Substance Use Disorders and Addictions

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Keith Morgen

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    Dedication

    To my parents and Viv, for supporting me throughout my education and career.

    To Melissa, for always knowing when I need to work and when I need to take a break. She always seems to magically know what I need to get things done and makes everything about me better.

    To Margaret, Charlie, and Nicholas, for the well-needed breaks of Monopoly, Star Wars, Arthur, Thomas, Minecraft, Wii, trains, the park, the pool, hiking, and other distractions while writing this book.

    Editors’ Preface

    Introduction to the Series Counseling and Professional Identity in the 21st Century

    While time, energy, and money have been poured into programs that target borders and drug trafficking, ignorance and naiveté, and even skill development in learning how to “just say no,” the reality is that substance use remains a major concern for all in this 21st century. Advances in our understanding of the psychosocial, biological, and neurological contributors to the development and maintenance of substance disorders and addiction have led to innovation in our approaches to both prevention and intervention. While much of what we have done in the past took on a “one size fits all” mentality, this research has helped us understand the highly unique and individualized nature of substance abuse and addiction. The text that you currently hold in your hands, Substance Use Disorders and Addictions by Keith Morgen, reflects the latest in what we know of the etiology, the prevention, and the intervention of substance abuse and addiction.

    In an area with many more questions than answers, Substance Use Disorders and Addictions provides clear direction in assessment, diagnosis, treatment, and prevention programming of substance use disorders and additions. Dr. Morgen demonstrates his gift in being able to take difficult concepts and constructs tied to things such as the psychoneurology of substance abuse and addiction and present them in easy-to-grasp language, supported by an ample array of rich case illustrations. Substance Use Disorders and Addictions is an essential reading for students and clinicians, regardless of their professional specialty or treatment focus.

    While we are proud of the content and topics covered within this text, we are more than aware that one text, one learning experience, will not be sufficient for the development of a counselor’s professional competency. The formation of both your professional identity and practice will be a lifelong process. It is a process that we hope to facilitate through the presentation of this text and the creation of our series Counseling and Professional Identity in the 21st Century.

    Counseling and Professional Identity in the 21st Century is a new, fresh, pedagogically sound series of texts targeting counselors in training. This series is NOT simply a compilation of isolated books matching that which is already in the market. Rather, each book, with its targeted knowledge and skills, will be presented as but one part of a larger whole. The focus and content of each text serve as a single lens through which a counselor can view his or her clients, engage in his or her practice, and articulate his or her own professional identity.

    Counseling and Professional Identity in the 21st Century is unique not just in the fact that it “packages” a series of traditional texts but that it provides an integrated curriculum targeting the formation of the readers’ professional identity and efficient, ethical practice. Each book within the series is structured to facilitate the ongoing professional formation of the reader. The materials found within each text are organized in order to move the reader to higher levels of cognitive, affective, and psychomotor functioning, resulting in his or her assimilation of the materials presented into both his or her professional identity and approach to professional practice. While each text targets a specific set of core competencies (cognates and skills), competencies identified by the professional organizations and accreditation bodies, each book in the series will emphasize each of the following:

    • The assimilation of concepts and constructs provided across the text found within the series, thus fostering the reader’s ongoing development as a competent professional;
    • The blending of contemporary theory with current research and empirical support;
    • A focus on the development of procedural knowledge with each text employing case illustrations and guided practice exercises to facilitate the reader’s ability to translate the theory and research discussed into professional ­decision making and application;
    • The emphasis on the need for and means of demonstrating accountability; and
    • The fostering of the reader’s professional identity and with it the assimilation of the ethics and standards of practice guiding the counseling profession.

    We are proud to have served as co-editors of this series, feeling sure that all the texts included, just like Substance Use Disorders and Addictions, will serve as a significant resource to you and your development as a professional counselor.

    Richard Parsons, PhD

    Naijian Zhang, PhD

    Author’s Preface

    Perspectives on the Current State of the Counseling Profession: How It Pertains to This Book

    I read a number of excellent books while writing this text. In the course of reading these other works, I began to see a common theme that substance use disorder and addiction counseling is defined as a practice that is based on the following criteria: (1) Substance use disorder and addiction counseling is evidence-based (e.g., motivational interviewing or brief structural family therapy—both of which will be discussed in this text); (2) Substance use disorder and addiction counseling should approach clients from a positive perspective; (3) The practice of substance use disorder and addiction counseling is complicated but relies on a collaborative stance between counselor and client, as well as between counselor and the other areas of influence in the treatment process (e.g., family, courts, or medical services); and (4) Substance use disorder and addiction counseling is built on solid ethical principles and emphasizes social justice and multicultural considerations for the best treatment and welfare of the client. These books all had titles such as Substance Abuse Counseling or Addiction Counseling. However, the four components listed above can also be used to describe the core components of the counseling profession for all disorders. That is why I chose to open this book with a discussion on what exactly the profession of “substance use disorders and addiction counseling” is, is not, and perhaps can one day be, at least how I see it.

    One unique aspect of the addiction field is that those providing treatment for individuals with substance use and addictive disorders can be physicians, psychologists, psychiatrists, licensed professional counselors (LPCs), social workers, or addiction counselors. But concerns remain about how adequately trained these professionals treating addiction are in providing such services (Miller, Scarborough, Clark, ­Leonard, & Keziah, 2010). In addition, concerns remain regarding the curricular and clinical practice content of the training (Morgen & Miller, 2013). Historically, these concerns arose because addiction counselors could receive certification without formal training in addiction or counseling (Miller et al., 2010). However, recent advances are strengthening the training process. For example, in 2009, the Council for Accreditation of Counseling and Related Programs (CACREP) finalized guidelines for addiction counseling education in relationship to knowledge, skills, and practices. CACREP also contains curricular mandates for the inclusion of addictions material into the core of professional counseling training. Other guidelines for training and competencies in addiction counseling were produced by the Center for Substance Abuse Treatment (CSAT) and the Substance Abuse and Mental Health Services Administration (SAMHSA). In addition, the National Addiction Studies Accreditation Commission (NASAC) was established to standardize addiction training. Finally, there is also an increased emphasis of the master’s degree as an entry-level requirement for practice, but in some states only a high school diploma or general equivalency diploma is required for credentialing in the addiction profession (Miller et al., 2010).

    Certification

    Certification provides a professional standard that is governed by an organization, thus establishing a common minimum competency for professionals. While there are state requirements for substance abuse counseling licensure and certification guidelines, there is a lack of nationwide continuity. This lack of congruence of standards between states produces a confused profession, even more confused trainees and students looking to enter the profession, and clients who do not understand the differences. For example, a client once asked me, “What is the difference if I receive addiction treatment from an addiction counselor or a psychologist or a counselor or a social worker?”

    I did not have an answer the client could understand. The real answer is just too confusing and basically is summed up in the remainder of my Preface.

    There are different certifications offered by various agencies both domestically and internationally (el-Guebaly & Violato, 2011). For example, the International Association of Addictions and Offender Counselors (IAAOC), which is a division of the American Counseling Association (ACA) working in conjunction with the National Board of Certified Counselors (NBCC), has developed standards and a program for the certification of master’s-level addiction counselors. One requirement for the master addiction counselor (MAC) credential is a passing score on the Examination for Master Addiction Counselors (www.nbcc.org). As of the writing of this book, the MAC application requirements are under review.

    According to the National Association of Alcoholism and Drug Abuse Counselors (NAADAC), the National Certification Commission for Addiction Professionals recognizes three levels of substance abuse certifications: the national certified addiction counselor level I (NCAC I), the national certified addiction counselor level II (NCAC II), and the MAC. The NAADAC also acknowledges additional specialties, such as the national certified adolescent addiction counselor (see Table 1 for a review of several of the certification exams and their associated applicant criteria and content). However, counselors’ level of certification or licensure will dictate their scope of practice in regard to their state regulations.

    Table 1 NAADAC Certifications and Associated Eligibility

    Certification Type

    Eligibility

    National Certified Addiction Counselor – Level I

    GED, High School Diploma, or higher.

    Current credential or license as a Substance Use Disorder/Addiction counselor issued by a state or credentialing authority.

    At least three years full-time or 6,000 hours of supervised experience as a Substance Use Disorder/Addiction counselor.

    At least 270 contact hours of education and training in Substance Use Disorders/Addiction or related counseling subjects. Must include six hours of ethics training and six hours of HIV/AIDS-specific training within the last six years. At least 50% of training hours must be face-to-face.

    Passing score on the NCAC I examination within four years of the application.

    National Certified Addiction Counselor – Level II

    Bachelor’s degree or higher in Substance Use Disorder/Addiction and/or related counseling subjects (social work, mental health counseling, psychology) from a regionally accredited institution of higher learning.

    Current credential or license as a Substance Use Disorder/Addiction counselor issued by a state or credentialing authority.

    At least five years full-time or 10,000 hours of supervised experience as a Substance Use Disorder/Addiction counselor.

    At least 450 contact hours of education and training in Substance Use Disorder/Addiction. Must include six hours of ethics training and six hours of HIV/AIDS-specific training within the last six years. At least 50% of training hours must be face-to-face.

    Passing score on the NCAC II examination within four years of the application.

    Master Addiction Counselor

    Master’s degree or higher in Substance Use Disorders/Addiction and/or related counseling subjects (social work, mental health counseling, psychology) from a regionally accredited institution of higher learning.

    Current credential or license as a Substance Use Disorder/Addiction counselor or professional counselor (social worker, mental health, marriage and family, professional counselor, psychologist, psychiatrist, medical doctor) issued by a state or credentialing authority.

    At least three years full-time or 6,000 hours of supervised experience as a Substance Use Disorder/Addiction counselor.

    At least 500 contact hours of education and training in Substance Use Disorder/Addiction. Must include six hours of ethics training and six hours of HIV/AIDS-specific training within the last six years. At least 50% of training hours must be face-to-face.

    Passing score on the MAC examination within four years of the application.

    National Dependence Specialist

    Bachelor’s degree or higher in a healing art (i.e., substance use or mental health disorders, nursing, respiratory therapy, or pharmacology etc.) from a regionally accredited institution of higher learning.

    Current credential or license in a healing art (i.e., substance use disorders, nursing, respiratory therapy, or pharmacology, etc.) issued by a state or credentialing authority.

    At least three years full-time or 6,000 hours of employment in a health care profession (i.e., substance use disorders, nursing, respiratory therapy, or pharmacology, etc.).

    At least 270 contact hours of education and training in healing art. Must include at least 40 hours of nicotine-specific education, six hours of ethics training, and six hours of HIV/AIDS-specific training within the last six years. At least 50% of training hours must be face-to-face.

    Passing score on NDS examination within four years of the application.

    National Certified Adolescent Addictions Counselor

    Bachelor’s degree or higher in Substance Use Disorders/Addiction and/or related counseling subjects (social work, mental health counseling, psychology) from a regionally accredited institution of higher learning.

    Current credential or license as a Substance Use Disorder/Addiction counselor issued by a state or credentialing authority.

    At least five years full-time or 10,000 hours of supervised experience working in Substance Use Disorder/Addiction and/or related counseling subjects. Must include two and a half years or 5,000 hours of supervised experience working with adolescents.

    At least 270 contact hours of education and training in Substance Use Disorder/Addiction and/or related counseling subjects. Must include at least 70 contact hours of training related to adolescent treatment, six hours of ethics training, and six hours of HIV/AIDS-specific training within the last six years. At least 50% of training hours must be face-to-face.

    Passing score on the NCAAC examination within four years of the application.

    National Certified Peer Recovery Support Specialist

    GED, High School Diploma, or higher.

    Minimum of one year full-time of direct practice (volunteer or paid) in a peer recovery support environment.

    At least 125 contact hours of peer recovery focused education and training to include education in documentation, community/family education, case management, crisis management, Recovery-Oriented Systems of Care (ROSC), screening and intake, Identification of Indicators of substance use and/or co-occurring disorders for referral, service coordination, service.

    planning, cultural awareness and/or humility, and basic pharmacology. Must include a minimum of six hours of ethics and six hours of HIV/AIDS-specific training within the last six years. At least 50% of training hours must be face-to-face.

    Minimum one year of recovery from Substance Use/Co-Occurring Mental Health Disorders (self-attestation).

    Passing score on the NCPRSS examination within four years of the application.

    National Endorsed Student Assistance Professional

    Bachelor’s degree or higher in Substance Use Disorder/Addiction and/or related counseling subjects (social work, mental health counseling, psychology) from a regionally accredited institution of higher learning.

    Current credential or license as a Substance Use Disorder/Addiction counselor issued by a state or credentialing authority.

    At least 4,500 hours of supervised experience (volunteer or paid) in Substance Use Disorder/Addiction, to include at least 3,000 hours of direct service delivering student assistance services.

    At least 100 contact hours of education and training in Substance Use Disorder/Addiction and/or related counseling subjects including six hours of ethics training and six hours of HIV/AIDS-specific training within the last six years. At least 70 hours must be related to student assistance services. At least 50% of the 70 hours must be face-to-face training.

    Passing score on the NESAP examination within four years of the application.

    National Clinical Supervision Endorsement

    Bachelor’s degree or higher in Substance Use Disorder/Addiction and/or related counseling subjects (social work, mental health counseling, psychology) from a regionally accredited institution of higher learning.

    Current credential or license in Substance Use Disorder/Addiction and/or related counseling subjects (social work, mental health counseling, psychology) issued by a state or credentialing authority for the past five years.

    At least five years full-time or 10,000 hours overall of employment as a Substance Use Disorder/Addiction counselor. This must include a minimum of two years full-time or 4,000 hours performing direct clinical supervision, and 200 hours of received supervision as a clinical supervisor.

    At least of 30 contact hours of education and training specific to Substance Use Disorder/Addiction clinical supervision. In addition, must include six hours of ethics training and six hours of HIV/AIDS-specific training within the last six years. At least 50% of training hours must be face-to-face.

    A passing score on the NCSE examination within four years of the application.

    National Endorsed Co-Occurring Disorders Professional

    Bachelor’s degree or higher in Substance Use Disorder/Addiction and/or related counseling subjects (social work, mental health counseling, psychology) from a regionally accredited institution of higher learning.

    Current credential or license in Substance Use Disorder/Addiction and/or related counseling subjects (social work, mental health counseling, psychology) issued by a state or credentialing authority for the past five years.

    At least five years full-time or 10,000 hours of supervised experience in Substance Use and Mental Health Disorders treatment, to include two and a half years full-time or 5,000 hours of supervised experience working with co-occurring persons.

    At least 70 contact hours of education and training in co-occurring disorders. Must include six hours of ethics training and six hours of HIV/AIDS-specific training within the last six years. At least 50% of training hours must be face-to-face.

    Passing score on the NECODP examination within four years of the application.

    Source: www.naadac.org.

    The confusion—in part—is that each credentialing body has different requirements for certification. And many of these requirements vary across agency and state. Morgen and Miller (2013) attempted to summarize the overall mission of these varied bodies and concluded that they all share three general goals: (1) Each defines a core set of counselor roles, (2) each addresses a set of expected addiction counseling competencies, and (3) each makes use of assessment measures and exams to evaluate these competencies in those seeking credentialing. But Morgen (2011) noted that many credentialing bodies and states differ in opinion regarding the content and quantity of competencies required for addiction counseling credentialing.

    To add another layer of confusion, some credentialing organizations actually have different levels of certification. For example, the International Certification and Reciprocity Consortium (IC&RC), a national organization of certifying boards providing national reciprocity of certification, has three levels of certification: (1) certified addiction counselor, (2) certified drug counselor, and (3) alcohol and drug counselor. Each level has different training, education, and supervision requirements experience (the higher the certification level, the greater degree of requirements exist; http://www.internationalcredentialing.org/).

    Licensure

    Licensure is the most rigorous form of professional regulation (Morgen & Miller, 2013). Unlike certification, which can be granted nationally (e.g., the NBCC national certified counselor status), state law establishes licensure; thus, each state determines the requirements for licensure. Licensure eligibility typically consists of two criteria: (1) a graduate degree (master’s or higher) in the addiction counseling, counseling, or (in some states) psychology professions; and (2) postgraduate supervised hours of clinical work in the counseling or addiction counseling profession. However, different states have different requirements for licensure in regard to the degree type eligibility, graduate course work required, the professional identity and training of the clinical supervisor, and the number of clinical hours performing professional or addiction counseling (and related) services (Morgen, Miller, & Stretch, 2012).

    Accreditation

    Accreditation applies to the graduate counselor education or counseling psychology training program within a college or university that educates and trains students in the addiction counseling or counseling discipline. Accreditation procedures are designed to verify the quality and standardization of the graduate education. In the accreditation process, standards are clearly specified for the training of addiction or counseling practitioners, for instance, the mandated academic course content or the expected experiential practicum or internship components of the graduate program. Programs that meet or exceed the specified standards are then accredited. In 2009, CACREP recognized addiction counseling as a counseling specialty and thus outlined the accreditation requirements for any addiction counselor graduate program. Table 2 shows these requirements.

    Table 2 CACREP (2015) Addiction Counseling Standards
    • FOUNDATIONS
      • history and development of addiction counseling
      • theories and models of addiction related to substance use as well as behavioral and process addictions
      • principles and philosophies of addiction-related self-help
      • principles, models, and documentation formats of biopsychosocial case conceptualization and treatment planning
      • neurological, behavioral, psychological, physical, and social effects of psychoactive substances and addictive disorders on the user and significant others
      • psychological tests and assessments specific to addiction counseling
    • CONTEXTUAL DIMENSIONS
      • roles and settings of addiction counselors
      • potential for addictive and substance use disorders to mimic and/or co-occur with a variety of medical and psychological disorders
      • factors that increase the likelihood for a person, community, or group to be at risk for or resilient to psychoactive substance use disorders
      • regulatory processes and substance abuse policy relative to service delivery opportunities in addiction counseling
      • importance of vocation, family, social networks, and community systems in the addiction treatment and recovery process
      • role of wellness and spirituality in the addiction recovery process
      • culturally and developmentally relevant education programs that raise awareness and support addiction and substance abuse prevention and the recovery process
      • classifications, indications, and contraindications of commonly prescribed psychopharmacological medications for appropriate medical referral and consultation
      • diagnostic process, including differential diagnosis and the use of current diagnostic classification systems, including the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD)
      • cultural factors relevant to addiction and addictive behavior
      • professional organizations, preparation standards, and credentials relevant to the practice of addiction counseling
      • legal and ethical considerations specific to addiction counseling
      • record keeping, third party reimbursement, and other practice and management considerations in addiction counseling
    • PRACTICE
      • screening, assessment, and testing for addiction, including diagnostic interviews, mental status examination, symptom inventories, and psychoeducational and personality assessments
      • assessment of biopsychosocial and spiritual history relevant to addiction
      • assessment for symptoms of psychoactive substance toxicity, intoxication, and withdrawal
      • techniques and interventions related to substance abuse and other addictions
      • strategies for reducing the persisting negative effects of substance use, abuse, dependence, and addictive disorders
      • strategies for helping clients identify the effects of addiction on life problems and the effects of continued harmful use or abuse, and the benefits of a life without addiction
      • evaluating and identifying individualized strategies and treatment modalities relative to clients’ stage of dependence, change, or recovery
      • strategies for interfacing with the legal system and working with court referred clients

    Source: CACREP (2015, pp. 18–19).

    In addition, CACREP (2015) also embeds required addictions training within the core professional counseling curriculum. Thus, a graduate master’s program (e.g., clinical-counseling) leading to eligibility as a licensed professional counselor must integrate addictions content into the curriculum. For example, CACREP stipulates that theories and etiology of addictions and addictive behaviors be included in the content covered within the course(s) meeting the human growth and development domain of the graduate counseling curriculum. Some studies have shown that CACREP counseling programs currently satisfy these standards, meaning that addictions content is currently being covered (Iarussi, Perjessy, & Reed, 2013). However, though there has been some discussion in the literature regarding the nuts and bolts of how to integrate addiction counseling content into the general professional counseling standards (e.g., Lee, Craig, Fetherson, & Simpson, 2013), there are still unanswered questions regarding the degree and quality of the addiction content integration into the counseling curriculum (Morgen, Miller, Chasek, DePue, & Ivers, 2015a, 2015b). For instance, if you consider the topic of addiction etiology and addiction behaviors, that seems to be a very expansive topic to try and integrate into even one or two full class sessions. Or if there is an addiction course, what is the quality of that course, and how do the students integrate this content into their broader counseling training?

    CACREP program accreditation is defined as designating the “acceptable” degree of training. So a graduate from a CACREP addiction counseling program could be seen as “more of an addiction counselor” than a graduate from a non-CACREP program. In essence, counselor or addiction counselor identity (as defined by CACREP and accepted by ACA and numerous states) is being shaped by program accreditation status (i.e., CACREP or other). If you consider this paradigm against the broader backdrop of all the different addiction certifications and academic/professional eligibility requirements, you begin to see how the CACREP issue is just one more component of a long national dialogue regarding the issue of counselor identity.

    If CACREP is playing a role in establishing the credentialing of an addiction counselor (or professional counselor), then perhaps more discussion regarding what exactly constitutes addiction counseling (or professional counseling) training seems warranted. That is why some other accrediting and professional counseling organizations are developing and growing in response to the CACREP standards. The alternate movement is not anti-accreditation or anti-CACREP. Any counselor would agree in a split second about how critical curricular oversight and accreditation are to the practice of training counselors. Training must be rigorous with a core of standard content and skills instilled in all counselors via the classroom and field experiences. The reasons for these new bodies seem more aligned with a desire for a clearer, and more unified, definition of what it means to be a counselor or addiction counselor. Some of these new or growing groups are the Alliance for Professional Counselors and the Master’s in Psychology and Counseling Accreditation Council (MPCAC). In the future, some of these (or other) organizations could also take a role in organizing the accreditation process focused on acceptable training and experience for qualification for licensure as an addiction counselor. For example, Table 3 reviews the accreditation for counseling programs within MPCAC. The reader can see where there is room for the inclusion of addiction counseling curricular and training matters within the existing standards (or where standards can expand to include addiction counseling content).

    Table 3 Master’s in Psychology and Counseling Accreditation Standards

    Professional counselor identity, ethical behavior, and social justice practices. Including but not limited to: assisting students to acquire knowledge related to the history of the helping profession; professional counseling roles and functions; ethical standards related to professional organizations in the field of counseling; and public policy processes including system advocacy strategies on behalf of the profession, clients, and the communities that counselors serve.

    Human development and wellness across the life span. Including but not limited to: the study of life span development; maturational and structural theories of human development; wellness counseling theories; strategies to deal with developmental processes and transitions; human behavior; disabilities; environmental, contextual and multicultural factors that contribute to healthy human development and relevant culturally competent counseling practices; and the promotion of social justice in society.

    Neuroscientific, physical, and biological foundations of human development and wellness. Including but not limited to: facilitating students’ acquisition of new knowledge related to neuroscience, health and wellness; addictions; and the use of neuroscientific research findings for culturally competent counseling practices and social justice advocacy interventions.

    Ecological, contextual, multicultural, social justice foundations of human development. Including but not limited to: the study of culture from ecological, contextual, multicultural, and social justice perspectives; evidence-based strategies for working with diverse groups (related to but not limited to age, race, culture, ethnicity, disability, sexual orientation, gender, class, religion/spirituality); the impact of power, privilege, and oppression and micro/macro aggressions on human development; and culturally competent counseling and social justice advocacy interventions.

    Counseling, consultation, and social justice advocacy theories and skills. Including but not limited to: training in preventive counseling; consultation; individual, group, couples, marriage, family and addictions counseling; systems change intervention strategies and skills; and social justice advocacy interventions.

    Group theory, practice, and social justice advocacy. Including but not limited to: principles of group dynamics, group process, and group leadership; theories and methods of group counseling; and the application of group work theory and practice to organizational dynamics and social justice advocacy in different environmental settings (e.g., family, school, university, workplace, and community settings).

    Career and life development. Including but not limited to: the study of vocational/career development theories and decision-making models; career assessment instruments and techniques; occupational and related educational systems; career development applications; career counseling processes/techniques; and the application of social justice theories to people’s vocational/career development.

    Assessment of human behavior and organizational/community/institutional systems. Including but not limited to: assessment and diagnosis of individual psychiatric disorders as defined by classification systems such as the Diagnostic Statistical Manual (DSM) and the International Classification of Diseases (ICD); understanding of defined diagnostic disorders relative to the helping context; knowledge of cultural biases associated with classification systems; assessment strategies designed to promote healthy human functioning; and assessment strategies that focus on organizational/community/social justice advocacy dynamics as they impact human development, wellness, and the perpetuation of psychiatric disorders as listed in various classification systems.

    Tests and measurements. Including but not limited to promoting an understanding of the theoretical and historical basis for, as well as knowledge of cultural biases associated with: assessment techniques; testing methods; knowledge of various types of tests and evaluation strategies that result in knowledgeable selection, administration, interpretation; and use of assessment/evaluation instruments and techniques that foster social justice among diverse client populations.

    Traditional and social justice-oriented research and evaluations. Including but not limited to: quantitative and qualitative research design and methods; statistical analyses, principles, practices, and application of needs assessments; the design and process of program evaluation; organizational, community, and social justice advocacy evaluation strategies; and knowledge of cultural biases associated with research practices.

    Practicum/Internship experiences. At least two (2) academic terms of supervised field placement experiences that focus on issues related to the promotion of mental health, human development, wellness, cultural competence, and social justice advocacy (at least three semester hours or five quarter hours per academic term in a counseling and/or related human service setting with 300 hours of supervised field training). The practicum/internship experience (commensurate with program goals and State licensure requirements) shall be completed under the clinical supervision of appropriately credentialed professionals (e.g., licensed professional counselor, social worker, marriage and family therapist, school counselor, psychologist, or physician with a specialty in psychiatry).

    Source: MPCAC Accreditation Manual (2016).

    For some counselors/programs, CACREP is problematic due to the following reasons. First, some training programs do not have the faculty resources to meet the CACREP mandate for faculty size. These programs would not be able to achieve CACREP accreditation and would thus be seen as perhaps “less-than” or offering a “poor quality” of training not appropriate for licensure. This seems unfair and not the norm across other mental health disciplines. For instance, some clinical or counseling psychologists graduate from non-American Psychological Association (APA) accredited doctoral programs (the program either is not accredited or currently seeking accreditation). These psychologists, though they may be shut out from some jobs that specify a graduate from an APA program, can get licensed in their state—it just may take extra paperwork and time due to the non-APA status of their doctoral degree-granting program. Second, these same psychologists, though not graduates from an APA program, would still be identified as psychologists. Would a graduate from a non-CACREP program be identified as a professional counselor? This is still a question left unclearly answered.

    There is also a subtle undertone indicating that counseling (as defined by CACREP and ACA) is different than counseling psychology. There is a strong emphasis on counselor professional identity within the counseling discipline. This is a good thing! However, some arguments center on CACREP’s (2015) stipulation regarding faculty identity and training:

    Core counselor education program faculty have earned doctoral degrees in counselor education, preferably from a CACREP-accredited program, or have related doctoral degrees and have been employed as full-time faculty members in a counselor education program for a minimum of one full academic year before July 1, 2013. (p. 6)

    In this case, a counseling psychologist could be a member of the core counseling faculty but only if he or she had been teaching in a program since (at minimum) July 1, 2012. The critical term there is core faculty. Core faculty are the heart of the counselor education program. In essence, they are the ones who instill the professional identity of counseling into the next generation of counselors (i.e., their students). Consequently, counseling psychology professionals who align with ACA/CACREP would be ineligible from serving as a core faculty member if not meeting this July 1, 2013, benchmark.

    If the counseling psychologist could qualify for the LPC in their state, why then are they deemed not eligible to serve as core faculty (due to graduating from an APA and not CACREP accredited doctoral program) and instill the counseling identity they obviously endorse as evidenced by their licensure (e.g., LPC) and (perhaps) certification status (e.g., National Certified Counselor)? This seems confusing to me (and many others, thus one of the reasons why you see these alternate CACREP organizations developing). Besides adding more layers to the already multilayered field, it also narrows who can be “defined” as a counselor eligible to train future addiction (and professional) counselors. Thus, more confusion.

    So how does this all associate with a book on substance use disorders and process addictions?

    Actually, it is imperative. As evidenced by the numerous certifications and other credentials that permeate the addiction counseling profession, who you are in a professional identity sense—these days—seems linked with the organization or credentialing body through which you are aligned. That would be easy and fine if there were only one body and all of the profession was in agreement. However, as clearly seen in this Preface, that is not the case. Thus, in the addiction profession and the larger professional counseling body there are competing organizations and professional identity definitions that in the end only serve to confuse the broader purpose of a unified profession. Though there has been some dialogue regarding more collaboration and/or merging of organizations (e.g., NAADAC and IC&RC), this degree of unification has not yet begun on a broad scale. Consider Table 4, which describes the different levels of substance abuse counselor scopes of practice as defined by SAMHSA (2011a). Different levels have varying degrees of education and training, and thus differing scopes of ­practice. If you examine Figure 1, you will see how these SAMHSA levels relate with the licensure and certification regulations across all the states.

    Table 4 Model Scopes of Practice and Career Ladder for Substance Use Disorders Counselors

    Category 4

    Practice of Independent Clinical Substance Use Disorder Counselor/Supervisor – An Independent Clinical Substance Use Disorder Treatment Counselor/Supervisor typically has a masterʼs or other postgraduate degree and is licensed to practice independently. The scope of practice for Independent Clinical Substance Use Disorder Counselor/Supervisor can include:

    • Clinical evaluation, including screening, assessment, and diagnosis of Substance Use Disorders (SUDs) and Co-Occurring Disorders (CODs)
    • Treatment planning for SUDs and CODs, including initial, ongoing, continuity of care, discharge, and planning for relapse prevention
    • Referral
    • Service coordination and case management in the areas of SUDs and CODs
    • Counseling, therapy, trauma informed care, and psycho-education with individuals, families, and groups in the areas of SUDs and CODs
    • Client, family, and community education
    • Documentation
    • Professional and ethical responsibilities
    • Clinical supervisory responsibilities for all categories of SUD Counselors

    The Independent Clinical Substance Use Disorder Counselor/Supervisor can practice under the auspice of a licensed facility, within a primary care setting, or as an independent private practitioner. It is the responsibility of the Independent Clinical Substance Use Disorder Counselor/Supervisor to seek out clinical supervision and peer support.

    Category 3

    Practice of Clinical Substance Use Disorder Counselor – The Clinical Substance Use Disorder Treatment Counselor typically has a masterʼs or other postgraduate degree. Depending on the jurisdiction, persons in this position either have not attained their license, or the license is restricted to practice only under supervision of a Category 4 Independent Clinical Substance Use Disorder Counselor/Supervisor. Category 3 Clinical Substance Use Disorder Counselor scope of practice can include:

    • Clinical evaluation, including screening, assessment, and diagnosis of Substance Use Disorders (SUDs) and Co-Occurring Disorders (CODs)
    • Treatment planning for SUDs and CODs, including initial, ongoing, continuity of care, discharge, and planning for relapse prevention
    • Referral
    • Service coordination and case management in the areas of SUDs and CODs
    • Counseling, therapy, trauma informed care, and psycho-education with individuals, families and groups in the areas of SUDs and CODs
    • Client, family, and community education
    • Documentation
    • Professional and ethical responsibilities
    • Clinical supervisory responsibilities for categories Levels 1 and 2 as well as Substance Use Disorder Technicians

    The Substance Use Disorder Counselor 3 can only practice under the auspice of a licensed facility, within a primary care setting, and under clinical supervision of a Clinical Substance Use Disorder Counselor 4.

    Category 2

    Practice of Substance Use Disorder Counselor – The Scope of Practice for the category of those with a bachelor’s degree includes the following activities with clinical supervision of a Clinical Substance Use Disorder Counselor or other state approved supervisor:

    • Clinical evaluation, including diagnostic impression or Screening, Brief Intervention, and Referral to Treatment Referral (SBIRT)
    • Treatment planning for SUDs and CODs, including initial, ongoing, continuity of care, discharge, and planning for relapse prevention
    • Referral
    • Service coordination and case management for SUDs and CODs
    • Counseling, therapy, trauma informed care, and psycho-education with individuals, families, and groups
    • Client, family, and community education
    • Documentation
    • Professional and ethical responsibilities
    • Clinical supervisory responsibilities for all categories of SUD Counselors

    The Substance Use Disorder Counselor 2 can only practice under the auspice of a licensed facility, within a primary care setting, and under the clinical supervision of Clinical Substance Use Disorder Counselor/Supervisor or Clinical Substance Abuse Counselor.

    Category 1

    Practice of Associate Substance Use Disorder Counselor – The Scope of Practice for the category of those with an associate’s degree include the following activities with clinical supervision from a Clinical Substance Abuse Counselor or state approved supervisor and/or administrative supervision of a Substance Abuse Counselor:

    • Diagnostic impression, and Screening, Brief Intervention, Referral to Treatment (SBIRT)
    • Monitor treatment plan/compliance
    • Referral
    • Service coordination and case management for SUD
    • Psycho-educational counseling of individuals and groups
    • Client, family, and community education
    • Documentation
    • Professional and ethical responsibilities

    The Associate Substance Use Disorder Treatment Counselor can only practice under the auspice of a licensed facility or a primary care setting, and under the clinical and/or administrative supervision of an Independent Clinical Substance Use Disorder Counselor/Supervisor and a Clinical Substance Use Disorder Counselor or the administrative oversight of the Substance Use Disorder Counselor.

    Technician

    Practice of Substance Use Disorder Technician – The Scope of Practice for the category of those with a high school diploma or a GED include the following activities with clinical supervision from a Clinical Substance Abuse Counselor/Supervisor, Clinical Substance Abuse Counselor or state approved supervisor and/or administrative supervision of a Substance Abuse Counselor:

    • Diagnostic impression, and Screening, Brief Intervention, Referral to Treatment (SBIRT)
    • Monitor treatment plan/compliance
    • Referral
    • Service coordination and case management for SUD
    • Psycho-educational counseling of individuals and groups
    • Client, family, and community Education
    • Documentation
    • Professional and ethical responsibilities

    The Substance Use Disorder Technician can only practice under the auspice of a licensed facility or a primary care setting, and under the clinical and/or administrative supervision of Clinical Substance Use Disorder Counselor/Supervisor, Clinical Substance Abuse Counselor, or the administrative oversight of the Substance Use Disorder Counselor.

    Source: SAMHSA (2011a, pp. 4–6).

    Figure 1 Types of State Individual Substance Abuse Counseling by Licensing/Certification Categories

    Source: The National Association of State Alcohol and Drug Abuse Directors (2013).

    Note: Categories based on SAMHSA Consensus Group Career Ladder and Scope of Practice (February 2011).

    Look at all that has been discussed so far throughout this Preface. The take-home message here is that the discipline covered by a book titled Substance Use Disorders and Process Addictions is varied, layered, at times inconsistent, and most important, fragmented. Now, we take some time to further examine how and why this fragmentation exists.

    Professional Identity and Addiction Counseling

    The question of professional identity within the counseling profession still exists today (Calley & Hawley, 2008; Cashwell, Kleist, & Schofield, 2009; ­Chronister, Chou, & Chan, 2016; Mellin, Hunt, & Nichols, 2011; Myers, Sweeney, & White, 2002; Nassar-McMillan & Niles, 2011; Prosek & Hurt, 2014; Remley & Herlihy, 2009). One possible reason for the continual debate around professional identity may lie in the multitude of specialty fields (e.g., addiction, career, and school) within counseling (Gale & Austin, 2003; Myers, 1995). This is a true distinguishing factor from the professions of psychology, psychiatry, and social work in that counseling is the only one of these “mental health” disciplines that licenses/certifies specialty areas. There is, though, a critical issue in need of discussion. Specialty areas such as career counseling and school counseling only denote a practice area (career issues) or population (K–12 students), whereas addiction counseling actually entails the profession of counseling for a Diagnostic and ­Statistical Manual of Mental Disorders (DSM-5; APA, 2013) disorder class ­(Substance-Related and Addictive Disorders). Consequently, all these licenses and certification statuses are focused on the treatment of one DSM-5 disorder class.

    Stop and think about this for a moment. No other DSM-5 disorder class has a similar model. For instance, there are no licensed anxiety disorder counselors. Nor are there state and national bodies certifying expertise in bipolar disorders in a similar fashion as the addictive disorders (i.e., is there an NBCC credential called the Master Bipolar Disorders Counselor?).

    Henriksen, Nelson, and Watts (2010) criticized the counseling specialty system and argued how the counseling specialties do not define counseling but merely denote a practice area, and that counseling specialty licensure/credentialing implies that only a small proportion of the counseling profession is qualified to work with this population. As you have seen thus far in this Preface to the book, the addiction area is one such area of specialization that comes with a separate licensure/credentialing process. As a practicing counselor who works with the addiction population and trains counselors to work with this population, I firmly believe that training is required and must be rigorous and extensive. At the same time, things get a little confusing if you stop and deconstruct the process. Here’s why.

    Consider the human development counseling domain and the requirement that all counselors receive training in the areas of addiction etiology and addiction behaviors. The graduate student in a CACREP program preparing them for licensure as an LPC receives (as per CACREP, 2015) at least some exposure to these topics in some courses. They move on and become licensed as LPCs.

    An addictions counseling license requires extensive course work and training. Obviously, a student in an addiction counseling master’s program receives a degree of training and classroom exposure to these topics that are both intensive and pervasive across numerous courses and educational experiences (classroom, practicum, internship, and perhaps “brown-bag” lecture series common in graduate programs). But in many states, the LPC is eligible to counsel and diagnose within the full breadth of the DSM, which includes substance use disorders. For example, in New Jersey, where I practice, an LPC has basically the same clinical purview over work with addictions as does a licensed clinical alcohol and drug counselor (LCADC). I perform counseling for substance use and addictive disorders as an LPC. One door down, my colleague does so as an LCADC. Though there are some clear and critical regulatory differences between the LCADC and LPC, for this argument, both legally permit for the counseling of a client struggling with, for example, cocaine use disorder recovery or alcohol use disorder.

    Obviously, for the LPC (and the LCADC) in New Jersey (and nationwide), the ACA ethics of adhering to competency apply here. The LPC should only work with the addictions if he or she has the training and experience to work with that population from an empirically supported and theoretically and clinically sound framework. That is one of the pressing questions. Yes, CACREP dictated student exposure to addiction content while in a graduate program leading to licensure as an LPC. But is that all that is needed? That seems far too brief in breadth and scope. So clearly, more training is needed. But how much? What classes? How many hours of supervised postgraduate work? If you recall from above, different certifications specified different requirements. Though the CACREP standards are present for counselors seeking an LPC, do they do enough to adequately train the counselor? Would or could other standards do better? In addition, these questions do not come up in the same manner for any other DSM-5 disorder. These questions directly pertain to a book such as this because it is the content in this type of book (and other related texts) that would constitute the material for training.

    These are hard questions because there really is not any precedent in a discipline beyond addiction counseling. If counselor trainees wish to specialize in major depressive disorder, there are no national certifications, CACREP standards, or state licenses dictating requirements specific to major depressive disorder (or any other DSM-5 disorder other than the substance-related and addictive disorders). The counselor trainees, in their postgraduate hours for licensure accrual, seek out supervision, training, and other continuing education experiences to make certain that they ethically develop a competency to work with clients struggling with major depressive disorders. But the story changes if the desired area of expertise is substance use and addictive disorders. The new counseling graduate accruing licensure hours or the already-licensed LPC, however, has to sift through the various state and national regulations, as well as the status quo/culture that sometimes seems to ignore the LPC’s ability to work with addictions via his or her state scope of practice (typically, this occurs because the addiction license or ­certification is the clearest way to establish a degree of competency and training in the addiction counseling area). For example, I have had countless graduate students (where I teach and from across the nation in the audience at some of my ACA talks) say that they never were certain if LPCs could work with the addictions because they see the addiction license and/or certification in their state separate from the LPC, counselors holding both the LPC and addictions license/certification, as well as the varied national certifications only focused on addiction (e.g., no NBCC certifications for any other DSM-5 disorder classes). Again, obviously training and clinical experience are mandatory for any counselor who wishes to work with the addictions. And again, this statement holds for a counselor wishing to work with any other DSM-5 disorder class. The substance use and addictive disorders require no degree of training and experience to competently work with clients that is any different than the degree of training and experience required to work competently with anxiety, mood, bipolar, personality, psychotic, and all other disorders. The difference is in the context in which the addiction counseling profession sits (e.g., separate state license/certification, no similar national certification/credentialing system, and a certification/credentialing ­system with multiple organizations and levels) as opposed to the other DSM-5 disorder classes.

    So coming back full circle, I felt this chapter needed to be written because the reader needs to understand the overall structure of the profession (i.e., this Preface) as well as the research and theory that go into the provision of services (i.e., Chapters 1–11). Take a moment and go back over the Preface. This is the general outline of the profession (at least how I see it, though others feel the same):

    • Regulations for addiction counseling licensure and/or certification vary by state.
    • Regulations for LPCs pertaining to work with addiction issues vary across some states.
    • There are multiple (and competing) national certifications that all demonstrate competence working with the addictive disorders.
    • There are varying levels of what can be considered a substance abuse counselor.
    • There is a CACREP set of guidelines for the counseling specialty of addiction counseling.
    • Those who may be engaged in the act of counseling for an addictive disorder can include a licensed addiction counselor from a CACREP program, an LPC from a CACREP program, an LPC from a non-CACREP program, a ­psychologist, or a social worker.
    • CACREP identifies professional counselor identity, so some counselors (e.g., counseling psychology background) may not be considered a “counselor” and not eligible as a core counseling education faculty member.
    • There is no standard and agreed-upon amount of training and education for someone not from an addiction counseling graduate background in regard to course work, supervised hours, and postgraduate experience. Many of these certifications and licenses overlap in areas of competency, class hours, and other matters, but the presence of so many similar credentials indicates a series of nuanced (or major) differences within the discipline pertaining to the expertise needed to practice as an addiction counselor (or other title) as per the specific credential criteria.
    • In many cases, professional identity seems dependent upon areas of competence that are externally defined.

    In 2011, I gave a talk at the ACA Conference in New Orleans which I titled “Will the Real Addictions Specialist Please Stand?” I want to give you a feel for the profession so you can see why that title made such sense to me (and others). This also sets the stage so you can understand my professional opinions and biases as the author of this book. They are as follows.

    My Opinions and Biases

    First, I do not conceptualize addiction counseling as a specialty area. I agree with Henriksen et al. (2010), who felt that type of specificity does more harm than good. I see counseling as a unified profession. In my case, I engage in the act of professional counseling for those who struggle with substance use disorders and addictive disorders. That is my perspective in regard to how I chose to write this book. I believe school counseling and career counseling are specialty counseling areas, but because addiction counseling (as named by CACREP) pertains to the counseling to treat a DSM-5 disorder class, the specialty designation is misused. My evidence to back my claim is the absence of any other counseling license designated for a specific DSM-5 disorder class. Any arguments made about the need for training, experience, and competency in the addiction profession are identically relevant for the counselor in the treatment of any other DSM disorder class. ­Substance use disorders and addictive disorders, in that sense, are not unique from the rest of the DSM-5. Training is critical. Supervision is critical. As with any other disorder, the counselor must be competent to practice.

    This idea about specialty areas may have some additional support in some of the recent work of Bobby (2013):

    CACREP must reexamine its accreditation structure to determine how it can accredit the overall counseling program being offered and not specialty areas within that counseling program. This could be accomplished if CACREP makes a decision to simply accredit counseling programs at the entry level, while offering guidelines for best practice in specialized practice areas or settings. Another option might be for CACREP to accredit programs’ postgraduate certificate or educational specialist add-on degrees for students who want to opt for more specialized training. (p. 42)

    Though still recognizing “addiction counseling” as a specialty area, it does move CACREP toward perhaps a much more useful model of setting up the necessary postgraduate training structure so all counselors can have a standard level of recognized training to facilitate counseling competence in the addictions. For LPCs, this could greatly benefit those who were misinformed that they needed the addiction license in a state where the full DSM is covered under the LPC’s scope of practice.

    Second, I believe that co-occurring disorders are the norm across all substance use disorders counseling. Whether DSM-5 diagnosable or subsyndromal, any client who presents with a diagnosable substance use disorder (especially at the moderate or severe levels) also presents with something else—sometimes multiple other issues. That is why the case that runs throughout this book is of a woman with major depressive disorder, opioid use disorder, and sex addiction. This is the severity and complexity of many of the clients that students will face. I felt it imperative that the reader understand that clients with substance use and a co-occurring disorder are not a special subpopulation; instead, they are the population. I felt some books on substance use disorders, whether outwardly or in a more subtle manner, implied to the reader the message that co-occurring disorders are more unique than the norm. I tried to interject this text with as many co-occurring examples as I could to attempt to show the concept as prevalent and expected within the SUD treatment population.

    Third (and this goes back to bias #1), I see this as a counseling text for work with the substance use disorders and not an addiction counseling text. This is more than just a fun play on semantics. I found many addiction counseling texts seemed to “claim” general counseling concepts. For instance, I once obtained a text on ethics in addiction counseling. I thought it was going to give me an applied review of ethical principles and codes through the addiction counseling perspective. Instead, I got a basic review of ethical principles (like you would find in any counseling text) with the “addiction” content being the examples provided about competency or boundaries. I am not trying to reinvent the wheel here. Many of these concepts are included in any good text on the subject matter (e.g., motivational interviewing, relapse prevention, cognitive-behavioral therapy). I do not try to condense these mammoth topic areas into a chapter, as I have found that sometimes leaves students feeling like they “rushed” through a theory and there must be more somewhere. I also do not try to “introduce” the reader to these concepts that are standard across counseling texts (addiction and otherwise). I consider this book a conversation. We step into the subject matter and review some (but not all) of the relevant content, all the while trying to emphasize the application to substance use disorders, addictive disorders, and co-occurring disorders.

    I always felt that what was missing from texts I read for myself and used in the classroom as a professor (and one time student) was the stated opinions and biases of the author. That is why I spent these first pages explaining my perceptions of the field this book covers. I am neither right nor wrong. These are just my thoughts as someone who has spent over 20 years in the substance use disorders and addictions profession. In the end, if you agree (even somewhat) with my perspective, then turn the page and we’ll start the conversation. If you do not agree, then that is cool as well. I am always at the ACA Conference each year. If you happen to see me in the halls, or attend a talk/poster of mine, please feel free to come up to me, say hi, let me know where we agree, where we disagree, and what you think about how I see the profession. And how you see the profession.

    In the interim, enjoy the book. …

    —Keith

    Acknowledgments

    This book is the summation of my over 20 years in the substance use disorders and addictions profession. I have encountered countless people over the years who have shaped and challenged and disputed my ideas, all which have resulted in how I see this profession today. It’s easiest to start at the beginning and go forward.

    Dating back to the mid-1990s, David Kerr, Ed Lyons, Dr. Judy Waters, and the hundreds of residents with whom I talked during my initiation into the profession as a researcher/grant writer at Integrity House, a therapeutic community in Newark, New Jersey. Dave Kerr is one of the pioneers of the therapeutic community process (and substance use disorders and addictions treatment), so having access to his perspectives and knowledge on a daily basis laid the foundation for my thinking. Ed Lyons, as a clinical director, took me through the pragmatics of how treatment operates. Finally, Dr. Judy Waters was my first mentor and partner in (what feels like) millions of conversations about academic theory and empirical findings regarding treatment, relapse, and other addictions counseling concepts. She introduced me to Dave—and thus, this field and my career—so thank you, Judy. And thank you, Dave and Ed.

    What feels like an eternity ago, I was trained at Lehigh University’s Counseling Psychology Doctoral Program. Dr. Arnie Spokane stands out as the psychologist who instilled in me the pressing need to be a fluent expert in a specific area of inquiry but to also be very aware of the broader counseling picture and to look where your area fits into the bigger professional narrative. He said that as professionals we oversee the profession and that if you look hard enough in a critical way, you will see where the problems lie with the field at that time. Then, it is your job to try and address them. Consequently, many of my thoughts on the profession (outlined in the Preface and influencing how I wrote this book in general) are directly due to Arnie (a long time ago) telling me that I was allowed to do that. Thanks, Arnie.

    The biggest “break” in my career came when I was fortunate to have been accepted as a predoctoral fellow in the Behavioral Science Training Program in Drug Abuse Research, funded by the National Institute on Drug Abuse and housed at the prestigious National Development and Research Institutes (NDRI) in New York City. Here, I gained my first doses of true professional training. The directors then were Dr. Greg Falkin and (the late) Dr. Bruce Johnson. They were rigorous, challenging, and in their own ways, supportive. Greg would spend hours with me in patience, encouraging me along the way until your dissertation chapter, article, or conference paper was done. Bruce, supportive and mentoring in his own way, would see me at the copier, say hi, and ask if that paper “is ever going to get done or what?” I think that in my own practices as a professor and research mentor, I have adopted both their styles. So Greg, Bruce, thanks.

    I remained at NDRI for a postdoctoral fellowship and then for a few years as a senior research associate. Here, I got to work with and learn from some of the giants in the profession like Drs. George De Leon, Gerald Melnick, Alexandre Laudet, and David Kressel. They imparted to me a tremendous wealth of knowledge about the profession, so George, Gerald, Alexandre, and Dave, thanks.

    In my “professional” career since NDRI, I have worked with some amazing colleagues on various projects. Dr. Janetta Astone-Twerell, at Samaritan Village, takes me back to my days at Integrity as we work on various TC projects. The fact that she calls me for research advice or statistical problem solving is always flattering in that, for such large and important projects, she trusts my opinion. I still learn little things here and there when we talk about the status of the profession from an administrative end. This informs my work, so Janetta, thank you.

    Dr. Tina Maschi (Fordham University) and I have worked together for 10 years on a variety of projects focused on older adult prisoners. It was this work that directly influenced and informed my research and clinical focus on including older adult issues into the substance use disorders discussion. That is why, unlike many other books, there is an older adults section for each chapter in this book. As a social worker, her perspectives widened my views on countless treatment and policy matters in the substance use disorders profession. So Tina, thank you.

    I spent several years within the governance of the ACA division called the IAAOC. I started as a committee chair (spirituality), moved on to secretary, and then was so fortunate to have been elected as president 2013–2014. My time with IAAOC was transformative in how it helped sharpen my thinking on some critical areas of relevance to me (training, licensure, credentialing). Some of the IAAOC and ACA members who were pivotal in this process were Drs. E. J. Eissic, Jerry Juhnke, Geri Miller, Todd Lewis, Bryce Hagedorn, Jack Culbreth, Trevor Buser, and Craig Cashwell. To all of you, thank you.

    I have worked with a countless number of clients over the years across many settings. Their stories of recovery success, setback, failure, and resilience always informs how I treat, how I research, how I teach, and how I theorize within this profession. The human being never fails to amaze me. Those who I think will succeed wind up struggling, whereas people who seem like they are going to fall away to addiction summon strength and become role models for others in recovery. To all of you, thank you.

    Finally, my colleagues at Centenary University. Specifically, the past president (Dr. Barbara-Jayne Lewthwaite) and current provost/VPAA (Dr. Jim Patterson), who have always been supportive of my work and efforts on behalf of the college. In addition, the psychology and counseling department chair (Dr. Harriett Gaddy), who always values, encourages and supports my work within the department with our students. Barbara, Jim, Harriett, and all of my Centenary colleagues, thank you.

    And to you. Thank you for bothering to see how I conceptualize this profession we seem to share.

    SAGE would like to acknowledge the following reviewers:

    Kevin A. Freeman, Mercer University

    Bill McHenry, Texas A&M University–Texarkana

    Nancy E. Sherman, Bradley University

    Richard S. Takacs, Carlow University

    About the Author

    Keith Morgen is Associate Professor of Counseling and Psychology at Centenary University (Hackettstown, New Jersey), where he teaches in the undergraduate psychology and graduate counseling programs. Dr. Morgen’s research on substance use, trauma, and prisoner mental health has been published in major scholarly journals such as Traumatology, Therapeutic Communities, The Gerontologist, The Professional Counselor, Journal of Correctional Healthcare, Journal of Addictions and Offender Counseling, Alcoholism Treatment Quarterly, Applied Research in Quality of Life, Journal of Drug Issues, and Journal of Alcohol and Drug Education. In addition, Dr. Morgen presents papers at major conferences such as the American Counseling Association, American Public Health Association, American Psychological Association, and the College on Problems of Drug Dependence. Dr. Morgen is a former president (2013–2014) of the International Association of Addictions and Offender Counselors (a division of the American Counseling Association). Dr. Morgen is a Licensed Professional Counselor (New Jersey) and Approved Clinical Supervisor and practices counseling part-time at Discovery Psychotherapy & Wellness Centers in Morristown, New Jersey. He is a past recipient of the Centenary College Distinguished Teaching Award. Dr. Morgen received his PhD in Counseling Psychology (Lehigh University) and was a National Institute on Drug Abuse funded Predoctoral and Postdoctoral Research Fellow at National Development and Research Institutes in New York City.

  • Closing Thoughts

    This book covers the basics (broadly defined) of what constitutes the information required for competent substance use disorders (SUDs) and addictions counseling. Going back to the Preface for a moment, all this content is obviously applied quite differently depending upon which of the credentials a counselor holds (whether licensure, certification, or Council for Accreditation of Counseling and Related Programs). That is why I am so concerned about the fragmentation of the profession. Recall my client who asked me what the difference would be between receiving addictions treatment from a psychologist, psychiatrist, addictions counselor, professional counselor, or social worker? Well, some of these differences could be considerable, and I try to briefly (on your way out the door from reading this book) leave you with some thoughts about the fragmented profession through the context of some of the content this book reviews.

    First, consider the widely accepted and documented fact that co-occurring psychiatric disorders (whether Diagnostic and Statistical Manual of Mental Disorders, 5th ed. [DSM-5], diagnosable or subsyndromal) are present in just about all moderate/severe SUD cases. In general, licensed professional counselors (LPCs), licensed psychologists, or licensed social workers have a clearer scope of practice and training associated with the diagnosis and treatment of co-occurring psychiatric disorders. But what of the licensed addictions counselor? These professionals do TREMENDOUS work. I have worked with them and overseen their work over the years. I proudly call some of them colleagues. However, I feel the fragmented system did them (and their clients) a disservice.

    I have heard the following scenario played out in many states over the years. An addictions counselor (licensed or certified as per their state) was working with a client who presented for alcohol use disorder. However, it soon became evident that the client presented problems that also included (for example) generalized anxiety disorder independent of the alcohol use disorder. Based on the scope of the license/certification, the addictions counselor may need to refer the client to a licensed professional counselor for the anxiety issues but would still see the client for the alcohol issues. The reasoning was that the addictions license/certification does not cover diagnosis and treatment of nonsubstance use disorders. So a client may need to see one clinician for anxiety and another clinician for the alcohol use disorder. This, to me, seems counterproductive to the client’s need for care and the unification of the counseling profession, but I hear about similar scope of practice type scenarios nationwide. That is why—though it is slowly starting to happen state by state—I firmly advocate for all licensed addictions counselors to be provided with a series of standardized and sound “mental health diagnosis” training and have their scope of practice expanded to fully and truly cover co-occurring disorders. LPCs and licensed addictions counselors are not competing professions (though some see differently). They are, and should be seen as, colleagues and equals. Some states are better at it than others, but all states should provide the counselors the skills, training, and regulatory ability to work with their clients in a nonfragmented manner.

    Second, consider the role that all the certifications and other credentials play in identifying an “addictions counselor.” In various treatment centers, clients would encounter staff of numerous titles, degrees, and credentials. For example, my colleagues in different states have experienced this issue, as have my students and I. A client is used to a certain set of credentials (they learn the acronyms quickly) and decide what they see is being an “addictions counselor.” When they next encounter (in a new treatment episode or after a transfer to a new level of care) another professional with different credentials, they challenge that counselor’s ability to offer services as a counseling professional who works with the SUDs and the addictions.

    This has ramifications in the area of (for instance) supervision and counseling. Dating back to the 1970s and 1980s (and up through the 1990s with the work by Culbreth & Borders, 1999), Strong, Welsh, Corcoran, and Hoyt (1992) studied the role of client-perceived counselor similarity, competence, and trustworthiness. Individuals informed different things about a counselor seen in a video (years of training, background, for example) greatly influenced perceptions about this counselor. Despite all watching the same video, different information produced different perceptions. Recovering clients may (from self and others) have a set belief about who is a counselor best qualified to treat them. That belief system directly influences how they would work with the counselor treatment matters or how the supervisee and supervisor may view each other’s qualifications for working in the field and what is needed to be considered competent and effective. If you ever review the addiction counseling competencies from the Substance Abuse and Mental Health Services Administration, they are many in number, but they are somewhat vague in description. So it falls to the counselor, supervisor, and perhaps client to make that final specific application.

    If all the other disorders which we treat had a similar national landscape, we would all just keep pushing along. But this profession (SUDs and addictions counseling) is unique in that there are so many voices out there stating what “should be” (and some of them even conflict with one another) in regard to the treatment of a DSM-5 disorder class. In addition, we are unique in that this is the only DSM-5 disorder class paired with a specific licensure/certification process. That’s why, in these last words I have to type, I want to leave you with what I think every good SUDs and addictions professional (i.e., a licensed professional counselor, licensed/certified addictions counselor, psychologist, social worker) should know:

    • The full breadth of the DSM substance-related and addictive disorders.
    • An understanding of a diagnostic scheme for addictions that have not yet made it into the DSM mainstream (sex, food, perhaps nonsuicidal self-injury).
    • A clear understanding of the basics behind the co-occurring psychiatric disorders condition.
    • An ability to balance an appreciation and respect for the neuropsychological and psychopharmacological influences in the addiction and withdrawal processes alongside an ability to instill self-ownership in clients of their actions now in trying to cease substance use and sustain recovery.
    • An ability to meet clients on whatever level they need, whether concrete (e.g., cognitive-behavioral therapy) or more esoteric (e.g., existential).
    • The flexibility to work with numerous other agencies in the treatment of a client while recognizing that (sometimes) not all parties fully share the same overall goals.
    • The capability to question and discuss spirituality matters in a nonrigid manner (i.e., more than just a simple inquiry of are you spiritual, yes or no?).
    • A true philosophical understanding of the meaning and application of the 12 steps and how to complement and supplement that process for the client’s recovery.
    • Regardless of your counseling orientation, the ability to challenge a client and the ability to be challenged by a client.
    • Knowledge of counseling theories; interviewing skills (not just motivational interviewing); diagnostic and assessment appreciation for SUDs and co-occurring psychiatric disorders; and how the brain, thoughts, emotions, and behaviors are altered by the active use, withdrawal, and recovery periods.

    There’s a lot of stuff to know and apply. Clients need our help. Students need our training so they can join the ranks of those who can help. Most (if not all) of what I list above falls within any certification, licensure, or accreditation list of required content. We all believe the content I covered in this book is relevant and critical to the treatment of SUDs. My hope is that the profession can figure out a more unified manner via which to make it known what we know, who knows it, and how we can help.

    Thanks for reading. If you want to continue the conversation, please feel free to send me an e-mail.

    References

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