), and/or individuals with a major psychiatric illness may continue to show signs of risk.
Point 7: Suicide attempts always must be taken seriously.
Explanation: There is often a mismatch between the intent of the suicidal act and the lethality of the method chosen (Brown, Henriques, Sosdjan, & Beck, 2004). Therefore, clients who genuinely want to die (and expect to die) may nonetheless survive because their method was not foolproof and/or because they were interrupted or rescued. Indeed, a prior suicide attempt is a highly potent risk factor for eventually dying by suicide (Kapur, Cooper, King-Hele, Webb, Lawlor, Rodway, et al., 2006). Any suicide attempt must be taken seriously, including those that involve little risk of death, and any suicidal thoughts must be carefully considered in relation to the client's history and current presentation.
Point 8: Suicidal individuals generally show warning signs.
Explanation: Fortunately, suicidal individuals usually give warning signs. Such warning signs come in many forms (e.g., expressions of hopelessness, suicidal communication) and are often repeated. The difficulty is in recognizing them for what they are. See the section on warning signs (pp. 11–12). Point 9: It is best to ask clients about suicide, and ask directly.
Explanation: Available data do not support the idea that asking about suicide will put this idea in an individual's mind (Gould et al., 2005). A counselor's power is limited and does not include the ability to place the idea of suicide in a client's head or to magically remove such an idea. You may never know about a client's suicidality unless you ask. You are encouraged to ask directly about suicide (see the Gathering Information section, pp. 14–18).
Point 10: The outcome does not tell the whole story.
Explanation: Suicide deaths have a much lower base rate than many other deleterious outcomes that counselors encounter (e.g., relapse, treatment dropout). A client at significant risk may survive despite never being screened, assessed, or offered intervention for suicide simply because of the relatively low base rate of suicide. Therefore, a good outcome (survival) does not, by itself, equate to proper treatment of suicidal thoughts and behaviors. On the other hand, a clinical team may do a solid job of screening, assessing, and intervening with a high-risk client. Despite these efforts, a high-risk client may eventually die by suicide. Therefore, a tragic outcome (death) does not, by itself, equate to improper treatment of suicidality.
Maintain Positive Attitudes
Attitudes toward suicide vary widely. Some people hold religious or spiritual views that have strong sanctions against suicidal behavior. Others see suicide as a viable option for ending unmanageable pain or suffering or as an acceptable option in other circumstances. Some hold the view that it is all right to think about suicide but not to act on those thoughts. Our attitudes are influenced by our culture, childhood experiences, and especially, by our professional and personal experiences with suicidal thinking and behavior.
Before working with clients who are suicidal, counselors are advised to conduct their own suicidal attitude inventory. The goal of the inventory is not to change your views but rather to help you understand what your views are and how those views can positively or negatively affect your interactions with clients. Some of the items you might consider in an inventory include:
• What is my personal and family history with suicidal thoughts and behaviors? • What personal experiences do I have with suicide or suicide attempts, and how do they affect my work with suicidal clients? • What is my emotional reaction to clients who are suicidal? • How do I feel when talking to clients about their suicidal thoughts and behaviors? • What did I learn about suicide in my formative years? • How does what I learned then affect how I relate today to people who are suicidal, and how do I feel about clients who are suicidal? • What beliefs and attitudes do I hold today that might limit me in working with people who are suicidal?
These views may also need to be further clarified by consultation with your clinical supervisor or with your peers.
As noted, your attitudes about suicide are strongly influenced by your life experiences with suicide and similar events. Needless to say, your responses to suicide and to people who are suicidal are highly susceptible to attitudinal influence, and these attitudes play a critical role in work with people who are suicidal. An empathic attitude can assist you in engaging and understanding people in a suicidal crisis. A negative attitude can cause you to miss opportunities to offer hope and help or to overreact to people in a suicidal crisis. Below are some attitudinal issues to consider in working with people who are suicidal.
Positive Attitude and Behavior 1: People in substance abuse treatment settings often need additional services to ensure their safety.
Explanation: Merely receiving substance abuse treatment may lessen the risk of suicide. A good working relationship with a substance abuse treatment professional is, in fact, a powerful protective factor against suicide. However, individuals who are acutely suicidal may need more services (e.g., mental health evaluation, short-term emergency hospitalization) to ensure their safety. In addition, certain clients, including those who are poorly connected to other clients and to treatment providers, clients who are making little progress in treatment, and clients at major transition points in care (e.g., moving from inpatient to outpatient care or being administratively discharged) may be at increased risk. An empathic attitude can help you recognize these challenging circumstances and proactively assess and intervene.
Positive Attitude and Behavior 2: All clients should be screened for suicidal thoughts and behaviors as a matter of routine.
Explanation: “Don't ask, don't tell” is not an effective agency suicide policy. Take the following actions to prevent clients from being exposed to life-threatening situations and to prevent exposing yourself and your agency to legal risk of malpractice:
• Screen for suicide and ask followup questions. • Follow up with a client when risk has been previously documented. • Take appropriate action when risk is detected. • Document suicide-related screening and interventions. • Communicate suicide risk to another professional or agency.
Positive Attitude and Behavior 3: All expressions of suicidality indicate significant distress and heightened vulnerability that require further questioning and action.
Explanation: Even in rare circumstances where clients appear to be purposefully using reports of suicidal thoughts or plans to manipulate their treatment regimen, expressions of suicidality must be taken seriously. Thus, when clients appear to “use” suicidality, it should be recognized as a very limited approach to coping. Indeed, there is often more than one reason for an act of suicide (e.g., one may simultaneously want to die and elicit attention). You must address clients “where they are” and not impose your own agenda. If suicidal thoughts or behaviors occur, addressing suicidality must be a priority. Even if a client really does not want to die, if his or her reports of suicidal ideation are not taken seriously, the client may act on them to “save face.”
Positive Attitude and Behavior 4: Warning signs for suicide can be indirect; you need to develop a heightened sensitivity to these cues.
Explanation: Fortunately, clients often give warning signs before making a suicide attempt, and often these warning signs include expressions of suicidal thoughts or plans. More indirect signals include expressions of hopelessness, feeling trapped, or having no purpose in life, and observable signs such as withdrawal from others, mood changes, or reckless behavior. Such signs require followup. Beyond screening for current risk, counselors should be aware of clients' histories of suicidal thoughts and behaviors and should be on watch for indications of recurrence of suicidal thoughts or behavior and/or the emergence of warning signs, particularly when acute stressful life events (such as relapse, relationship breakup, or psychological trauma) occur.
Positive Attitude and Behavior 5: Talking about a client's past suicidal behavior can provide information about triggers for suicidal behavior.
Explanation: Discussing past suicidal thoughts or behaviors is an important part of gathering information for suicide screening. The circumstances of past suicidal ideation and attempts can provide important insights into the scenario(s) that may promote future risk. Some clients may also wish to discuss past suicidal behavior in more depth for a variety of reasons (e.g., they never talked about it before, it represented their “hitting bottom,” the spiritual implications) that should be honored.
Positive Attitude and Behavior 6: You should give clients who are at risk of suicide the telephone number of a suicide hotline; it does no harm and could actually save a life.
Explanation: It is true that some clients will never use a hotline number. However, others will use a hotline resource. It is best to give all clients who may be at risk of suicide a hotline number because you cannot predict which clients will take advantage of it. In addition, always give at- risk clients other options, including how to contact emergency resources after hours, mental health emergency services in the community, and instructions to go to the nearest hospital emergency room. The national suicide hotline, 1-800-273-TALK, and 911 can be accessed from anywhere in the United States. How to use a safety card with emergency contact information is discussed later in this chapter.
Summary
Positive, empathic attitudes toward clients experiencing suicidal thoughts and behaviors do not, by themselves, mean that clients will initiate or receive appropriate services. However, they do form the platform on which proactive, effective services can be built. It is important to remember that the thoughts, emotions, and behaviors accompanying negative attitudes toward suicidality can be a major impediment to quality care. Understanding that clients with suicidal thoughts and behaviors can benefit from intervention and treatment, that people who make verbal expressions of suicidality have needs that aren't being addressed, and that there is a relationship between a client's suicidality and his or her substance abuse can make a huge difference in a client's overcoming a suicidal crisis and staying in recovery.
Background Information
The Link Between Substance Abuse and Suicidality
There is a strong link between substance use disorders and risk for suicidal behavior
• Suicide is a leading cause of death among people who abuse alcohol and drugs (Wilcox et al., 2004). • Compared with the general population, individuals treated for alcohol abuse or dependence are at about 10 times greater risk for suicide; people who inject drugs are at about 14 times greater risk for suicide (Wilcox, et al., 2004). • Individuals with substance use disorders are also at increased risk for suicidal ideation and suicide attempts (Kessler et al., 1999). • Depression is a common co-occurring diagnosis among people who abuse substances that confers risk for suicidal behavior (Conner et al., 2007; Murphy, Wetzel, Robins, & McEvoy, 1992; Roy, 2001, 2002). Other mental disorders are also implicated. • People with substance use disorders often seek treatment at times when their substance use difficulties are at their peak—a vulnerable period that may be accompanied by suicidal thoughts and behaviors.
There is a strong link between acute substance use and risk for suicidal behavior
• Alcohol's acute effects include disinhibition, intense focus on the current situation with little appreciation for consequences, and promoting depressed mood, all of which may increase risk for suicidal behavior (Hufford, 2001). Other central nervous system depressants may act similarly. • Acute alcohol intoxication is present in about 30–40 percent of suicide attempts and suicides (Cherpitel, Borges, & Wilcox, 2004). • Intense, short-lived depression is prevalent among treatment-seeking people who abuse cocaine, methamphetamines, and alcohol, among other groups (Brown et al., 1995; Cornelius, Salloum, Day, Thase, & Mann, 1996; Husband et al., 1996). Even transient depression is a potent risk factor for suicidal behavior among people with substance use disorders.
Overdose suicides often involve multiple drugs like alcohol, benzodiazepines, opioids, and other psychiatric medications (Darke & Ross, 2002).
The risk for suicidal behavior can increase at any point in treatment
• Suicide risk may increase at transition points in care (inpatient to outpatient, intensive treatment to continuing care, discharge), especially when a planned transition breaks down. Anticipating risk at such transition points should be regarded as an issue in treatment planning. • Suicide risk may increase when a client is terminated administratively (e.g., because of poor attendance, chronic substance use) or is refused care. It is unethical to discharge a client and/or refuse care to someone who is suicidal without making appropriate alternative arrangements for treatment to address suicide risk. • Suicide risk may increase in clients with a history of suicidal thoughts or attempts who relapse. Treatment plans for such clients should provide for this possibility. • Suicide risk may increase in clients with a history of suicidal thoughts or attempts who imply that the worst might happen if they relapse (e.g., “I can't go through this again,” “if I relapse, that's it”)—especially for those who make a direct threat (e.g., “This is my last chance; if I relapse, I'm going to kill myself”). Treatment plans for such clients should provide for this possibility. • Suicide risk may increase in clients with a history of suicidal thoughts or attempts when they are experiencing acute stressful life events. Treatment plans for such clients should provide for this possibility, for example, by adding more intensive treatment, closer observation, or additional services to manage the life crises.
Types of Suicidal Thoughts and Behaviors
Precise definitions of four types of suicide-related concepts will help clarify important nuances in the subject matter of this TIP.
Suicidal thoughts
Suicidal ideation: Suicidal ideation is much more common than suicidal behavior (Conner et al., 2007; Kessler et al., 1999). Suicidal ideation lies on a continuum of severity from fleeting and vague thoughts of death to those that are persistent and highly specific. Serious suicidal ideation is frequent, intense, and perceived as uncontrollable.
Suicide plans: Suicide plans are important because they signal more serious risk to carry out suicidal behavior than suicidal ideation that does not involve planning (Conner et al., 2007; Kessler et al., 1999). Suicide planning lies on a continuum from vague and unrealistic plans to those that are highly specific and feasible. Serious suicide planning may also involve rehearsal or preparation for a suicide attempt.
Suicidal behaviors
Suicide attempt: A suicide attempt is a deliberate act of self-harm that does not result in death and that has at least some intent to die (Silverman, Berman, Sanddal, O'Carroll, & Joiner, 2007). Attempts have two major elements: (a) the subjective level of intent to die (from the client's subjective perspective, how intensely did he or she want to die and to what extent did he or she expect to die?); and (b) the objective lethality of the act (from a medical perspective, how likely was it that the behavior would have led to death?) (Beck, Schuyler, & Herman, 1974; Harriss, Hawton, & Zahl, 2005). Although all suicide attempts are serious, those with high intent (client clearly wanted to die and expected to die) and high lethality (behavior could have easily led to death) are the most serious.
Suicide: Suicide is an acute, deliberate act of self-harm with at least some intention to die resulting in death (Silverman et al., 2007). Other suicide-related concepts
Suicidal intention: Suicidal intention (also called “intent”) signals high, acute risk for suicidal behavior. Having suicidal intent is always serious because it signals that the client “intends” to make a suicide attempt. Some indicators of “high intent” include drafting a suicide note or taking precautions against discovery at the time of an attempt.
Suicide preparation: Behaviors that suggest preparation signal high, acute risk for suicidal behavior. Preparation may come in many forms, such as writing a suicide note or diary entry, giving away possessions, writing a will, acquiring a method of suicide (e.g., hoarding pills, buying a weapon), making a method more available (e.g., moving a gun from the attic to beside the bed), visiting a site where suicide may be carried out (e.g., driving to a bridge), rehearsing suicide (e.g., loading and unloading a weapon), and saying goodbye to loved ones directly or symbolically.
Other harmful behaviors
Non-suicidal self-injury (NSSI): NSSI is also commonly referred to in the literature as “deliberate self-harm” and “suicidal gesture.” NSSI (for example, self-mutilation or self-injury by cutting for the purpose of self-soothing with no wish to die and no expectation of dying) is distinguished from a suicide attempt or suicide because NSSI does not include suicidal intent. This TIP does not focus on NSSI. Suicidal behaviors and NSSI can co-exist in the same person and both can lead to serious bodily injury.
Self-destructive behaviors: Behaviors that are repeated and may eventually lead to death (e.g., drug abuse, smoking, anorexia, pattern of reckless driving, getting into fights) are distinguished from suicidal behavior because an act of suicide is an acute action intended to bring on death in the short term. This TIP does not focus on self-destructive behaviors.
Warning Signs for Suicide
Warning signs are defined as acute indications of elevated risk. In other words, they signal potential risk for suicidal behavior in the near future. Warning signs may be evident at intake or may arise during the course of treatment. Warning signs always require asking followup questions (discussed in the Gathering Information section, pp. 14–18). As identified by a panel of experts on suicidal behavior (Rudd et al., 2006), warning signs can be direct or indirect. Direct indications of acute suicidality are given the highest priority. They are:
• Suicidal communication: Someone threatening to hurt or kill him- or herself or talking of wanting to hurt or kill him- or herself. • Seeking access to a method: Someone looking for ways to kill him- or herself by seeking access to firearms, available pills, or other means. • Making preparations: Someone talking or writing about death, dying, or suicide, when these actions are out of the ordinary for the person.
You may also observe indirect warning signs in substance abuse clients who are not suicidal. Nonethe-less, these warning signs are critical to follow up on to determine the extent to which they may signal acute risk for suicidal behavior. You can remember them by the mnemonic IS PATH WARM:
• I = Ideation • S = Substance Abuse • P = Purposelessness • A = Anxiety • T = Trapped • H = Hopelessness • W = Withdrawal • A = Anger • R = Recklessness • M = Mood Changes
Some of the IS PATH WARM warning signs are self-evident (e.g., substance abuse); others require brief explanation. “Purposelessness” refers to a lack of a sense of purpose in life or reason for living. “Trapped” refers to perceiving a terrible situation from which there is no escape. “Withdrawal” refers to increasing social isolation. “Anger” refers to rage, uncontrolled anger, or revenge-seeking. “Anxiety” is a broad term that refers to severe anxiety, agitation, and/or sleep disturbance. “Mood changes” refers to dramatic shifts in emotions.
Warning signs are often in evidence following acute stressful life events. Among people who abuse substances, break-up of a partner relationship is most common. It is also important to look for warning signs in your clients when relapse occurs and during acute intoxication.
Stressful life events include:
• Break-up of a partner relationship. • Experience of trauma. • Legal event. • Job loss or other major employment setback. • Financial crisis. • Family conflict or disruption. • Relapse. • Intoxication.
Each of the direct warning signs indicates potential for suicidal behavior in its own right, and, if present, requires rigorous followup. The indirect warning signs may or may not signal risk for acute suicidal behavior (for example, “substance abuse” is the norm among your clients). In all cases, they require further followup questions to determine if they may indeed indicate acute suicidality.
Risk Factors
Risk factors are defined as indicators of long-term (or ongoing) risk. They are different from warning signs, which signal immediate risk. Risk factors for suicidal thoughts and behaviors among individuals with substance use disorders have been well researched (Conner, Beautrais, & Conwell, 2003; Conner et al., 2007; Darke & Ross, 2002; Ilgen et al., 2007; Murphy et al., 1992; Preuss et al., 2002; Roy, 2001; Schneider et al., 2006). The list below, although not exhaustive, is informed by these studies.
Risk factors for suicidal thoughts and behaviors include:
• Prior history of suicide attempts (most potent risk factor, although it should be remembered that about half of all deaths by suicide are first-time attempts). • Family history of suicide. • Severe substance use (e.g., dependence on multiple substances, early onset of dependence). • Co-occurring mental disorder: Depression (including substance-induced depression).
Anxiety disorders (especially PTSD).
Severe mental illness (schizophrenia, bipolar disorder).
Personality disorder (best researched are borderline and antisocial personality disorders).
Anorexia nervosa.
• History of childhood abuse (especially sexual abuse). • Stressful life circumstances: Unemployment and low level of education, job loss, especially when nearing retirement.
Divorce or separation.
Legal difficulties.
Major and sudden financial losses.
Social isolation, low social support.
Conflicted relationships.
• Personality traits: Proneness to negative affect (sadness, anxiety, anger).
Aggression and/or impulsive traits.
• Firearm ownership or access to a firearm. • Probable risk factors (although greater certainty requires more research in people with substance use disorders): Inflexible/rigid personality characteristics.
Sexual orientation (lesbian, gay, or bisexual).
Chronic pain.
Protective Factors
Protective factors are defined as buffers that lower long-term risk. Unlike risk factors, factors that are protective against suicidal behavior are not well researched (Goldsmith, Pellmar, Kleinman, & Bunney, 2002). Fewer protective factors than risk factors have been identified among people who abuse substances and other populations. Reasons for living are perhaps the best researched protective factors in the literature (Linehan Goodstein, Nielsen, & Chiles, 1983; Oquendo Dragasti et al., 2005).
The following are known and likely protective factors:
• Reasons for living. • Being clean and sober. • Attendance at 12-Step support groups. • Religious attendance and/or internalized spiritual teachings against suicide. • Presence of a child in the home and/or childrearing responsibilities. • Intact marriage. • Trusting relationship with a counselor, physician, or other service provider. • Employment. • Trait optimism (a tendency to look at the positive side of life).
A caution about protective factors: If acute suicide warning signs and/or multiple risk factors are in evidence, the presence of protective factors does not change the bottom-line assessment that preventive actions are necessary, and should not give you a false sense of security. Although protective factors may sustain someone showing ongoing signs of risk (e.g., due to chronic depression), they do not immunize clients from suicidal behavior and may afford no protection in acute crises.
Protective factors vary with cultural values. For example, in cultures where extended families are closely knit, family support can act as a protective factor. Others include a strong affiliation with a clan, tribe, or ethnic community; faith in and reliance on traditional healing methods; strong spiritual values shared among community members; and absence of cultural trauma such as that of families of Holocaust survivors and American Indians who were sent unwillingly to boarding schools to be acculturated.
Suicide Versus Suicide Attempt
Prevalence: Suicide attempts are much more common than suicides. In the United States, there are approximately 32,000 suicides annually (National Center for Injury Prevention and Control [NCIPC], 2007). More than 10 times that number of self-inflicted injuries were reported in 2006, although the proportion of these injuries in which there was intent to die is unknown (NCIPC, 2007).
Suicide Methods: The most common method of attempted suicide is an attempt to overdose. Cutting (for instance, wrists) with a knife is also common.
Lethality: Use of a firearm and hanging are the most lethal methods of suicide. The most common method of death by suicide is firearms, followed by hanging (NCIPC, 2007). Attempts by overdose and self-cutting are much more likely to be survived (Shenassa, Catlin, & Buka, 2003).
Risk of Suicide and Suicide Attempts: Age, Gender, and Race or Ethnicity
Age
Adolescents and young adults are more likely to make nonfatal suicide attempts than older individuals (NCIPC, 2007). However, older individuals are more likely to die by suicide. Older adults' elevated risk for suicide deaths is attributable to their tendency to show high suicide intent, to use more deadly methods, and to their bodies' greater fragility to the effects of acts of self-harm (Conwell, Duberstein, & Caine, 2002). Because many older adults live alone, they are less likely to be rescued (Szanto et al., 2002). The extent to which these general population patterns pertain to people treated for substance use disorders is not clear.
Gender
Women are more likely to attempt suicide than men, although the difference in prevalence of suicide attempts between men and women is not as high as once believed (Nock & Kessler, 2006). Men are more likely to die by suicide than women (NCIPC, 2007). Overall, men carry out fewer suicidal acts, but they tend to show higher intent to die (Nock & Kessler, 2006), and use more deadly methods (Goldsmith et al., 2002). The extent to which these general population patterns pertain to people treated for substance use disorders is not clear.
Race and ethnicity
According to national statistics on suicide (NCIPC, 2007), Whites and Native Americans have higher rates of suicide than African Americans; males are at highest risk in all of these racial groups. The highest rate of suicide among White males is during older adulthood (age 70 and older), while the highest rates of suicide among Native American and African American males occur much younger—during late adolescence and young adulthood. It should be noted that suicide rates among Native Americans vary significantly depending on tribe and region of the country. Some data also suggest that risk factors differ across racial groups. For example, the presence of an anxiety disorder may be an especially important risk factor for suicide attempts among Blacks (Joe, Baser, Breeden, Neighbors, & Jackson, 2006). The extent to which these general population patterns pertain to people treated for substance use disorders is not clear. There is a particularly low prevalence of deaths by suicide among African American females, although it is unknown if this data holds true for African American females with a substance use disorder (NCIPC, 2007).
Hispanics/Latinos have fairly similar rates of suicidal thoughts and behavior compared with White, non-Hispanic individuals (NCIPC, 2007). Among youth and young adults, the prevalence of suicidal thoughts and behavior increases among Hispanics/Latinos who are more acculturated to mainstream American culture, particularly among females (Zayas, Lester, Cabassa, & Fortuna, 2007). The extent to which these general population patterns pertain to people treated for substance use disorders is not clear. Additional information on race and ethnicity and substance abuse treatment can be obtained in the planned TIP, Improving Cultural Competence in Substance Abuse Treatment (CSAT, in development d ).
Reasons for Suicidal Behavior
There is often more than one reason for a suicide attempt. For example, a client may want to get back at his or her estranged partner (induce guilt), demonstrate distress (cry for help), and want to die. Therefore, it is important not to trivialize suicide attempts that may involve motivations other than to die. In other words, if at least some wish to die was present at the time of the attempt, regardless of whether there were other reasons for the act, then the behavior should be considered a suicide attempt. Some, but not all, potential reasons for a suicide attempt include:
• Desire to die. • Hopelessness. • Extreme or prolonged sadness. • Perceived failure or self-hate following relapse. • Loneliness. • Feeling like a burden to others. • Disinhibition while intoxicated. • Escape from a painful emotional state. • Escape from an entrapping situation. • Get attention. • Impulsive reaction to an acute stressful life event (e.g., break-up). • Hurt another individual (e.g., make another individual feel guilty). • Paranoia or other psychosis (e.g., command hallucination to take one's life). • Escape a progressively deteriorating health situation (e.g., terminal disease).
GATE: Procedures for Substance Abuse Counselors
Gather information
Access supervision
Take responsible action
Extend the action The Consensus Panel agreed on a formulation of the role of substance abuse treatment counselors in addressing suicidal thoughts and behaviors identified by the acronym GATE. The elements in GATE reflect behaviors that are within your scope of competence as a substance abuse counselor regarding helping clients who are at risk for suicide. You are familiar with gathering information from clients with substance use disorders; this skill can be translated into gathering information about suicidal thoughts and behaviors. Supervision may be a regular part of your agency's program; with a client who is suicidal, it is a necessity. You know how to plan for the treatment of a client with a substance use disorder; this skill can be applied to planning for a client to address his or her suicidal thoughts and behaviors. You typically follow up with clients to coordinate care, check on referral appointments, monitor progress, and enlist support from family and community resources. These counselor activities are essential when working with clients who are suicidal.
If you have advanced training in a mental health discipline (such as social work, psychology, or professional counseling) along with specialized training in suicidality, you might also be prepared to take on other treatment tasks with clients with suicidal thoughts and behaviors, such as assessment, specialized suicide interventions, or treatment of co-occurring mental disorders such as depression and psychological trauma. These advanced skills, while very important, are not a primary focus of this TIP, although some advanced skills are illustrated in the clinical vignettes of Vince and Rena in chapter 2.
The quick overview below is supplemented by a flow chart (see p. 16) and the more detailed sections that follow.
Quick Overview of GATE
G: Gather information
There are two steps to gathering information: (1) screening and spotting warning signs, and (2) asking followup questions. Screening consists of asking very brief, uniform questions at intake to determine if further questions about suicide risk are necessary. Spotting warning signs consists of identifying telltale signs of potential risk. Ask followup questions when clients respond “yes” to one or more screening questions or any time you notice a warning sign(s). The purpose of asking followup questions is to have as much information as possible so that you and your supervisor and/or treatment team can develop a good plan of action. You will want to provide as much information as possible to another provider should you make a referral. Examples of screening questions, warning signs, and followup questions are provided below.
A: Access supervision and/or consultation
You should never attempt to manage suicide risk alone even if you have substantial specialized training and education. With suicidal clients, two or three heads are almost always better than one. Therefore, speak with a supervisor, an experienced consultant who has been vetted by your agency, and/or your multidisciplinary treatment team when working with a client who you suspect may be dealing with suicidal concerns. It is a collective responsibility, not yours alone, to formulate a preliminary impression of the seriousness of risk and to determine the action(s) that will be taken. Accessing supervision or consultation can provide invaluable input to promote the client's safety, give you needed support, and reduce your personal liability. Some guidelines for making effective use of supervision and consultation are provided below.
T: Take responsible action(s)
The guiding principle here is that your action(s) should make good sense in light of the seriousness of suicide risk. The phrase “make good sense” indicates that your action(s) is “responsible,” given the seriousness of risk. The next section expands on this principle and provides a list of potential actions covering a wide range of intensity and immediacy that you and your supervisor or team may take.
E: Extend the action(s)
Too often, suicide risk is dealt with acutely, on a one-time basis, and then forgotten. As with substance abuse, vulnerable clients may relapse into suicidal thoughts or behaviors. This means that you will need to continue to observe and check in with the client to identify a possible return of risk. Another common problem is referring a suicidal client but failing to coordinate or even follow up with the provider. Suicide risk management requires a team approach, and as your client's addiction counselor, you are an essential part of this team. A range of extended actions is provided below.
Documenting all the actions you have taken is important because it creates a medical and legal account of the client's care: what information you obtained, when and what actions were taken, and how you followed up on the client's substance abuse treatment and suicidal thoughts and behaviors. This record can be useful for your supervision or consultation, to your team, and to other providers.
On the next page is a graphic depiction of the elements of GATE (Figure 1.1). It is designed to help you see how the completion of one element leads to decisions and specific actions in the next.
Detailed Explanation of Gate
G: Gather information
This stage proceeds in two steps: (1) screening and/or spotting warning sign(s) and (2) asking followup questions. Substance abuse counselors should be expected to gather information about suicidal thoughts and behaviors. Gathering information is different from formal assessment because an assessment is a process by which a professional synthesizes and interprets information. Substantial training, supervision, and experience is required to have sufficient clinical judgment to make the fine distinctions necessary for assessment.
As much as possible, you should avoid “stacking” questions (peppering clients with one closed- end question after the other), which will tend to generate defensiveness and/or false reassurances of safety. If you are unclear about the answer from the client or if you sense a degree of defensiveness, you might consider asking the same question in a different way somewhat later in the interview. Ambiguous or vague answers are always important to pursue further because they may be a sign of discomfort with the topic, anxiety about disclosure, evasiveness, and/or uncertainty (e.g., “I don't know”, “I'm not sure”), with the understanding that clients will not always be able or willing to provide greater clarity.
Screening Sample screening questions: If your agency does not provide you with standard screening question(s) on suicidal thoughts and behaviors, use the questions provided below. They introduce the topic of suicide and screen for suicidal thoughts and attempts. The timing of the questions is important; they should be asked in the context of a larger discussion of, for instance, mood or quality of life. Ask the same screening questions verbatim for every new client.
Introducing the topic (use either statement):
1. Now I am going to ask you a few questions about suicide.
2. I have a few questions to ask you about suicidal thoughts and behaviors.
Screening for suicidal thoughts (ask either question):
3. Have you thought about killing yourself?
4. Have you thought about carrying out suicide?
Screening for suicide attempts (ask either question):
5. Have you ever tried to take your own life?
6. Have you ever attempted suicide?
Note that the introductory items are brief and straightforward. With slight word changes, items 3 and 5 are taken from a research interview for the study of alcoholism (Bucholz et al., 1994) that have been used in research on suicidal thoughts and behavior (Conner et al., 2007), and items 4 and 6 are taken from a national survey that has provided information on suicidal thoughts and behavior in the general population (Kessler et al., 1999).
The National Suicide Prevention Lifeline has produced a wallet-sized card for counselors entitled: “Assessing Suicide Risk: Initial Tips for Counselors” that lists five questions counselors can ask abut suicide. The card additionally provides the warning signs contained in “IS PATH WARM” (described on p. 11 of this TIP) and offers brief advice on actions to take with people who are at risk. The card is available online at http://download.ncadi.samhsa.gov/ken/pdf/SVP06-0153/SVP06-0153.pdf. Bulk copies (item SVP06-0153) can be ordered at http://nmhicstore.samhsa.gov/publications/ordering.aspx.
Additional options for screening
Multi-item measures that contain an item about suicidal thoughts and behaviors may also be used for screening. Items that screen for suicidal thoughts can be found on several other well- validated depression measures including the original and revised versions of the Beck Depression Inventory (BDI or BDI-II; Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961; Beck, Steer, & Brown, 1996) and Hamilton Depression Rating Scale (Hamilton, 1960) as well as on instruments that are administered verbally, including versions of the Addiction Severity Index (ASI; McLellan et al., 1992). The BDI-II may be purchased, whereas the ASI may be downloaded at no cost from the Internet (http://www.tresearch.org/resources/instruments.htm). If a client endorses any level of suicidality on the relevant items from these measures, you will want to ask followup questions. TIP 42: Substance Abuse Treatment for Persons With Co- Occurring Disorders (CSAT, 2005d), also contains useful suicide screening options for persons with co-occurring disorders.
Asking followup questions It is important to ask followup questions when a client answers “yes” to a screening question at intake, when you note a warning sign(s), or at any time during the course of treatment when you suspect the client is suicidal, even if you can't pinpoint why. Followup questions and their answers enable you to have as much information as possible when you discuss the situation with your supervisor or team and allow you to convey solid information if you make a referral to another provider.
Sample followup questions about suicidal thoughts:
1. Can you tell me about the suicidal thoughts?
2. If the client requires more direction:
For example, What brings them on?
How strong are they?
How long do they last?
3. If you do not already know: Have you made a plan? (If yes) What is your plan? Do you have access to a method of suicide? A gun? An overdose? Do you intend to attempt suicide?
Always ask an open-ended question first (see sample question 1). Clients may tell you spontaneously all of the information you need to know. Open-ended questions can help you avoid “grilling” the client. Information not provided by clients may be elicited with followup questions to determine characteristics such as the precipitants, strength, and duration of the suicidal thoughts (see sample question 2). Finally, if information related to planning, method, and intent does not come to light spontaneously, always gather these critical pieces of information (see sample question 3). A client's inability or unwillingness to provide the necessary information may be an indicator of increased risk and that should be noted in discussion with your treatment team or your supervisor.
Gathering additional information about suicide attempts is straightforward. You will want to ask the client to explain the attempt through an open-ended question such as “Please tell me about the attempt” and ask followup questions to find out more about it. If there was more than one suicide attempt, ask these questions about the most recent attempt and the most severe attempt (if it differs from the most recent act). The answers to these questions will be very helpful in characterizing the seriousness of suicidal behavior. Sample followup questions about suicide attempts:
1. Please tell me about the attempt.
2. If the client requires more direction:
For example, What brought it on? Where were you? Were you drinking or high?
3. If you do not already know: To gather information about lethality: What method did you use to try to kill yourself? Did you receive emergency medical treatment? To gather information about intent: Did you want to die? How much? Afterward, were you relieved you survived, or would you rather have died?
The lessons that apply to asking about suicidal thoughts also apply here: ask an open-ended question first, ask followup questions to determine the circumstances of the attempt such as the precipitating event, setting, and the role of acute alcohol or drug use, and finally, if information related to lethality and intent does not come to light spontaneously, always continue to gather these critical pieces of information (see sample question 3).
Summary of G: Gather information
The gathering information task consists of collecting relevant facts. Screening questions should be asked of all new clients when you note warning sign(s) and any time you have a concern about suicide, whether or not you can pinpoint the reason. Inquiries about suicidal thoughts and attempts always start with an open-ended question that invites the client to provide more information. Followup questions are then asked to gather additional, critical information. Routine monitoring of suicide risk throughout treatment should be a basic standard in all substance abuse treatment programs.
A: Access supervision or consultation
You should not make a judgment about the seriousness of suicide risk or try to manage suicide risk on your own unless you have an advanced mental health degree and specialized training in suicide risk management and it is understood by your agency that you are qualified to manage such risk independently. For this step, obtaining consultation does not refer to merely getting input from a peer. Although such input may be helpful, consultation is a more formal process whereby information and advice are obtained from (a) a professional with clear supervisory responsibilities, (b) a multidisciplinary team that includes such person(s), and/or (c) a consultant experienced in managing suicidal clients who has been vetted by your agency for this purpose. When obtaining supervision or consultation, assemble all the information you have gathered on your client's suicidal thoughts and/or suicide attempts through the screening and followup questions, as well as data from other sources of information (e.g., other providers, family members, treatment records).
In some circumstances, you will need to obtain immediate consultation (see the vignettes in chapter 2 on Clayton and Leon). In other circumstances, obtaining consultation at regularly scheduled supervision or team meetings may be sufficient (regular consultation). The examples listed below are for illustrative purposes only; other circumstances requiring immediate consultation may exist.
Circumstances at intake requiring access to immediate supervision or consultation include:
• Direct warning signs are evident (suicidal communication, seeking access to method, making preparations). • Followup questions to suicide screening questions suggest that there is current risk. • Followup questions to indirect warning signs suggest that there is current risk. • Additional information (e.g., from the referral source, family member, medical record) suggests that there is current risk.
Circumstances during treatment that require access to immediate supervision or consultation include:
• Emergence (or re-emergence) of direct warning signs. • Emergence (or re-emergence) of indirect warning signs that, on followup questioning, suggest current risk. • Your client's answers to suicide screening questions asked during the course of treatment suggest current risk. • Additional information (e.g., from another provider or family member) suggests current risk.
Circumstances at intake requiring access to regularly scheduled supervision or consultation include:
• One or more indirect warning signs are present, but followup questions indicate that there is no reason to suspect current risk for suicidal behavior per se (e.g., a client is socially isolated and abusing substances, but otherwise shows no indications of suicidality). • One or more risk factors are present, but there are no accompanying warning signs or other indications to suspect current risk for suicidal behavior. • During screening, your client discloses a history of suicidal thoughts or suicide attempt(s), but there are no accompanying warning signs or other indications to suspect current risk for suicidal behavior. • Additional information (e.g., from the referral source or family member) suggests your client has a history of suicidal thoughts or attempts, but there are no accompanying warning signs or other indications to suspect current risk for suicidal behavior.
Circumstances during treatment that require access to regularly scheduled supervision or consultation include:
• Your client reports (or alludes to) a history of suicidal thoughts that you had not previously been aware of, but there are no accompanying warning signs or other indications to suspect current risk for suicidal behavior. • Your client reports (or alludes to) prior suicide attempt(s) that you had not previously been aware of, but there are no accompanying warning signs or other indications to suspect current risk for suicidal behavior. • Additional information (e.g., from another provider or family member) suggests a history of suicidal thoughts or attempts that you had not previously been aware of, but there are no accompanying warning signs or other indications to suspect current risk for suicidal behavior. • Client with a history of suicidal thoughts or behavior experiences an acute stressful life event or a setback in treatment (e.g., substance abuse relapse), but there are no accompanying warning signs or other indications to suspect current risk for suicidal behavior.
You will find it useful to know who your consultant (supervisor, team, outside consultant) is for issues of sucidality in your program, what your agency policy is regarding acutely suicidal clients, and where such patients could be referred. Having this information in advance can free you to focus on the immediate situation when a crisis arises. If you suspect that information on acute suicidality might arise in a session, it is wise to alert your supervisor in advance that you might contact him or her for information, support or consultation while the client is still in your office.
Summary of A: Access supervision or consultation
Risk for suicidal behavior may be evident at intake or at any time during the course of treatment. Supervision or consultation to address risk may be obtained immediately or at a regularly scheduled time, depending on the urgency of the situation. Having a plan in place ahead of time for obtaining immediate supervision or consultation will help ensure a therapeutic response and will avoid unnecessary distress and scrambling.
Immediate supervision or consultation should be obtained when clients exhibit direct suicide warning signs (see p. 11 for direct warning signs) or when they report at intake having made a recent suicide attempt. Substance abuse relapse during treatment is also an indication for supervisory involvement for clients who have a history of suicidal behavior or attempts.
T: Take responsible action
A useful guiding principle in taking responsible action is that your actions should make good sense in light of the seriousness of suicide risk. This section explains this principle, applies it to taking responsible action(s), and provides a list of potential actions. In the legal system, the standard used to assess responsibility and liability is to compare a given practitioner's judgment and behavior with what another equally trained and experienced treatment practitioner would have done in the same circumstances.
The key factor—although not the only factor—in considering the action(s) to take is a judgment about the seriousness of risk. Seriousness is defined as the likelihood that a suicide attempt will occur and the potential consequences of an attempt. Briefly, if a client is judged to be likely to carry out a suicide attempt (for example, has persistent suicidal thoughts and a clear plan) and if the client expects the suicide attempt to be lethal (for example, a plan to use a gun that the client keeps at home), there is high seriousness. In contrast, if a client is judged to be unlikely to carry out an attempt (for example, has fleeting ideation, no clear plan, and no intention to act) and any attempt may be expected to be nonlethal (for example, thoughts of swallowing some aspirin if there is any in the medicine cabinet), there is lower seriousness. In chapter 2, you will meet counselors who address issues of seriousness of a threat or attempt to make judgments about how to proceed with the session. Judgments about the degree of seriousness of risk should be made in consultation with a supervisor and/or a treatment team, not by a counselor acting alone.
The actions taken should be sensible in light of the information that has been gathered about suicidal thoughts and/or previous suicide attempts. Although the potential actions are many, they can generally be described along a continuum of intensiveness. In instances of greater seriousness, you will generally take more intensive actions. For less serious circumstances, you will be more likely to take less intensive actions. Note that “less intensive” does not equate to inaction; it merely indicates that there may be more time to formulate a response, the actions may be of lower intensity, and/or fewer individuals and resources may be involved.
In some instances, an immediate response is required (see the vignettes in chapter 2 about Clayton, Vince, and Rena). In general, responses that require immediate action may be considered more intensive. Examples of immediate actions include arranging transportation to a hospital emergency department for evaluation, contacting a spouse to have him or her arrange for removal of a gun from the home and arrange safe storage, and arranging on the spot to have a mental health specialist in your program further evaluate a client. Examples of non-immediate, but important, actions include making a referral for a client to an outpatient mental health facility for evaluation, scheduling the client to see a psychiatrist for possible medication management, and ordering past mental health records from another provider.
Some interventions can be considered more intensive than others. These include interventions that reduce freedom of movement (e.g., arranging an ambulance to transport a client to a hospital emergency department), are expensive (e.g., inpatient hospitalization), compromise privacy (e.g., contacting the police to check on a high-risk client), and/or restrict autonomy (e.g., asking a spouse to arrange for safe storage of a weapon). Other interventions in managing suicide risk, although less intensive, may also go beyond the usual care of a substance abuse client and may be experienced by a client as unnecessary or intrusive. Arranging further assessment with an outpatient mental health provider or through a home visit by a mental health mobile crisis team, for instance, may be seen as burdensome to the client. Less intensive interventions do not reduce freedom of movement, do not sacrifice privacy, are comparatively inexpensive, and/or do not restrict autonomy. Another aspect of intensiveness concerns the number of individuals involved (e.g., client, case manager, counselor, mental health professional, concerned spouse) and the number of actions taken (e.g., psychiatric medications, substance abuse counseling, family sessions, case management coordination). In other words, in general, the greater the number of interventions, and the more individuals involved, the more intensive the action(s).
What actions can you take?
Safety Cards and Safety Plans
With all clients with suicidal risk, consider developing with the client a written safety card that includes at a minimum:
• A 24-hour crisis number (e.g., 1-800-273-TALK). • The phone number and address of the nearest hospital emergency department. • The counselor's contact information. • Contact information for additional supportive individuals that the client may turn to when needed (e.g., sponsor, supportive family member).
To maximize the likelihood that the client will make use of the card, it should be personalized and created with the client (not merely haded to him or her). Discuss with the client the type(s) of signs and situations that would warrant using one or more of the resources on the card. It is ideal to create a wallet-size card with this information so clients can easily keep it with them. Have backup copies of the card available in the event that the client loses the card (which frequently happens) so that it can be quickly replaced. Consistent with this TIP's emphasis on Extending the action, you should check in with the client from time to time to confirm that he or she still has the card (ask the client to show it to you) and remains willing to use it if the need arises. Counselors with advanced mental health training and experience in work with clients who are suicidal may be in a position to formulate a more detailed safety plan. Such a safety plan and an example of its use with a client are described in chapter 2 in the vignette with Rena.
The list of actions below is not exhaustive but includes the most common actions. At times, one action will suffice, whereas at other times, more than one (and perhaps many) will be required. You and your supervisor or team will strive to do things that make good sense in terms of their intensity. Your actions should match the seriousness of risk. Often your response will involve arranging a referral (if the necessary resources are not available within your agency). The list below is in no particular order.
• Gather additional information from the client to assist in a more accurate clinical picture and treatment plan. • Gather additional information from other sources (e.g., spouse, other providers). • Arrange a referral: To a clinician for further assessment of suicide risk.
To a provider for mental health counseling.
To a provider for medication management.
To an emergency provider (e.g., hospital emergency department) for acute risk assessment (see the vignette on Vince for a discussion of relevant issues).
To a mental health mobile crisis team that can provide outreach to a physically inaccessible client at his or her home (or shelter) and make a timely assessment.
To a more intensive substance abuse treatment setting.
• Restrict access to means of suicide. • Temporarily increase the frequency of care, including more frequent telephone check-ins. • Temporarily increase the level of care (e.g., refer to day treatment). • Involve a case manager (e.g., to coordinate care, to check on the client occasionally). • Involve the primary care provider. • Encourage the client to attend (or increase attendance) at 12-Step meetings such as Alcoholics Anonymous, Narcotics Anonymous, or Cocaine Anonymous. • Enlist family members or significant others (selectively, depending on their health, closeness to the client, and motivation) in observing indications of a return of suicide risk. • Observe the client for signs of a return of risk • Create a safety card (see below) with the client in the event of a return of acute suicidality. • Create a detailed safety plan (see below) with the client in the event of relapse to alcohol or drugs. • Give the client an emergency hotline number, for instance, the national hotline 1-800- 273-TALK. • Invite the client to contact you (or an emergency hotline) in the event of acute suicidality.
As mentioned earlier, there is little or no empirical evidence to support “suicide contracts” (an agreement from a client to contact the counselor or someone else before making a suicide attempt) as a “stand alone” intervention. However, the consensus panel strongly recommends that counselors help clients at risk of suicidal thoughts and behaviors develop a safety card, sometimes referred to as an emergency card. Such a plan ideally identifies who a client in crisis can turn to for immediate help, where they can go for help, other proactive behaviors the client can take (such as maintaining sobriety), and what kind of information they should give to providers so that the crisis is recognized and addressed. A related technique is a Commitment to Treatment agreement, which focuses the client's attention on the specific behaviors (such as attending treatment sessions, setting recovery goals, completing homework assignments, and taking medications as prescribed) that support recovery and potentially reduce suicidal thoughts and behaviors. The difference in the two techniques is that safety cards and plans focus on preventing or intervening in crises, while the Commitment to Treatment agreement focuses on behaviors that positively support treatment outcome.
For counselors with more experience and training in work with clients who are suicidal, an advanced skills safety plan can be used. An example of an advanced skills plan is described in the vignette with Rena. An advanced plan might emphasize helping the client recognize when direct and indirect warning signs are becoming more apparent, develop coping responses, and focus on the client's emotional regulation.
Referring a client who Is ambivalent about treatment or is resisting treatment: It is common to make a referral either for further evaluation, treatment of suicide risk, treatment of a mental health condition (for example, depression), or for a combination of services. Sometimes, however, there will be times when you make a referral that a client does not agree is necessary or simply does not wish to accept. By taking the time to discuss the reasons for your actions and by listening and acknowledging their concerns, clients who are suicidal will usually soften their stance and become more willing. Eliciting a client's input as to what he or she believes would be most helpful and using these suggestions, as appropriate, can also go a long way to eliciting cooperation. Anything appropriate that you can do to give a client a sense of choice or control will be helpful.
Although a referral for emergency evaluation is usually not necessary and less intensive action(s) will typically suffice, there will be times when such an action is needed. In these instances, a resistant client may become more willing if provided some sense of control, for example, through a question such as “Would you prefer to call your family before you go to the emergency department or would you rather I call them after you get there?”
In the end, if a client refuses to cooperate in additional evaluation, you (in close coordination with your supervisor or team) will need to take the necessary steps to arrange for the evaluation (e.g., by arranging an ambulance or police escort) as described in your agency policy. The client should not be left unaccompanied while such arrangements are being made. Supervisors can facilitate their counselors' current knowledge of the company's policy on emergency referrals by reviewing it with them on a regular basis, as appropriate.
A note on inpatient treatment for suicidality: It is important that counselors, clients, and their family members know what to expect from inpatient psychiatric hospitalization. Generally, the treatments are short term (5–7 days), and if the clinical team concludes that suicidality is substance-induced, the stay may be shorter (Ries, Yuodelis-Flores, Comtois, Roy-Byrne, & Russo, 2008). During hospitalization, the focus is typically on medication management and disposition planning, with a minimal focus on addressing ongoing stressors therapeutically. As a result, most or all of the psychosocial difficulties that prompted admission will still need to be addressed when the client returns to treatment. A study of psychiatric inpatient admissions to one large, university-based hospital showed that “substance-induced suicidality,” as rated by clinicians, represented 40 percent of all admissions, indicating the extent to which substance- related problems promote such admissions (Ries et al., 2008). Summary of T: Take responsible action
The intensiveness of the actions that you take in coordination with your supervisor or team should make good sense in light of the information that you have gathered, with more serious risk requiring more intensive action(s). The action(s) may include referring the client for a formal assessment or for additional treatment. Taking the time to prepare clients for a referral and providing them some sense of control will be helpful in eliciting their cooperation.
E: Extend the action
A common misconception is that suicide risk is an acute problem that, once dealt with, ends. Unfortunately, individuals who are suicidal commonly experience a return of suicide risk following any number of setbacks, including relapse to substance use, a distressing life event (e.g., break-up with a partner), increased depression, or any number of other situations. Sometimes suicidal behavior even occurs in the context of substantial improvement in mood and energy. Therefore, monitoring for signs of a return of suicidal thoughts or behavior is essential. There is also a tendency to refer a client experiencing suicidal thoughts and behaviors to another provider and then assume that the issue has been taken care of. This is a mistake. It is essential to follow up with the provider to determine that the client kept the appointment. It is also critical to coordinate care on an ongoing basis, for example, to alert a provider that a client has relapsed and may be vulnerable to suicidal thoughts. Extending the action emphasizes the importance of watching for a return of suicidal thoughts and behaviors, following up with referrals, and coordinating on an ongoing basis with providers who are addressing the client's suicidal thoughts and behaviors.
What extended actions can you take?
The list below mentions many common extended actions but is not exhaustive. It is in no particular order.
• Confirm that a client has kept the referral appointment with a mental health provider (or other professional). • Follow up with the hospital emergency department when a client has been referred for acute assessment. • Coordinate with a mental health provider (or other professional) on an ongoing basis. • Coordinate with a case manager on an ongoing basis. • Check in with the client about any recurrence of or change in suicidal thoughts or attempts. • Check in with family members (with the client's knowledge) about any recurrence of or change in suicidal thoughts or attempts. • Reach out to family members to keep them engaged in the treatment process after a suicide crisis passes. • Observe the client for signs of a return of risk. • Confirm that the client still has a safety plan in the event of a return of suicidality. • Confirm that the client and, where appropriate, the family, still have an emergency phone number to call in the event of a return of suicidality. • Confirm that the client still does not have access to a major method of suicide (e.g., gun, stash of pills). • Follow up with the client about suicidal thoughts or behaviors if a relapse (or other stressful life event) occurs. • Monitor and update the treatment plan as it concerns suicide. • Document all relevant information about the client's condition and your responses, including referrals made and the outcomes of the referrals. • Complete a formal treatment termination summary when and under whatever circumstances this stage of care is reached.
Summary of E: Extend the action
Suicide prevention efforts are not one-time actions. They should be ongoing because suicidal clients are vulnerable to a recurrence of risk. A team approach is also essential, as it requires you to follow up on referrals and coordinate with other providers in an ongoing manner. The actions listed above represent many, but not all, of the extended actions you may use to promote safety throughout treatment. Work closely with your supervisor or team in developing a plan of extended actions. Finally, document the client's eventual progress and status at the point of your treatment termination.
Documenting GATE
Documentation of suicidality is critical to promoting client safety, coordinating care among treatment professionals, and establishing a solid medical and legal record. Documentation entails providing a written summary of any steps taken pertaining to GATE, along with a statement of conclusions that shows the rationale for the resultant plan. The plan should make good sense in light of the seriousness of risk. Examples of Roberta, Mark, and Fernando, below, illustrate documentation across a continuum of seriousness of suicidality. Counselors, supervisors, or consultants may provide such documentation. Many programs or State regulatory bodies recommend or mandate a particular format in which this documentation can occur. Generally, such formats can accommodate all of the information contained in our GATE protocol.
In the notes below, the italicized text is the actual note. These examples are “ideals.” Notes in routine clinical practice may fall short of this level of detail and organization. Nonetheless, the notes serve as models for documentation. Agencies may implement checklists as well (e.g., warning signs, risk factors, protective factors) to assist you with documentation. Even with the use of a checklist, a conclusion statement and the articulation of the plan are always needed.
Documentation example 1
The following is from an intake evaluation of Roberta, a 40-year-old African-American woman seeking treatment for cocaine dependence. The situation was not acute, so regular supervision was used and no immediate actions were taken.
Gather information: The client made a suicide attempt at age 31 by overdosing on over-the- counter sleeping pills following a sexual assault for which she received overnight treatment in a hospital emergency department. She was ambivalent about the suicide attempt and immediately afterward was relieved that she survived. Since that time, she has not reattempted; she reported no current or recent ideation, plan, or intent. She reported that she no longer uses sleeping pills and has none in her possession. She stated that her strong faith in God prevents her from making another attempt. No warning signs for suicidal behavior were evident.
Conclusion: There is a history of suicidal behavior but no indication of a need for action.
Access supervision: Her suicide-related history will be discussed at the next team meeting on January 14.
Documentation example 2
The following is from an intake evaluation of Mark, a 29-year-old White male who is separated from his wife and entering treatment for alcohol dependence. The situation required immediate supervision and an intervention of intermediate intensity.
Gather information: Mark reports that he has thoughts of suicide when intoxicated (about once a week), during which he becomes preoccupied with the separation from his wife. The thoughts last a few hours, until he falls asleep. They occur while he is home alone. He has not acted on them, reports no plan or intent to attempt suicide, and reports that he does not own a firearm. He reports no history of suicide attempts.
Access supervision: This writer took a break in the intake to review this information with supervisor, John Davidson, LCSW.
Conclusion: It was concluded that emergency intervention is not required because Mark has not acted on his suicidal thoughts and has no plan or intent. However, further assessment is indicated given suicidal ideation, marital estrangement, and active alcohol dependence.
Take action: I reviewed these considerations with Mark and he agreed to a referral for an outpatient mental health evaluation. Mark has an appointment scheduled for June 18 at 1:00 p.m. with Martha Jones, MSW, of the Mental Health Clinic.
Extend the action: On Tuesday, June 17, this writer called Mark to remind him of his appointment. He said he remembered his appointment and planned to attend. I called the Mental Health Clinic late in the afternoon on June 18. Mark had kept his appointment and scheduled a second appointment for the following week.
Documentation example 3
The following is from a progress note for Fernando, a 22-year-old Hispanic male. He is an Iraq war veteran who had been doing well in treatment for dependence on alcohol and opiates, but had missed group therapy sessions and not returned phone calls for the past 10 days. This situation occurred in a substance abuse clinic within a hospital and required accessing immediate supervision and interventions of high intensity.
Gather information: Fernando came in, unannounced, at 10:30 a.m. today and reported that he relapsed on alcohol and opiates 10 days ago and has been using daily and heavily since. Breathalyzer was .08, and he reported using two bags of heroin earlier this morning. He reported that he held his loaded rifle in his lap last night while high and drunk, contemplating suicide.
Access supervision: This writer's supervisor, Janice Davis, CDC, was called to join the session.
Conclusion: It was determined that emergency intervention is necessary because of intense substance use, suicidal thoughts with a lethal plan, and access to a weapon.
Take action: At 11:00 a.m., a hospital security guard and this writer escorted Fernando to the emergency department where he was checked in. He was cooperative throughout the process.
Extend the action: Dr. McIntyre, the Emergency Department physician, determined that Fernando requires hospitalization. He is currently awaiting admission. This writer will follow up with the hospital unit after he is admitted and will raise the issue of his access to a gun.
Competencies
You now have some basic information about suicide and the effects of suicidal thoughts and behaviors on substance abuse treatment. Through the steps summarized as GATE in this TIP, you are becoming familiar with your role in addressing suicidal thoughts and behaviors. These capabilities result in a short list of the knowledge, skills, and attitudes you need to be able to effectively work with people in substance abuse treatment who are suicidal or have a history of suicidal thoughts and behaviors.
The consensus panel agreed on eight competencies for working with clients who are suicidal in substance abuse treatment settings. These competencies are derived from a variety of resources, including Practice Guideline and Resources for the Assessment and Treatment of Patients with Suicidal Behaviors (American Psychiatric Association, 2003), Assessing and Managing Suicidal Risk: Core Competencies for Mental Health Professionals (American Association of Suicidology, Suicide Prevention Resource Center, and Education Development Center, 2006), and The Assessment and Management of Suicidality (Rudd, 2006). They reflect the core knowledge, skills, and attitudes that you as a substance abuse counselor should incorporate to work effectively with clients who evidence suicidal thoughts and behaviors and form the basis for the skills presented in the vignettes in chapter 2 of this TIP. Few counselors will be proficient in all of these competencies. However, it will be helpful to evaluate your strengths and weaknesses in light of these competencies, so you can increase your skills in working with these individuals.
Next Steps
You have probably started thinking about how you might assist a suicidal client in your own substance abuse treatment program. Now you have basic information, fundamental clinical principles and positive attitudes, basic facts about suicide and its relationship to substance use disorders, a set of competencies that will help you address suicidality, and guidelines about what your role as a substance abuse counselor can be in working with clients who are suicidal.
In the next chapter, you will meet a number of clients who are experiencing or have experienced suicidal thoughts and behaviors of varying degrees of intensity. The dialog among clients, counselors, and supervisors illustrates a number of ways substance abuse treatment and suicidality intervention can interact, and how GATE can be implemented in several treatment settings, and with different types of complicating factors. Copyright and Disclaimer
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AHCPR Archived reports, Put Prevention Into Practice and Minnesota Health Technology Advisory Committee SAMHSA/CSAT Treatment Improvement Protocols 35. TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment
Chapter 3—Motivational Interviewing as a Counseling Style
Motivational interviewing is a way of being with a client, not just a set of techniques for doing counseling. Miller and Rollnick, 1991
Motivational interviewing is a technique in which you become a helper in the change process and express acceptance of your client. It is a way to interact with substance-using clients, not merely as an adjunct to other therapeutic approaches, and a style of counseling that can help resolve the ambivalence that prevents clients from realizing personal goals. Motivational interviewing builds on Carl Rogers' optimistic and humanistic theories about people's capabilities for exercising free choice and changing through a process of self-actualization. The therapeutic relationship for both Rogerian and motivational interviewers is a democratic partnership. Your role in motivational interviewing is directive, with a goal of eliciting self- motivational statements and behavioral change from the client in addition to creating client discrepancy to enhance motivation for positive change (Davidson, 1994; Miller and Rollnick, 1991). Essentially, motivational interviewing activates the capability for beneficial change that everyone possesses (Rollnick and Miller, 1995). Although some people can continue change on their own, others require more formal treatment and support over the long journey of recovery. Even for clients with low readiness, motivational interviewing serves as a vital prelude to later therapeutic work.
Motivational interviewing is a counseling style based on the following assumptions:
• Ambivalence about substance use (and change) is normal and constitutes an important motivational obstacle in recovery. • Ambivalence can be resolved by working with your client's intrinsic motivations and values. • The alliance between you and your client is a collaborative partnership to which you each bring important expertise. • An empathic, supportive, yet directive, counseling style provides conditions under which change can occur. (Direct argument and aggressive confrontation may tend to increase client defensiveness and reduce the likelihood of behavioral change.) This chapter briefly discusses ambivalence and its role in client motivation. Five basic principles of motivational interviewing are then presented to address ambivalence and to facilitate the change process. Opening strategies to use with clients in the early stages of treatment are offered as well. The chapter concludes with a summary of a 1997 review by Noonan and Moyers that studied the effectiveness of motivational interviewing.
Ambivalence
Individuals with substance abuse disorders are usually aware of the dangers of their substance- using behavior but continue to use substances anyway. They may want to stop using substances, but at the same time they do not want to. They enter treatment programs but claim their problems are not all that serious. These disparate feelings can be characterized as ambivalence, and they are natural, regardless of the client's state of readiness. It is important to understand and accept your client's ambivalence because ambivalence is often the central problem--and lack of motivation can be a manifestation of this ambivalence (Miller and Rollnick, 1991). If you interpret ambivalence as denial or resistance, friction between you and your client tends to occur.
The motivational interviewing style facilitates exploration of stage-specific motivational conflicts that can potentially hinder further progress. However, each dilemma also offers an opportunity to use the motivational style to help your client explore and resolve opposing attitudes. Examples of how these conflicts might be expressed at different stages of change are provided in Figure 3-1.
Five Principles of Motivational Interviewing
In their book, Motivational Interviewing: Preparing People To Change Addictive Behavior, Miller and Rollnick wrote,
[M]otivational interviewing has been practical in focus. The strategies of motivational interviewing are more persuasive than coercive, more supportive than argumentative. The motivational interviewer must proceed with a strong sense of purpose, clear strategies and skills for pursuing that purpose, and a sense of timing to intervene in particular ways at incisive moments (Miller and Rollnick, 1991, pp. 51-52).
The clinician practices motivational interviewing with five general principles in mind:
1. Express empathy through reflective listening. 2. Develop discrepancy between clients' goals or values and their current behavior. 3. Avoid argument and direct confrontation. 4. Adjust to client resistance rather than opposing it directly. 5. Support self-efficacy and optimism.
Express Empathy Empathy "is a specifiable and learnable skill for understanding another's meaning through the use of reflective listening. It requires sharp attention to each new client statement, and the continual generation of hypotheses as to the underlying meaning" (Miller and Rollnick, 1991, p. 20). An empathic style
• Communicates respect for and acceptance of clients and their feelings • Encourages a nonjudgmental, collaborative relationship • Allows you to be a supportive and knowledgeable consultant • Sincerely compliments rather than denigrates • Listens rather than tells • Gently persuades, with the understanding that the decision to change is the client's • Provides support throughout the recovery process
Empathic motivational interviewing establishes a safe and open environment that is conducive to examining issues and eliciting personal reasons and methods for change. A fundamental component of motivational interviewing is understanding each client's unique perspective, feelings, and values. Your attitude should be one of acceptance, but not necessarily approval or agreement, recognizing that ambivalence about change is to be expected. Motivational interviewing is most successful when a trusting relationship is established between you and your client.
Expressing Empathy
Reprinted with permission.
• Acceptance facilitates change. • Skillful reflective listening is fundamental to expressing empathy. • Ambivalence is normal.
Although empathy is the foundation of a motivational counseling style, it "should not be confused with the meaning of empathy as identification with the client or the sharing of common past experiences. In fact, a recent personal history of the same problem area...may compromise a counselor's ability to provide the critical conditions of change" (Miller and Rollnick, 1991, p. 5). The key component to expressing empathy is reflective listening.
Expressing Empathy With Native American Clients
For many traditional Native American groups, expressing empathy begins with the introduction. Native Americans generally expect the clinician to be aware of and practice the culturally accepted norms for introducing oneself and showing respect. For example, when first meeting a Navajo, the person often is expected to say his name, clan relationship or ethnic origin, and place of origin. Physical contact is kept to a minimum, except for a brief handshake, which may be no more than a soft touch of the palms.
If you are not listening reflectively but are instead imposing direction and judgment, you are creating barriers that impair the therapeutic relationship (Miller and Rollnick, 1991). The client will most likely react by stopping, diverting, or changing direction. Twelve examples of such nonempathic responses have been identified (Gordon, 1970):
1. Ordering or directing. Direction is given with a voice of authority. The speaker may be in a position of power (e.g., parent, employer) or the words may simply be phrased and spoken in an authoritarian manner. 2. Warning or threatening. These messages are similar to ordering but they carry an overt or covert threat of impending negative consequences if the advice or direction is not followed. The threat may be one the clinician will carry out or simply a prediction of a negative outcome if the client doesn't comply--for example, "If you don't listen to me, you'll be sorry." 3. Giving advice, making suggestions, or providing solutions prematurely or when unsolicited. The message recommends a course of action based on the clinician's knowledge and personal experience. These recommendations often begin with phrases such as, "What I would do is...." 4. Persuading with logic, arguing, or lecturing. The underlying assumption of these messages is that the client has not reasoned through the problem adequately and needs help to do so. 5. Moralizing, preaching, or telling clients their duty. These statements contain such words as "should" or "ought" to convey moral instructions. 6. Judging, criticizing, disagreeing, or blaming. These messages imply that something is wrong with the client or with what the client has said. Even simple disagreement may be interpreted as critical. 7. Agreeing, approving, or praising. Surprisingly, praise or approval also can be an obstacle if the message sanctions or implies agreement with whatever the client has said. Unsolicited approval can interrupt the communication process and can imply an uneven relationship between the speaker and the listener. Reflective listening does not require agreement. 8. Shaming, ridiculing, labeling, or name-calling. These messages express overt disapproval and intent to correct a specific behavior or attitude. 9. Interpreting or analyzing. Clinicians are frequently and easily tempted to impose their own interpretations on a client's statement and to find some hidden, analytical meaning. Interpretive statements might imply that the clinician knows what the client's real problem is. 10. Reassuring, sympathizing, or consoling. Clinicians often want to make the client feel better by offering consolation. Such reassurance can interrupt the flow of communication and interfere with careful listening. 11. Questioning or probing. Clinicians often mistake questioning for good listening. Although the clinician may ask questions to learn more about the client, the underlying message is that the clinician might find the right answer to all the client's problems if enough questions are asked. In fact, intensive questioning can interfere with the spontaneous flow of communication and divert it in directions of interest to the clinician rather than the client. 12. Withdrawing, distracting, humoring, or changing the subject. Although humor may represent an attempt to take the client's mind off emotional subjects or threatening problems, it also can be a distraction that diverts communication and implies that the client's statements are unimportant.
Ethnic and cultural differences must be considered when expressing empathy because they influence how both you and your client interpret verbal and nonverbal communications.
Expressing Empathy With African-American Clients
One way I empathize with African-American clients is, first and foremost, to be a genuine person (not just a counselor or clinician). The client may begin the relationship asking questions about you the person, not the professional, in an attempt to locate you in the world. It's as if the client's internal dialog says, "As you try to understand me, by what pathways, perspectives, life experiences, and values are you coming to that understanding of me?" Typical questions my African-American clients have asked me are
• Are you Christian? • Where are you from? • What part of town do you live in? • Who are your folks? • Are you married?
Develop Discrepancy
Motivation for change is enhanced when clients perceive discrepancies between their current situation and their hopes for the future. Your task is to help focus your client's attention on how current behavior differs from ideal or desired behavior. Discrepancy is initially highlighted by raising your clients' awareness of the negative personal, familial, or community consequences of a problem behavior and helping them confront the substance use that contributed to the consequences. Although helping a client perceive discrepancy can be difficult, carefully chosen and strategic reflecting can underscore incongruities.
Separate the behavior from the person and help your client explore how important personal goals (e.g., good health, marital happiness, financial success) are being undermined by current substance use patterns. This requires you to listen carefully to your client's statements about values and connections to community, family, and church. If the client shows concern about the effects of personal behavior, highlight this concern to heighten the client's perception and acknowledgment of discrepancy.
Once a client begins to understand how the consequences or potential consequences of current behavior conflict with significant personal values, amplify and focus on this discordance until the client can articulate consistent concern and commitment to change.
One useful tactic for helping a client perceive discrepancy is sometimes called the "Columbo approach" (Kanfer and Schefft, 1988). This approach is particularly useful with a client who prefers to be in control. Essentially, the clinician expresses understanding and continuously seeks clarification of the client's problems but appears unable to perceive any solution. A stance of uncertainty or confusion can motivate the client to take control of the situation by offering a solution to the clinician (Van Bilsen, 1991).
Tools other than talking can be used to reveal discrepancy. For example, show a video and then discuss it with the client, allowing the client to make the connection to his own situation. Juxtaposing different media messages or images that are meaningful to a client can also be effective. This strategy may be particularly effective for adolescents because it provides stimulation for discussion and reaction.
You can help your client perceive discrepancy on a number of different levels, from physical to spiritual, and in different domains, from attitudinal to behavioral. To do this, it is useful to understand not only what an individual values but also what the community values. For example, substance use might conflict with the client's personal identity and values; it might conflict with the values of the larger community; it might conflict with spiritual or religious beliefs; or it might conflict with the values of the client's family members. Thus, discrepancy can be made clear by contrasting substance-using behavior with the importance the clients ascribe to their relationships with family, religious groups, and the community.
Developing Discrepancy
• Developing awareness of consequences helps clients examine their behavior. • A discrepancy between present behavior and important goals motivates change. • The client should present the arguments for change.
The client's cultural background can affect perceptions of discrepancy. For example, African- Americans may regard addiction as "chemical slavery," which may conflict with their ethnic pride and desire to overcome a collective history of oppression. Moreover, African-Americans may be more strongly influenced than white Americans by the expressed values of a larger religious or spiritual community. In a recent focus group study with adolescents, African- American youths were much more likely than other youths to view cigarette smoking as conflicting with their ethnic pride (Luke, 1998). They pointed to this conflict as an important reason not to smoke.
The Columbo Approach
Sometimes I use what I refer to as the Columbo approach to develop discrepancy with clients. In the old "Columbo" TV series, Peter Falk played a detective who had a sense of what had really occurred but used a somewhat bumbling, unassuming Socratic style of querying his prime suspect, strategically posing questions and making reflections to piece together a picture of what really happened. As the pieces began to fall into place, the object of Columbo's investigation would often reveal the real story.
Avoid Argument
You may occasionally be tempted to argue with a client who is unsure about changing or unwilling to change, especially if the client is hostile, defiant, or provocative. However, trying to convince a client that a problem exists or that change is needed could precipitate even more resistance. If you try to prove a point, the client predictably takes the opposite side. Arguments with the client can rapidly degenerate into a power struggle and do not enhance motivation for beneficial change. When it is the client, not you, who voices arguments for change, progress can be made. The goal is to "walk" with clients (i.e., accompany clients through treatment), not "drag" them along (i.e., direct clients' treatment).
A common area of argument is the client's unwillingness to accept a label such as "alcoholic" or "drug abuser." Miller and Rollnick stated that
[T]here is no particular reason why the therapist should badger clients to accept a label, or exert great persuasive effort in this direction. Accusing clients of being in denial or resistant or addicted is more likely to increase their resistance than to instill motivation for change. We advocate starting with clients wherever they are, and altering their self-perceptions, not by arguing about labels, but through substantially more effective means (Miller and Rollnick, 1991, p. 59).
Although this conflicts with some clinicians' belief that clients must be persuaded to self-label, the approach advocated in the "Big Book" of Alcoholics Anonymous (AA) is that labels are not to be imposed (AA, 1976). Rather, it is a personal decision of each individual.
Avoiding Arguments
Reprinted with permission.
• Arguments are counterproductive. • Defending breeds defensiveness. • Resistance is a signal to change strategies. • Labeling is unnecessary.
Roll With Resistance
Resistance is a legitimate concern for the clinician because it is predictive of poor treatment outcomes and lack of involvement in the therapeutic process. One view of resistance is that the client is behaving defiantly. Another, perhaps more constructive, viewpoint is that resistance is a signal that the client views the situation differently. This requires you to understand your client's perspective and proceed from there. Resistance is a signal to you to change direction or listen more carefully. Resistance actually offers you an opportunity to respond in a new, perhaps surprising, way and to take advantage of the situation without being confrontational.
Adjusting to resistance is similar to avoiding argument in that it offers another chance to express empathy by remaining nonjudgmental and respectful, encouraging the client to talk and stay involved. Try to avoid evoking resistance whenever possible, and divert or deflect the energy the client is investing in resistance toward positive change.
How do you recognize resistance? Figure 3-2 depicts four common behaviors that indicate that a client is resisting treatment. How do you avoid arguing and, instead, adapt to resistance? Miller and colleagues have identified and provided examples of at least seven ways to react appropriately to client resistance (Miller and Rollnick, 1991; Miller et al., 1992). These are described below.
Simple reflection
The simplest approach to responding to resistance is with nonresistance, by repeating the client's statement in a neutral form. This acknowledges and validates what the client has said and can elicit an opposite response.
Client: I don't plan to quit drinking anytime soon.
Clinician: You don't think that abstinence would work for you right now.
Amplified reflection
Another strategy is to reflect the client's statement in an exaggerated form--to state it in a more extreme way but without sarcasm. This can move the client toward positive change rather than resistance.
Client: I don't know why my wife is worried about this. I don't drink any more than any of my friends.
Clinician: So your wife is worrying needlessly.
Double-sided reflection
A third strategy entails acknowledging what the client has said but then also stating contrary things she has said in the past. This requires the use of information that the client has offered previously, although perhaps not in the same session.
Client: I know you want me to give up drinking completely, but I'm not going to do that!
Clinician: You can see that there are some real problems here, but you're not willing to think about quitting altogether.
Shifting focus
You can defuse resistance by helping the client shift focus away from obstacles and barriers. This method offers an opportunity to affirm your client's personal choice regarding the conduct of his own life.
Client: I can't stop smoking reefer when all my friends are doing it.
Clinician: You're way ahead of me. We're still exploring your concerns about whether you can get into college. We're not ready yet to decide how marijuana fits into your goals.
Agreement with a twist
A subtle strategy is to agree with the client, but with a slight twist or change of direction that propels the discussion forward.
Client: Why are you and my wife so stuck on my drinking? What about all her problems? You'd drink, too, if your family were nagging you all the time.
Clinician: You've got a good point there, and that's important. There is a bigger picture here, and maybe I haven't been paying enough attention to that. It's not as simple as one person's drinking. I agree with you that we shouldn't be trying to place blame here. Drinking problems like these do involve the whole family.
Reframing
A good strategy to use when a client denies personal problems is reframing--offering a new and positive interpretation of negative information provided by the client. Reframing "acknowledges the validity of the client's raw observations, but offers a new meaning...for them" (Miller and Rollnick, 1991, p. 107).
Client: My husband is always nagging me about my drinking--always calling me an alcoholic. It really bugs me.
Clinician: It sounds like he really cares about you and is concerned, although he expresses it in a way that makes you angry. Maybe we can help him learn how to tell you he loves you and is worried about you in a more positive and acceptable way.
In another example, the concept of relative tolerance to alcohol provides a good opportunity for reframing with problem drinkers (Miller and Rollnick, 1991). Many heavy drinkers believe they are not alcoholics because they can "hold their liquor." When you explain that tolerance is a risk factor and a warning signal, not a source of pride, you can change your client's perspective about the meaning of feeling no effects. Thus, reframing is not only educational but sheds new light on the client's experience of alcohol.
Rolling With Resistance
Reprinted with permission.
• Momentum can be used to good advantage. • Perceptions can be shifted. • New perspectives are invited but not imposed. • The client is a valuable resource in finding solutions to problems.
Siding with the negative
One more strategy for adapting to client resistance is to "side with the negative"--to take up the negative voice in the discussion. This is not "reverse psychology," nor does it involve the ethical quandaries of prescribing more of the symptom, as in a "therapeutic paradox." Typically, siding with the negative is stating what the client has already said while arguing against change, perhaps as an amplified reflection. If your client is ambivalent, your taking the negative side of the argument evokes a "Yes, but..." from the client, who then expresses the other (positive) side. Be cautious, however, in using this too early in treatment or with depressed clients.
Client: Well, I know some people think I drink too much, and I may be damaging my liver, but I still don't believe I'm an alcoholic or in need of treatment.
Clinician: We've spent considerable time now going over your positive feelings and concerns about your drinking, but you still don't think you are ready or want to change your drinking patterns. Maybe changing would be too difficult for you, especially if you really want to stay the same. Anyway, I'm not sure you believe you could change even if you wanted to.
Support Self-Efficacy
Many clients do not have a well-developed sense of self-efficacy and find it difficult to believe that they can begin or maintain behavioral change. Improving self-efficacy requires eliciting and supporting hope, optimism, and the feasibility of accomplishing change. This requires you to recognize the client's strengths and bring these to the forefront whenever possible. Unless a client believes change is possible, the perceived discrepancy between the desire for change and feelings of hopelessness about accomplishing change is likely to result in rationalizations or denial in order to reduce discomfort. Because self-efficacy is a critical component of behavior change, it is crucial that you as the clinician also believe in your clients' capacity to reach their goals.
Discussing treatment or change options that might still be attractive to clients is usually helpful, even though they may have dropped out of other treatment programs or returned to substance use after a period of being substance free. It is also helpful to talk about how persons in similar situations have successfully changed their behavior. Other clients can serve as role models and offer encouragement. Nonetheless, clients must ultimately come to believe that change is their responsibility and that long-term success begins with a single step forward. The AA motto, "one day at a time," may help clients focus and embark on the immediate and small changes that they believe are feasible.
Education can increase clients' sense of self-efficacy. Credible, understandable, and accurate information helps clients understand how substance use progresses to abuse or dependency. Making the biology of addiction and the medical effects of substance use relevant to the clients' experience may alleviate shame and guilt and instill hope that recovery can be achieved by using appropriate methods and tools. A process that initially feels overwhelming and hopeless can be broken down into achievable small steps toward recovery.
Self-Efficacy
Reprinted with permission.
• Belief in the possibility of change is an important motivator. • The client is responsible for choosing and carrying out personal change. • There is hope in the range of alternative approaches available.
Five Opening Strategies For Early Sessions
Clinicians who adopt motivational interviewing as a preferred style have found that the five strategies discussed below are particularly useful in the early stages of treatment. They are based on the five principles described in the previous section: express empathy, develop discrepancy, avoid argument, adjust to rather than oppose client resistance, and support self- efficacy. Helping clients address their natural ambivalence is a good starting point. These opening strategies ensure your support for your client and help the client explore ambivalence in a safe setting. The first four strategies, which are derived from client-centered counseling, help clients explore their ambivalence and reasons for change. The fifth strategy is specific to motivational interviewing and integrates and guides the other four.
In early treatment sessions, determine your client's readiness to change or stage of change (see Chapters 1, 4, and 8). Be careful to avoid focusing prematurely on a particular stage of change or assuming the client is at a particular stage because of the setting where you meet. As already noted, using strategies inappropriate for a particular change stage or forming an inaccurate perception regarding the client's wants or needs could be harmful. Therefore, try not to identify the goals of counseling until you have sufficiently explored the client's readiness.
Ask Open-Ended Questions
Asking open-ended questions helps you understand your clients' point of view and elicits their feelings about a given topic or situation. Open-ended questions facilitate dialog; they cannot be answered with a single word or phrase and do not require any particular response. They are a means to solicit additional information in a neutral way. Open-ended questions encourage the client to do most of the talking, help you avoid making premature judgments, and keep communication moving forward (see Figure 3-3).
Listen Reflectively
Reflective listening, a fundamental component of motivational interviewing, is a challenging skill in which you demonstrate that you have accurately heard and understood a client's communication by restating its meaning. That is, you hazard a guess about what the client intended to convey and express this in a responsive statement, not a question. "Reflective listening is a way of checking rather than assuming that you know what is meant" (Miller and Rollnick, 1991, p. 75).
Reflective listening strengthens the empathic relationship between the clinician and the client and encourages further exploration of problems and feelings. This form of communication is particularly appropriate for early stages of counseling. Reflective listening helps the client by providing a synthesis of content and process. It reduces the likelihood of resistance, encourages the client to keep talking, communicates respect, cements the therapeutic alliance, clarifies exactly what the client means, and reinforces motivation (Miller et al., 1992).
This process has a tremendous amount of flexibility, and you can use reflective listening to reinforce your client's positive ideas (Miller et al., 1992). The following dialog gives some examples of clinician's responses that illustrate effective reflective listening. Essentially, true reflective listening requires continuous alert tracking of the client's verbal and nonverbal responses and their possible meanings, formulation of reflections at the appropriate level of complexity, and ongoing adjustment of hypotheses.
Clinician: What else concerns you about your drinking?
Client: Well, I'm not sure I'm concerned about it, but I do wonder sometimes if I'm drinking too much.
Clinician: Too much for...?
Client: For my own good, I guess. I mean it's not like it's really serious, but sometimes when I wake up in the morning I feel really awful, and I can't think straight most of the morning.
Clinician: It messes up your thinking, your concentration.
Client: Yes, and sometimes I have trouble remembering things.
Clinician: And you wonder if that might be because you're drinking too much?
Client: Well, I know it is sometimes.
Clinician: You're pretty sure about that. But maybe there's more...
Client: Yeah, even when I'm not drinking, sometimes I mix things up, and I wonder about that.
Clinician: Wonder if...?
Client: If alcohol's pickling my brain, I guess. Clinician: You think that can happen to people, maybe to you.
Client: Well, can't it? I've heard that alcohol kills brain cells.
Clinician: Um-hmm. I can see why that would worry you.
Client: But I don't think I'm an alcoholic or anything.
Clinician: You don't think you're that bad off, but you do wonder if maybe you're overdoing it and damaging yourself in the process.
Client: Yeah.
Clinician: Kind of a scary thought. What else worries you?
Summarize
Most clinicians find it useful to periodically summarize what has occurred in a counseling session. Summarizing consists of distilling the essence of what a client has expressed and communicating it back. "Summaries reinforce what has been said, show that you have been listening carefully, and prepare the client to move on" (Miller and Rollnick, 1991, p. 78). A summary that links the client's positive and negative feelings about substance use can facilitate an understanding of initial ambivalence and promote the perception of discrepancy. Summarizing is also a good way to begin and end each counseling session and to provide a natural bridge when the client is transitioning between stages of change.
Summarizing also serves strategic purposes. In presenting a summary, you can select what information should be included and what can be minimized or left out. Correction of a summary by the client should be invited, and this often leads to further comments and discussion. Summarizing helps clients consider their own responses and contemplate their own experience. It also gives you and your client an opportunity to notice what might have been overlooked as well as incorrectly stated.
Affirm
When it is done sincerely, affirming your client supports and promotes self-efficacy. More broadly, your affirmation acknowledges the difficulties the client has experienced. By affirming, you are saying, "I hear; I understand," and validating the client's experiences and feelings. Affirming helps clients feel confident about marshaling their inner resources to take action and change behavior. Emphasizing their past experiences that demonstrate strength, success, or power can prevent discouragement. For some clients, such as many African- Americans, affirmation has a spiritual context. Affirming their inner guiding spirit and their faith may help resolve their ambivalence. Several examples of affirming statements (Miller and Rollnick, 1991) follow:
• I appreciate how hard it must have been for you to decide to come here. You took a big step. • I think it's great that you want to do something about this problem. • That must have been very difficult for you. • You're certainly a resourceful person to have been able to live with the problem this long and not fall apart. • That's a good suggestion. • It must be difficult for you to accept a day-to-day life so full of stress. I must say, if I were in your position, I would also find that difficult.
Elicit Self-Motivational Statements
Engaging the client in the process of change is the fundamental task of motivational interviewing. Rather than identifying the problem and promoting ways to solve it, your task is to help the client recognize how life might be better and choose ways to make it so.
Remember that your role is to entice the client to voice personal concerns and intentions, not to convince him that a transformation is necessary. Successful motivational interviewing requires that clients, not the clinician, ultimately argue for change and persuade themselves that they want to and can improve. One signal that the client's ambivalence and resistance are diminishing is the self-motivational statement.
Four types of motivational statements can be identified (Miller and Rollnick, 1991):
• Cognitive recognition of the problem (e.g., "I guess this is more serious than I thought.") • Affective expression of concern about the perceived problem (e.g., "I'm really worried about what is happening to me.") • A direct or implicit intention to change behavior (e.g., "I've got to do something about this.") • Optimism about one's ability to change (e.g., "I know that if I try, I can really do it.")
Figure 3-4 illustrates how you can differentiate a self-motivational statement from a countermotivational assertion. You can reinforce your client's self-motivational statements by reflecting them, nodding, or making approving facial expressions and affirming statements. Encourage clients to continue exploring the possibility of change. This can be done by asking for an elaboration, explicit examples, or more details about remaining concerns. Questions beginning with "What else" are effective ways to invite further amplification. Sometimes asking clients to identify the extremes of the problem (e.g., "What are you most concerned about?") helps to enhance their motivation. Another effective approach is to ask clients to envision what they would like for the future. From there, clients may be able to begin establishing specific goals.
Figure 3-5 provides a useful list of questions you can ask to elicit self-motivational statements from the client. Effectiveness of Motivational Interviewing
A recent review of 11 clinical trials of motivational interviewing concluded that this is a "useful clinical intervention...[and] appears to be an effective, efficient, and adaptive therapeutic style worthy of further development, application, and research" (Noonan and Moyers, 1997, p. 8). Motivational interviewing is a counseling approach that more closely reflects the principles of motivational enhancement than the variety of brief interventions reviewed in Chapter 2, and it also links these basic precepts to the stages-of-change model.
Of the 11 studies reviewed, 9 found motivational interviewing more effective than no treatment, standard care, extended treatment, or being on a waiting list before receiving the intervention. Two of the 11 studies did not support the effectiveness of motivational interviewing, although the reviewers suggested that the spirit of this approach may not have been followed because the providers delivered advice in an authoritarian manner and may not have been adequately trained (Noonan and Moyers, 1997). Moreover, one study had a high dropout rate. Two studies supported the efficacy of motivational interviewing as a stand-alone intervention for self-identified concerned drinkers who were provided feedback about their drinking patterns but received no additional clinical attention. Three trials confirmed the usefulness of motivational interviewing as an enhancement to traditional treatment, five supported the effectiveness of motivational interviewing in reducing substance-using patterns of patients appearing in medical settings for other health-related conditions, and one trial compared a brief motivational intervention favorably with a more extensive alternative treatment for marijuana users.
Motivational Interviewing and Managed Care
In addition to its effectiveness, motivational interviewing is beneficial in that it can easily be applied in a managed care setting, where issues of cost containment are of great concern. Motivational interviewing approaches are particularly well suited to managed care in the following ways:
• Low cost. Motivational interviewing was designed from the outset to be a brief intervention and is normally delivered in two to four outpatient sessions. • Efficacy. There is strong evidence that motivational interviewing triggers change in high-risk lifestyle behaviors. • Effectiveness. Large effects from brief motivational counseling have held up across a wide variety of real-life clinical settings. • Mobilizing client resources. Motivational interviewing focuses on mobilizing the client's own resources for change. • Compatibility with health care delivery. Motivational interviewing does not assume a long-term client-therapist relationship. Even a single session has been found to invoke behavior change, and motivational interviewing can be delivered within the context of larger health care delivery systems. • Emphasizing client motivation. Client motivation is a strong predictor of change, and this approach puts primary emphasis on first building client motivation for change. Thus, even if clients do not stay for a long course of treatment (as is often the case with substance abuse), they have been given something that is likely to help them within the first few sessions. • Enhancing adherence. Motivational interviewing is also a sensible prelude to other health care interventions because it has been shown to increase adherence, which in turn improves treatment outcomes.
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