breining institute - The Register of Addiction Specialists

Transcription

globalbundle
All 40-hours of Continuing Education topics required for renewal of
Registered Addiction Specialist (RAS)
Registered Addiction Specialist - Level II (RAS-II)
Masters Level - Registered Addiction Specialist (M-RAS)
Clinical Supervisor Credential (CSC)
Master Counselor in Addictions (MCA)
breining institute
BREINING INSTITUTE
40-hour Continuing Education (CE) Packet - Global Bundle
globalbundle
Course Material and Exam Questions Packet
Course No:
GB-2012
Course Title:
40-hour Addiction Professional Credential Renewal Course
Course Objective:
40-hour bundle of Continuing Education (CE) courses includes all of the
topics and hours required for renewal every two years of the RAS, RAS-II,
M-RAS, CSC and MCA credentials,1 including: TAP 21 curriculum;
provision of services to special populations; 12 hours of ethics;
communicable diseases; prevention of sexual harassment; and 10 hours of
clinical supervisor coursework.2
CE Credit Hours:
40.0 hours
Exam Questions:
Forty (40) multiple-choice questions.
Answer Sheet:
Use the on-line Answer Sheet for automatic grading of your exam, and to
automatically receive your Certificate of Completion by e-mail.
Recommendation: Review the exam questions before you read the Course Material. The
Exam Questions are based upon the information presented in the Course
Material. You should choose the best answer based upon the information
contained within the Course Material.
GOOD LUCK!
1
These credentials are registered service marks, and may only be used by professionals who
have been awarded these credentials by Breining Institute: "Registered Addiction Specialist"
and "RAS" credentials - Service Mark Reg. No. 65739, Class Number 41; "Clinical Supervisor
Credential" and "CSC" credentials - Service Mark Reg. No. 66826, Class Number 41;
and "Master Counselor in Addictions" and "MCA" credentials - Service Mark Reg. No. 66746,
Class Number 41.
2
This bundle also satisfies the topics and 40-hour requirements for renewal of AOD counselor
certifications required by the State of California law contained within the California Code of
Regulations (CCR) Title 9, Division 4, Chapter 8, sections 13055(a) and (c).
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Course Material
• Curriculum contained in TAP 21: Understanding Addiction, Treatment Knowledge,
Application to Practice, Professional Readiness (9 hours)
o Codependency among health care professionals: Is an understanding of
codependency important to the therapeutic counseling process? ........................ 4
o Relapse Prevention: An examination of relapse issues which includes relevance
of the issue, an historical perspective, a survey of existing knowledge, and ideas
counter to disease concept beliefs ...................................................................... 20
o Anger Management for Substance Abuse and Mental Health Clients ................ 44
• Provision of services to special populations (3 hours)
o Substance Use Disorders in People with Physical and Sensory Disabilities .... 110
• Ethics (12 hours)
o Professional Ethics: Counselor Certification in California ................................. 118
o The Confidentiality of Alcohol and Drug Abuse Patient Records Regulation and
the HIPAA Privacy Rule: Implications for Alcohol and Substance Abuse
Programs ........................................................................................................... 150
o Professional and Ethical Standards of Case Management ............................... 175
o Analyzing the Pros and Cons of Multiple Relationships between Chemical
Addiction Therapists and their Clients ............................................................... 185
• Communicable diseases (3 hours)
o HIV / ARC / AIDS / Hepatitis ............................................................................. 192
• Prevention of sexual harassment (3 hours)
o Preventing Sexual Harassment ......................................................................... 202
•
Clinical Supervisor coursework (10 hours)
o Clinical Supervisor Training Manual .................................................................. 218
Exam Questions
o Exam Questions (must answer 70% correct to earn CE credit) ........................ 281
Copyright Notice
The copyright for all of the Course Material in this packet is either owned by Breining Institute,
Breining Research and Education Foundation, or is in the public domain. This material may be
copied or reprinted for private use only, and may not be redistributed for a fee.
Contact
Breining Institute, 8894 Greenback Lane, Orangevale, California USA 95662-4019
Telephone 916-987-2007
E-mail [email protected]
Web site www.breining.edu
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JOURNAL
OF
ADDICTIVE DISORDERS
Codependency among health care professionals:
Is an understanding of codependency issues important to the therapeutic
counseling process?1
H. Spencer O’Neal, LEP
“MANTECA, Calif. — The woman desperately gripped a windshield wiper blade, her
body splayed across the hood of the minivan as it raced down a Northern California
freeway in the middle of the night, reaching 100 mph… [The woman’s husband]…
got into the family's minivan around 12:30 a.m. Saturday after he and his wife had an
argument at their Manteca home, said police spokesman ... "She kind of goes with
the van to try to stop him, gets up on the hood and is hanging on to the wiper blade,"
he said. "She obviously didn't think he would keep driving." [The woman’s
husband]… sped through Manteca, got on the freeway and didn't pull over until he
reached Pleasanton… One witness followed [the van] most of the way and told
police his speed reached 100 mph. The wild ride happened several days after [the
woman’s husband]… was arrested for being under the influence of a controlled
substance…” (Huffpost Staff Writer, 2011)
The above March 2, 2011 news article illustrates a classic example of some of the
dramatic types of behaviors that can often occur in the alcoholic / chemical dependent
household. The interpersonal relationships between the husband and wife in this article will
appear sad and obviously dysfunctional to the outside observer. Typically however, to most
couples in similar situations, the relationship they share is one of seeming normalcy to them. He
is enraged by her focus on his addictive indulgences, and she becomes his self-appointed
protector. Climbing onto the hood of a car is obviously a very dangerous thing to do. If she were
asked why she got onto the hood of the car, her most likely response would be “Because I love
him! He was drinking (using) again and I didn’t want him to wreck the car or hurt himself.”
In an attempt to try to understand such a dramatic emotional response and such
extreme potentially self-harmful behavior, and in response to the question “How do alcoholics
affect families and friends?” the Al-Anon Family Groups comprised of the families and friends of
alcoholics states:
1
This copyrighted material may be copied in whole or in part, provided that the material used is
properly referenced, and that the following citation is used in full: O’Neal, H.S. (2011).
Codependency among health care professionals: Is an understanding of codependency issues
important to the therapeutic counseling process? Journal of Addictive Disorders. Retrieved
[date retrieved] from Breining Institute at http://www.breining.edu.
2011 © BREINING INSTITUTE (2011JAD1104220951)
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JOURNAL OF ADDICTIVE DISORDERS
“Alcoholism is a family disease. The disease affects all those who have a relationship
with a problem drinker. Those of us closest to the alcoholic suffer the most, and
those who care the most can easily get caught up in the behavior of another person.
We react to the alcoholic's behavior. We focus on them, what they do, where they
are, how much they drink. We try to control their drinking for them. We take on the
blame, guilt, and shame that really belong to the drinker. We can become as
addicted to the alcoholic, as the alcoholic is to alcohol. We, too, can become ill.” (AlAnon Family Groups, 2006)
Another support group for codependency is Codependence Anonymous or (CoDA).
CoDA does not specifically define Codependency, but rather describes “Patterns and
Characteristics of Codependence”. These patterns and characteristics are provided for the
individual sufferer to explore for self-review. The category headings for these Patterns and
Characteristics are: Denial Patterns; Low Self Esteem Patterns; Compliance Patterns; Control
Patterns; and Avoidance Patterns. (CoCA, 2011). These Patterns and Characteristics are a
good source of information for use in self-evaluation for anyone who is exposed to chemically
dependent individuals and are recommended for review by new and prospective Addiction
Professionals as well.
Codependency is defined in Wikipedia as:
“Codependency (or codependence, co-narcissism or inverted narcissism) is a
tendency to behave in overly passive or excessively caretaking ways that negatively
impact one's relationships and quality of life. It also often involves putting one's
needs at a lower priority than others while being excessively preoccupied with the
needs of others. Codependency can occur in any type of relationship, including in
families, at work, in friendships, and also in romantic, peer or community
relationships. Codependency may also be characterized by denial, low self-esteem,
excessive compliance, and/or control patterns.” (Wikipedia, 2011)
The pattern of codependency of the wife who climbed on the hood of the car in the
example cited earlier is fairly easy to see. Such a pattern of codependent behavior is also fairly
easily definable as noted in this definition. What is not so easy to see is how codependency can
seep into almost any caring relationship, including the counseling relationship. Codependency
often comes in shades and tones that are much more subtle than those seen in the initial
example. Codependency can also be situational. In other words, an individual may exhibit
normal emotions and behaviors in most interpersonal relationships, but in certain situations, or
in relationships with certain people, this same individual may experience varying degrees of
codependency.
Addictive Behaviors breed Codependent Responses
Codependency essentially is a state of mental and emotional being that often occurs
when a caring individual is in a close relationship with, or is in relatively close contact with,
someone who is progressing through the various stages of alcoholism, chemical dependency,
or other addiction. The book Alcoholics Anonymous (Anonymous, 2001, p. 21) defines the “Real
Alcoholic” as someone who:
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“… may start off as a moderate drinker.” “… at some stage of his drinking career he
begins to lose all control… once he starts to drink.” He puzzles you… “in his lack of
control.” “He does absurd, incredible, tragic things while drinking. He is a real Dr.
Jekyll and Mr. Hyde.”… “His disposition resembles his normal nature but little. He
may be one of the finest fellows in the world. Yet let him drink for a day, and he
frequently becomes disgustingly, and even dangerously anti-social.”… “He is…. Well
balanced concerning everything except liquor, but in that respect he is incredibly
dishonest and selfish. He often possesses special abilities, skills, and aptitudes, and
has a promising career ahead of him. He uses his gifts to build up a bright outlook for
his family and himself, and then pulls the structure down on his head by a senseless
series of sprees.”
This description of the alcoholic, which also roughly describes characteristic patterns of
behavior present with other addictions, is presented here in order to illustrate the personality
change that occurs when the addicted person is engaged in his or her addictive behavior
(drunk, loaded, gambling, eating, etc.). An article on alcoholic behavior noted that most people
who drink, and even those who sometimes get drunk “will keep their same personality”
(Alcoholic Behavior, 2009). The obvious implication then is that those who, as noted above, are
real alcoholics, and/or those otherwise addicted, will change into someone or something they
are not. The non-addicted individuals who love, care for, and/or have a close relationship with
the addicted individual, generally will stay with and assist the addicted individual, and
unknowingly commence to go through the process of becoming codependent. Even though they
may be shocked and often hurt by the behavior of the addicted individual, they generally stay
with, forgive, and rationalize the addicted individual’s behavior. They have great affection for
their dear friend Dr. Jekyll, and are stunned when faced with Mr. Hyde. They only desire for the
return of Dr. Jekyll, and will not leave one stone unturned until they have helped the good
Doctor rid himself of his unwelcomed intruder, Mr. Hyde. They feel this behavior change was so
out of the ordinary that it is most likely an anomalous behavior that is probably a one-time
occurrence. The addicted individual helps them in this belief by sincerely promising such
behavior “will never happen again”. The fledgling codependent internalizes this promise and
continues the relationship. If the offending individual is truly addicted, the same or similar
behaviors will occur again and again and again. With each new occurrence, the codependent
again rationalizes, assists, and excuses the behavior. Now, the codependent individual may
begin to shield and protect the addicted person from having to take responsibility for his or her
actions. The definition of insanity that is typically applied to both dependent and codependent
individuals now becomes apropos: “Insanity is doing the same thing, over and over again, but
expecting different results.” (Franklin). Thus, the “Merry-Go-Round of Denial” starts to spin
(Kellermann, 1969).
Codependency in the Therapeutic Process
Nature instills in most humans an innate desire to help others who are in need of
assistance. In particular, this innate helping instinct is peaked when a friend, family member, or
loved one is afflicted with significant difficulties. Most humans react with a compassionate desire
to help when someone close to them is in desperate need. Such needs could include disease,
physical or emotional pain, financial difficulties, legal complications, mental health concerns,
family or relationship problems, etc. As a caring individual begins to provide assistance to the
addicted individual in order to help them out of their difficulty, “just this once,” then the
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groundwork for a pattern of codependency begins forming. As the addicted individual is rescued
from his or her immediate dilemma, the inner voice of their addiction speaks and, although they
may say they are grateful for being helped out of their problem, instead of learning their lesson
and staying away from the addictive behavior(s) that others can see as the cause of their initial
problem, they react by engaging in the destructive addictive behavior yet again. Why do they do
this? Because their addiction says to them “See, there is nothing wrong with you. Did you see
how easy it was to get out of that situation? It wasn’t so bad after-all. Your can have another
[drink]. One won’t hurt you.”
As the addicted individual succumbs again to his or her addiction, the cycle begins to
repeat itself (Kellermann, 1969). As the cycle repeats itself, the original non-addicted, caring
individual who only intended and desired to help a friend, or loved one, becomes increasingly
enmeshed in the addict’s downward spiral. As the dependency (disease) of the addicted
individual increases so too does the dependency (disease) of the helping individual. Thus, both
the addicted individual and the helping individual are both dependent on the same dependency
producing substance or behavior. As such, the helping individual is codependent. The helping
individual then becomes addicted in the addiction of the addict. This addiction is therefore called
“codependency”. The addict begins to form a pattern of behaviors that elicits codependent
responsiveness in those with whom they establish relationships. Various types of counselors
and addiction professionals will come in contact with addicted individuals who are involved in
situations where they are in need of significant help. In these cases, it is essential that the
addiction professional / counselor understand the dependency – codependency process and not
permit the cycle to begin. In essence, the addiction is controlling the emotions and behavior of
both the dependent addict and the codependent. Acknowledgement of the existence of this
cycle, and consciously (counter- intuitively) breaking or interrupting this cycle, is often the only
way out the addiction process for either or both participants.
The Importance of Understanding Codependency in the Therapeutic Process
Why do counselors and other mental health practitioners need to understand
codependency and its relationship to the therapeutic process? The answer to this question is
the basis of why the question needs to be asked. The answer is the counselor’s predilection to
the traits of love and caring. Prior to the 1935 advent of Alcoholic Anonymous there is no
historical record of any lasting, successful treatment for alcoholism or other addictions. All prior
attempts at facilitating such rehabilitation ultimately failed (Breining, et al., 2008, pp. 21-22). This
failure was due in large part due to the addictive properties of codependency. Counselors may
initially be drawn to the mental health field for a variety of reasons, but typically decide to enter
the profession to “fulfill a need to help others…” (Breining, et al., 2008, pp. 359-366). Those
helping individuals who enter the Counseling profession typically possess particular attitudes
and characteristics, the most important of which is caring. “The counselor is a knowing person,
but … is also a caring person. Most people can know all that a counselor knows, but unless a
person cares, he is not a counselor… Counseling is caring.” (Wrenn, 1973).
The primary traits of the quality counselor are helping and caring. The dilemma of the
counselor who is engaged in therapeutic relationships with those addicted to alcohol and other
chemicals or behaviors, is that addicted individuals are not helped by being helped (Al-Anon
Family Group B-6, 1978, pp. 35, 196). In fact, the more helping the counselor attempts to be,
the more comfortable clients becomes in their addiction, and the less likely are their chances of
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recovery. The natural inclination for the counselor then, when the helping therapeutic approach
hasn’t produced the desired movement toward recovery, is for the counselor to feel that he or
she isn’t being helpful and caring enough. In this frame of reference, the counselor redoubles
his or her efforts to care harder. As a result, the addicted individual consciously or
unconsciously begins to gain emotional control over the counselor/counselee relationship and
thus subverts the therapeutic process. In this incremental progression, the counselor begins the
gradual slide into a codependent role in the counseling relationship.
So far, the discussion of “counselors” has centered on the traits usually found in typical
individuals who enter the mental health field and are professionally trained as counselors or
therapists. However, somewhat of a distinction must be drawn in the area of addiction
counseling. The success behind the program of Alcoholics Anonymous, and discussed in their
book from which the organization gleaned its name, was the premise that “one alcoholic talking
to another alcoholic” was the key ingredient to helping a problem drinker to achieve sobriety
(Anonymous, 2001, pp. 15-16, 18, 89-103). As centers for the treatment of alcoholism and other
addictions began to emerge in the late 1960’s, 70’s, and early 80’s, counselors in these facilities
often required no formal training in counseling techniques or certification, but were often
required to be a sober alcoholic with a specified period of sobriety (Miller, 1980, pp. 3-7). The
field of Addictions Counseling has become more formalized and certification is now required for
both current and new counselors (California Department of Alcohol and Drug Programs, 2011).
However, it is no longer a prerequisite that an addictions counselor be an individual who has
recovered from a substance abuse or other addiction. The removal of this prerequisite makes it
imperative that an understanding of codependency issues be instilled in new counselors as they
will be more susceptible to be lured into the codependent role than those who are in a recovery
program themselves.
At a conference of the Philadelphia Psychiatric Society in April, 1946, some interesting
comments were made by members in attendance. Their comments were preserved in Society
Transactions of the Archives of Neurology & Psychiatry (Hadden, 1946). Research into the field
of chemical dependency has made significant strides since 1946 and many of the statements
made in this article are not accurate by today’s standards, however, it is interesting to note the
progression of medical thought. Medical thought in the absence of research, often displays
logical, well-reasoned, and common sense solutions. Codependency was not a recognized
disorder when this article was written, never-the-less, when Dr. Keyes’ statements are viewed in
light of today’s knowledge of codependency, the progression of thought for mental health
providers begins to take shape. Dr. Keyes stated he was pleased that the legal profession was
coming to see that Alcoholism was a “disease” that required “care and prevention rather than
punishment and incarceration.” He noted that alcohol provides “quick relief” from anxieties for
the alcoholic and that “most investigators of the causes of alcoholism are agreed” that
“weaknesses and deviations of personality” in combination with a compelling desire for the relief
of “acute stress” eventually cause alcoholism. Dr. Keyes continues that the primary necessity for
treatment is “…the patient must himself wish to recover from his alcoholism, for unless he holds
to this decision firmly he is certain to fail any measure outlined to help.” “In many cases,
however, the patient cannot reach this conclusion without a great deal of patience, tolerance
and understanding on the part of those trying to guide him” (Keyes, 1947). Certainly current
research demonstrates Dr. Keyes conclusion that the alcoholic patient “must wish to recover,”
but his conclusion that the counselor must provide a “great deal of patience, tolerance and
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understanding” for the perspective he was alluding to, may only tend to breed codependency in
the counselor and thus can inhibit recovery.
Speaking at the same conference, as recorded in the same journal article, Dr. C. Nelson
Davis presented his experience with the program of Alcoholics Anonymous. He painted a
positive picture of Alcoholics Anonymous but presented his findings as related to his role as a
therapist who works with alcoholics, and those addicted to other substances, outside of that
program and usually prior to an individual commencing attendance in the Alcoholics Anonymous
program. As to those individuals Dr. Davis states: “The alcoholic addict hurts many people – his
father, his mother, his sister, his brother, his employer. He even hurts his physician, for of all the
patients the doctor treats the alcoholic is probably the most contemptible, and the one who will
not follow advice. Frequently, the alcoholic patient comes to the doctor because he is literally
dragged to him, and of course that places the physician at a disadvantage (Davis, 1947).
Why is it important to understand codependency in the therapeutic process? The simple
answer is that the client will not recover if the counselor displays significant symptoms of
codependency. Additionally, when they continually fail to see their patients make progress
toward recovery, good counselors, despite caring with all their might, may experience loss of
confidence in their abilities and may encounter professional burn-out. This burn-out also breeds
resentment of addicted clients, particularly those who go on to recover seemingly without the
loving therapeutic support of the counselor. This phenomenon of resentment is described in the
book Alcoholics Anonymous. Although contained in a chapter directed “To Wives” of alcoholics,
the codependent emotional resentment discussed here can be applied to any individual who is
in a helping relationship with the addict. The passage states that resentment may be felt in that
“…love and loyalty could not cure our husbands of alcoholism. We do not like the thought that
the contents of a book or the work of another alcoholic has accomplished in a few weeks that for
which we struggled for years” (Anonymous, 2001, p. 118). This resentment in combination with
love/caring then became two key elements in what was later to become the concept of
codependency. As mentioned earlier, prior to the advent of the program of Alcoholics
Anonymous there was no effective treatment for alcoholism or other addictions. Following
Alcoholic Anonymous’ appearance on the scene, mental health professionals began to
reluctantly admit that the Alcoholics Anonymous program was producing results where their
scientific knowledge had all but failed. These therapeutic professionals were reluctant to discuss
the spiritual element contained in the program of Alcoholics Anonymous, but in some instances
admitted that they could not disprove such an element played a significant role in the recovery
of alcoholics. Examples include: Dr. Davis: “The previous speakers have mentioned the spiritual
side. There is no doubt that it does play an important part. Alcoholics Anonymous has helped a
great many men. There are since the first year or two 41 members who have remained dry; that
is a much better record than I have attained….” (Davis, 1947); Dr. Silkworth, in a paper
discussing a successful approach to treatment for alcoholics stated “Here is a movement that
puts its arm around medicine on one side, and religion on the other.” “The physician while an
earnest seeker after truth is in no position to recommend all the fads presented to him. Here is a
plan emanating from no “authority,” no leaders, nothing to sell, strictly ethical, and asking for
and receiving the cooperation of physicians.” (Silkworth, A Highly Successful Approach To The
Alcoholic Problem Confirmed in Medical and Sociological Results, 1941); Dr. Silkworth, as the
prominent physician who’s expertise on alcoholism was noted in the book Alcoholics
Anonymous in which he is described as the “chief physician at a nationally prominent hospital
specializing in alcoholic and drug addiction…” made comments relevant to this discussion of
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codependency. He implied that there is a class of alcoholic that is “hopeless”; and “as for two of
you men, whose stories I have heard, there is no doubt in my mind that you were 100%
hopeless, apart from divine help”; He discussed too how the medical profession struggled with
spiritual concepts vs. science. He stated, “We doctors have realized for a long time that some
form of moral psychology was of urgent importance to alcoholics, but its application presented
difficulties beyond our conception. What with our ultra-modern standards, our scientific
approach to everything, we are perhaps not well equipped to apply the powers of good that lie
outside our synthetic knowledge.” The emphasis in this statement were added in order to clarify
that Dr. Silkworth used the phrases, “moral psychology” and “the powers of good”, to denote
spiritual concepts in secular terms (Anonymous, 2001, pp. xxv-xxxii & 43). Based on the
premise then, that Alcoholics Anonymous was effective in treatment of alcohol addiction, its
general principles and 12 steps eventually became a model and guide for the treatment of
virtually all other addictions.
Counselor safeguards against codependency
To summarize briefly, for those individuals with a chemical dependency or other
addiction, being provided with help often has the opposite effect. More often than not, helping
doesn’t help. In fact, helping the addicted individual is often counterproductive to his or her
recovery. Logically, and in most other types of therapy, the greatest asset of a mental health
professional is his or her ability to care for the client’s issues and the desire to help the client.
However, for those clients suffering from addictions, this quality typically found in helping
professionals, if it leads to the development of codependency, can be very detrimental.
Herein lies the dilemma for the addiction specialist or substance abuse counselor. These
addiction professionals do care and do desire to help their clients. The counselor’s dilemma is
solved by a shift in mindset and a realization that the therapeutic strategy that must be
employed to actually help the client is counterintuitive to their initial logical and emotional
reaction to the client’s presenting issues. Under normal circumstances, if we witness a person
starting to fall, our immediate instinct would be to reach out catch them. By catching them,
preventing them from falling, we would prevent them from injuring themselves – and, they would
be grateful. Such an action is considered to be intuitive. Letting them fall would be
counterintuitive. Letting them fall goes against the natural human reactive instinct to help. This
reactive instinct is subconscious and comes immediately and without conscious thought. In
virtually all other circumstances, this intuitive-reactive saving process is the correct action to
take.
The problem faced with addicted individuals, is that if someone is there to catch them as
they fall, they will assume and expect that someone will always be there to break their fall and
catch them, thus preventing them from being injured. Based on their expectation that someone
will always be there to catch them, they will continue to place themselves in situations where
they are likely to fall again. What they learn from being caught is that someone will rescue them
from the consequences of their actions. Therefore, they will continue placing themselves in
situations that are potentially harmful to them or others. Additionally, even though they know
that their actions are problematic and harmful, if rescued, they will not take the serious steps
necessary to prevent future occurrences. If they don’t fall, they won’t hit bottom. If they don’t hit
bottom, they won’t find it necessary to begin the process of recovering from their addiction. It is
reasonable to state then that therapists often don’t help by helping. By continuously interceding
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on behalf of the client, and not permitting them to experience the consequences of their actions,
the counselor can literally intuitively love the client to death. Recognizing and overcoming the
naturally intuitive desire to help the client minimize the effects of his or her behavior, will then
permit the client to fully experience the natural consequences of their behavior and will assist
the client in taking ownership in their behaviors and provide motivation to alter the patterns of
their behavior.
Purpose of this Study
The purpose of this study is to explore the therapeutic process between the addictions
counselor and the addicted client. This relationship is often unique in the helping professions in
that the client–counselor interaction involves the risk of codependency on the part of the
counselor. The very characteristics necessary to produce quality counselors are typically the
same ones that make them vulnerable to codependency. General characteristics of the
dependent addict and the codependent have been presented, along with some of the resulting
difficulties that proceed from the interpersonal relationship between these types of individuals.
To this point, information has been examined that describes the necessary
characteristics typically prevalent in counselors and inherent in those individuals who are
attracted to the helping professions as prospective counselors. Some of these elements include:
empathy, compassion, understanding, knowledge, a desire to learn helping techniques
(counseling philosophies), a desire to be of service, a desire to help, a desire to engage in
productive and meaningful interactions with clients, a striving to gain fulfillment through assisting
in the facilitation of the client’s positive, successful growth, and in helping others achieve a new
and better quality of life. These elements have been summed in this study under the labels of
loving/caring and helping (Shertzer & Stone, 1980). Counselors, addiction professionals,
psychologists, therapists, etc. who possess these helping characteristics are then confronted
with their clients. The addicted client generally exhibits traits such as: “excessive dependency;
an inability to express emotions; low frustration tolerance; emotional immaturity; a high level of
anxiety in interpersonal relationships; low self-esteem; grandiosity; feelings of isolation;
perfectionism; ambivalence to authority; and guilt” (Woititz, 1983), and additional traits that
include: “justification; sensitivity; impulsiveness; and defiance” (Renascent, 2009). Addicted
clients also tend to exhibit explosive outbursts and a dual personality (Anonymous, 2001, p. 73)
(Al-Anon Family Groups B-4, 1989, p. 8).
As noted previously, counselors who interact with addicted clients in an effort to help
them overcome their myriad of difficulties may be prone to the same emotional forces that afflict
other caring individuals who have attempted to assist the addicted individual. As such,
counselors, particularly those new to the profession or those who work with addicted clients
sporadically, may wish to consider a counterintuitive approach to therapy.
Counseling Concerns and Considerations
Following are two areas of concern to be considered by Addiction Counseling
Professionals. The first are general treatment issues that may be reflected on in preparation for
entering into addiction counseling. The second area is primarily concerned with suggestions
related to safeguarding the counselor from negative consequences that may arise from
characteristics typical of counselors that make them susceptible to codependency issues.
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General Treatment Issues
•
•
•
•
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New client characteristics or thought processes may include: fear of the unknown;
evasiveness; manipulation; responding in ways he/she feels the counselor wants to
hear; a desire to ‘get the heat off’; protection of the future ability to drink or use; the
feeling that the counseling process and related programs of recovery are stupid and
irrelevant to them; the feeling ‘my case is different’; feeling that the counselor doesn’t
know what he/she is talking about; trying to use the counselor to help them regain loses
such as: family, job, home, spouse, esteem, finances, legal problems, cars, etc. The
client will often be contemplating ways to ‘pretend’ that they are making progress in
counseling and that treatment is ‘working’ for them, however, they are not actually
following the therapeutic process or internalizing the information presented.
The nature of the disease of addiction is that the sufferer does not believe he or she is ill.
As such, if recovery is to occur, the alcoholic/addict must come to recognize their need
of help, and be willing to take the steps necessary to facilitate recovery (Al-Anon Family
Groups B-1, 1984, p. xvii).
A subtle but distinct difference exists between the nature of alcoholism and drug
addiction. Alcoholics are genetically predisposed to alcoholism, i.e., They suffer from an
inherent abnormal physical affliction or allergy which instills an emotional attachment of
which they must come to terms. The drug addict is addicted to an addictive substance.
They may have no emotional or “psychological attachment” to the substance other than
a “physical addiction” (Moyes, 2011). In other words, the addict may believe that there is
nothing wrong with them. Implications for treatment and recovery between these
addictions are distinctive as their origins differ substantially (O'Neal, 2011).
Despite the successes of Alcoholics Anonymous, the American Psychiatric Association
maintained substance abuse disorders as “untreatable personality disorders” and clients
with addictive behaviors were “labeled as recalcitrant and resistive recidivists.” These
were regarded as hopeless and terminal conditions.” With greater research and
treatment knowledge, the then new Diagnostic and Statistical Manual of Mental
Disorders, Third Edition (DSM-III) included alcohol abuse and dependence in a category
titled "substance use disorders" rather than as a personality disorder (Miller, 1980, p. 6).
The initial purpose of treatment is to bring the client to a tipping point where the
preponderance of information, experience, and reality of their disease brings on an
epiphany concerning the nature of their condition and rendering them amenable to
accept and internalize treatment. The prelude to successful treatment requires that the
client be brought to an understanding that a problem exists and formulating an actual
desire to quit. “Primarily, the patient must himself wish to recover….” (Keyes, 1947).
“The only requirement for membership is a desire to stop drinking” (Anonymous, 2001,
p. 562) or, “The only requirement for membership is an honest desire to stop drinking”
(Anonymous, 2001, p. xiv). In the Book Alcoholics Anonymous this tipping point is
described as “We learned that we had to fully concede to our innermost selves that we
were alcoholics. This is the first step in recovery” (Anonymous, 2001, p. 30).
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Counseling Practices to Safeguard Against Codependency
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A starting point for the Addiction Professional, particularly for those who are new to the
profession, and especially those who do not come from a recovery background, in
dealing with the issue of codependency, is self-examination. A prepared counselor will
know their own issues with regard to addictions: Am I an alcoholic? Drug addict? Am I
prone to other addictions? Did I come from an alcoholic/drug addicted home? Do I
already struggle with codependency issues? Am I emotionally prepared? Are my
motives appropriate and ethical? A prepared counselor will know their limitations.
Prepared does not mean perfect. However, when the counselor knows where his or her
limits are, they can step back when those limits are being approached and thus avoid
being drawn into difficulty. If the counselor begins to feel uncomfortable or perhaps their
own weaknesses/issues are surfacing, then it may be time to take a break, consult with
another counselor, ask for the assistance of another counselor, or restate the issue in a
manner that redirects the session to safer emotional ground, etc.
Set Boundaries. Establish clear ground rules for conduct of the counseling interaction.
Do not deviate from the boundaries. Even minor deviations will be viewed as a chink in
the armor from which more procedural concessions can be manipulated.
Accept action only as a basis for compliance with counseling progress. Addicts are often
masterful at creating excuses/reasons for non-compliance with therapeutic assignments,
etc. Their words are only valid if backed by action.
Stay Emotionally Detached. Counselors are by nature caring and nurturing. They find
themselves easily drawn to emotional attachment to their clients. Addiction counselors
can and should have regard and concern for their clients, but need to remain emotionally
detached as a safeguard to drifting into codependency, but to avoid manipulation by the
client. Certainly as the counselor observes major therapeutic progress in the client, a
closer, more encouraging relationship may be apropos.
Personal Attraction, Awareness of. Along the same lines as Emotional Detachment, the
counselor needs to be aware of certain personality types, physical appearance, and
gender issues that they may be attracted to. There are certain individuals whose
personality types ‘gel.’ With these types of individuals, conversation is easy, counseling
sessions are a joy, rapport is easily built, and trust rapidly established. The counselor
may tend to back off of boundary issues, may not require the same stringent ‘action’
requirements, etc., and leave themselves open for codependency issues to encroach
into the relationship. This same ease of attachment too is often likely to occur with
opposite sex clients with which the counselor may be physically attracted to. Physical
attraction may not be immediate, but may grow over the course of treatment. In 12 step
programs there is an unwritten rule-of-thumb that “Men work with men and women work
with women”. Experience shows that this rule has merit in avoiding situations that may
compromise the sobriety of both parties. This procedure is obviously not a luxury that is
available to the addiction counselor. However, the concept and principle involved needs
to be consciously guarded against by the counselor. Significant boundaries and
emotional detachment by the counselor are issues that should remain front and center in
the therapeutic relationship to avoid compromise. In each case it should be noted by the
counselor that newly sober clients don’t emotionally know who they are. They are not
accustomed to the emotions they are about to connect with and ‘feel’ in sobriety. An
emotional attachment to such individuals will leave the counselor vulnerable to the full
range of emotion and transference-countertransference issues that may come as
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•
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‘feelings’ and ‘reality’ hit the newly sober client full force. Additionally, such close
attachment may leave the counselor with feeling of guilt, remorse, and responsibility
should the client relapse.
Along with Detachment is the concept of Expectations. The counselor and the client are
aware of the nature of treatment and what is expected of the client. In order to help
guard against the emotions that may lead the counselor into codependency the
counselor should remain not only detached emotionally, but have no expectation that the
client will follow his or her recovery plan or act upon the suggestions of the counselor.
An Al-Anon principle is that “Expectations are premeditated resentments” (Al-Anon
Family Groups B-16, 1992, p. 153). For the counselor, this rule-of-thumb implies that if
one does not have an expectation then one has nothing to be upset about. Conversely,
if/when good things begin to occur, then actual progress is being made. In either case,
detachment is maintained. Resentments in the counseling relationship can be very
detrimental. One definition of resentment heard in 12 step programs is that having a
“resentment is like taking poison and waiting for the other person to die” (McCourt,
(n.d.)). As such then, if counselors do not remain relatively detached, begin to have
‘expectations’ of their clients, begin to prod, excuse, or accept unmet expectations –
which will lead to more unmet expectations – attempt to do for the client what the client
should be doing for themselves in order to ‘help’ the client meet counselor expectations.
Then when those expectations are not met, anger and resentment sets in,
codependency is firmly established and hopes of an effective counseling relationship are
virtually non-existent.
With Emotional Detachment and having no Expectations of the client, the counselor is in
good stead with self. Counselors often expect much of themselves. They should of
course continually strive to improve their skills and abilities. However, they should not
entirely base their success and personal esteem on the progress/success of their clients.
Naturally, a higher than average failure rate would require examination, but
codependency thrives on basing one’s esteem on the lives of others.
Communicate with, and gain/provide support from/to other addiction professionals. As
noted above, a counselor should not totally base their personal esteem on the
successes or failures of their clients. However, the healthy counselor will build a support
network with which to vent, consult, console, commiserate, inquire from, learn from,
share experiences with, seek support/recommendations from, and realistically compare
self to. Such a professional support network will assist the counselor in staying firmly
grounded. If the counselor is not firmly and professionally grounded codependent
feelings of being isolated, alone, and/or seeking of support and reassurance from the
client may subconsciously commence, thus thwarting the therapeutic processes.
Additionally, if the counselor is a person in recovery, then staying firmly grounded in and
to their individual program also is paramount. Counselors should remain active
participants in their own programs and accountable to their own sponsors, etc.
Furthermore, it may be advantageous to all area addiction professionals, therapists,
counselors, etc. to form a private/closed Al-Anon meeting. Such a meeting could help
address, and thus help to prevent isolation and other codependency issues from
developing in the individual counselors involved.
Spirituality is the solution denoted in the founding principles of all 12 step based
recovery programs. Regardless of what Power the counselor views as important in their
lives, the important principle in the counseling for recovery process is to comprehend
that the counselor is there to guide, but the solution is outside their control. Ego and
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believing that they, the counselor, are the primary element in the recovery of the client
will also lead to codependency in that the counselor will again base their pride and ego
on their own abilities (hence on the success of the client) and will doom themselves to
eventual failure. Counselors should find their spiritual center; define their personal ‘right
and wrong’ based on that center, and stay there. Grow spiritually, but don’t deviate to
accommodate the needs or desires of the client – or the counselor’s need or desire for
the client. The counselor and the client will be well served if the counselor views
themselves as an instrument of their spiritual center and as being of service of others.
Counselors are often presented with personal problems, questions, outside concerns,
etc. with clients. Various temptations to act, well meaning, innocent, or otherwise may
arise. Before acting, of course, check for ethical implications, but in all cases the
counselor should ask themselves three questions: “What’s my motive? Is it any of my
business? And will my taking this action measure up to my spiritual principles?”
Remember that addiction involves a personality change in the client. Consequently,
recovery will bring to light ‘someone’ who may be totally different than the person who
entered into treatment. Counselors need to anticipate that change will occur. A
counselor who has started down the path of codependency with the client will often
attempt to prevent this personality change from occurring in the client and thus impede
the recovery process.
Don’t help. Remember that the counselor does not help by helping. The client is
responsible for his or her own recovery process. They will do it or they won’t. Protecting
the client from the consequences of their own actions or inactions will prolong or prevent
recovery and build codependency in the counselor.
Counselors are by nature helping, caring, and loving individuals. These very traits make them
susceptible to codependency. Is an understanding of codependency issues important in the
therapeutic counseling process? It is the view of this researcher that the answer is in fact, yes.
Codependency issues in the therapeutic process, if not understood and well managed, can
have a devastatingly adverse effect on both the client and the counselor. Counselors must
countermand the urge to help their clients. Clients learn from experience. Counselors may know
an easier way that would help the client not experience the consequences of their actions, but it
is often those consequences and resulting pain that will be the touch-stone of their growth and
recovery. As with most of us, clients learn from experience, and from the experiences of
everyone they encounter. In some of these experiences they learn what to do; in others they
learn things to avoid doing. They learn by listening and observing the reactions and behaviors of
others. They may test the limits and boundaries of their counselors and attempt to manipulate
therapy to avoid the work involved in the process. They may not view their counselor(s) as
having the therapeutic knowledge and skills necessary to handle the client’s self-perceived
unique needs – and may bluntly express these feelings to the counselor. However, in spite of
his or her manipulative tactics, the client will learn significant recovery lessons by observing
their counselor’s calm resolve to set and observe boundaries, require therapeutic action,
observe the importance the counselor places on his or her own spiritual (moral and ethical
principles) center, and ‘feel’ the goal for the client that the counselor continually points to. That
goal is for the client to reach the tipping point or self-admission or surrender to their difficulties
and gaining the personal desire for recovery. By observing these things in the counselor the
client will know they are loved, cared for, and have been helped by an Addiction Professional
Counselor. A counselor who cared enough to overcome the emotional tug of codependency,
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stay true to the principled approach, and become the steadfast rock the client may now wish to
emulate in recovery. “I remember when I was in treatment my counselor said…”
_______________________________________________
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ACKNOWLEDGEMENTS AND NOTICES
This article may contain opinions that do not reflect the opinion of Breining Institute, and
Breining Institute does not warrant the information and/or opinions contained herein.
properly referenced, and that the following citation is used in full: O’Neal, H.S. (2011).
Codependency among health care professionals: Is an understanding of codependency issues
important to the therapeutic counseling process? Journal of Addictive Disorders. Retrieved
[date retrieved] from Breining Institute at http://www.breining.edu.
__________________________________
This article was prepared by H. Spencer O’Neal, candidate for the Doctor of
Addictive Disorders (Dr.AD) Degree from Breining Institute, and a Licensed
Educational Psychologist (Lic. No. 2480) in California.
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JOURNAL
OF
ADDICTIVE DISORDERS
Relapse Prevention: An examination of relapse issues includes consideration of the
relevance of this issue, an historical perspective, a survey of existing knowledge on the
subject, and ideas counter to disease concept beliefs. 1
ARTICLE
Sam has quit drinking; it was not easy. He is thirty-eight years old and has been working
full time since graduating from high school. He was fifteen when he first tried alcohol. It
worked; he felt great. However, his years of drinking finally caught up with him when he got his
second DUI (driving under the influence). He “sort of ignored” the first one. But now, with the
second DUI, he is scared of more legal trouble. Since the second DUI, Sam has worked hard to
abstain, suffering three relapses in the process. He has now attained seven months of sobriety
and is working daily to stay clean and sober. He is attending a twelve-step meeting, has a
sponsor for support, and has successfully kept his job. More troublesome for Sam is his desire
for his old drinking buddies even though he knows they mean danger to him. Making new
friends is hard. Thus describes the composite client who completed the survey for this work.
Like Sam, we humans have been drinking and doing drugs in one form or another for
eons. Alcohol predates humans who discovered it as a naturally occurring product, as do many
now-illicit drugs (Kinney, 2003). Relapse issues would not exist were it not for the damaging
effects of alcohol and other drugs. These damaging effects, including relapses, have been
noted and documented for hundreds of years while proactive relapse prevention issues have
only been formally addressed for about twenty years, according to Daley in his 1987 article for
the publication Social Work. In another work a few years later, Daley notes the “…vast amounts
of examples of what does not work,” regarding relapse prevention while there is not very much
about what does work (Daley, 1991).
Exploring relapse issues for this work includes consideration of the relevance of this
issue, an historical perspective, a survey of existing knowledge on the subject, and ideas
counter to disease concept beliefs. Additionally, inquiry into why relapse happens and what can
be done to prevent relapses will include results from the survey (see Appendix) completed
assessing attitudes about what helps people remain abstinent.
properly referenced, and that the following citation is used in full: Anderson, S.T. (2005).
Relapse Prevention: An examination of relapse issues includes consideration of the relevance
of this issue, an historical perspective, a survey of existing knowledge on the subject, and ideas
counter to disease concept beliefs. Journal of Addictive Disorders. Retrieved from
http://www.breining.edu.
1
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Terence T. Gorski, acknowledged as the father-of or guru-for relapse prevention,
believes, “Relapse is a complex process.” He further asserts addiction is a bio-psycho-social
disease and, therefore, relapse prevention must address each of these areas: biological,
psychological, and relationships (Gorski, 1986). Addiction and relapse issues affect millions of
Americans daily. “Nearly one half of the patients who visit a family practice doctor have an
alcohol or drug disorder,” states author Miller in 1998. That percentage has most likely risen in
the subsequent years.
Complicating relapse issues is our country’s growing managed health care system which
focuses more on managing costs than on the patients’ needs. Given the reality of this focus,
anyone needing recurring care is under greater scrutiny. The addict faces more roadblocks and
is routinely castigated due to common attitudes blaming the addict for their addiction. This is
not true of the heart or diabetic patient. “What everyone must recognize is that relapse is part
of treatment. The field is just now coming to grips with that,” notes Darcy (Experts, 1996). More
in line with the managed care industry’s approach is Wanigarante’s view that addictive behavior
can be overcome by a person’s own individual efforts, unlike other diseases (1990). Echoing
Wanigarante’s views, Trimpey in his The Small Book challenges the disease concept of
alcoholism claiming that over the long haul, over the centuries, “…far more people have
probably helped themselves independently than through recovery programs.” (1992).
As early as the 1840’s a focus on helping people leaving institutions to integrate back
into society was evident. Even though primitive by current standards, this aftercare included,
“…placing the patient with sober friends and encouraging the patient’s affiliation with a church or
fraternal temperance society.” (White, 1998). Durfee’s ‘Practicing Farm’ was well known in the
early 1900’s for their treatment with alcoholics. These efforts at early relapse prevention
included Durfee helping his clients define ‘zero hour’, those times and situations most likely to
elicit cravings and lead to drinking. He then helped each person to develop alternative activities
to get beyond the crisis or critical time. By the mid 1900’s medications were in use, notably
Disulfiram (Antabuse) to help gain abstinence. Later, in 1992, Naltrexone (ReVia) studies
showed this drug could help reduce alcohol relapse rates by reducing cravings, among other
effects (White, 1998). Acamprosate (Campral), approved in 2004, assists in balancing brain
chemistry to help the addict maintain abstinence after detoxification is complete.
The term, relapse prevention, was “…coined by Professor G. Alan Marlatt who described
it as a collection of cognitive-behavioral strategies and lifestyle change procedures aimed at
preventing relapse in addictive behaviours.” (Wanigarante, 1990). The New Lexicon Webster’s
Dictionary of the English Language defines relapse as “to fall back into ill health” and prevention
as “the act of preventing, to cause not to do something, to cause not to happen.” Thus relapse
prevention can be defined as to cause one to not fall back into ill health, i.e., alcoholism or drug
addiction (1987). Interestingly the Oxford Dictionary of Psychology has no listing for either
‘relapse’ or ‘prevention’ (Coleman, 2003). More to the point is the absence of either word in the
DSM-IV (Diagnostic & Statistical Manual). Various kinds of remission are mentioned when the
patient does not meet criteria for substance dependence or substance abuse. Only an implied
reference to relapse prevention can be inferred from the qualifier on agonist therapy as the use
of an agonist/antagonist agent is one way to help prevent relapses (American, 2000).
“Relapse, by definition, involves a failure to maintain behavior change, rather than a
failure to initiate change,” notes Annis (1994). Daley calls relapse “…a process of building up
that, if not responded to, is very likely to lead back to addictive use of alcohol, drugs…”. He
further notes relapse is an event of returning to the addictive behavior or as a process where
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warning signs occur cautioning one that they are likely to return to the substance or behavior
unless positive steps are taken. One can be in the relapse process before engaging in the
behavior, as thinking one can handle purchasing the substance or avoiding healthy peers. The
addict has not indulged at this point but will relapse unless he is able to stop himself. “Relapse
should be seen as a complex process culminating in a predictable outcome rather than as a
discrete event. Relapse results from an interaction of affective, behavioral, cognitive,
environmental, physiological, psychological, spiritual, interpersonal, and treatment factors.”
(Daley, 1987; Daley, 1991). Wanigarante offers her pithy comment, “Relapse is an anathema
for those who work in the field, for it is generally considered to be the most common outcome of
treatment.” (1990).
Relapse rates are fairly consistent over time and completed studies. Daley notes the,
“…majority of people with an addictive disorder experience at least one relapse.” Most studies
show the majority of relapses happen within the first three months. Gorski reported over sixty
percent of alcoholics treated in private sector programs relapsed. Miller and Hester reviewed
7,500 alcohol treatment outcomes with the conclusion that over seventy-four percent relapsed
within the first year (Daley, 1987; Daley, 1991; Gorski, 1982; Ringwald, 2002; Thomas, 1994).
In considering psycho-social treatment to prevent relapse, Miller notes Alcoholics Anonymous
(A.A.) shows an eighty to ninety percent abstinence success rate in the first year when the
addicts received weekly continuing care after discharge (Miller, 1998).
The Rand Corporation’s 1976 study Alcoholism and Treatment found a fifty percent rate
of remission for both groups: those who had a single contact with a center and received no
treatment, and those who were treated. This suggests treatment may play only an incremental
role in recovery. “The crucial factor for success may indeed be the client’s decision to contact a
treatment center for help in the first place and to remain in treatment, rather than something that
occurs during the process of formal treatment itself.” (Ringwald, 2002). Conversely, Kelley notes
most studies show longer lengths of stay in residential treatment centers are more effective in
promoting abstinence. He believes this is related to, “…the natural healing of these symptoms
that occurs over time when the patient is confined in a protective environment.” (1994). Breining
brings both thoughts together noting, “the greater the motivation to avoid problems by changing,
the higher the incident of uninterrupted recovery.” (2000).
Vaillant’s fifty year study of 660 men reported more subjects who recovered from
alcohol dependence began abstinence at A. A. than in treatment. This study concluded,
“…changing an addiction required four elements: a substance dependency; ritual reminders that
one drink could cause relapse; repair of social and medical damage; and self esteem.” (Vaillant,
1995). Father Martin states, “The disease of alcoholism is the most terminal of all terminal
illnesses. I also believe that alcoholism is the most prevalent disease in the United States
today.” He estimates there are at least twenty million alcoholics (Martin, 1982). That number
has certainly risen in the ensuing twenty years. A final sobering note is Ringwald’s observation,
“on any given day, about one million Americans are being treated for substance abuse.” (2002).
Yet the vast majority of alcoholics and drug addicts are not receiving treatment and continue to
relapse.
Gorski was asked, ‘What might I do that would cause a relapse’? His response: “You
don’t have to do anything. Stop using alcohol and other drugs, but continue to live your life the
way you always have. Your disease will do the rest. It will trigger a series of automatic and
habitual reactions to life’s problems that will create so much pain and discomfort that a return to
chemical use will seem like a positive option.” (1989). A few years earlier he had noted, “The
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relapse process does not only involve the act of taking a drink or using drugs. It is a
progression that creates the overwhelming need for alcohol or drugs.” (1986). Gorski
developed his Relapse Syndrome and Relapse Progression lists itemizing the steps a person
goes through to get to the actual relapse. These involved detailing an individual’s internal
dysfunction, external dysfunction and loss of control. Later he simplified the process of
relapsing to six progressive items: high-risk factors, trigger events, internal dysfunction,
external dysfunction, loss of control, and finally, the lapse or relapse (Gorski, 1989). He has
also listed the phases and warning signs of relapse as well as written volumes of other work;
understandable given his long and intense involvement with relapse prevention treatment
issues.
Dr. G. Alan Marlatt, another major contributor to relapse prevention thinking, believes
there are two main factors contributing to relapse: immediate determinants and covert
antecedents. The immediate determinants include high- risk situations, coping skills, outcome
expectancies, and the abstinence violation effect. His covert antecedents include lifestyle
factors, urges, and cravings. These ideas form the central aspect of his cognitive-behavior
model of relapse prevention (Larimer, 1999). Marlatt speaks of his ‘relapse chain’ noting,
“Each relapse warning sign or clue can be seen as one link in this relapse chain. Each link
represents an event or situation in which we make a decision that in one way or another affects
relapse or recovery.” Marlatt further asserts we make decisions seemingly unrelated to a
potential relapse, but in reality have a great deal to do with a relapse. One example is the
gambling addict who just happens to choose a restaurant knowing it has a casino in that
restaurant. Marlatt called these “apparently irrelevant decisions” that are not irrelevant at all
(Daley, 1991).
“An inability to deal effectively with high-risk situations involving negative emotional
states also has been found to be predictive of relapse,” notes Annis (1994). On first reading
this seems obvious and it is. Yet these seemingly obvious observations of reality need to be
said and dealt with for the benefit of the person trying to stay clean and sober. Most of the
knowledgeable people in the relapse field speak to the importance of identifying and learning to
deal with high-risk situations (Daley, 1991; Gorski, 2000; Larimer, 1999). To one trying to
maintain change and not relapse, challenges and high-risk situations are inevitable. Some can
be avoided, i.e., staying out of bars, but most cannot. “Hence whether or not the person has the
ability to cope with high-risk situations becomes a crucial factor in preventing relapse.”
(Wanigarante, 1990). She goes on to list common categories of high-risk situations including
negative emotional states, positive emotional states, interpersonal conflict and social pressure.
Note her inclusion of both negative and positive emotional states as each can be included in her
definition of high-risk situations: any situation or condition that poses a risk or threat to the
individual’s sense of control and increases the risk of relapse. Larimer adds “…although the
relapse prevention model considers the high-risk situation the immediate relapse trigger, it is
actually the person’s response to the situation that determines whether he or she will
experience a lapse. A person’s coping behavior in high-risk situations is a particularly critical
determinant of the likely outcome.” (1999). Or, in other words, the greater the coping strategies
the less likely one is to relapse.
Marlatt & Gordon’s Relapse Prevention Model analysis concludes that two situations
served as triggers for over half of all relapses. They are negative emotional states and
situations involving another or group of people, especially interpersonal conflict. Even
something seemingly beneficial as a recreational activity can be a high-risk situation. “High-risk
leisure situations include leisure-based situations that pose a threat to an individual’s sense of
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control in maintaining sobriety.” Deiser gives the example of an alcoholic going bowling where
alcohol is served. In this case the facility and activity could be considered a high-risk leisure
situation (Deiser, 1998).
Warning signs for the majority of people show up gradually as the process of relapse
slowly evolves. These warning signs are usually a combination of internal (thoughts, feelings,
attitudes) and external (behaviors and actions). Most people have warning signs that are
unique to that person and situation (Daley, 1991). An internal warning sign could be your not
caring anymore or believing you are cured. Failing to notice these warning signs at the earliest
possible time could well lead one to relapse. “The most frequently cited (external) behaviors
related to the relapse process include returning to places or contacting people associated with
the addict’s habit.” (Daley, 1991). Other examples of external warning signs include cutting or
eliminating participation in recovery groups and showing increasing stress symptoms, such as,
anxiety, trouble sleeping, or eating too much or too little. Claudia Black notes, “…for the addict,
triggers bring them closer to relapse. One particularly strong trigger is euphoric recall. This is
when we romanticize using behaviors and forget about the negative consequences.” (2000).
Her advice is to immediately disengage from the fantasy and/or leave the situation. Too many
addicts find this impossible to do. Along these lines, Bill W. wrote, “Resentment is the Number
One offender. It destroys more alcoholics than anything else.” We must let go or release our
resentments. Otherwise, “if we maintain our resentments, we find that we want support in our
misery and seek out people who will provide that.” At which point, we are one step closer to
relapse (Black, 2000).
Marlatt & Gordon’s work, (1985), noted the covert antecedent most strongly related to
relapse risk, “…involves the degree of balance in the person’s life between perceived external
demands (i.e., “shoulds”) and internally fulfilling or enjoyable activities (i.e., “wants”).” Someone
with a life full of ‘shoulds’, i.e., constant stress and high-risk situations, is most vulnerable. This
enhances their desire for pleasure and the rationalization that indulgence is justified. (“I owe
myself that drink or hit.”). If no other pleasurable activity is available, the drinking/drugging can
be viewed as the only pleasurable option. These covert antecedents, because they are
concealed, are less obvious yet powerful in influencing the rate of vulnerability to relapse.
Lifestyle factors (overall stress levels) and cognitive factors (denial, rationalization, and desire
for immediate gratification, as urges and cravings) play a major role in determining if one
relapses or not (Marlatt, 1985).
Coping skills are identified as critical to one’s ability to stay clean and sober. Jack
Trimpey created his acronym, BEAST, to help the addict remember these enemies of relapse.
He teaches that focusing on these thoughts allows one to avoid relapse. BEAST stands for:
Boozing opportunity where one considers doing; Enemy voice recognition of any positive idea
about alcohol and drugs; Accuse the voice of malice as a distancing technique; Self-control and
self-worth reminders as rational antidotes to poor impulse control; and Treasure your sobriety by
reaffirming the intrinsic value of sobriety (Trimpey, 1992).
The importance of coping skills as major determinants of relapse is recognized by many
in the field. The lack of coping responses almost guarantees relapse. Thus teaching coping
skills is critical. One’s self efficacy is also critical to maintaining sobriety and is “…associated
with positive treatment outcome(s).” (Annis, 1994). This sense of self efficacy is built on coping
skills and responses the client has or learns. These include environmental support, behavioral
coping, cognitive coping, and affect coping. Annis cautions these coping skills must be learned
from the easy to the more difficult as perceived by the client. This affords the client early
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success which must happen for the client to be willing to risk at the next more difficult level.
Early success is also needed so the client does not just give up after an initial failure. These
efforts are designed to help clients feel better about themselves and to minimize their tendency
to blame others which is all too common with those having a lower sense of self-efficacy (Annis,
1991; Annis, 1994; Daley, 1987; Wanigarante, 1990).
Jack Trimpey’s counterclaim to the disease concept of alcoholism, as spelled out in his
book, The Small Book, (1992), argues, “Sobriety is not a miracle: it is a decision. If you want to
stop drinking, you can quit right now and you know it….Accept that you are in control of your
own drinking and drugging and that you have been in control all along.” Trimpey charges that
relapse is a failure to have a big plan for life coupled with the failure to follow that plan. In his
view relapse is a violation of that plan which is a, “…covenant with yourself that is next to
sacred.” He continues, “Faith and reason are diametrically opposed to each other, and each
forms the philosophical basis for AA and RR (Rational Recovery), respectively.” This reasoning
asserts that if one accepts that he is in charge of his emotions then he can control his thinking
and in that way can avoid relapse. “Relapses don’t just happen. There is always a conscious
element. Even when alcohol is accidentally ingested, such as at a party where the punch has
been spiked, a relapse is a full-fledged conscious decision. Everytime. A lapse, where a drink
has been accidentally or impulsively taken, is not a relapse, but a lapse of judgment.” (Trimpey,
1992).
Other writers and researchers have weighed in about relapse ramifications. Maultsby
states, “…within a year of treatment most cured (dry) alcoholics take a running jump off the
wagon. That’s right. Alcoholics don’t fall off the wagon; they take a running jump.” He notes
two reasons: confusion about what the main problem is and the treatment has not taught them
how to live happily without alcohol. Maultsby’s summation is, “The main problem is not
alcohol. Their main problem is habitual alcohol abuse…that is, drinking to solve personal
problems. For such alcoholics to stay cured, they must learn how to solve their personal
problems without alcohol.” (Maultsby, 1978). Taking a more measured view, Mackay and
Marlatt advise, “Rather than seeing a lapse as a return to the diseased state, relapse can be
viewed as a single step backward that does not predict what direction the next step will be.
Continued worsening is not inevitable.” (1994).
While obviously divergent views regarding all aspects of relapse exist, a commonality is
the agreement that the alcoholic or drug addict must be willing and able to cooperate with
treatment. Without this ability to follow the treatment, no approach has relevancy. Gorski’s
comments seem especially astute when he states, “Recovery is like walking up a down
escalator. It is impossible to stand still.” He continues, “When you stop moving forward, you
find yourself moving backwards. You do not have to do anything in particular to develop
symptoms that lead to relapse. All you need to do is fail to take appropriate recovery steps.
The symptoms develop spontaneously in the absence of a strong recovery program.” (Gorski,
1986).
“Abstinence from alcohol and other drugs is only the beginning of sobriety. It’s the ticket
to get into the theater, not the movie we are going to see.” Gorski continues by explaining his
six relapse prevention stages, which are: 1) transition or giving up the need to control alcohol
and other drug use; 2) stabilization as recuperating from the damage caused by the addictive
use; 3) early recovery noted by internal change, i.e., change of thinking, feeling and acting
regarding alcohol and drug use; 4) middle recovery shown by external change, i.e., repairing
lifestyle damage caused by addictive use and developing a balanced lifestyle; 5) late recovery
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of growing beyond childhood limitations; and lastly, 6) maintenance where one lives a balanced
life and continues growth and development (Gorski, 1989). Later, Gorski listed his relapse plan
recovery activities as seeking professional counseling, self-help programs, a proper diet, an
exercise program, stress management, a spiritual development program, and morning and
evening inventories. He believes each of these needs to be addressed and incorporated into
any successful recovery plan (2000). Gorski with others believe a good relapse prevention plan
must include an assessment of lifestyle factors related to relapse, a list of personal warning
signs showing the person the steps leading from stable recovery to relapse, warning sign
management strategies and a revised program with on-going identification and management of
relapse warning signs (Experts, 1996).
“Recovery begins when addicts accept the possibility that they can live happily and
usefully, without drugs.” Ringwald, (2002), continues noting many addicts use the acronym HO-W to remind themselves of the required virtues of being honest, open and willing. Breining,
(2000), lists factors he believes are necessary for a recovering person to live happily without
drugs. These keys to a sober recovery are: getting to a painful stopping off place; intense early
involvement in treatment; appreciation and gratitude for a changed lifestyle; acceptance of one’s
powerlessness over drugs and a willingness to follow another’s advice; a willingness to embark
on a program that “defies scientific inquiry and intellectual grandiosity”; surrender the need for
instant gratification and self-centeredness; and finally, acknowledging one’s own limitations and
acceptance of the need for a mentor.
As early as 1983, Prochaska and Di Clementi proposed a series of discrete stages one
goes through regarding any behavior change, including achieving and maintaining abstinence.
These take us from pre-contemplation, prior to seeing any need for change, through
contemplation, making a decision, actively changing, to the inevitable relapse, and ultimately,
maintenance. One is advised this path is circular, not linear. In this circular model, one can
enter and leave at any point; one is not required to go through the stages in specific order
(Wanigarante, 1990).
Traditional alcohol treatment took the dichotomous view of treatment outcome: they
were either abstinent or relapsed. In contrast, several models based on social, cognitive or
behavioral theories, such as Annis, Litman, Marlatt, and Gordon, see relapse “…as a
transitional process, a series of events that unfold over time.” (Larimer, 1999). This transitional
process view provides a broader conceptual framework for intervening in the relapse process to
prevent or reduce relapse episodes, and thus improve treatment outcomes. Wanigarante,
(1990), further elaborates, “…the practice of relapse prevention is focused on the client’s
ongoing process of change, as opposed to a fixed treatment goal such as permanent
abstinence. I often describe relapse prevention as a maintenance strategy, a method to work
with the ongoing process (including lapses, relapses, and prolapses) that people experience as
they change their behavior.”
All recommendations for relapse prevention can be included in three main categories:
cognitive, emotional, and behavioral. Or more simply put: thinking, feeling and doing. These
tools include learning coping skills, increasing awareness and changing one’s lifestyle. The
Alcoholics Anonymous publication, Living Sober, (1998), offers many thoughts to assist in living
a sober life including getting active, become aware of one’s anger and resentments, and
steering clear of emotional entanglements. The book offers many more ideas, all of which
include healthier thinking, feeling and behaving. Other recommendations for maintaining
sobriety include self-monitoring, relaxation training, assertiveness training, detachment,
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changing one’s thinking, and positive addictions. An emergency recovery card was also
mentioned so one would have a list of people to call and reminders of what to do in a high-risk
situation. Spirituality was noted frequently with participation in twelve-step meetings highly
recommended. Larimer’s intervention strategies ask one to identify and cope with high-risk
situations, enhance self-efficacy, eliminate myths and any placebo effects, manage any lapses
and apply cognitive restructuring. His lifestyle self-control strategies include learning to lead a
balanced lifestyle with positive addictions, stimulus-control techniques, and urge-management
techniques, in addition to creating a personal relapse prevention road map (Larimer, 1999).
”Recall the past, live in the present,” reminds Fletcher, (2001), as she writes of the
people who have maintained sobriety which she calls ‘the masters’. These people “…over and
over told me that they remain motivated by never allowing themselves to forget the past.” She
continues noting how this one thought is the most powerful and consistent theme in all the
information she gathered from these masters. Countering negative memories of drinking days
with vivid awareness of the many rewards of sobriety allows one to remember the negative old
while focusing on the positive new. All believed the efficacy of learning many things to do and
say to cope with the usual situations of daily life, i.e., company parties, dinner at friends, travel
for work, or attending any social event. “Everything you do to keep yourself sober comprises
your recovery program,” asserts Fleming, quietly underscoring the importance of each and
everything we do (1991). If addiction was the only coping skill, then the person is more likely to
be weak or deficient in healthier, more adaptive coping responses. This person would have
great difficulty coping with any stressor once they have given up the addiction because the only
skill they had was the addiction. Looking for other ways to avoid relapse, researcher Zinberg
and others found differences between non-addicted people and those addicted. The nonaddicted had activities and people in their lives completely apart from drug usage whereas the
addicts did not (Daley, 1991; Peele, 2004; Ringwald, 2002; & Wanigarante, 1990).
Additional challenges to the disease model of addiction include challenging A. A.’s
emphasis on past wrongdoings rather than focusing on the future. Another contention asserts
that addiction is a challenge to grow rather than a disease to pull one backward. “In a
progressive disease model, the afflicted individual is always on the verge of succumbing to the
inevitable downward pull of the disease – always ‘recovering’, never ‘recovered’. An alternative
relapse prevention slogan is: ‘I’m discovering, not recovering’.” (Wanigarante, 1990). Peele,
(2004), suggests moderation, not abstinence, is the opposite of addiction. He champions
moderate use so one does not attempt abstinence and then fail (relapse).
While these views diverge, they do agree on the need for treatment including the need
for cognitive, emotional, behavioral and social changes for the addict’s best chance at long term
sobriety. For what is success but an increasingly long length of time between relapses? No
matter what relapse prevention techniques we employ, abstinence is the marker of
achievement. Ergo: success is the ever-increasing length of time between relapses, whether
that is one day longer than the last time or until the day one dies.
A look at ways to prevent relapse includes considering what medications are available.
Many are used to treat the various addictions with three drugs specifically approved for use in
the treatment of alcoholism. Antabuse (Disulfiram) has been used for many years as aversion
therapy making the drinker very ill if combined with alcohol. Because the symptoms of this
effect can be life threatening, it is not used as often now as it was in prior years. The key to
successful use is patient motivation for abstinence and the expectation of adverse reactions.
ReVia (Naltrexone) has been principally used in the treatment of opiate addiction with more
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recent use for alcoholism treatment. Studies show it is effective in reducing the number of days
per relapse and reducing cravings for alcohol. It has fewer side effects than Antabuse and has
been successful in reducing the desired ‘high’ effect. Campral (Acamprosate) was approved
recently and is now available. It is used for its anti-craving effects. It is thought to stabilize the
brain’s glutamate system to make it feel normal allowing patients to not feel the strong need to
drink. This drug’s efficacy is best when combined with counseling or other psycho-social
support. Campral is recommended to help maintain abstinence after successful alcohol
detoxification. Dolophine, better known as Methadone, has been used for many years as a
harm reduction agent to assist in withdrawal of heroin and opiate addiction. It, like all other
medications, is more effective in conjunction with other psycho-social treatment and support.
Other medications are used for addiction treatment in addition to the illnesses they were first
designed to treat. These include Triazolam, Midazolam, Lorazepam, Valium, Clonidine,
Wellbutrin, and Librium (Gelowitz, 1996; Inaba, 2000; Lawson, 1988; Miller, 1998).
The opinion survey completed for this work was designed to ascertain what works for
people in their efforts to stay clean and sober. Ninety-eight people responded out of a total
population of approximately 375 clients of a rural alcohol and drug treatment agency serving the
general population as well as court referred people for driving under the influence and drug
related convictions. Before describing the results of this survey which took place over a two
month period earlier this year, the following quote from a survey participant deserves to be
recognized as it relates well to relapse issues. The participant wrote, “Our thoughts are how we
feel and act. Learn to control our thoughts, and our behaviors will change. An example:
thinking about the past will enable us to stay focused on the present. Thinking about the future
will take our focus off the here and now. To avoid relapse is to just not drink or use. No matter
what, don’t use! Until you are ready to get and stay sober, relapse is just a word used instead
of saying, ‘I got loaded’.”
Of the 98 survey participants, 78 were male and 20 were female, all eighteen years of
age or older. The age range is shown on Chart 1 below. More than half the women are
between 36 and 45 years old. The men’s ages were more spread out with an equal number
between 18 and 25 and between 36 and 45. The third highest category is ages 46 to 55. Men
definitely become alcohol and drug treatment agency clients at an earlier average age.
SURVEY RESPONSE BY AGE
25
20
NUMBER OF RESPONSES
20
20
17
15
14
FEMALE
MALE
11
10
7
5
4
3
2
0
0
18-25
26-35
36-45
46-55
56-UP
AGE GROUPS
Chart 1 – Age Range of Participants
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Education levels vary showing two thirds of the respondents have graduated from high
school or earned some college credits. Of the balance, it is equally divided between people
who have not completed high school and those who have graduated from college or have done
post graduate work. See Chart 2 for details.
LEVEL OF EDUCATION
30
28
25
24
NUMBER OF RESPONSES
20
15
15
FEMALE
MALE
10
8
7
7
5
3
3
2
1
0
SOME HIGH SCHOOL
HIGH SCHOOL
GRADUATE
SOME COLLEGE
COLLEGE GRADUATE
POST GRADUATE
EDUCATION LEVEL
Chart 2 – Educational Level of Participants
An overwhelming seventy percent of the respondents are employed full time. About ten
percent stated they are not employed with the balance either working part time, are retired or
are currently a student.
Numbers for men and women diverge regarding drug or alcohol related convictions. For
the women, almost half have one conviction with another twenty five percent having two
convictions. The men’s number of convictions is higher with about fifty-seven percent having
one or two convictions while over forty percent of the men have three or more convictions.
Twenty-two percent of the men stated they have five or more convictions. See Chart 3 for
details.
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NUMBER OF DRUG / ALCOHOL CONVICTIONS
25
23
21
20
NUMBER OF RESPONSES
17
15
15
FEMALE
MALE
10
8
5
5
3
2
2
2
0
0
1
2
3-4
5+
NUMBER OF CONVICTIONS
Chart 3 – Number of Convictions
Again, the men and women’s experience is different regarding the age of first use.
Forty-five percent of the women reported beginning use between the ages of 12 and 17, with an
equal number beginning at age 18 or over. For the men, sixty percent stated they began using
between 12 and 17 years of age. Only fifteen percent of the men began use at age 18 or over.
Perhaps this is an indication of the availability of drugs to the young males. More likely the
young men are more willing to test and try what appeals to them coupled with more freedom to
experiment. See Chart 4 for details.
AGE OF FIRST USE
18
1 7
16
16
1
1
NUMBER OF RESPONSES
12
10
10
F E M A L E
MALE
8
7
7
6
5
5
3
2
2
2
0
0
0-9
10-11
12-13
1
-15
16-17
18-25
26-OVER
A G E
Chart 4 – Age at First Use
Alcohol was listed as drug of choice for half the respondents. Marijuana,
methamphetamines, and stimulants were each listed by about fifteen percent with the balance
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naming eating disorders, gambling, sedatives, shopping, and tobacco. Seven percent did not
state a drug of choice. Approximately forty percent of the respondents stated they are currently
using their drug of choice and about sixty percent have stopped using. Of the group who are
currently using, thirty-six percent specifically noted they simply do not want to stop. Twentythree percent stated they see no benefit to quitting with another twenty percent admitting they
have tried to quit but returned or they are just not strong enough to quit. Some noted they do
desire to quit and others admitted they are not sure how they feel about the issue. See Chart 5
for further details.
REASONS FOR NOT QUITTING
16
14
14
NUMBER OF RESPONSES
12
10
9
FEMALE
MALE
8
6
4
4
4
4
3
2
2
1
2
1
0
0
DON'T WANT
TO
LIKE THE
EFFECTS
2
1
FAMILY
INFLUENCE
0
FRIENDS
INFLUENCE
TRIED BUT
STILL USING
NOT STRONG
ENOUGH
DON'T SEE ANY
BENEFIT
REASON
Chart 5 – Reasons for Continued Use
The length of time being clean and sober is quite varied for the group of people who
have quit. Seventeen percent have less than 30 day’s sobriety. About twenty percent have
been sober 31 to 60 days, seventeen percent stating three to six months’ sobriety, and an
additional twenty-three percent have earned seven to twelve months’ sobriety. Thus almost
eighty percent have been sober less than one year. The balance of about twenty percent have
one or more year’s sobriety with five percent of this group sober for more than ten years. See
Chart 6 for further details.
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LENGTH OF TIME BEING CLEAN/SOBER
16
15
14
12
NUMBER OF RESPONSES
12
10
10
10
FEMALE
MALE
8
7
6
6
5
4
3
3
2
2
1
2
1
0
0
0-30 DAYS
31-90 DAYS
3-6 MONTHS
7-12 MONTHS
1-5 YEARS
6-10 YEARS
OVER 10 YEARS
DURATION
Chart 6 – Length of Clean and/or Sober Time Achieved
The age of the respondent at the time of first quitting is shown on Chart 7 below. Sixty
percent of the respondents noted they first tried to stop between the ages of 26 and 45.
Another thirty-six percent tried to stop at age 25 or before, while the remainder of the people
were 46 or over before they attempted to quit drinking or using. To take one example, those
men who started at age 12 or 13 used their drug of choice on average fifteen to twenty years
before trying to stop. Perhaps at around age 30 to 35, people have gained a measure of
maturity and realize the damage drugs are doing to them. Thus begins the long road to
abstinence.
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AGE AT TIME OF FIRST QUITTING
25
21
NUMBER OF RESPONSES
20
17
15
FEMALE
MALE
10
9
7
5
4
3
2
3
2
1
0
0
0-18
18-25
26-35
36-45
46-55
0
56 & OVER
AGE
Chart 7 – Age at Time of First Quitting
Given eighty percent of the respondents noted they had been clean and sober for less
than one year, it is understandable that thirty-six percent of that group reported being sober less
than thirty days with a total of almost half stating being sober for ninety days or fewer. This is
consistent with other studies noting most relapse at least once in the first ninety days and
seventy-four percent relapse within the first year. If the quest for abstinence is achieved, it
seems to be quite successful as twenty percent of the respondents stated they have been sober
over one year, with about twelve percent noting over six years of sobriety.
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The struggle for successful abstinence is a rough road indeed as shown in Chart 8
below. At one extreme are the twelve percent of people noting they have relapsed more than
fifteen times in their quest. Another twenty-five percent state they endured from four to ten
relapses. More tolerable for the respondents are the thirty-six percent who had one to three
relapses. A full twenty-six percent have not had any relapses. It is reasonable to assume these
people with fewer relapses are in the group who has been sober under one year; however,
NUMBER OF RELAPSES PRIOR TO BEING CLEAN/SOBER
18
17
16
14
NUMBER OF RESPONSES
12
11
10
9
9
8
8
FEMALE
MALE
6
6
5
4
3
2
2
2
1
1
1
0
0
0
1
2-3
4-6
7-10
11-15
16 & OVER
NUMBER OF TIMES
exceptions do exist.
Chart 8 – Number of Relapses Suffered
Most experts in the field have published lists, procedures, concepts and philosophies for
relapse prevention treatment. Often lacking were specific things a person might do to stay
abstinent. The survey lists seventy-five items which have been known to assist. Respondents
to the survey were asked to note which of the items were helpful to one degree or another.
These items were later consolidated into six categories: the cognitive, emotional and behavioral
elements of both social-external oriented actions and of personal-internal oriented actions. An
example of the social-external-behavior action would be to join a club while talking yourself out
of using is a personal-internal-cognitive action. Only twenty-one to thirty-one percent of the men
rated any of these items very helpful. In contrast, forty-two to fifty-seven percent of the women
rated items very helpful. Perhaps the men are more accustomed to independent action and the
women more open to accepting help. Clearly no one thing works for everyone. See Chart 9
below for details. The margin of error for all charts is +/- 8.52.
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COMPARISION OF PERCENTAGE BY GENDER THAT FEEL THESE ACTIVTIES ARE VERY HELPFUL TO STAYING
CLEAN/SOBER
60
57
54
49
50
45
45
42
PERCENTAGE
40
31
30
30
26
25
26
FEMALE
MALE
21
20
10
PE
RS
ON
AL
/BE
HA
VIO
R
PE
RS
ON
AL
/EM
OT
ION
AL
PE
RS
ON
AL
/CO
GN
ITIV
E
SO
CIA
L/B
EH
AV
IO
R
SO
CIA
L/E
MO
TIO
NA
L
SO
CIA
L/C
OG
NIT
IVE
0
ACTIVITY
Chart 9 – Very Helpful Activities Rated by Gender
Specifically, of the seventy-five activities listed in the survey, the sixteen most helpful
ones for women were, in descending order: making time for self, learn a new skill, don’t let
others pressure you to drink, stay away from drinking/drugging friends, get more sleep/rest, take
a hot bath, work to change negative thinking, talk yourself out of using, learn to speak your truth
clearly, find own spiritual strengths, increase awareness of emotions, spend more time with
family, take medications only as directed, recognize your cravings and wait, distract self with
other activity, and increase patience with self and others.
The men’s most helpful list reads: stay away from drinking/drugging friends followed by:
exercise more, make new clean and/or sober friends, stay out of bars, don’t let others pressure
you to drink, reduce frustration levels, pay attention to how you feel, distract self with other
activity, work to change negative thinking, spend more time with family, learn to speak your truth
clearly, find own spiritual strengths, take up new hobby, express emotions appropriately, sports
participation, and eat more nutritious/healthy foods.
While these lists for men and women differ, there are seven activities noted by both men
and women. They are: stay away from drinking/drugging friends, don’t let others pressure you
to drink, distract yourself with other activities, spend more time with family, learn to speak your
truth clearly, work to change negative thinking, and find own spiritual strength. Interestingly, five
of these involve self-management and self-awareness while the other two involve action and
other people. Crucial to abstinence, then, is choosing one’s companions and consistent, longterm learning and growing in self-awareness and maturity. This is challenging work; no wonder
abstinence is such an illusive goal for millions.
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Conclusion
Ultimately, then, what does work for relapse prevention? In short, anything and nothing.
Anything one does can work; conversely nothing anyone does will help. It all depends on the
person. The crux of the matter lies in the motivation of the individual. Will she accept help?
Does he want to stop? What about the person who didn’t call his sponsor when he recognized
he was heading for a relapse? His answer, “I didn’t want to be stopped.” He recognized he
wanted to get drunk at a funeral because, “That’s what everyone I know does at funerals.”
Does she recognize her addiction causes her difficulties? Or does she assign blame to anyone
and everyone else? What about the woman who repeatedly laments that her children “drive her
to drink”? Is she willing to accept she is addicted and get the help she must have? Or will she
continue on her course of destruction? For the person who is both able and willing to seek and
accept help, everything is helpful. For the person who is not able or willing to be helped,
nothing works. Perhaps this is the essence of the issue of addiction. Getting the person to that
place where they are able to accept help is critical and a monumental achievement.
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******* APPENDIX *******
Thank you for taking time to answer this questionnaire. Your answers will help
me with the research I need for a college paper about relapse issues. I very much
appreciate your assistance.
No names please. This is completely anonymous.
This first page asks for basic demographic information.
The next page asks about your drug or activity of choice.
If you have more than one, please use one that you have quit using, rather than
one you currently use.
The last two pages ask you to tell what activities work for you to remain clean
and/or sober.
Please ask any questions you may have. Thank you.
Demographic
Information
Gender
Age
Education
Male
Female
18 - 25
26 – 35
Less than
High
School
High
School
Graduate
36 – 45
Some
College
46 – 55
College Post
Graduate Graduate
Work
Employment/Work Not
Part time
Full time
Retired
employed employment employment
Number of drug or
alcohol related
convictions?
0
1
2
56 &
over
3–4
Student
5 or
more
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Please write name of your drug or activity of choice______________________________
Just in case, here is a list of common drugs and activities: Alcohol, Amphetamines,
Anti-depressants, Barbiturates, Caffeine, Cocaine, Darvon, Eating disorders, Gambling,
Hallucinogens, Heroin, Inhalants, Internet, LSD/acid, Marijuana/Cannabis, MDMA,
Morphine, Nicotine/Tobacco, Over-the-counter drugs, PCP, Prescription Drugs/Rx,
Ritalin, Sex/Love, Spending/Shopping, Steroids, Tranquilizers.
Now CIRCLE your answer to each question about your named drug or activity of choice
Regarding your
named drug or
activity:
Your age at first
use?
Under
9
Are you currently
using/doing?
10-11
Yes
12-13
14-15
16-18
18-25
Over
25
No
If NO (you have
quit the activity)
how long have you
been clean and/or
sober?
0 – 30
days
31 –
90
days
3–6
months
7 – 12
months
1–5
years
6 – 10
years
Over
10
years
Prior to becoming
clean and/or sober,
how many relapses
did you endure?
None
One
2–3
4-6
7 – 10
11 –
15
16 &
over
How long ago was
the last relapse?
0 – 30
days
31 –
60
days
61 – 90
days
3–6
months
7 – 12 1 – 5
months years
Your age when
you first quit?
Under
18
18 –
25
26 – 35
36 – 45
46 - 55
If YES (you
currently use) do
you want to quit?
What keeps you
from quitting?
Yes
Don’t
want
to quit
6 – 10
years
56 &
over
Not sure
No
Like
Family
Friends
Tried,
influence influence but go
the
effects
back to
using
Don’t
feel
strong
enough
Don’t
see
any
benefit
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Please rank how useful each of these
items, activities or qualities is to helping
you stay clean and/or sober.
Please mark appropriate box.
Not at
all or
Does
not
apply
A bit
helpful
Or use
seldom
Somewhat
helpful or
use once
or twice a
month
Mostly
helpful
or use
at least
weekly
Very
helpful
or use
almost
daily
Stay out of bars
Sports participation
Take up new hobby
Work more hours
Work fewer hours
Get new job
Quit stressful job
Exercise more
Meditate
Write in journal or diary
More leisure/fun time
Less leisure/fun time
Join a club
Join support group (AA/NA/church)
Make new clean and/or sober friends
Stay away from drinking/drugging friends
Enroll in educational classes
Join a health/sports club
Spend more time with children
Spend less time with children
Spend more time with family
Spend less time with family
Eat more nutritious/healthier foods
Make time for self
Don’t let others pressure you to drink/use
Pay attention to how you feel
Reduce frustration levels
Call someone/sponsor when tempted
Call someone when upset/frustrated
“Talk” yourself out of using
Distract self with other activity
Take a hot bath
Take a long walk
Work with your dreams
Learn new coping skills
Manage or control pain
Increase awareness of emotions
Increase awareness of rising tensions
Get hugs from safe people
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Please rank how useful each of these
items, activities or qualities is to helping
you stay clean and/or sober.
Please mark appropriate box.
Not at
all or
Does
not
apply
A bit
helpful
Or use
seldom
Somewhat
helpful or
use once
or twice a
month
Mostly
helpful
or use
at least
weekly
Very
helpful
or use
almost
daily
Learn new ways to deal with anger
Learn a new skill
Teach someone a skill you know
Increase patience with self
Increase patience with others
Spend more time with animals
Obtain individual counseling
Obtain group counseling
Learning to be less impulsive
Tolerate delays and frustration
Recognize your cravings and wait
Learn how long your cravings last
Remind self of what worked before
Learn and use deep breathing to calm
Write your goals/desires
Write your progress toward your goals
Work to change negative thinking
Ask for help when needed
Get finances in order/reduce debts
Volunteering/helping others
Finding own spiritual strengths
Learn better communications skills
Express emotions appropriately
Learn to speak your truth clearly
Get more sleep/rest
Remain aware of tendency to deny truth
Take a vacation
Write poetry
Write letters to others
Spend time with the elderly
Spend time with the very young
Learn a new language
Get medical help for any illness/disability
Take medications only as directed
Lose excess weight
Gain pounds if underweight
Other:
Other:
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REFERENCES AND ADDITIONAL RESOURCES
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drinking. New York, NY: Alcoholics Anonymous World Services, Inc.
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders
(4th Ed.). Washington, DC: Author.
Annis, H. & Davis, C. (1991). Relapse Prevention. Alcohol Health & Research World. Vol. 15,
Issue 3. Retrieved 1/30/05 http://web11.epnet.com/citation.asp
Annis, H. & Davis. C. (1994). Practice New Behaviors in Difficult Situations to Prevent Relapse.
Addiction Letter. March, 1994, Vol. 10, Issue 3. Retrieved 1/30/05
http://web11.epnet.com/citation.asp
Black, C. (2000). A Hole in the Sidewalk, The Recovering Person’s Guide to Relapse
Prevention. Bainbridge Island, WA: MAC Publishing.
Breining, B. (2000). Chemical Dependency and other Addictive Disorders, Workbook Five.
Orangevale, CA: Breining Institute.
Coleman, A., (2003). Oxford Dictionary of Psychology. Oxford, England: Oxford University
Press.
Converse, J. & Presser, S. (1986). Survey Questions, Handcrafting the Standardized
Questionnaire. London, England: Sage Publications.
Daley, D. (1987). Relapse Prevention with Substance Abusers: Clinical Issues and Myths.
Social Work. March/April, 1987.
Daley, D. (1991). Kicking Addictive Habits Once and for All. San Francisco, CA: Jossey-Bass
Publishers.
Deiser, R. & Voight, A. (1998). Therapeutic Recreation and Relapse Prevention Intervention.
Parks & Recreation. May 1998, Vol. 33, Issue 5. Retrieved 1/30/05
Experts Say Treatment Programs Can Overcome Issue of Relapse. (1996). Alcoholism & Drug
Abuse Weekly. May 1996, Vol. 8, Issue 22. Retrieved 1/30/05
Fleming, M. (1991). Commitment to Sobriety, A Relapse Prevention Guide for Adults in
Recovery. Minneapolis, MN: Johnson Institute-QVS, Inc.
Fletcher, A. (2001). Sober for Good, New Solutions for Drinking Problems-Advice from Those
Who Have Succeeded. New York, NY: Houghton Mifflin Company.
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Fowler, Jr., F. (1995). Improving Survey Questions, Design and Evaluation. London, England:
Sage Publications.
Gelowitz, D. (1996). Pharmacological Treatment of Alcoholism. The BC Recover Net, Recovery
Resources and Issues. Retrieved 7/12/00 http://www.bcrecovernet.org/medical/
Gorski, T. (1982). Gaining a Perspective on Relapse in Alcoholism. Hazel Crest, IL: Alcoholism
Systems Associates.
Gorski, T. (1989). Passages Through Recovery, An Action Plan for Preventing Relapse. Center
City, MN: Hazelden.
Gorski, T. & Miller, M. (1986). Staying Sober, A Guide for Relapse Prevention. Independence,
MO: Herald House/Independence Press.
Gorski, T. (with Trundy, A.). (2000). Relapse Prevention Counseling Workbook. Independence,
MO: Herald House/Independence Press.
Inaba, D. & Cohen, W. (2000). Uppers, Downers, All Arounders. Ashland, OR: CNS
Publications, Inc.
Kelley, J. (1994). Relapse Prevention Before Relapse: An Intensified Approach. Behavioral
Health Management. May/June 1994, Vol. 14, Issue 3. Retrieved 1/30/05
Kinney, J. (2003). Loosening the Grip, A Handbook of Alcohol Information. Boston, MA:
McGraw Hill.
Larimer, M. & Palmer, R. (1999). Relapse Prevention, An Overview of Marlatt’s CognitiveBehavioral Model. Alcohol Research & Health. Vol. 23, Issue 2. Retrieved 1/30/05
Lawson, G. & Cooperrider, C. (1998). Clinical Psychopharmacology. Rockville, MD: Aspen
Publishers, Inc.
Mackay, P. & Marlatt, G. (1994). Relapse: A Slip Doesn’t Mean Treatment has Failed. Addiction
Letter. April 1994, Vol. 10, Issue 4. Retrieved 1/30/05
Marlatt, G. & Gordon, J. (Eds.) (1985). Relapse Prevention: Maintenance Strategies in the
Treatment of Addictive Behaviors. New York, NY: Guilford Press.
Martin, J. (1973). Chalk Talks on Alcohol. San Francisco, CA: HarperSanFrancisco.
Maultsby, Jr., M. (1978). Stay Sober and Straight, How to Prevent Addiction Relapse with the
Rational Self-Help Treatment Method. Alexandria, VA: Rational Behavior Therapy
Center, LLC.
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Miller, N. & Gold, M. (1998). Management of Withdrawal Syndromes and Relapse Prevention in
Drug and Alcohol Dependence. American Family Physician. July 1998, Vol. 58, Issue 1.
Retrieved 1/30/05 http://web11.epnet.com/citation.asp
New Lexicon Webster’s Dictionary of the English Language. (1987). New York, NY: Lexicon
Publications, Inc.
Peele, S. (2004). 7 Tools to Beat Addiction. New York, NY: Three Rivers Press.
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Sons, Inc.
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Management. May/June 1994, Vol. 14, Issue 3. Retrieved 1/30/05
Trimpey, J. (1992). The Small Book, A Revolutionary Alternative for Overcoming Alcohol and
Drug Dependence. New York, NY: Dell Publishing.
Vaillant, G. (1995). The Natural History of Alcoholism Revisited. Boston, MA: Harvard
University Press.
Wanigarante, S., Wallace, W., Pullin, J., Keaney, F., & Farmer, R. (1990). Relapse Prevention
for Addictive Behaviours, A Manual for Therapists. London, England: Blackwell Scientific
Publications.
White, W. (1998). Slaying the Dragon. Bloomington, IL: Chestnut Health Systems/Lighthouse
Institute.
This article was prepared by Suzanne Tener Anderson, MA, who is a Registered Addiction
Specialist (RAS) and earned her Master of Arts in Addictive Disorders degree from Breining
Institute.
properly referenced, and that the following citation is used in full: Anderson, S.T. (2005).
Relapse Prevention: An examination of relapse issues includes consideration of the relevance
of this issue, an historical perspective, a survey of existing knowledge on the subject, and ideas
counter to disease concept beliefs. Journal of Addictive Disorders. Retrieved from
http://www.breining.edu.
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Anger Management
for Substance Abuse and
Mental Health Clients
A Cognitive Behavioral Therapy Manual
Patrick M. Reilly, Ph.D.
Michael S. Shopshire, Ph.D.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
1 Choke Cherry Road
Rockville, MD 20857
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Anger Management for Substance Abuse and Mental Health Clients
Acknowledgments
Numerous people contributed to the development of this manual (see appendix). The docu
ment was written by Patrick M. Reilly, Ph.D., and Michael S. Shopshire, Ph.D., of the San
Francisco Treatment Research Center. Sharon Hall, Ph.D., was the Treatment Research
Center’s Principal Investigator.
Disclaimer
This document is, in part, a product of research conducted with support from the National
Institute on Drug Abuse, Grant DA 09253, and the Department of Veterans Affairs to the San
Francisco VA Medical Center, San Francisco Treatment Research Center, Department of
Psychiatry, University of California, San Francisco. The document was produced by Johnson,
Bassin & Shaw, Inc., under Contract No. 270 99 7072 with the Substance Abuse and Mental
Health Services Administration (SAMHSA), U.S. Department of Health and Human Services
(DHHS). Karl White, Ed.D., served as the Center for Substance Abuse Treatment (CSAT)
Knowledge Application Program (KAP) Project Officer. The content of this publication does not
necessarily reflect the views or policies of CSAT, SAMHSA, or DHHS.
Public Domain Notice
All material appearing in this report is in the public domain and may be reproduced or copied
without permission from SAMHSA or CSAT. Citation of the source is appreciated. However, this
publication may not be reproduced or distributed for a fee without the specific, written authori
zation of the Office of Communications, SAMHSA, DHHS.
Electronic Access and Copies of Publication
This publication can be accessed electronically through the following Internet World Wide Web
connection: www.kap.samhsa.gov. For additional free copies of this document, please call
SAMHSA’s National Clearinghouse for Alcohol and Drug Information at 1 800 729 6686
or 1 800 487 4889 (TDD).
Recommended Citation
Reilly PM and Shopshire MS. Anger Management for Substance Abuse and Mental Health
Clients: A Cognitive Behavioral Therapy Manual. DHHS Pub. No. (SMA) 08 4213. Rockville, MD:
Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services
Administration, 2002, reprinted 2003, 2005, 2006, 2007, and 2008.
Originating Office
Quality Improvement and Workforce Development Branch, Division of Services Improvement,
Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services
Administration, 1 Choke Cherry Road, Rockville, MD 20857.
DHHS Publication No. (SMA) 08 4213
Printed 2002
Reprinted 2003, 2005, 2006, 2007, and 2008
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Foreword
d
Substance use and abuse often coexist with anger and violence. Data from the Substance
Abuse and Mental Health Services Administration’s National Household Survey on Drug Abuse,
for example, indicated that 40 percent of frequent cocaine users reported engaging in some
form of violent behavior. Anger and violence often can have a causal role in the initiation of
drug and alcohol use and can also be a consequence associated with substance abuse.
Individuals who experience traumatic events, for example, often experience anger and act vio
lently, as well as abuse drugs or alcohol.
Clinicians often see how anger and violence and substance use are linked.
Many substance abuse and mental health clients are victims of traumatic life events, which,
in turn, lead to substance use, anger, and violence.
Despite the connection of anger and violence to substance abuse, few treatments have been
developed to address anger and violence problems among people who abuse substances.
Clinicians have found the dearth of treatment approaches for this important issue disheartening.
To provide clinicians with tools to help deal with this important issue, the Center for Substance
Abuse Treatment of the Substance Abuse and Mental Health Services Administration is
pleased to present Anger Management for Substance Abuse and Mental Health Clients:
A Cognitive Behavioral Therapy Manual and its companion book Anger Management for
Substance Abuse and Mental Health Clients: Participant Workbook.
The anger management treatment design in this manual, which has been delivered to hun
dreds of clients over the past 8 years, has been popular with both clinicians and clients. This
treatment design can be used in a variety of clinical settings and will be beneficial to the field.
Terry L. Cline, Ph.D.
Administrator
H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM
Director
Washington, D.C.
iii
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Contents
s
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
How To Use This Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Session 1
Overview of Group Anger Management Treatment. . . . . . . . . . . . . . . . . . . . 7
Session 2
Events and Cues: A Conceptual Framework for
Understanding Anger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Session 3
Anger Control Plans: Helping Group Members Develop a Plan for Controlling Anger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Session 4
The Aggression Cycle: How To Change the Cycle . . . . . . . . . . . . . . . . . . . . 27
Session 5
Cognitive Restructuring: The A-B-C-D Model and Thought Stopping. . . . . 33
Session 6
Review Session #1: Reinforcing Learned Concepts . . . . . . . . . . . . . . . . . . 37
Sessions 7 & 8
Assertiveness Training and the Conflict Resolution Model:
Alternatives for Expressing Anger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Sessions 9 & 10
Anger and the Family: How Past Learning Can
Influence Present Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Session 11
Review Session #2: Reinforcing Learned Concepts . . . . . . . . . . . . . . . . . . 49
Session 12
Closing and Graduation: Closing Exercise and
Awarding of Certificates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Appendix: Authors’ Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
v
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Introduction
n
This manual was designed for use by qualified substance abuse and mental health clinicians
who work with substance abuse and mental health clients with concurrent anger problems.
The manual describes a 12-week cognitive behavioral anger management group treatment.
Each of the 12 90-minute weekly sessions is described in detail with specific instructions for
group leaders, tables and figures that illustrate the key conceptual components of the treat
ment, and homework assignments for the group participants. An accompanying Participant
Workbook is available (see Anger Management for Substance Abuse and Mental Health
Clients: Participant Workbook, Reilly, Shopshire, Durazzo, & Campbell, 2002) and should be
used in conjunction with this manual to enable the participants to better learn, practice, and
integrate the treatment strategies presented in the group sessions. This intervention was devel
oped for studies at the San Francisco Veterans Affairs (SFVA) Medical Center and San
Francisco General Hospital.
Cognitive behavioral therapy (CBT) treatments have been found to be effective, time-limited
treatments for anger problems (Beck & Fernandez, 1998; Deffenbacher, 1996; Trafate, 1995).
Four types of CBT interventions, theoretically unified by principles of social learning theory, are
most often used when treating anger disorders:
• Relaxation interventions, which target emotional and physiological components of anger
• Cognitive interventions, which target cognitive processes such as hostile appraisals and
attributions, irrational beliefs, and inflammatory thinking
• Communication skills interventions, which target deficits in assertiveness and conflict reso
lution skills
• Combined interventions, which integrate two or more CBT interventions and target multiple
response domains (Deffenbacher, 1996, 1999).
Meta-analysis studies (Beck & Fernandez, 1998; Edmondson & Conger, 1996; Trafate, 1995)
conclude that there are moderate anger reduction effects for CBT interventions, with average
effect sizes ranging from 0.7 to 1.2 (Deffenbacher, 1999). From these studies, it can be
inferred that the average participant under CBT conditions fared better than 76 percent of con
trol participants. These results are consistent with other meta-analysis studies examining the
effectiveness of CBT interventions in the treatment of depression (Dobson, 1989) and anxiety
(Van Balkom et al., 1994).
The treatment model described in this manual is a combined CBT approach that employs relax
ation, cognitive, and communication skills interventions.
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This combined approach presents the participants with options that draw on these different
interventions and then encourages them to develop individualized anger control plans using as
many of the techniques as possible. Not all the participants use all the techniques and inter
ventions presented in the treatment (e.g., cognitive restructuring), but almost all finish the
treatment with more than one technique or intervention on their anger control plans.
Theoretically, the more techniques and interventions an individual has on his or her anger
control plan, the better equipped he or she will be to manage anger in response to angerprovoking events.
In studies at the SFVA Medical Center and San Francisco General Hospital using this treatment
model, significant reductions in self-reported anger and violence have consistently been found,
as well as decreased substance use (Reilly, Clark, Shopshire, & Delucchi, 1995; Reilly,
Shopshire, & Clark, 1999; Reilly & Shopshire, 2000; Shopshire, Reilly, & Ouaou, 1996). Most
participants in these studies met Diagnostic and Statistical Manual of Mental Disorders, 4th
Edition (DSM-IV) (American Psychiatric Association, 1994) criteria for substance dependence,
and many also met DSM-IV criteria for posttraumatic stress disorder. A study comparing
Caucasian and African-American patients found that patients from both groups reduced their
anger significantly (Clark, Reilly, Shopshire, & Campbell, 1996). Another study showed that
women also benefited from the intervention—that is, reported decreased levels of anger (Reilly
et al., 1996).
In the anger management studies using this manual, the majority of patients were from ethnic
minority groups. Consistent reductions in anger and aggressive behavior occurred in these
groups, indicating that anger management group treatment is effective. The treatment model
is flexible and can accommodate racial, cultural, and gender issues. The events or situations
that trigger someone’s anger may vary somewhat depending on his or her culture or gender.
The cues or warning signs of anger may vary in this regard as well. Nevertheless, the overall
treatment model still applies and was found effective with different ethnic groups and with
both men and women. A person still has to identify the triggering event, recognize the cues to
anger, and develop anger management (cognitive behavioral) strategies in response to the
event and cues, regardless of whether these events and cues are different for other men and
women or for people in other cultural groups.
The intervention involves developing individualized anger control plans. For example, some
women identified their relationships with their boyfriends or partners or parenting concerns as
events that triggered their anger but men rarely identified these issues. Effective individual
strategies could be developed, however, to address these issues, provided the women accept
the concepts of monitoring anger (using the anger meter) and having (and using) an anger con
trol plan.
This treatment model was also used successfully with non–substance-abusing clients seen in
the outpatient SFVA Mental Health Clinic. These clients were diagnosed with a variety of prob
lems, including mood, anxiety, and thought disorders. The treatment components described in
this manual served as the core treatment in these studies.
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The anger management treatment should be delivered in a group setting. The ideal number of
participants in a group is 8, but groups can range from 5 to 10 members. There are several
reasons for this recommendation. First, solid empirical support exists for group cognitive
behavioral interventions (Carroll, Rounsaville, & Gawin, 1991; Maude-Griffin et al., 1998;
Smokowski & Wodarski, 1996); second, group treatment is efficient and cost-effective (Hoyt,
1993; Piper & Joyce, 1996); and third, it provides a greater range of possibilities and flexibility
in roleplays (Yalom, 1995) and behavioral rehearsal activities (Heimberg & Juster, 1994; Juster
& Heimberg, 1995). Counselors and social workers should have training in cognitive behavioral
therapy, group therapy, and substance abuse treatment (preferably, at the master’s level or
higher; doctoral-level psychologists have delivered the anger management treatment as well).
Although a group format is recommended for the anger management treatment, it is possible
for qualified clinicians to use this manual in individual sessions with their clients. In this case,
the same treatment format and sequence can be used. Individual sessions provide more time
for in-depth instruction and individualized behavioral rehearsal.
The anger management treatment manual is designed for adult male and female substance
abuse and mental health clients (age 18 years and above). The groups studied at SFVA
Medical Center and San Francisco General Hospital have included patients who have used
many substances (e.g., cocaine, alcohol, heroin, methamphetamine). These patients have been
able to use the anger management materials and benefit from the group treatment despite dif
ferences in their primary drug of abuse.
It is recommended that participants be abstinent from drugs and alcohol for at least 2 weeks
prior to joining the anger management group. If a participant had a “slip” during his or her
enrollment in the group, he or she was not discharged from the group. However, if he or she
had repeated slips or a full-blown relapse, the individual was referred to a more intensified
treatment setting and asked to start the anger management treatment again.
Many group participants were diagnosed with co-occurring disorders (e.g., posttraumatic stress
disorder [PTSD], mood disorder, psychosis) but benefited from the anger management group
treatment. Patients were compliant with their psychiatric medication regimen and were moni
tored by interdisciplinary treatment teams. The San Francisco group found that, if patients
were compliant with their medication regimen and abstinent from drugs and alcohol, they
could comprehend the treatment material and effectively use concepts such as timeouts and
thought stopping to manage anger. However, if a participant had a history of severe mental ill
ness, did not comply with instructions on his or her psychiatric medication regimen, and had
difficulty processing the material or accepting group feedback, he or she was referred to his or
her psychiatrist for better medication management.
Several practitioners have requested the manual to work with adolescent clients in substance
abuse treatment, but no preliminary data from these treatment encounters are available.
Because of the many problems often experienced by substance abuse and mental health
clients, this intervention should be used as an adjunctive treatment to substance abuse and
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mental health treatment. Certain issues, such as anger related to clients’ family of origin and
past learning, for example, may best be explored in individual and group therapy outside the
anger management group.
Finally, the authors stress the importance of providing ongoing anger management aftercare
groups. Participants at the SFVA Medical Center repeatedly asked to attend aftercare groups
where they could continue to practice and integrate the anger management strategies they
learned in this treatment. At the SFVA Medical Center, both an ongoing drop-in group and a
more structured 12-week phase-two group were provided as aftercare components. These
groups help participants maintain (and further reduce) the decreased level of anger and
aggression they achieved during the initial 12-week anger management group treatment.
Participants can also be referred to anger management groups in the community.
It is hoped that this anger management manual will help substance abuse and mental health
clinicians provide effective anger management treatment to clients who experience anger prob
lems. Reductions in frequent and intense anger and its destructive consequences can lead to
improved physical and mental health of individuals and families.
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How To Use This Manual
l
The information presented in this manual is intended to allow qualified mental health and sub
stance abuse professionals to deliver group cognitive behavioral anger management treatment
to clients with substance abuse and mental health disorders. Each of the 12 90-minute weekly
sessions is divided into four sections:
• Instructions to Group Leaders
• Check-In Procedure (beginning in the second session)
• Suggested Remarks
• Homework Assignments.
The Instructions to Group Leaders section summarizes the information to be presented in the
session and outlines the key conceptual components. The Check-In Procedure section provides
a structured process by which group members check in at each session and report on the
progress of their homework assignments from the previous week. The Suggested Remarks sec
tion provides narrative scripts for the group leader presenting the material in the session.
Although the group leader is not required to read the scripts verbatim, the group leader should
deliver the information as closely as possible to the way it is in the script. The Homework
Assignment section provides instructions for group members on what tasks to review and prac
tice for the next meeting. Session 1 also includes a special section that provides an overview
of the anger management treatment and outlines the group rules.
This manual should be used in conjunction with the Anger Management for Substance Abuse
and Mental Health Clients: Participant Workbook (Reilly, Shopshire, Durazzo, & Campbell,
2002). The workbook provides group members with a summary of the information presented in
each session, worksheets for completing homework assignments, and space to take notes dur
ing each session. The workbook will facilitate the completion of homework assignments and
help reinforce the concepts presented over the course of the anger management treatment
program.
Although participants are kept busy in each session, 90 minutes should be enough time to
complete the tasks at hand. The group leader needs to monitor and, at times, limit the
responses of participants, however. This can be done by redirecting them to the question or
activity.
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Overview of Group Anger
r
Management Treatment
t
Session 1
Outline of Session 1
Instructions to Group Leaders
In the first session, the purpose, overview, group
rules, conceptual framework, and rationale for the
anger management treatment are presented. Most
of this session is spent presenting conceptual infor
mation and verifying that the group members
understand it. Then the leader takes the group
members through an introductory exercise and a
presentation of the anger meter.
– Purpose and Overview
– Group Rules
– The Problem of Anger:
Some Operational Definitions
– Myths About Anger
– Anger as a Habitual Response
Suggested Remarks
– Breaking the Anger Habit
(Present the following script or put this in your
own words.)
– Participant Introductions
Purpose and Overview
The purpose of the anger management group is to:
– Anger Meter
• Homework Assignment
1. Learn to manage anger
2. Stop violence or the threat of violence
3. Develop self-control over thoughts and actions
4. Receive support and feedback from others.
Group Rules
1. Group Safety: No violence or threats toward staff and other group members is allowed. It is
important that members perceive the group as a safe place to share their experiences and
feelings without threats or possible physical harm.
2. Confidentiality: Group members should not discuss outside the group what group members
say during group sessions. There are limits to confidentiality, however. In every State, health
laws govern how and when professionals must report certain actions to the proper authori
ties. These actions may include any physical or sexual abuse inflicted on a child younger
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than age 18, a person older than age 65, or a dependent adult. A dependent adult is
someone between 18 and 64 years who has physical or mental limitations that restrict his
or her ability to carry out normal activities or to protect his or her rights. Reporting abuse of
these persons supersedes confidentiality laws involving clients and health professionals.
Similarly, if a group member makes threats to physically harm or kill another person, the
group leader is required, under the Tarasoff Ruling (Tarasoff v. Regents of the University of
California, 529 P.2d 553 (Cal. 1974), vacated, reheard en bank, and affirmed, 131 Cal.
Rptr. 14, 551 P.2d 334 (1976)), to warn the intended victim and notify the police.
3. Homework Assignments: Brief homework assignments will be given each week. Doing the
homework assignments will improve group members’ anger management skills and allow
them to get the most from the group experience. Like any type of skill acquisition, anger
management requires time and practice. Homework assignments provide the opportunity
for skill development and refinement.
4. Absences and Cancellations: Members should call or otherwise notify the group leader in
advance when they cannot attend a session. Because of the amount of material presented
in each session, members may not miss more than 3 of the 12 sessions. If a group mem
ber misses more than three sessions, he or she would not be able to adequately learn,
practice, and apply the concepts and skills that are necessary for effective anger manage
ment. He or she can continue to attend the group sessions, but the group member will not
receive a certificate of completion. He or she can join another session as space becomes
available.
5. Timeout: The group leader reserves the right to call for a timeout. If a group member’s
anger begins to escalate out of control during a session, the leader will ask that member to
take a timeout from the topic and the discussion. This means that the member, along with
the rest of the members of the group, will immediately stop talking about the issue that is
causing the member’s anger to escalate. If the participant’s anger has escalated to the
point that he or she cannot tolerate sitting in the group, the leader may ask the person to
leave the group for 5 or 10 minutes or until he or she can cool down. The participant is
then welcomed back to the group, provided he or she can tolerate continued discussion in
the group.
A timeout is an effective anger management strategy and will be discussed in more detail
later in this session and in session 3. Eventually, group members will learn to call a timeout
themselves when they feel they may be losing control as the result of escalation of their
anger. For this session, however, it is essential that the leader calls for a timeout and that
members comply with the rule. This rule helps ensure that the group will be a safe place to
discuss and share experiences and feelings. Therefore, failure to comply with the timeout
rule may lead to termination from the group.
6. Relapses: If a participant has a relapse during his or her enrollment in the group, he or she
is not discharged. However, if the participant has repeated relapses, he or she will be
asked to start the treatment again and will be referred to a more intense treatment setting.
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The Problem of Anger: Some Operational Definitions
In the most general sense, anger is a feeling or emotion that ranges from mild irritation to
intense fury and rage. Anger is a natural response to those situations where we feel threat
ened, we believe harm will come to us, or we believe that another person has unnecessarily
wronged us. We may also become angry when we feel another person, like a child or someone
close to us, is being threatened or harmed. In addition, anger may result from frustration when
our needs, desires, and goals are not being met. When we become angry, we may lose our
patience and act impulsively, aggressively, or violently.
People often confuse anger with aggression. Aggression is behavior that is intended to cause
harm to another person or damage property. This behavior can include verbal abuse, threats,
or violent acts. Anger, on the other hand, is an emotion and does not necessarily lead to
aggression. Therefore, a person can become angry without acting aggressively.
A term related to anger and aggression is hostility. Hostility refers to a complex set of attitudes
and judgments that motivate aggressive behaviors. Whereas anger is an emotion and
aggression is a behavior, hostility is an attitude that involves disliking others and evaluating
them negatively.
In this group, clients will learn helpful strategies and techniques to manage anger, express
anger in alternative ways, change hostile attitudes, and prevent aggressive acts, such as verbal
abuse and violence.
When Does Anger Become a Problem?
Anger becomes a problem when it is felt too intensely, is felt too frequently, or is expressed
inappropriately. Feeling anger too intensely or frequently places extreme physical strain on the
body. During prolonged and frequent episodes of anger, certain divisions of the nervous sys
tem become highly activated. Consequently, blood pressure and heart rate increase and stay
elevated for long periods. This stress on the body may produce many different health problems,
such as hypertension, heart disease, and diminished immune system efficiency. Thus, from a
health standpoint, avoiding physical illness is a motivation for controlling anger.
Another compelling reason to control anger concerns the negative consequences that result
from expressing anger inappropriately. In the extreme, anger may lead to violence or physical
aggression, which can result in numerous negative consequences, such as being arrested or
jailed, being physically injured, being retaliated against, losing loved ones, being terminated
from a substance abuse treatment or social service program, or feeling guilt, shame, or regret.
Even when anger does not lead to violence, the inappropriate expression of anger, such as ver
bal abuse or intimidating or threatening behavior, often results in negative consequences. For
example, it is likely that others will develop fear, resentment, and lack of trust toward those
who subject them to angry outbursts, which may cause alienation from individuals, such as
family members, friends, and coworkers.
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Payoffs and Consequences
The inappropriate expression of anger initially has many apparent payoffs. One payoff is being
able to manipulate and control others through aggressive and intimidating behavior; others
may comply with someone’s demands because they fear verbal threats or violence. Another
payoff is the release of tension that occurs when one loses his or her temper and acts aggres
sively. The individual may feel better after an angry outburst, but everyone else may feel worse.
In the long term, however, these initial payoffs lead to negative consequences. For this reason
they are called “apparent” payoffs because the long-term negative consequences far outweigh
the short-term gains. For example, consider a father who persuades his children to comply with
his demands by using an angry tone of voice and threatening gestures. These behaviors imply
to the children that they will receive physical harm if they are not obedient. The immediate pay
off for the father is that the children obey his commands. The long-term consequence, howev
er, may be that the children learn to fear or dislike him and become emotionally detached from
him. As they grow older, they may avoid contact with him or refuse to see him altogether.
Myths About Anger
Myth #1: Anger Is Inherited. One misconception or myth about anger is that the way we
express anger is inherited and cannot be changed. Sometimes, we may hear someone say, “I
inherited my anger from my father; that’s just the way I am.” This statement implies that the
expression of anger is a fixed and unalterable set of behaviors. Evidence from research stud
ies, however, indicates that people are not born with set, specific ways of expressing anger.
These studies show, rather, that because the expression of anger is learned behavior, more
appropriate ways of expressing anger also can be learned.
It is well established that much of people’s behavior is learned by observing others, particularly
influential people. These people include parents, family members, and friends. If children
observe parents expressing anger through aggressive acts, such as verbal abuse and violence,
it is very likely that they will learn to express anger in similar ways. Fortunately, this behavior
can be changed by learning new and appropriate ways of anger expression. It is not necessary
to continue to express anger by aggressive and violent means.
Myth #2: Anger Automatically Leads to Aggression. A related myth involves the misconception
that the only effective way to express anger is through aggression. It is commonly thought that
anger is something that builds and escalates to the point of an aggressive outburst. As has
been said, however, anger does not necessarily lead to aggression. In fact, effective anger man
agement involves controlling the escalation of anger by learning assertiveness skills, changing
negative and hostile “self-talk,” challenging irrational beliefs, and employing a variety of behav
ioral strategies. These skills, techniques, and strategies will be discussed in later sessions.
Myth #3: People Must Be Aggressive To Get What They Want. Many people confuse assertive
ness with aggression. The goal of aggression is to dominate, intimidate, harm, or injure another
person—to win at any cost. Conversely, the goal of assertiveness is to express feelings of anger
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in a way that is respectful of other people. For example, if you were upset because a friend was
repeatedly late for meetings, you could respond by shouting obscenities and name-calling. This
approach is an attack on the other person rather than an attempt to address the behavior that
you find frustrating or anger provoking.
An assertive way of handling this situation might be to say, “When you are late for a meeting
with me, I get pretty frustrated. I wish that you would be on time more often.” This statement
expresses your feelings of frustration and dissatisfaction and communicates how you would
like the situation changed. This expression does not blame or threaten the other person and
minimizes the chance of causing emotional harm. We will discuss assertiveness skills in more
detail in sessions 7 and 8.
Myth #4: Venting Anger Is Always Desirable. For many years, the popular belief among numer
ous mental health professionals and laymen was that the aggressive expression of anger, such
as screaming or beating on pillows, was healthy and therapeutic. Research studies have found,
however, that people who vent their anger aggressively simply get better at being angry
(Berkowitz, 1970; Murray, 1985; Straus, Gelles, & Steinmetz, 1980). In other words, venting
anger in an aggressive manner reinforces aggressive behavior.
Anger as a Habitual Response
Not only is the expression of anger learned, but it can become a routine, familiar, and pre
dictable response to a variety of situations. When anger is displayed frequently and aggressive
ly, it can become a maladaptive habit because it results in negative consequences. Habits, by
definition, are performed over and over again, without thinking. People with anger manage
ment problems often resort to aggressive displays of anger to solve their problems, without
thinking about the negative consequences they may suffer or the debilitating effects it may
have on the people around them.
Breaking the Anger Habit
Becoming Aware of Anger. To break the anger habit, you must develop an awareness of the
events, circumstances, and behaviors of others that “trigger” your anger. This awareness also
involves understanding the negative consequences that result from anger. For example, you may
be in line at the supermarket and become impatient because the lines are too long. You could
become angry, then boisterously demand that the checkout clerk call for more help. As your
anger escalates, you may become involved in a heated exchange with the clerk or another cus
tomer. The store manager may respond by having a security officer remove you from the store.
The negative consequences that result from this event are not getting the groceries that you
wanted and the embarrassment and humiliation you suffer from being removed from the store.
Strategies for Controlling Anger. In addition to becoming aware of anger, you need to develop
strategies to effectively manage it. These strategies can be used to stop the escalation of
anger before you lose control and experience negative consequences. An effective set of
strategies for controlling anger should include both immediate and preventive strategies.
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Immediate strategies include taking a timeout, deep-breathing exercises, and thought stopping.
Preventive strategies include developing an exercise program and changing your irrational
beliefs. These strategies will be discussed in more detail in later sessions.
One example of an immediate anger management strategy worth exploring at this point is the
timeout. The timeout can be used formally or informally. For now, we will only describe the
informal use of a timeout. This use involves leaving a situation if you feel your anger is escalat
ing out of control. For example, you may be a passenger on a crowded bus and become angry
because you perceive that people are deliberately bumping into you. In this situation, you can
simply get off the bus and wait for a less crowded bus.
The informal use of a timeout may also involve stopping yourself from engaging in a discussion
or argument if you feel that you are becoming too angry. In these situations, it may be helpful
to actually call a timeout or to give the timeout sign with your hands. This lets the other person
know that you wish to immediately stop talking about the topic and are becoming frustrated,
upset, or angry.
In this group, you should call a timeout if you feel that your anger is escalating out of control.
You also are encouraged to leave the room for a short period of time if you feel that you need
to do so. However, please come back for the remainder of the group session after you have
calmed down.
Participant Introductions
At this point, ask group members to give their names, the reasons they are interested in partic
ipating in the anger management group, and what they hope to achieve in the group. After
each member’s introduction, offer a supportive comment that validates his or her decision to
participate in the group. Experience shows that this helps members feel the group will meet
their needs and helps reduce the anxiety associated with the introductions and the first group
session in general.
Anger Meter
One technique that is helpful in increasing the awareness of anger is learning to monitor it. A
simple way to monitor anger is to use the “anger meter.” A 1 on the anger meter represents a
complete lack of anger or a total state of calm, whereas a 10 represents a very angry and
explosive loss of control that leads to negative consequences. Points between 1 and 10 repre
sent feelings of anger between these extremes. The purpose of the anger meter is to monitor
the escalation of anger as it moves up the scale. For example, when a person encounters an
anger-provoking event, he or she does not reach a 10 immediately, although it may sometimes
feel that way. In reality, the individual’s anger starts at a low number and rapidly moves up the
scale. There is always time, provided one has learned effective coping skills, to stop anger from
escalating to a 10.
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One difficulty people have when learning to use the anger meter is misunderstanding the
meaning of a 10. A 10 is reserved for instances when an individual suffers (or could suffer)
negative consequences. An example is when an individual assaults another person and is
arrested by the police.
A second point to make about the anger meter is that people may interpret the numbers on
the scale differently. These differences are acceptable. What may be a 5 for one person may
be a 7 for someone else. It is much more important to personalize the anger meter and
become comfortable and familiar with your readings of the numbers on the scale. For the
group, however, a 10 is reserved for instances when someone loses control and suffers (or
could suffer) negative consequences.
Exhibit 1. The Anger Meter
• Explosion
• Violence
• Loss of Control
• Negative Consequences
• You Lose!
10
9
8
7
6
5
4
• You have a choice!
• Use your anger control
plan to avoid reaching 10!
3
2
1
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Homework Assignment
Have group members refer to the participant workbook. Ask them to review the group’s pur
pose, rules, definitions of anger and aggression, myths about anger, anger as a habitual
response, and the anger meter. Ask them to monitor their levels of anger on the anger meter
during the upcoming week and report their highest level of anger during the Check-In
Procedure of next week’s session.
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Events and Cues
A Conceptual Framework for Understanding Anger
Session 2
This session teaches group members how to ana
– Events That Trigger Anger
lyze an anger episode and to identify the events
and cues that indicate an escalation of anger.
– Cues to Anger
Begin the session with a check in (following up
• Explaining the Check-In
on the homework assignment from the last
Procedure
week, namely, have group members report on
the highest level of anger they reached on the
anger meter during the past week) and follow with
a presentation and discussion of events and cues. A more complete Check-In Procedure will be
used in session 3 after members have been taught to identify specific anger-provoking events
and the cues that indicate an escalation of anger.
After the Check-In Procedure, ask group members to list specific events that trigger their anger.
Pay special attention to helping them distinguish between the events and their interpretation of
these events. Events refer to facts. Interpretations refer to opinions, value judgments, or per
ceptions of the events. For example, a group member might say, “My boss criticized me
because he doesn’t like me.” Point out that the specific event was that the boss criticized the
group member and that the belief that his boss doesn’t like him is an interpretation that may
or may not be accurate.
Be aware of gender differences. Women participants often identify relationships with their
boyfriend or partner or parenting concerns as events that trigger their anger. Men, however,
may rarely identify these issues as triggers.
Finally, present the four cues to anger categories. After describing each category, ask group
members to provide examples. It is important to emphasize that cues may be different for each
individual. Members should identify cues that indicate an escalation of their anger.
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Suggested Remarks
(Use the following script or put this in your own words.)
Events That Trigger Anger
When you get angry, it is because an event has provoked your anger. For example, you may
get angry when the bus is late, when you have to wait in line at the grocery store, or when a
neighbor plays his stereo too loud. Everyday events such as these can provoke your anger.
Many times, specific events touch on sensitive areas in your life. These sensitive areas or “red
flags” usually refer to long-standing issues that can easily lead to anger. For example, some of
us may have been slow readers as children and may have been sensitive about our reading
ability. Although we may read well now as adults, we may continue to be sensitive about this
issue. This sensitivity may be revealed when someone rushes us while we are completing an
application or reviewing a memorandum and may trigger anger because we may feel that we
are being criticized or judged as we were when we were children. This sensitivity may also
show itself in a more direct way, such as when someone calls us “slow” or “stupid.”
In addition to events experienced in the here-and-now, you may also recall an event from
your past that made you angry. You might remember, for example, how the bus always seemed
to be late before you left home for an important appointment. Just thinking about how late
the bus was in the past can make you angry in the present. Another example may be when
you recall a situation involving a family member who betrayed or hurt you in some way.
Remembering this situation, or this family member, can raise your number on the anger
meter. Here are examples of events or issues that can trigger anger:
• Long waits to see your doctor
• Traffic congestion
• Crowded buses
• A friend joking about a sensitive topic
• A friend not paying back money owed to you
• Being wrongly accused
• Having to clean up someone else’s mess
• Having an untidy roommate
• Having a neighbor who plays the stereo too loud
• Being placed on hold for long periods of time while on the telephone
• Being given wrong directions
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• Rumors being spread about your relapse that are not true
• Having money or property stolen from you.
Cues to Anger
A second important aspect of anger monitoring is to identify the cues that occur in response to
the anger-provoking event. These cues serve as warning signs that you have become angry and
that your anger is continuing to escalate. They can be broken down into four cue categories:
physical, behavioral, emotional, and cognitive (or thought) cues.
Physical Cues. Physical cues involve the way our bodies respond when we become angry. For
example, our heart rates may increase, we may feel tightness in our chests, or we may feel hot
and flushed. These physical cues can also warn us that our anger is escalating out of control
or approaching a 10 on the anger meter. We can learn to identify these cues when they occur
in response to an anger-provoking event.
Can you identify some of the physical cues that you have experi
enced when you have become angry?
Behavioral Cues. Behavioral cues involve the behaviors we display when we get angry, which
are observed by other people around us. For example, we may clench our fists, pace back and
forth, slam a door, or raise our voices. These behavioral responses are the second cue of our
anger. As with physical cues, they are warning signs that we may be approaching a 10 on the
anger meter.
What are some of the behavioral cues that you have experienced
when you have become angry?
Emotional Cues. Emotional cues involve other feelings that may occur concurrently with our
anger. For example, we may become angry when we feel abandoned, afraid, discounted, disre
spected, guilty, humiliated, impatient, insecure, jealous, or rejected. These kinds of feelings are
the core or primary feelings that underlie our anger. It is easy to discount these primary feel
ings because they often make us feel vulnerable. An important component of anger manage
ment is to become aware of, and to recognize, the primary feelings that underlie our anger. In
this group, we will view anger as a secondary emotion to these more primary feelings.
Can you identify some of the primary feelings that you have experi
enced during an episode of anger?
Cognitive Cues. Cognitive cues refer to the thoughts that occur in response to the angerprovoking event. When people become angry, they may interpret events in certain ways. For
example, we may interpret a friend’s comments as criticism, or we may interpret the actions
of others as demeaning, humiliating, or controlling. Some people call these thoughts “self-talk”
because they resemble a conversation we are having with ourselves. For people with anger
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problems, this self-talk is usually very critical and hostile in tone and content. It reflects beliefs
about the way they think the world should be; beliefs about people, places, and things.
Closely related to thoughts and self-talk are fantasies and images. We view fantasies and
images as other types of cognitive cues that can indicate an escalation of anger. For example,
we might fantasize about seeking revenge on a perceived enemy or imagine or visualize our
spouse having an affair. When we have these fantasies and images, our anger can escalate
even more rapidly.
Can you think of other examples of cognitive or thought cues?
Explaining the Check-In Procedure
In this session, group members began to monitor their anger and identify anger-provoking
events and situations. In each weekly session, there will be a Check-In Procedure to follow up
on the homework assignment from the previous week and to report the highest level of anger
reached on the anger meter during the week.
Have participants identify the event that triggered their anger, the cues that were associated
with their anger, and the strategies they used to manage their anger in response to the event.
They will be using the following questions to check in at the beginning of each session:
1. What was the highest number you reached on the anger meter during the past week?
2. What was the event that triggered your anger?
3. What cues were associated with the anger-provoking event? For example, what were the
physical, behavioral, emotional, or cognitive cues?
4. What strategies did you use to avoid reaching 10 on the anger meter?
They will also be asked to monitor and record the highest number they reach on the anger
meter for each day of the upcoming week after each session.
Exhibit 2. Cues to Anger: Four Cue Categories
1. Physical
(examples: rapid heartbeat, tightness in chest, feeling hot or
flushed)
2. Behavioral
(examples: pacing, clenching fists, raising voice, staring)
3. Emotional
(examples: fear, hurt, jealousy, guilt)
4. Cognitive/Thoughts
(examples: hostile self-talk, images of aggression
and revenge)
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Homework Assignment
Have group members refer to the participant workbook. Ask them to monitor and record their
highest level of anger on the anger meter during the upcoming week. In addition, ask them to
identify the event that made them angry and list the cues that were associated with the angerprovoking event. Tell participants they should be prepared to report on these assignments dur
ing the Check-In Procedure in next week’s session.
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Anger Control Plans
Helping Group Members Develop a Plan
for Controlling Anger
Session 3
• Check-In Procedure
In this session, begin teaching group members
cognitive behavioral strategies for controlling
their anger. By now, participants have begun to
– Anger Control Plans
learn how to monitor their anger and identify
– Relaxation Through Breathing
anger-provoking events and situations. At this
point, it is important to help them develop a
repertoire of anger management strategies. This
repertoire of strategies is called an anger control
plan. This plan should consist of immediate strategies, those that can be used in the heat of
the moment when anger is rapidly escalating, and preventive strategies, those that can be
used to avoid escalation of anger before it begins. It is important to encourage members to
use strategies that work best for them. Some find cognitive restructuring (e.g., challenging hos
tile self-talk or irrational beliefs) very effective. Others might prefer using strategies such as a
timeout or thought stopping. The main point is to help group members individualize their anger
control plans and to help them develop strategies that they are comfortable with and that they
will readily use. In the remaining sessions, you will continue to help group members develop
effective strategies for controlling their anger and clarify and reinforce these strategies during
the Check-In Procedure.
Participants should be encouraged to seek support and feedback from people they can trust to
support their recovery, including anger management strategies that will de-escalate, rather
than escalate, the situation. Participants should seek advice from one another and other
patients who are in recovery and from members in support networks, including members of
12-Step groups, 12-Step sponsors, or religious group members.
In addition to helping group members begin to develop their anger control plans, start the ses
sion with the Check-In Procedure, and end the session with a breathing exercise as a form of
relaxation training. Before leading members in the breathing exercise, ask whether anyone has
had experience with different forms of relaxation. Describe the continuum of relaxation tech
niques, which can range from simple breathing exercises to elaborate guided imagery. Explain
that in the group, they will practice two short and simple relaxation exercises, deep-breathing
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and progressive muscle relaxation. Further explain that experience shows that group members
are more likely to use these simple forms of relaxation.
Check-In Procedure
Ask group members to report the highest level of anger they reached on the anger meter
during the past week. Make sure they reserve the number 10 for situations where they lost
control of their anger and experienced negative consequences. Ask them to describe the
anger-provoking event that led to their highest level of anger. Help them identify the cues that
occurred in response to the anger-provoking event, and help them classify these cues into the
four cue categories.
Exhibit 3. Event, Cues, and Strategies Identified During the Check-In Procedure
Event
Cues
Strategies
Suggested Remarks
Anger Control Plans
Up to this point, you have been focusing on how to monitor your anger. In the first session, you
learned how to use the anger meter to rate your anger. Last week, you learned how to identify
the events that trigger anger, as well as the physical, behavioral, emotional, and cognitive cues
associated with each event. Today, you will begin to discuss how to develop an anger control
plan and how you can use specific strategies, such as timeouts and relaxation, to control your
anger. In later sessions, you will cover other strategies, such as learning to change negative or
hostile self-talk and using the Conflict Resolution Model (see page 39). These more advanced
strategies can be used along with timeouts and relaxation.
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The basic idea in developing an anger control plan is to try many different strategies and find
the anger control techniques that work best for you. Once you identify these strategies, you can
add them to your anger control plans and use them when you start to get angry. Some people
refer to their anger control plans as their toolbox and the specific strategies they use to control
their anger as their tools. This analogy may be very helpful. Again, it is important to identify the
specific anger control strategies that work best for you. These strategies should be put down in
a formal anger control plan for referral when you encounter an anger-provoking event.
An effective strategy that many people use, for example, is to talk about their feelings with a
supportive friend who was not involved with the event that made them angry. By discussing
anger, you can begin to identify the primary emotions that underlie it and determine whether
your thinking and expectations in response to the anger-provoking event are rational. Often a
friend whom you trust can provide a different perspective on what is going on in your life. Even
if your friend just listens, expressing your feelings can often make you feel better.
The long-term objective of the anger management treatment is to develop a set of strategies
that you can use appropriately for specific anger-provoking events. Later sessions will introduce
a menu of strategies and techniques that are helpful in managing anger. Once you have select
ed the strategies that work best, you should refine them by applying them in real-life situations.
To use the toolbox analogy, different tools may be needed for different situations. We will
return to this concept in later sessions and highlight the importance of developing an anger
control plan that helps you manage anger effectively in a variety of situations.
Timeout. As mentioned in session 1, the concept of a timeout is especially important to anger
management. It is the basic anger management strategy recommended for inclusion in every
one’s anger control plan. Informally, a timeout is defined as leaving the situation that is caus
ing the escalation of anger or simply stopping the discussion that is provoking it.
Formally, a timeout involves relationships with other people: it involves an agreement or a pre
arranged plan. These relationships may involve family members, friends, and coworkers. Any of
the parties involved may call a timeout in accordance with rules that have been agreed on by
everyone in advance. The person calling the timeout can leave the situation, if necessary. It is
agreed, however, that he or she will return to either finish the discussion or postpone it,
depending on whether all those involved feel they can successfully resolve the issue.
Timeouts are important because they can be effective in the heat of the moment. Even if your
anger is escalating quickly on the anger meter, you can prevent reaching 10 by taking a timeout and leaving the situation.
Timeouts are also effective when they are used with other strategies. For example, you can
take a timeout and go for a walk. You can also take a timeout and call a trusted friend or fami
ly member or write in your journal. These other strategies should help you calm down during
the timeout period.
Can you think of specific strategies that you might use to control
your anger?
Should these strategies be included on your anger control plan?
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Exhibit 4. Sample of an Anger Control Plan
Anger Control Plan
1. Take a timeout (formal or informal)
2. Talk to a friend (someone you trust)
3. Use the Conflict Resolution Model to express anger
4. Exercise (take a walk, go to the gym, etc.)
5. Attend 12-Step meetings
6. Explore primary feelings beneath the anger
Relaxation Through Breathing
We have discussed the physical cues to anger, such as an increased heartbeat, feeling hot or
flushed, or muscle tension. These types of physical cues are examples of what is commonly
called the stress response. In the stress response, the nervous system is energized, and in this
agitated state, a person is likely to have trouble returning to lower levels on the anger meter. In
this state, additional anger-provoking situations and events are likely to cause a further escala
tion of anger.
An interesting aspect of the nervous system is that everyone has a relaxation response that
counteracts the stress response. It is physically impossible to be both agitated and relaxed at
the same time. If you can relax successfully, you can counteract the stress or anger response.
We will end this session by practicing a deep-breathing exercise as a relaxation technique. In
session 4, we will practice progressive muscle relaxation as a secondary type of relaxation
technique.
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Note to Group Leader:
Lead a Breathing Exercise
(Use this script or put this in your own words.)
Get comfortable in your chair. If you like, close your eyes; or just gaze at the floor.
Take a few moments to settle yourself. Now make yourself aware of your body. Check your
body for tension, beginning with your feet, and scan upward to your head. Notice any ten
sion you might have in your legs, your stomach, your hands and arms, your shoulders,
your neck, and your face. Try to let go of the tension you are feeling.
Now, make yourself aware of your breathing. Pay attention to your breath as it enters and
leaves your body. This can be very relaxing.
Let’s all take a deep breath together. Notice your lungs and chest expanding. Now slowly
exhale through your nose. Again, take a deep breath. Fill your lungs and chest. Notice how
much air you can take in. Hold it for a second. Now release it and slowly exhale. One more
time, inhale slowly and fully. Hold it for a second, and release.
Now on your own, continue breathing in this way for another couple of minutes. Continue
to focus on your breathing. With each inhalation and exhalation, feel your body becoming
more and more relaxed. Use your breathing to wash away any remaining tension.
(Allow group members to practice breathing for 1 to 2 minutes in silence.)
Now let’s take another deep breath. Inhale fully, hold it for a second, and release. Inhale
again, hold, and release. Continue to be aware of your breath as it fills your lungs. Once
more, inhale fully, hold it for a second, and release.
When you feel ready, open your eyes.
How was that? Did you notice any new sensations while you were breathing? How do you
feel now?
This breathing exercise can be shortened to just three deep inhalations and exhalations.
Even that much can be effective in helping you relax when your anger is escalating. You
can practice this at home, at work, on the bus, while waiting for an appointment, or even
while walking. The key to making deep-breathing an effective relaxation technique is to
practice it frequently and to apply it in a variety of situations.
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Homework Assignment
highest level of anger on the anger meter during the upcoming week. Ask them to identify the
event that made them angry, the cues that were associated with the anger-provoking event,
and the strategies that they used to manage their anger in response to the event. Ask them to
practice the deep-breathing exercise, preferably once a day during the upcoming week, and
develop a preliminary version of their anger control plans. Inform group members that they
should be prepared to report on these assignments during the Check-In Procedure at the next
week’s session.
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The Aggression Cycle
How To Change the Cycle
Session 4
This session presents the aggression cycle and
introduces progressive muscle relaxation. As in
the previous two sessions, begin with the
Check-In Procedure. Then present the threephase aggression cycle, which consists of esca
lation, explosion, and postexplosion. It serves as
a framework that incorporates the concepts of
the anger meter, cues to anger, and the anger
control plan.
– The Aggression Cycle
– Progressive Muscle Relaxation
End the session by presenting a progressive muscle relaxation exercise. Progressive muscle
relaxation is another technique that has been effective in reducing anger levels. An alternative
to the deep-breathing exercise introduced in last week’s session, it is straightforward and easy
to learn.
Check-In Procedure
during the past week. Make sure they reserve the number 10 for situations where they lost
control of their anger and experienced negative consequences. Ask them to describe the
anger-provoking event that led to their highest level of anger. Help them identify the cues that
occurred in response to the anger-provoking event, and help them classify those cues into the
four cue categories. Include, as part of the Check-In Procedure, a followup on the homework
assignment from the previous week’s session. Ask participants to report on the specific anger
management strategies listed, thus far, on their anger control plans. In addition, inquire
whether they practiced the deep-breathing exercise that was introduced in last week’s session.
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Suggested Remarks
The Aggression Cycle
In the last three sessions, we reviewed the anger meter, cues to anger, and the anger control
plan; in this session, the framework for integrating these anger management concepts is pre
sented. This framework is the aggression cycle.
From an anger management perspective, an episode of anger can be viewed as consisting of
three phases: escalation, explosion, and postexplosion. Together, they make up the aggression
cycle. In this process, the escalation phase is characterized by cues that indicate anger is
building. As stated in session 2, these cues can be physical, behavioral, emotional, or cognitive
(thoughts). As you may recall, cues are warning signs, or responses, to anger-provoking events.
Events, on the other hand, are situations that occur every day that may lead to escalations of
anger if effective anger management strategies are not used. Red-flag events are types of situ
ations that are unique to you and that you are especially sensitive to because of past events.
These events can involve internal processes (e.g., thinking about situations that were anger
provoking in the past) or external processes (e.g., experiencing real-life, anger-provoking situa
tions in the here and now).
If the escalation phase is allowed to continue, the explosion phase will follow. The explosion
phase is marked by an uncontrollable discharge of anger displayed as verbal or physical
aggression. This discharge, in turn, leads to negative consequences; it is synonymous with the
number 10 on the anger meter.
The final stage of the aggression cycle is the postexplosion phase. It is characterized by nega
tive consequences resulting from the verbal or physical aggression displayed during the explo
sion phase. These consequences may include going to jail, making restitution, being terminat
ed from a job or discharged from a drug treatment or social service program, losing family and
loved ones, or feelings of guilt, shame, and regret.
The intensity, frequency, and duration of anger in the aggression cycle varies among individu
als. For example, one person’s anger may escalate rapidly after a provocative event and, within
just a few minutes, reach the explosion phase. Another person’s anger may escalate slowly but
steadily over several hours before reaching the explosion phase. Similarly, one person may
experience more episodes of anger and progress through the aggression cycle more often than
the other. However, both individuals, despite differences in how quickly their anger escalates
and how frequently they experience anger, will undergo all three phases of the aggression
cycle.
The intensity of these individuals’ anger also may differ. One person may engage in more vio
lent behavior than the other in the explosion phase. For example, he or she may use weapons
or assault someone. The other person may express his or her anger during the explosion phase
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by shouting at or threatening other people. Regardless of these individual differences,
the explosion phase is synonymous with losing control and becoming verbally or physically
aggressive.
Notice that the escalation and explosion phases of the aggression cycle correspond to the lev
els on the anger meter. The points below 10 on the anger meter represent the escalation
phase, the building up of anger. The explosion phase, on the other hand, corresponds to 10 on
the anger meter. Again 10 on the anger meter is the point at which one loses control and
expresses anger through verbal or physical aggression that leads to negative consequences.
One of the primary objectives of anger management treatment is to keep from reaching the
explosion phase. This is accomplished by using the anger meter to monitor changes in your
anger, attending to the cues or warning signs that indicate anger is building, and employing the
appropriate strategies from your anger control plans to stop the escalation of anger. If the
explosion phase is prevented from occurring, the postexplosion phase will not occur, and the
aggression cycle will be broken. If you use your anger control plans effectively, your anger
should ideally reach between a 1 and a 9 on the anger meter. This is a reasonable goal to aim
for. By preventing the explosion phase (10), you will not experience the negative consequences
of the postexplosion phase, and you will break the cycle of aggression.
Exhibit 5. The Aggression Cycle
*Based on the Cycle of Violence by Lenore Walker (1979). The Battered Woman. New York: Harper & Row.
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Note to Group Leader:
Lead a Progressive Muscle Relaxation Exercise
(Use this script or put this in your own words.)
Last week you practiced deep-breathing as a relaxation technique. Today I will introduce
progressive muscle relaxation. Start by getting comfortable in your chairs. Close your eyes
if you like. Take a moment to really settle in. Now, as you did last week, begin to focus on
your breathing. Take a deep breath. Hold it for a second. Now exhale fully and completely.
Again, take a deep breath. Fill your lungs and chest. Now release and exhale slowly.
Again, one more time, inhale slowly, hold, and release.
Now, while you continue to breathe deeply and fully, bring your awareness to your hands.
Clench your fists very tightly. Hold that tension. Now relax your fists, letting your fingers
unfold and letting your hands completely relax. Again, clench your fists tightly. Hold and
release the tension. Imagine all the tension being released from your hands down to your
fingertips. Notice the difference between the tension and complete relaxation.
Now bring your awareness to your arms. Curl your arms as if you are doing a bicep curl.
Tense your fists, forearms, and biceps. Hold the tension and release it. Let the tension in
your arms unfold and your hands float back to your thighs. Feel the tension drain out of
your arms. Again, curl your arms to tighten your biceps. Notice the tension, hold, and
release. Let the tension flow out of your arms. Replace it with deep muscle relaxation.
Now raise your shoulders toward your ears. Really tense your shoulders. Hold them up for a
second. Gently drop your shoulders, and release all the tension. Again, lift your shoulders,
hold the tension, and release. Let the tension flow from your shoulders all the way down
your arms to your fingers. Notice how different your muscles feel when they are relaxed.
Now bring your awareness to your neck and face. Tense all those muscles by making a
face. Tense your neck, jaw, and forehead. Hold the tension, and release. Let the muscles
of your neck and jaw relax. Relax all the lines in your forehead. One final time, tense all
the muscles in your neck and face, hold, and release. Be aware of your muscles relaxing
at the top of your head and around your eyes. Let your eyes relax in their sockets, almost
as if they were sinking into the back of your head. Relax your jaw and your throat. Relax
all the muscles around your ears. Feel all the tension in your neck muscles release.
Now just sit for a few moments. Scan your body for any tension and release it. Notice how
your body feels when your muscles are completely relaxed.
When you are ready, open your eyes. How was that? Did you notice any new sensations?
How does your body feel now? How about your state of mind? Do you notice any
difference now from when we started?
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Homework Assignment
Have group members refer to the participant workbook. During the coming week have them
monitor and record their highest level of anger on the anger meter. Ask them to identify the
event that made them angry, the cues associated with the anger-provoking event, and the
strategies they used to manage their anger in response to the event. Ask them to review the
aggression cycle and practice progressive muscle relaxation, preferably once a day, during the
coming week. Remind them to continue to develop their anger control plans.
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Cognitive Restructuring
The A-B-C-D Model and Thought Stopping
Session 5
In this session, present the A-B-C-D Model (a
form of cognitive restructuring originally devel
– The A-B-C-D Model
oped by Albert Ellis [Ellis, 1979; Ellis & Harper,
– Thought Stopping
1975]) and the technique of thought stopping.
Cognitive restructuring is an advanced anger
management technique that requires group
members to examine and change their thought
processes. People differ in their ability to learn and apply these techniques. Some may be
generally familiar with cognitive restructuring, whereas others may have little or no experience
with this concept. In addition, some people may initially have difficulty understanding the con
cept or may not yet be ready to challenge or change their irrational beliefs. It is important to
accept these group members, whatever their level of readiness and understanding, and help
them identify how their irrational beliefs perpetuate anger and how modifying these beliefs can
prevent further escalation of anger.
In addition to presenting the A-B-C-D Model, include a discussion on thought stopping. Thought
stopping is accepted and readily understood by most clients. Regardless of whether they view
particular beliefs as irrational or maladaptive, most people recognize that these specific beliefs
increase anger and lead to the explosion phase (10 on the anger meter). Thought stopping
provides an immediate and direct strategy for helping people manage the beliefs that cause
their anger to escalate.
Check-In Procedure
during the past week. Make sure they reserve 10 for situations where they lost control of their
anger and experienced negative consequences. Ask them to describe the anger-provoking
event that led to their highest level of anger and to identify the cues that occurred in response
to the anger-provoking event. Help them classify these cues into the four cue categories.
Include, as part of the Check-In Procedure, a followup of the homework assignment from last
week’s session. Specifically ask group members to report on the development of their anger
control plans. In addition, inquire whether they practiced the progressive muscle relaxation
exercise.
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Anger Management
Suggested Remarks
The A-B-C-D Model
Albert Ellis developed a model that is consistent with the way we conceptualize anger manage
ment treatment. He calls his model the A-B-C-D or rational-emotive model. In this model, “A”
stands for an activating event, what we have been calling the red-flag event. “B” represents the
beliefs people have about the activating event. Ellis claims that it is not the events themselves
that produce feelings such as anger, but our interpretations of and beliefs about the events.
“C” stands for the emotional consequences of events. In other words, these are the feelings
people experience as a result of their interpretations of and beliefs concerning the event.
According to Ellis and other cognitive behavioral theorists, as people become angry, they
engage in an internal dialog, called “self-talk.” For example, suppose you were waiting for a
bus to arrive. As it approaches, several people push in front of you to board. In this situation,
you may start to get angry. You may be thinking, “How can people be so inconsiderate! They
just push me aside to get on the bus. They obviously don’t care about me or other people.”
Examples of the irrational self-talk that can produce anger escalation are reflected in state
ments such as “People should be more considerate of my feelings,” “How dare they be so
inconsiderate and disrespectful,” and “They obviously don’t care about anyone but themselves.”
Ellis says that people do not have to get angry when they encounter such an event. The event
itself does not get them upset and angry; rather, it is people’s interpretations of and beliefs
concerning the event that cause the anger. Beliefs underlying anger often take the form of
“should” and “must.” Most of us may agree, for example, that respecting others is an
admirable quality. Our belief might be, “People should always respect others.” In reality, how
ever, people often do not respect each other in everyday encounters. You can choose to view
the situation more realistically as an unfortunate defect of human beings, or you can let your
anger escalate every time you witness, or are the recipient of, another person’s disrespect.
Unfortunately, your perceived disrespect will keep you angry and push you toward the explosion
phase. Ironically, it may even lead you to show disrespect to others, which would violate your
own fundamental belief about how people should be treated.
Ellis’ approach consists of identifying irrational beliefs and disputing them with more rational
or realistic perspectives (in Ellis’ model, “D” stands for dispute). You may get angry, for exam
ple, when you start thinking, “I must always be in control. I must control every situation.” It is
not possible or appropriate, however, to control every situation. Rather than continue with
these beliefs, you can try to dispute them. You might tell yourself, “I have no power over things
I cannot control,” or “I have to accept what I cannot change.” These are examples of ways to
dispute beliefs that you may have already encountered in 12-Step programs such as Alcoholics
Anonymous or Narcotics Anonymous.
People may have many other irrational beliefs that may lead to anger. Consider an example
where a friend of yours disagrees with you. You may start to think, “Everyone must like me and
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give me approval.” If you hold such a belief, you are likely to get upset and angry when you
face rejection. However, if you dispute this irrational belief by saying, “I can’t please everyone;
some people are not going to approve of everything I do,” you will most likely start to calm
down and be able to control your anger more easily.
Another common irrational belief is, “I must be respected and treated fairly by everyone.” This
also is likely to lead to frustration and anger. Most folks, for example, live in an urban society
where they may, at times, not be given the common courtesy they expect. This is unfortunate,
but from an anger management perspective, it is better to accept the unfairness and lack of
interpersonal connectedness that can result from living in an urban society. Thus, to dispute
this belief, it is helpful to tell yourself, “I can’t be expected to be treated fairly by everyone.”
Other beliefs that may lead to anger include “Everyone should follow the rules,” or “Life should
be fair,” or “Good should prevail over evil,” or “People should always do the right thing.” These
are beliefs that are not always followed by everyone in society, and, usually, there is little you
can do to change that. How might you dispute these beliefs? In other words, what thoughts
that are more rational and adaptive and will not lead to anger can be substituted for such
beliefs?
For people with anger control problems, these irrational beliefs can lead to the explosion phase
(10 on the anger meter) and to the negative consequences of the postexplosion phase. It is
often better to change your outlook by disputing your beliefs and creating an internal dialog or
self-talk that is more rational and adaptive.
Exhibit 6. The A-B-C-D Model
A-B-C-D Model*
A = Activating Situation or Event
B = Belief System
What you tell yourself about the event (your self-talk)
Your beliefs and expectations of others
C = Consequence
How you feel about the event based on your self-talk
D = Dispute
Examine your beliefs and expectations
Are they unrealistic or irrational?
*Based on the work of Albert Ellis, 1979, and Albert Ellis and R.A. Harper, 1975.
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Thought Stopping
A second approach to controlling anger is called thought stopping. It provides an immediate
and direct alternative to the A-B-C-D Model. In this approach, you simply tell yourself (through a
series of self-commands) to stop thinking the thoughts that are getting you angry. For example,
you might tell yourself, “I need to stop thinking these thoughts. I will only get into trouble if I
keep thinking this way,” or “Don’t buy into this situation,” or “Don’t go there.” In other words,
instead of trying to dispute your thoughts and beliefs as outlined in the A-B-C-D Model
described above, the goal is to stop your current pattern of angry thoughts before they lead to
an escalation of anger and loss of control.
Homework Assignment
highest level of anger on the anger meter during the coming week. Ask them to identify the
and the strategies they used to manage their anger in response to the event. Ask members to
review the A-B-C-D Model and to record at least two irrational beliefs and how they would dis
pute these beliefs. In addition, instruct them to use the thought-stopping technique, preferably
once a day during the coming week. Remind them to continue to develop their anger control
plans.
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Review Session #1
Reinforcing Learned Concepts
Session 6
In this session, you will review and summarize the
basic concepts of anger management presented
• Review of Learned Concepts
thus far. Special attention should be given to clari
fying and reinforcing concepts (i.e., the anger meter,
cues to anger, anger control plans, the aggression
cycle, and cognitive restructuring). Provide encouragement and support for efforts to develop
anger control plans and to balance cognitive, behavioral, immediate, and preventive strategies.
Check-In Procedure
Ask group members to report the highest level of anger they reached on the anger meter during
the past week. Make sure they reserve 10 for situations where they lost control of their anger
and experienced negative consequences. Ask them to describe the anger-provoking event that
led to their highest level of anger. Help them identify the cues that occurred in response to the
anger-provoking event and help them classify these cues into the four cue categories. Include,
as part of the Check-In Procedure, a followup of the homework assignment from last week’s
session. Ask group members to report on their use of the A-B-C-D Model during the past week
and to provide a brief update on the ongoing development of their anger control plans.
Suggested Remarks
This session will serve as a review session for the anger management material we have cov
ered thus far. We will review each concept and clarify any questions that you may have.
Discussion is encouraged during this review, and you will be asked to describe your under
standing of the anger management concepts.
Homework Assignment
and the strategies they used to manage their anger in response to the event. Remind them to
continue to develop their anger control plans.
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Assertiveness Training and the
Conflict Resolution Model
Alternatives for Expressing Anger
Sessions 7 & 8
Outline of Sessions 7 & 8
Sessions 7 and 8 are combined because it takes
more than one session to adequately address
assertiveness, aggression, passivity, and the
Conflict Resolution Model.
– Assertiveness Training
– Conflict Resolution Model
Assertiveness is such a fundamental skill in inter
personal interactions and anger management that
the group will spend 2 weeks developing and practicing
this concept. These two 90-minute sessions will present an introduction to assertiveness train
ing. The majority of this week’s session will be spent reviewing the definitions of assertiveness,
aggression, and passivity and presenting the Conflict Resolution Model. The Conflict Resolution
Model is an assertive device for resolving conflicts with others. It consists of a series of prob
lem solving steps that, when followed closely, minimize the potential for anger escalation. Next
week’s session, in contrast, will focus on group members roleplaying real-life situations using
the Conflict Resolution Model. It is important to emphasize that assertive, aggressive, and pas
sive responses are learned behaviors and not innate, unchangeable traits. The goal of these
two sessions is to teach members how to use the Conflict Resolution Model to develop
assertive responses rather than aggressive or passive responses.
Check-In Procedure
Ask group members to report the highest level of anger they reached on the anger meter dur
ing the past week. Make sure they reserve 10 for situations where they lost control of their
event that led to their highest level of anger. Help them identify the cues that occurred in
response to the anger-provoking event, and help them classify these cues into the four cue cat
egories. Ask members to report on the ongoing development of their anger control plans.
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Suggested Remarks
Assertiveness Training
Sessions 7 and 8 provide an introduction to assertiveness training and the Conflict Resolution
Model. Assertiveness involves a set of behaviors and skills that require time and practice to
learn and master. In this group, we focus on one important aspect of assertiveness training,
that is, conflict resolution. The Conflict Resolution Model can be particularly effective for help
ing individuals manage their anger.
Many interpersonal conflicts occur when you feel that your rights have been violated. Before
entering anger management treatment, you may have tended to respond with aggressive
behavior when you believed that another person showed you disrespect or violated your rights.
In today’s session, we will discuss several ways to resolve interpersonal conflicts without
resorting to aggression.
As we discussed in session 1, aggression is behavior that is intended to cause harm or injury to
another person or damage property. This behavior can include verbal abuse, threats, or violent
acts. Often, when another person has violated your rights, your first reaction is to fight back or
retaliate. The basic message of aggression is that my feelings, thoughts, and beliefs are impor
tant and that your feelings, thoughts, and beliefs are unimportant and inconsequential.
One alternative to using aggressive behavior is to act passively or in a nonassertive manner.
Acting in a passive or nonassertive way is undesirable because you allow your rights to be vio
lated. You may resent the person who violated your rights, and you may also be angry with
yourself for not standing up for your rights. In addition, it is likely that you will become even
more angry the next time you encounter this person. The basic message of passivity is that
your feelings, thoughts, and beliefs are important, but my feelings, thoughts, and beliefs are
unimportant and inconsequential. Acting in a passive or nonassertive way may help you avoid
the negative consequences associated with aggression, but it may also ultimately lead to nega
tive personal consequences, such as diminished self-esteem, and prevent you from having
your needs satisfied.
From an anger management perspective, the best way to deal with a person who has violated
your rights is to act assertively. Acting assertively involves standing up for your rights in a way that
is respectful of other people. The basic message of assertiveness is that my feelings, thoughts,
and beliefs are important, and that your feelings, thoughts, and beliefs are equally important. By
acting assertively, you can express your feelings, thoughts, and beliefs to the person who violated
your rights without suffering the negative consequences associated with aggression or the devalu
ation of your feelings, which is associated with passivity or nonassertion.
It is important to emphasize that assertive, aggressive, and passive responses are learned
behaviors; they are not innate, unchangeable traits. Using the Conflict Resolution Model, you
can learn to develop assertive responses that allow you to manage interpersonal conflicts in a
more effective way.
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In summary, aggression involves expressing feelings, thoughts, and beliefs in a harmful and
disrespectful way. Passivity or nonassertiveness involves failing to express feelings, thoughts,
and beliefs or expressing them in an apologetic manner that others can easily disregard.
Assertiveness involves standing up for your rights and expressing feelings, thoughts, and
beliefs in direct, honest, and appropriate ways that do not violate the rights of others or show
disrespect.
It is helpful to think of real-life situations to help you understand what is meant by assertive
ness. Suppose you have been attending an Alcoholics Anonymous meeting several times a
week with a friend. Suppose you have been driving your friend to these meetings for several
weeks. In the last few days, however, he has not been ready when you have come to pick him
up. His tardiness has resulted in both of you being late for meetings. Because you value being
on time, this is something that bothers you a great deal. Consider the different ways you might
act in this situation. You can behave in an aggressive manner by yelling at your friend for being
late and refusing to pick him up in the future. The disadvantage of this response is that he may
no longer want to continue the friendship. Another response would be to act passively, or in a
nonassertive fashion, by ignoring the problem and not expressing how you feel. The disadvan
tage of this response is that the problem will most likely continue and that this will inevitably
lead to feelings of resentment toward your friend. Again, from an anger management perspec
tive, the best way to deal with this problem is to act assertively by expressing your feelings,
thoughts, and beliefs in a direct and honest manner, while respecting the rights of your friend.
Conflict Resolution Model
One method of acting assertively is to use the Conflict Resolution Model, which involves five
steps that can easily be memorized. The first step involves identifying the problem that is caus
ing the conflict. It is important to be specific when identifying the problem. In this example, the
problem causing the conflict is that your friend is late. The second step involves identifying the
feelings associated with the conflict. In this example, you may feel annoyance, frustration, or
taken for granted. The third step involves identifying the specific impact of the problem that is
causing the conflict. In this example, the impact or outcome is that you are late for the meet
ing. The fourth step involves deciding whether to resolve the conflict or let it go. This may best
be phrased by the questions, “Is the conflict important enough to bring up? If I do not try to
resolve this issue, will it lead to feelings of anger and resentment?” If you decide that the con
flict is important enough, then the fifth step is necessary. The fifth step is to address and
resolve the conflict. This involves checking out the schedule of the other person. The schedule
is important because you might bring up the conflict when the other person does not have the
time to address it or when he or she may be preoccupied with another issue. Once you have
agreed on a time with the person, you can describe the conflict, your feelings, and the impact
of the conflict and ask for a resolution.
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For example, the interaction may sound like this:
Joe:
Hey, Frank, sorry I’m late.
Frank:
Hi, Joe. Can I talk to you about that?
Joe:
Sure. Is something wrong?
Frank:
Joe, I’ve noticed you’ve been late for the last few days when I’ve come to
pick you up. Today, I realized that I was starting to feel frustrated and a
bit taken for granted. When you are late, we are both late for the meeting,
which makes me uncomfortable. I like to be on time. I’m wondering if you
can make an effort to be on time in the future.
Joe:
Frank, I didn’t realize how bothered you were about that. I apologize for
being late, and I will be on time in the future. I’m glad you brought this
problem up to me.
Of course, this is an idealized version of an outcome that may be achieved with the Conflict
Resolution Model. Joe could have responded unfavorably, or defensively, by accusing Frank of
making a big deal out of nothing. Joe may have minimized and discounted Frank’s feelings,
leaving the conflict unresolved.
The Conflict Resolution Model is useful even when conflicts are not resolved. Many times, you
will feel better about trying to resolve a conflict in an assertive manner rather than acting pas
sively or aggressively. Specifically, you may feel that you have done all that you could do to
resolve the conflict. In this example, if Frank decided not to give Joe a ride in the future, or if
Frank decided to end his friendship with Joe, he could do so knowing that he first tried to
resolve the conflict in an assertive manner.
Exhibit 7. The Conflict Resolution Model
1.
Identify the problem that is causing the conflict
2.
Identify the feelings that are associated with the conflict
3.
Identify the impact of the problem that is causing the conflict
4.
Decide whether to resolve the conflict
5.
Work for resolution of the conflict
How would you like the problem to be resolved?
Is a compromise needed?
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Have the group members practice using the Conflict Resolution Model by roleplaying. Be care
ful not to push group members into a roleplay situation if they are not comfortable about it or
ready. Exercise your clinical judgment.
The following are some topics for roleplays:
• Dealing with a rude or unhelpful salesclerk
• Dealing with a physician who will not take the time to explain how a medication works
• Dealing with a supervisor who does not listen to you
• Dealing with a counselor who repeatedly cancels your therapy/counseling sessions
• Dealing with a friend who does not respect your privacy.
Homework Assignment
and the strategies they used to manage their anger in response to the event. Ask them to
review the definitions of assertiveness, aggression, and passivity. Instruct them to practice
using the Conflict Resolution Model, preferably once a day during the coming week. Remind
them to continue to develop their anger control plans.
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Anger and the Family
How Past Learning Can
Influence Present Behavior
Outline of Sessions 9 & 10
Sessions 9 & 10
As with sessions 7 and 8, sessions 9 and 10 are
combined because it takes more than one
session to answer the questions beginning on page
46 and connect the responses to current behavior.
– Anger and the Family
Sessions 9 and 10 (comprising two 90-minute sessions) help group members gain a better
understanding of their anger with regard to the interactions they had with their parents and
the families that they grew up in (Reilly & Grusznski, 1984). Help them see how these past
interactions have influenced their current behavior, thoughts, feelings, and attitudes and the
way they now interact with others as adults.
Many people are unaware of the connection between past learning and current behavior.
Present a series of questions to the group members that will help them understand how their
learning histories relate to current patterns of behavior. Because of the nature and content of
this exercise, with its focus on family interactions, it is important that you monitor and structure
the exercise carefully, but at the same time provide a warm and supportive environment.
Experience has shown there is a tendency for group members to elaborate on many detailed
aspects of their family backgrounds that are beyond the scope of this exercise. Keep in mind
that family issues may bring up difficult and painful memories that could potentially trigger
anxiety, depression, or relapse to drug and alcohol use. It is important, therefore, to tell group
members that they are not required to answer any questions if they feel that they would be
emotionally overwhelmed by doing so. Instead, tell them that they can pursue these and other
issues with their individual or group therapist.
Check-In Procedure
response to the anger-provoking event, and help them classify these cues into the four cue
categories. Ask them to report on their use of the Conflict Resolution Model and the ongoing
development of their anger control plans.
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Suggested Remarks
Anger and the Family
In these sessions, you will explore how anger and other emotions were displayed by your par
ents and in the families in which you grew up. For many of us, the interactions we have had
with our parents have strongly influenced our behaviors, thoughts, feelings, and attitudes as
adults. With regard to anger and its expression, these feelings and behaviors usually were
modeled for us by our parents or parental figures. The purpose of these sessions is to examine
the connection between what you have learned in the past, in the families in which you grew
up, and your current behavior and interactions with others now as adults. You will be asked a
series of questions concerning your parents and families. This is an involved and often emo
tionally charged topic, so if you are not comfortable answering any questions, you do not have
to do so. Also, because there is a natural tendency to want to elaborate on family issues
because of their emotional content, please focus on answering the specific questions:
1. Describe your family. Did you live with both parents? Did you have any brothers and sisters?
Where did you grow up?
2. How was anger expressed in your family while you were growing up? How did your father
express anger? How did your mother express anger? (Possible probes to use: Did your par
ents yell or throw things? Were you ever threatened with physical violence? Was your father
abusive to your mother or you?)
3. How were other emotions such as happiness and sadness expressed in your family? Were
warm emotions expressed frequently, or was emotional expression restricted to feelings of
anger and frustration? Were pleasant emotions expressed at birthdays or holidays?
4. How were you disciplined and by whom? Did this discipline involve being spanked or hit
with belts, switches, or paddles? (An assumption of the anger management treatment is
that no form of physical discipline is beneficial to a child. Empirical studies have shown that
nonphysical forms of discipline are very effective in shaping childhood behavior [Barkley,
1997; Ducharme, Atkinson, & Poulton, 2000; Webster-Stratton & Hammond, 1997]).
5. What role did you take in your family? For example, were you the hero, the rescuer, the vic
tim, or the scapegoat?
6. What messages did you receive about your father and men in general? In other words, in
your experience, how were men supposed to act in society? What messages did you receive
about your mother and women in general? How were women supposed to act in society?
(Note: Many of the messages group members have received differ from messages that are
socially appropriate today. Point out the changing roles of men and women during the past
three decades.)
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7. What behaviors, thoughts, feelings, and attitudes carry over into your relationships as
adults today? What purpose do these behaviors serve? What would happen if you gave up
these behaviors? (The group leader should help group members see the connection
between past social learning and their current behavior.)
Homework Assignment
event that made them angry, the cues associated with the anger-provoking event, and the
strategies they used to manage their anger in response to the event. Remind them to continue
to develop their anger control plans.
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Review Session #2
Reinforcing Learned Concepts
Session 11
In this session, the basic concepts of anger man
agement that were presented are reviewed and
summarized. Give special attention to clarifying
and reinforcing concepts (i.e., the anger meter, cues
to anger, anger control plans, the aggression cycle, cognitive restructuring, and conflict
resolution). Provide encouragement and support for efforts to develop anger control plans
and to balance cognitive, behavioral, immediate, and preventive strategies.
Check-In Procedure
response to the anger-provoking event, and help them classify these cues into the four cue
categories. Ask them to report on the ongoing development of their anger control plans.
Suggested Remarks
This session involves a second review of the anger management material covered in all the
sessions. We will review each concept and clarify any questions that you may have. We encour
age discussion during this review, and we will be asking you for your understanding of the
anger management concepts.
Homework Assignment
event that made them angry, the cues that were associated with the anger-provoking event, and
the strategies they used to manage their anger in response to the event. Ask them to update
their anger control plans and to be prepared to present them in the final session next week.
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Closing and Graduation
Closing Exercise and Awarding of Certificates
Session 12
In the final session, group members review their
anger control plans, rate the treatment components for their usefulness and familiarity, and
complete a closing exercise. Review each anger control plan to balance cognitive, behavioral,
immediate and preventive strategies. Give corrective feedback if necessary. Congratulate the
group members for completing the anger management treatment. Provide each member with
a certificate of completion (see sample on the following page).
Suggested Remarks
1. What have you learned about anger management?
2. List anger management strategies on your anger control plan. How can you use these
strategies to better manage your anger?
3. In what ways can you continue to improve your anger management skills? Are there
specific areas that need improvement?
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[NAME], Chief, Substance Abuse
Outpatient Clinic
[NAME OF COUNSELOR]
[DATE]
In Recognition of Completing the Phase One Anger Management Group
in the Substance Abuse Outpatient Clinic
(ADD NAME)
Anger Manag
gement
Thomas Smith
CONGRATU
ULATIONS
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Appendix:
Authors’ Acknowledgments
The authors would like to acknowledge the following clinicians and researchers for their various
contributions to the development of this manual:
Robert Awalt, Psy.D., Peter Banys, M.D., Torri Campell, Ph.D., Darcy Cox, Ph.D., John Coyne,
M.A., Timothy Durazzo, Ph.D., Sharon Hall, Ph.D., Anthony Jannetti, Ph.D., Monika Koch, M.D.,
Peg Maude-Griffin, Ph.D., Robert Ouaou, Ph.D., Teron Park, Ph.D., Amy Rosen, Psy.D., Sheila
Shives, M.A., James Sorensen, Ph.D., David Thomson, LCSW, Donald Tusel, M.D., David
Wasserman, Ph.D., and Lisa Wasserman, M.A.
We would also like to acknowledge H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM, Director of
the Center for Substance Abuse Treatment, for his valuable contributions to the early stages of
this treatment manual and the anger management project. Dr. Durazzo assisted in editing the
manual.
Johnson, Bassin & Shaw, Inc., personnel involved in the production of this manual and the
accompanying participant workbook included Barbara Fink, M.P.H., Project Director; Nancy
Hegle, Quality Control Manager; Frances Nebesky, M.A., Editor; and Terrie Young, Graphic
Designer.
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DHHS Publication No. (SMA) 08-4213
Printed 2002
Reprinted 2003, 2005, 2006, 2007, and 2008
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In Brief
August 2011 • Volume 6 • Issue 1
Substance Use Disorders in People With
Physical and Sensory Disabilities
Approximately 23 million people in the United
States, including people with disabilities, need
treatment for substance use disorders (SUDs), a major
behavioral health disorder.1 In addition, more than
24 million adults in the United States experienced
serious psychological distress in 2006.2 People with
and without disabilities may face many of the same
barriers to substance abuse treatment, such as lacking
insurance or sufficient funds for treatment services, or
feeling they do not need treatment.
In addition, people with disabilities may face other
barriers to SUD treatment, particularly finding
treatment facilities that are fully accessible. Vocational
rehabilitation (VR) counselors, vocational education
providers, and others who work with people with
disabilities report that their clients with SUDs have
less successful vocational outcomes than clients
without SUDs.3
To improve outcomes, it is important that clients
with disabilities and SUDs receive services for both
conditions and that the disabilities do not prevent
clients from receiving treatment for SUDs. This In
Brief is intended to help people who work with people
with physical and sensory disabilities—hearing
loss, deafness, blindness, and low vision—to better
understand SUDs and assist their clients in finding
accessible SUD treatment services.
What is an SUD?
Substance use disorder is a broad term that encompasses
abuse of and dependence on drugs or alcohol
(Exhibit 1). It includes using illegal substances, such
as heroin, marijuana, or methamphetamines, and using
legal substances, such as prescription or over-the-counter
medications, in ways not prescribed or recommended.
SUDs Harm People With
Disabilities
It is difficult to estimate the number of people with
physical disabilities who have SUDs. Some studies
suggest that people with disabilities have higher rates
of legal and illegal substance use than the general
population, whereas other studies show lower rates.5
Although debate exists among researchers about the
prevalence of SUDs among people with disabilities,
there is agreement that active SUDs can seriously
Exhibit 1. Defining Substance Abuse and Dependence
Both substance abuse and substance dependence refer to maladaptive patterns of substance use. Substance abuse usually refers
to using any substance in a way that leads to a failure to fulfill major responsibilities at work, school, or home, or to substancerelated legal or interpersonal problems. It also includes using substances in situations that put one’s physical safety at risk.
Substance dependence usually manifests as continued use of a substance despite negative physical or psychological effects,
inability to cut down or control the use of the substance, tolerance (using more of the substance to get the same effect), and
withdrawal symptoms when the substance is no longer consumed. The Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision (DSM-IV-TR)4 provides fuller definitions of substance abuse and substance dependence.
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover
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Brief
harm the health and quality of life of individuals with
disabilities. An active SUD can:
■ Interfere with successful engagement in rehabilitation
services.3
■ Interact with prescribed medications; alcohol, for
example, can interfere with antiseizure medications.
■ Impede coordination and muscle control.
■ Impair cognition.
■ Reduce the ability to follow self-care regimens.
■ Contribute to social isolation, poor communication,
and domestic strife.
■ Contribute to poor health, secondary disabling conditions, or the hastening of disabling diseases (e.g., cirrhosis, depression, bladder infections). ■ Inhibit educational advancement.
■ Lead to job loss, underemployment, and housing instability.
■Pain
■Access to prescription pain medications
■Chronic medical problems
■Depression
■Social isolation
■Enabling by caregivers
■Unemployment
■Low socioeconomic level
Across all age groups, more women than men are disabled.
Women with co-occurring disabilities and SUDs are at high
risk for experiencing physical abuse and domestic violence.
6
One study of people with disabilities and SUDs found
that 47 percent of women reported histories of physical,
sexual, or domestic violence, compared with 20 percent
of men with disabilities reporting abuse experiences. In
the same study, 37 percent of women reported sexual abuse,
compared with 7 percent of men.7
Another study found that 56 percent of women with
disabilities reported abuse, with 89 percent of these
reporting multiple abusive incidents.8 What is more, being a
victim of physical or sexual abuse is a risk factor for SUD.
For some people, drug or alcohol abuse is a direct or
indirect cause of their disability, for example, by their
becoming intoxicated and then falling or causing a car
crash. Without SUD treatment, people who had SUDs
Exhibit 2. SUD Risk Factors for People With Disabilities
■Limited education
Women With Disabilities and SUDs
SUD Risk Factors and Warning
Signs
before sustaining a disability will likely continue to use
substances afterward Other people may have developed
SUDs after using substances such as pain medications or
alcohol to cope with aspects of their disability or to cope
with social isolation or depression. Exhibit 2 lists SUD
risk factors for people with disabilities.
■Little exposure to SUD prevention education
■History of physical or sexual abuse
Numerous signs may suggest the presence of an active
SUD. These include, but are not limited to:
■ Dilated or constricted pupils.
■ Slurred speech.
■ Inability to focus, visually or cognitively.
■ Unsteady gait.
■ Blackouts.
■ Insomnia.
■ Irritability or agitation.
■ Depression, anxiety, low self-esteem, resentment.
■ Odor of alcohol on breath.
■ Excessive use of aftershave or mouthwash (to mask
the odor of alcohol).
■ Mild tremor.
■ Nasal irritation (suggestive of cocaine insufflation).
■ Eye irritation (suggestive of exposure to marijuana
smoke).
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Substance Use Disorders in People With Physical and Sensory Disabilities
August 2011, Volume 6, Issue 1
■ Odor of marijuana on clothing.
■ Abuse of drugs or alcohol by family members.
■ Many missed appointments with VR, job interviews,
and the like.
■ Difficulty learning new tasks.
■ Attention deficits.
■ Lack of initiative.
Some manifestations of certain disabilities may be difficult
to distinguish from the signs of SUDs mentioned above.
For example, people with multiple sclerosis may have an
unsteady gait, slurred speech, and memory impairment.
Other signs, such as depression or anxiety, may indicate a
different, distinct behavioral health condition.
Screening for SUDs
Screening is not the same as diagnosing; it simply indicates
whether further evaluation by an SUD professional
is indicated. The National Institute on Alcohol Abuse
and Alcoholism (NIAAA) developed a single-question
screening tool for alcohol use disorder (Exhibit 3). Clients
should also be screened for illicit drug use and prescription
medication abuse. VR professionals, physical therapists,
and others may benefit from training on how to administer
screening and assessment tools.
Exhibit 3. Single-Question Screening Test
Ask men:
Ask women:
“How many times in the past year have
you had 5 or more drinks in a day?”
“How many times in the past year have
you had 4 or more drinks in a day?”
A response of more than 1 day is considered positive.
Other common screening tools are:
■ Alcohol Use Disorders Identification Test, available
at http://www.projectcork.org/clinical_tools/html/
AUDIT.html
■ Michigan Alcoholism Screening Test, available at
http://www.projectcork.org/clinical_tools/html/
MAST.html
■ Drug Abuse Screening Test (including prescription
drugs), available at http://www.projectcork.org/
clinical_tools/html/DAST.html
■ National Institute on Drug Abuse (NIDA)-modified
Alcohol, Smoking, and Substance Involvement
Screening Test, which includes prescription drugs,
available at http://www.drugabuse.gov/nidamed/
screening/
Screening is not the same as
diagnosing; it simply indicates
whether further evaluation
by an SUD professional is
indicated.
No screening tools have been validated in Deaf populations.9
If possible, clients who exhibit warning signs or symptoms
should be screened for SUDs. If screening is not possible or
if the screening is positive, the client should be referred to
an SUD treatment provider for further assessment.
Some clients may benefit from a brief intervention (a
discussion of 5 minutes or less) to prevent their substance
use from becoming an SUD. Information on brief
interventions for alcohol use disorders is available from
The Substance Abuse and Mental Health Services Administration (SAMHSA)/Center for Substance Abuse Treatment Family
Centered Substance Abuse Treatment Grants for Adolescents and their Families (Assertive Adolescent and Family Treatment) was
designed to provide substance abuse services to adolescents (including those with disabilities and those from military families)
and their families or primary caregivers in geographic areas where services are needed. Grantees implement evidenced-based
practices that are family centered and context specific and focus on the interaction between youth and their environments.
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NIAAA at http://pubs.niaaa.nih.gov/publications/AA66/
AA66.htm. Clients whose signs suggest a mental health
issue should be referred to a professional for further
assessment.
Types of SUD Services
SUD services include:
■ Prevention education—information in various
formats that helps people understand the risks of
substance use.
■ Indepth assessment—an evaluation by a treatment
provider to determine whether an SUD is present
and, if so, what level of care is needed and what
treatment options are available.
■ Outpatient or inpatient detoxification—medically
supervised withdrawal from alcohol or drugs.
■ Outpatient treatment—psychosocial interventions
and individual and group counseling on substance
use.
■ Medication-assisted treatment and counseling—
methadone, buprenorphine, and other medications
for opioid dependence or acamprosate, disulfiram,
and naltrexone for alcohol use disorders; medicationassisted treatment works best if combined with
psychosocial counseling interventions.
■ Residential programs—short- and long-term
structured living to help people re-enter their
community.
In addition, people in recovery often attend mutual-help
groups, such as Alcoholics Anonymous (AA), Narcotics
Anonymous (NA), and SMART (Self Management and
Recovery Training) Recovery to share experiences and
support one another’s recovery efforts. Many meetings of
AA and NA that are wheelchair accessible are identified
in meeting lists. Online meetings are an option for those
who are Deaf and hard of hearing, people with visual
disabilities, or people who live in locations without
accessible meetings. Some AA groups will pay for a
sign language interpreter or make use of sign language
interpreters who are in recovery themselves.
Accessible SUD Treatment
Facilities
Despite requirements of the Americans with
Disabilities Act (ADA), studies suggest that many
treatment facilities are not fully accessible to people
with disabilities.10, 11, 12, 13, 14 Examples of physical barriers
include doors and hallways too narrow for wheelchairs,
uneven flooring, nonfunctioning elevators, and a reliance
Barriers to Treatment for People Who Are Blind or Visually Impaired
A survey of VR counselors and SUD treatment providers found that barriers to SUD treatment for people who are blind or visually
impaired are formidable. Frequently identified barriers are presented below:
■Negative attitudes and prejudices about people with SUDs. Some VR professionals regarded people with SUDs and disabilities as “not worthy” of SUD treatment, particularly if outcomes are perceived as poor for people with these two co-occurring conditions. ■Lack of staff training. SUD counselors reported a need to learn about working with people who are blind, and VR counselors
report a need to learn about SUDs in their clients.
■Inaccessible methods and materials. Many facilities that provide SUD services reported that they are “handicapped accessible” if they provide ramps for clients. But people who are visually impaired require Braille signs and other navigational features and alternatives to sight-based counseling treatment activities like films and booklets to have genuine accessibility to treatment services. Survey respondents noted it is important to identify which agency will coordinate comprehensive client care. Respondents also
commonly mentioned that, because there are no formal mechanisms for shared communication and case management, SUD and
VR services providers may not know how to manage cases and work together across fields to provide services for their clients.15
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Treatment Innovations for People Who Are Deaf or Hard of Hearing
Few fully accessible SUD treatment services exist for people who are Deaf. Specialty treatment facilities for people who are
Deaf exist, but the number has declined in the last decade. In 2009, only five providers in the United States offered inpatient
SUD services especially for people who are Deaf, and four provided outpatient treatment.16 A national survey in 2008 by
SAMHSA found that 27 percent of opioid treatment facilities offered interpretation services for people who are Deaf or hard of
hearing.17 However, there are numerous barriers to providing fully accessible mainstream SUD treatment to people who are Deaf,
including cultural and linguistic barriers, lack of local SUD treatment providers trained to work with people who are Deaf, lack
of American Sign Language interpreters, inability of people who are Deaf to participate in group counseling (a mainstay of SUD
treatment), increased costs associated with making treatment accessible to people who are Deaf, and more.18
One way to fill the treatment gap is to advocate telehealth SUD treatment services for people who are Deaf. Telehealth
technology, such as electronic mailing lists and video conferencing, can connect people who are Deaf to appropriate SUD
specialists across the country, and it can be adapted for an array of SUD services, from recovery support after treatment to
mutual-help groups. Telehealth could also be used to train more people who are Deaf to be SUD counselors. One promising
model piloted by Wright State University is Deaf off Drugs and Alcohol (DODA), a program for Ohio residents that supplements
local SUD treatment with Internet- and video-based case management, group therapy, individual therapy, and followup. DODA
also manages mutual-help/12-Step meetings available 7 days a week, which are conducted via video conferences and open to
anyone in the country.18 More information on innovative SUD services for people who are Deaf is available at http://www.med.
wright.edu/citar/sardi/doda html.
on signage to provide directions, which leaves people with
low or no vision without a means to find their way through
facilities.
Many other types of barriers exist. Some SUD treatment
administrators believe that their facilities are more
accessible than they actually are.14 Of various types of
healthcare providers, outpatient SUD treatment providers
are among the least likely to report that their services are
accessible to people with disabilities or that they have had
training on mobility impairments.10
Comparatively little information is available on how many
people with disabilities have been denied SUD treatment
because of physical barriers in the treatment facility itself.
One survey of 174 SUD treatment providers in Virginia
found that 87 percent of people with multiple sclerosis,
75 percent of people with muscular dystrophy, and
67 percent of people with spinal cord injuries who sought
services were denied SUD treatment services because of
physical barriers at the treatment facility.13
Ways to Help Clients With SUDs
VR counselors, physical therapists, and others who work
with people with disabilities are in a good position to
understand the importance of identifying and treating
behavioral health conditions, such as SUDs, and to
advocate for their clients’ right to accessible SUD
treatment services. To help clients with SUDs:
1. Learn about behavioral health issues, such as SUDs,
and promote prevention. A wealth of information about
drug and alcohol use, abuse, and dependence and their
consequences can be found online.
■ Free ADA-compliant publications on SUDs can be
downloaded from SAMHSA’s Publication Ordering
Web page, at http://www.store.samhsa.gov/home
■ Information about drugs of abuse is on NIDA’s Web
site, at http://www.nida.nih.gov
■ Information about alcohol use disorders is located on
NIAAA’s Web site, at http://www.niaaa.nih.gov
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In Brief
Brief
■ An overview on SUDs for VR counselors, Substance
Use Disorders and Vocational Rehabilitation: VR
Counselor’s Desk Reference, and other information on
substance use and people with disabilities is available
from Wright State University, at http://www.med.
wright.edu/citar/sardi/products.html
2. Don’t ignore signs of a possible SUD in clients with
disabilities. When there is doubt that disability alone
explains a sign or behavior, screen the client for an SUD or
refer the client to a behavioral health specialist for further
evaluation. SUD is a preventable and treatable condition.
A nonjudgmental approach to giving feedback to clients
about the potential consequences of their substance use
can enhance their motivation to seek further evaluation and
treatment.
3. Build a directory of local treatment providers and
facilities that work with or would be willing to learn to
work with people with disabilities. SAMHSAʼs online
Substance Abuse Treatment Facility Locator includes
more than 11,000 U.S. treatment facilities. State-specific
information is available at http://dasis3.samhsa.gov.
Online recovery meetings are available in a variety of
formats, including text-based chats and discussion forums,
audio and telephonic meetings, and video meetings.
Information about online meetings is available at:
■ Alcoholics Anonymous Online Intergroup
http://aa-intergroup.org/index.php ■ Narcotics Anonymous Chat and Online Meetings for
Drug Addicts
http://www.12stepforums.net/na
■ SMART Recovery Online
http://www.smartrecovery.org/meetings/olschedule.htm
4. Where possible, help SUD treatment administrators
understand how they can make their facilities
accessible to people with disabilities. SAMHSA’s
Treatment Improvement Protocol (TIP) 29: Substance
Use Disorder Treatment for People With Physical
and Cognitive Disabilities, was written to help SUD
treatment providers work with people with cognitive and
physical disabilities. Appendix D, in particular, is useful
for advocating accessibility in treatment facilities. The
TIP is available online at http://www.ncbi.nlm.nih.gov/
bookshelf/br.fcgi?book=hssamhsatip&part=A52487. A
Quick Guide based on TIP 29 was created to help SUD
treatment administrators comply with ADA requirements
and better serve people with disabilities. The Quick Guide
is available at http://www.store.samhsa.gov/product/
QGCT29.
Other resources include:
■ Baylor College of Medicine Center for Research on
Women with Disabilities
http://www.bcm.edu/crowd
Click on “Secondary conditions.” From the resulting
page, click on “Substance abuse.”
■ Minnesota Chemical Dependency Program for Deaf
and Hard of Hearing Individuals
http://www.mncddeaf.org
■ Wright State University Substance Abuse Resources
and Disability Issues (SARDI) Program
http://www.med.wright.edu/citar/sardi
Many links are available from the SARDI home page.
The “Materials” link offers access to several print
resources available free or for a small fee. These
include Substance Use Disorders and Vocational
Rehabilitation: VR Counselorʼs Desk Reference;
Substance Abuse, Disability & Vocational
Rehabilitation; and Blindness, Visual Impairment, and
Substance Abuse.
5. Once a client enters treatment and is ready for VR,
work with the client’s primary care physician, SUD
case manager, and other treatment professionals to
best serve the client. TIP 29 (Chapter 4) presents ideas on
establishing linkages for case management. The chapter
can be viewed at http://www.ncbi.nlm.nih.gov/bookshelf/
br.fcgi?book=hssamhsatip&part=A52886.
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Resources
TIP 29: Substance Use Disorder Treatment For People
With Physical and Cognitive Disabilities, offers treatment
providers guidelines on caring for people with either
physical or cognitive disabilities, as well as drug abuse
or alcohol abuse problems. The TIP discusses screening,
treatment planning, and counseling, and links to other
service providers (http://www.ncbi.nlm.nih.gov/books/
NBK14408/).
Products based on TIP 29:
KAP Keys for Clinicians Based on TIP 29: Substance
Use Disorder Treatment for People With Physical and
Cognitive Disabilities
http://www.kap.samhsa.gov/products/tools/keys/pdfs/
KK_29.pdf
Quick Guide for Clinicians Based on TIP 29: Substance
Use Disorder Treatment for People With Physical and
Cognitive Disabilities
http://www.kap.samhsa.gov/products/tools/cl-guides/pdfs/
QGC_29.pdf
Quick Guide for Administrators Based on TIP 29:
Substance Use Disorder Treatment for People With
Physical and Cognitive Disabilities
http://www.kap.samhsa.gov/products/tools/ad-guides/pdfs/
QGA_29.pdf
Notes
1
2
3
Substance Abuse and Mental Health Services Administration.
(2010). Results from the 2009 National Survey on Drug Use
and Health: National findings. NSDUH Series H-38A, HHS
Publication No. (SMA) 10-4856. Rockville, MD: Author.
(2007). Results from the 2006 National Survey on Drug Use
and Health: National findings. NSDUH Series H-32, HHS
Publication No. (SMA) 07-4293. Rockville, MD: Author.
Davis, S. J., Koch, D. S., McKee, M. F., & Nelipovich, M.
(2009). AODA training experiences of blindness and visual
impairment professionals. Journal of Teaching in the
Addictions, 8(1), 42–50.
4
American Psychiatric Association. (2000). Diagnostic and
statistical manual of mental disorders (4th ed., text
revision). Washington, DC: Author.
5
Yu, J., Huang, T., Newman, L., & SRI International. (2008).
Substance use among young adults with disabilities: Facts
from National Longitudinal Transition Study 2. Washington,
DC: Department of Education Institute of Education Science.
6
Centers for Disease Control and Prevention. (2009). Prevalence
and most common causes of disability among adults—
United States, 2005. MMWR, 58(16), 421–426.
7
Wolf-Branigin, M. (2007). Disability and abuse in relation to
substance abuse: A descriptive analysis. Journal of Social
Work in Disability & Rehabilitation, 6(3), 65–74.
8
Milberger, S., Israel, N., Le Roy, B., Martin, A., Potter, L., &
Patchak-Schuster, P. (2003). Violence against women with
physical disabilities. Violence and Victims, 18(5), 581–591.
9
Alexander, T. D., & Tidblom, I. (2005). Screening for alcohol
and other drug use problems among the Deaf. Alcoholism
Treatment Quarterly, 23(1), 63–78.
10
Bachman, S. S., Vedrani, M., Drainoni, M. L., Tobias, C., &
Andrew, J. (2007). Variations in provider capacity to offer
accessible health care for people with disabilities. Journal of
Social Work in Disability & Rehabilitation, 6(3), 47–63.
11
Thapar, N., Warner, G., Drainoni, M. L., Williams, S. R.,
Ditchfield, H., Wierbicky, J., & Nesathurai, S. (2004). A
pilot study of functional access to public buildings and
facilities for persons with impairments. Disability and
Rehabilitation, 26(5), 280–289.
12
West, S. L. (2007). The accessibility of substance abuse
treatment facilities in the United States for persons with
disabilities. Journal of Substance Abuse Treatment, 33(1),
1–5.
13
West, S. L., Graham, C. W., & Cifu, D. X. (2009). Rates
of alcohol/other drug treatment denials to persons with
physical disabilities: Accessibility concerns. Alcoholism
Treatment Quarterly, 27, 305–316.
14
Voss, C. P., Cesar, K. W., Tymus, T., & Fiedler, I. G. (2002).
Perceived versus actual physical accessibility of substance
abuse treatment facilities. Topics in Spinal Cord Injury
Rehabilitation, 7(3), 47–55.
7
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15
Koch, D. S., Shearer, B., & Nelpovich, M. (2004). Service
delivery for persons with blindness or visual impairment
and addiction as coexisting disabilities: Implications for
addiction science education. Journal of Teaching in the
Addictions, 3(1), 21–48.
17
(2010). Overview of Opioid Treatment Programs Within the
United States. Rockville, MD: Author. Retrieved June 3,
2011, from http://www.oas.samhsa.gov/2k10/222/
222USOTP2k10 htm
16
Titus, J. C., & Guthmann, D. (2010). Addressing the black hole
in substance abuse treatment for Deaf and hard of hearing
individuals: Technology to the rescue. Journal of the
American Deafness and Rehabilitation Association, 43(2),
92–100.
18
Moore, D., Guthmann, D., Rogers, N., Fraker, S., & Embree,
J. (2009). E-therapy as a means for addressing barriers to
substance use disorder treatment for persons who are Deaf.
Journal of Sociology & Social Welfare, 36(4), 75–92.
In Brief
This In Brief was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA) by the
Knowledge Application Program (KAP), a Joint Venture of The CDM Group, Inc., and JBS International, Inc., under contract
number 270-09-0307, with SAMHSA, U.S. Department of Health and Human Services (HHS). Christina Currier served as
the Government Project Officer.
Disclaimer: The views, opinions, and content expressed herein do not necessarily reflect the views or policies of SAMHSA
or HHS. No official support of or endorsement by SAMHSA or HHS for these opinions or for particular instruments,
software, or resources is intended or should be inferred.
Public Domain Notice: All materials appearing in this document except those taken from copyrighted sources are in the
public domain and may be reproduced or copied without permission from SAMHSA or the authors. Citation of the source
is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written
authorization of the Office of Communications, SAMHSA, HHS.
Electronic Access and Copies of Publication: This publication may be ordered from SAMHSA’s Publications Ordering
Web page at http://www.store.samhsa.gov/home. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727). The
document can be downloaded from the KAP Web site at http://www kap.samhsa.gov.
Recommended Citation: Substance Abuse and Mental Health Services Administration. (2011). Substance Use Disorders in
People With Physical and Sensory Disabilities. In Brief, Volume 6, Issue 1.
In Brief
Substance Use Disorders in People With Physical
and Sensory Disabilities
www.breining.edu
HHS Publication No. (SMA) 11-4648
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DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS
Adoption of Chapter 8 (commencing with Section 13000), and
Amendment of Sections 9846, 10125, and 10564, Division 4, Title 9,
California Code of Regulations
COUNSELOR CERTIFICATION
Text of Final Regulations
§ 9846. Staff Qualifications and Functions.
(a)
The DUI program administrator shall have the following minimum experience
and/or education:
(1)
Two years of experience providing alcohol and/or other drug treatment or
recovery services;
(2)
One year of experience supervising personnel; and
(3)
One year of experience managing an accounting system, or preparing or
directing the preparation of budgets or cost reports. Satisfactory
completion of two college-level courses in accounting may be substituted
for the one year of experience required in this subsection. As used in this
regulation, "satisfactory completion" means attainment of a grade "C" or
better.
(b)
Program staff who conduct educational sessions shall have a minimum of two
years of experience in providing alcohol and/or drug education and information to
persons with alcohol and/or other drug problems in a classroom setting.
(c)
Except for new hires, as specified in Section 13035(e), by April 1, 2010 all
program staff who provide counseling services (as defined in Section 13005)
shall be licensed, certified, or registered to obtain certification pursuant to
Chapter 8 (commencing with Section 13000).
(d)
Program staff who provide counseling services (as defined in Section 13005)
shall comply with the code of conduct, pursuant to Section 13060, developed by
the organization by which they were certified or registered.
(e)
Volunteers may assist in conducting educational sessions, group counseling
sessions, intake interviews, face-to-face interviews, or assessments of alcohol
and/or other drug problems.
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(f)
(1)
Volunteers assisting in the provision of educational sessions shall be
under the direct supervision of a staff member who meets the
requirements of Subsection (b) of this regulation. Volunteers assisting in
the provision of counseling services shall be under the direct supervision
of a certified counselor and shall adhere to the code of conduct specified
in Section 13060.
(2)
Volunteers shall not provide services unless the supervising staff member
is present in the room during the provision of services.
The program may employ interns to conduct counseling or educational sessions.
As used in this regulation, an “intern” is an entry level, paid staff member who
does not have a minimum of 2,080 hours of experience in providing educational
or counseling services to persons with alcohol and/or other drug problems. Prior
to employing interns, the licensee shall provide the Department with a description
of its intern program, which shall comply with following requirements:
(1)
Interns may not comprise more than twenty percent of the program’s
counseling staff.
(2)
The licensee shall designate a staff member who is licensed or certified
pursuant to Chapter 8 (commencing with Section 13000) as the coordinator
of its intern program.
(3)
Prior to conducting services without direct supervision, each intern shall
observe at least three hours of face-to-face interviews, 12 hours of
educational classes conducted by staff who meet the requirements of (b)
of this regulation, and 20 hours of group counseling sessions conducted
by a certified counselor. The licensee shall document the sessions in the
intern’s personnel record.
(4)
The intern coordinator shall provide individual progress reviews with each
intern on a weekly basis as long as the intern is employed as an intern or
until the intern meets the requirements of (b) and (c) of this section. The
licensee shall document individual progress reviews in the intern’s
personnel record.
(5)
Administration and associated costs of interns may be allocated over as
many AOD treatment programs within a given agency as use interns,
proportionate to the number of interns used by each program.
(g)
As used in this regulation, "one year of experience" means 1,776 total hours of
full or part time, compensated or uncompensated, work experience.
(h)
The licensee shall maintain personnel records for all staff, including DUI program
administrators, containing:
(1)
Name, address, telephone number, position, duties, and date of
employment; and
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(2)
Resumes, applications, and/or transcripts documenting work experience
and/or education used to meet the requirements of this regulation.
(3)
Personnel records for staff who provide counseling services (as defined in
Section 13005) shall also contain:
(A)
Written documentation of licensure, certification, or registration to
obtain certification pursuant to Chapter 8 (commencing with Section
13000); and
(B)
A copy of the code of conduct of the registrant’s or certified AOD
counselor’s certifying organization pursuant to Section 13060.
NOTE: Authority cited: Sections 11755 and 11836.15, Health and Safety Code.
Reference: Section 11836.15, Health and Safety Code.
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§ 10125. Counselors.
(a)
Counselors may be physicians, physician’s assistants, nurses, nurse
practitioners, psychologists, social workers, psychiatric technicians, marriage and
family therapists, certified counselors, or others as long as they have training or
experience in treating persons with an opiate addiction.
(b)
shall be licensed, certified, or registered to obtain certification or licensure
pursuant to Chapter 8 (commencing with Section 13000).
(c)
the organization or entity by which they were registered, licensed, or certified.
(d)
The licensee shall maintain personnel records for all staff containing:
(1)
employment; and
(2)
(3)
(A)
13000); and
(B)
NOTE: Authority cited: Sections 11755, 11864 and 11876(a), Health and Safety Code.
Reference: Sections 11876(a), and 11880, Health and Safety Code.
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§10564.
(a)
Personnel Requirements.
Facility administrator qualifications
(1)
(b)
The facility administrator shall demonstrate abilities and competency in the
following areas:
(A)
Knowledge of the requirements for providing the type of alcoholism
or drug abuse recovery or treatment services needed by residents.
(B)
Knowledge of and ability to comply with applicable laws and
regulations.
(C)
Ability to direct the work of others, when applicable.
(D)
Ability to develop and manage the facility's alcohol or drug abuse
recovery or treatment services and budget.
(E)
Ability to recruit, employ, train, and evaluate qualified staff, and to
terminate employment of staff, if applicable.
(2)
Each licensee shall make provisions for continuing operation and
administration during any absence of the regular administrative personnel.
(3)
The licensee, if an individual, or any member of the governing board of the
licensed corporation or association, shall be permitted to be the facility
administrator provided that he/she meets the qualifications specified in this
section, and in applicable regulations.
Staff Qualifications
(1)
Facility personnel including volunteers shall be competent to provide the
services necessary to meet resident needs and shall be adequate in
numbers necessary to meet such needs. Competence shall be
demonstrated by accrued work, personal, and/or educational experience
and/or on-the-job performance.
(2)
The department shall have the authority to require any licensee to provide
additional staff whenever the department determines and documents that
existing staff is unable to provide services as described in the plan of
operation submitted to the department. The licensee shall be informed in
writing of the reasons for the department's determination. The following
factors shall be taken into consideration in determining the need for
additional staff:
(A)
Needs of the residents;
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(3)
(B)
Extent of the services provided by the facility; and
(C)
Physical arrangements of the particular facility.
All personnel shall be trained or shall have experience which provides
knowledge of the skills required in the following areas, as appropriate to
the job assigned, and as evidenced by safe and effective job performance:
(A)
General knowledge of alcohol and/or drug abuse and the principles
of recovery.
(B)
Housekeeping and sanitation principles.
(C)
Principles of communicable disease prevention and control.
(D)
Recognition of early signs of illness and the need for professional
assistance.
(E)
Availability of community services and resources.
(F)
Recognition of individuals under the influence of alcohol and/or
drugs.
(G)
Principles of nutrition, food preparation and storage, and menu
planning.
(c)
In addition to the requirements of (b) of this regulation, program staff who provide
counseling services (as defined in Section 13005) shall be licensed, certified, or
registered to obtain certification pursuant to Chapter 8 (commencing with Section
13000).
(d)
the organization by which they were certified or registered
(e)
All personnel shall be in good health.
(1)
Except as specified in (3) below, good physical health shall be verified by
a health screening, including a test for tuberculosis, performed under
licensed medical supervision not more than 60 days prior to or 7 days
after employment with tuberculosis testing renewable every year.
Personnel with a known record of tuberculosis or record of positive testing
shall not be required to be retested if a physician verifies the individual has
been under regular care and monitoring for tuberculosis. Such verification
will be renewed annually.
(2)
A health screening report signed by the person performing such screening
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shall be made for each person specified above, and shall indicate the
following:
(3)
(A)
The person's physical qualifications to perform assigned duties.
(B)
The presence of any health condition that would create a hazard to
the person, residents or other staff members.
The good physical health of each volunteer who works in the facility shall
be verified by a statement signed by each volunteer affirming that he/she
is in good health, and a test for tuberculosis performed under licensed
medical supervision not more than 60 days prior to or 7 days after initial
presence in the facility and annually thereafter. At the discretion of the
licensee, tuberculosis testing need not be required for volunteers whose
functions do not necessitate frequent or prolonged contact with residents.
Volunteers with a known record of tuberculosis or record of positive testing
shall not be required to be re-tested if a physician verifies the individual
has been under regular care and monitoring for tuberculosis. Such
verification will be renewed annually.
(f)
Personnel with evidence of physical illness that poses a threat to the health and
safety of residents shall be temporarily relieved of their duties.
(g)
Residents shall not be used as substitutes for required staff but shall be
permitted to participate in duties and tasks as a voluntary part of their program of
activities.
(h)
When regular staff members are absent, there shall be coverage by personnel
capable of performing assigned tasks as evidenced by on-the-job performance,
experience or training. Residents shall not be utilized to fulfill this requirement.
(i)
Personnel shall provide services without physical or verbal abuse, exploitation or
prejudice.
(j)
All personnel shall be instructed to report observation or evidence of violations of
personal rights as specified in Section 10569 of this subchapter.
(k)
The licensee shall develop, maintain, and implement an ongoing training program
for all staff in the areas identified in Section 10564 (b)(3) of this subchapter in
addition to specific training related to their duties. Staff participation in the
training program shall be documented and maintained on file for 3 years.
(l)
The licensee shall maintain personnel records for all staff, including program
administrators, containing:
(1)
employment; and
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(2)
(3)
(A)
13000); and
(B)
NOTE: Authority cited: Section 11834.50, Health and Safety Code.
Reference: Section 11834.27, Health and Safety Code.
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CHAPTER 8. CERTIFICATION OF ALCOHOL AND OTHER DRUG COUNSELORS
Subchapter 1. General Administration
13000
13005
Application and Purpose of Chapter
Definitions
Subchapter 2. Requirement for Certification for Individuals Providing
Counseling Services in AOD Recovery and Treatment Programs
13010
13015
13020
13025
13030
13035
Requirement for Certification
Requirements for Certification of Licensed Professionals
Requirements for Previously Certified AOD Counselors
Requirements for Certification by Testing
Requirements for Counselors Certified or Licensed in Other
States or by Other Certifying Organizations
Certifying Organizations
Subchapter 3. Requirements for Certification of AOD Counselors
13040
13045
13050
13055
13060
13065
13070
13075
Requirements for Initial Certification of AOD Counselors
Issuance of Certification as an AOD Counselor
Length of Certification
Renewal of Certification
Code of Conduct
Investigation of Complaints, Suspension, and Revocation
Administrative Review
Maintenance of Records
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Chapter 8. Certification of Alcohol and Other Drug Counselors.
Subchapter 1. Application and Purpose of Chapter and Definitions.
§ 13000. Application and Purpose of Chapter.
The regulations contained in this Chapter shall apply to all individuals providing
counseling services in an alcohol or other drug (AOD) program, to all organizations
certifying AOD counselors, and to all AOD programs, as defined in Section 13005.
NOTE: Authority cited: Sections 11755 and 11834.50 of the Health and Safety Code.
Reference: Sections 11833 and 11834.27 of the Health and Safety Code.
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§ 13005. Definitions.
(a)
The following definitions apply to terminology used in this Chapter:
(1)
(2)
“Alcohol and other drug (AOD) program” means any of the following:
(A)
A driving under the influence program licensed pursuant to
Chapter 9 (commencing with Section 11836), Part 2, Division 10.5
of the Health and Safety Code (HSC), and the provisions of
Chapter 3 (commencing with Section 9795), Division 4, Title 9 of
the California Code of Regulations (CCR);
(B)
A narcotic treatment program licensed pursuant to Article 1,
Chapter 10 (commencing with Section 11839), Part 2, Division
10.5, HSC, and the provisions of Chapter 4 (commencing with
Section 9995), Division 4, Title 9, CCR;
(C)
A residential alcohol or drug abuse recovery or treatment program
licensed pursuant to Chapter 7.5 (commencing with Section
11834.01), Part 2, Division 10.5, HSC, and the provisions of
Chapter 5 (commencing with Section 10500), Division 4, Title 9,
CCR;
(D)
An alcohol or drug recovery or treatment program certified to
receive Medi-Cal reimbursement pursuant to Section 51200, Title
22, CCR;
(E)
An alcohol or drug recovery or treatment program certified pursuant
to Section 11830, Chapter 7, Part 2, Division 10.5, HSC; or
(F)
An alcohol or drug recovery or treatment program funded pursuant
to Part 2, Division 10.5, HSC (commencing with Section 11760).
“Certified AOD counselor” means an individual certified by a certifying
organization pursuant to Section 13035.
(3)
“Certifying organization” means an organization approved to certify
individuals as AOD counselors, as listed in Section 13035.
(4)
“Counseling services” means any of the following activities:
(A)
Evaluating participants’, patients’, or residents’ AOD treatment or
recovery needs, including screening prior to admission, intake, and
assessment of need for services at the time of admission;
(B)
Developing and updating of a treatment or recovery plan;
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(C)
Implementing the treatment or recovery plan;
(D)
Continuing assessment and treatment planning;
(E)
Conducting individual counseling sessions, group counseling
sessions, face-to-face interviews, or counseling for families,
couples, and other individuals significant in the life of the
participants, patients, or residents; and
(F)
Documenting counseling activities, assessment, treatment and
recovery planning, clinical reports related to treatment provided,
progress notes, discharge summaries, and all other client related
data.
(5)
“Days” means calendar days unless otherwise specified.
(6)
“Department” means the Department of Alcohol and Drug Programs.
(7)
“Hour” means sixty (60) minutes unless otherwise specified.
(8)
“Registrant” means an individual registered with any certifying organization
to obtain certification as an AOD counselor.
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Subchapter 2. Requirement for Certification for Individuals
Providing Counseling Services in AOD Recovery and Treatment Programs.
§ 13010. Requirement for Certification.
(a)
By April 1, 2010, at least thirty percent (30%) of staff providing counseling
services in all AOD programs shall be licensed or certified pursuant to the
requirements of this Chapter. All other counseling staff shall be registered
pursuant to Section 13035(f).
(b)
Each AOD program may determine which of the Department approved certifying
organizations, as specified in Section 13035, it will recognize when hiring AOD
counselors certified by or registered with that/those organization(s).
(c)
Certification pursuant to this Chapter does not confer on any individual any right
or privilege to provide AOD treatment services outside of an AOD program or to
practice any other profession for which licensure is required.
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§ 13015. Requirements for Certification of Licensed Professionals.
(a)
As used in this regulation, “licensed professional” means a physician licensed by
the Medical Board of California; or a psychologist licensed by the Board of
Psychology; or a clinical social worker or marriage and family therapist licensed
by the California Board of Behavioral Sciences, or an intern registered with the
California Board of Psychology or the California Board of Behavioral Sciences.
(b)
Licensed professionals, providing counseling services in an AOD program, who
are in good standing with their licensing agency, shall not be required to become
certified as AOD counselors pursuant to this Chapter. As used in this regulation,
“in good standing” means that the individual’s license is valid and is not revoked,
suspended, or otherwise terminated.
(c)
Licensed professionals, providing counseling services in an AOD program, shall
provide to the AOD program by which they are employed, for retention in their
personnel files, a copy of their license to practice in the State of California.
(d)
Licensed professionals, providing counseling services in an AOD program, shall
complete 36 hours of continuing education during every two year period of
licensure beginning January 1, 2006. Such continuing education shall be based
on the curriculum described in Section 13055 and shall be provided or approved
by the AOD program employing the licensed professional or one of the certifying
organizations specified in Section 13035. Licensed professionals shall be
required to complete 36 hours of continuing education during every two year
period of licensure; however, at the discretion of the employing AOD program,
the continuing education units required by the licensed professional’s licensing
board shall satisfy this requirement.
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§ 13020. Requirements for Previously Certified AOD Counselors.
(a)
Any individual who was certified to provide counseling services in an AOD
program, by a certifying organization (listed in Section 13035), as of April 1,
2005, shall be deemed certified pursuant to the requirements of this Chapter.
All such individuals shall comply with all other requirements of Subchapter 3
(commencing with Section 13055) of this Chapter.
(b)
Any individual, certified to provide counseling services in an AOD program, as of
April 1, 2005, shall present to the AOD program by which he/she is employed, for
retention in his/her personnel file, a copy of his/her certificate as an AOD
counselor.
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§ 13025. Requirements for Certification by Testing.
At its discretion, until April 1, 2007, any of the certifying organizations listed in Section
13035 may certify any individual employed as an AOD counselor as of April 1, 2005, if
the individual:
(a)
Registers to obtain certification with a certifying organization listed in Section
13035;
(b)
Provides written documentation to the certifying organization that he/she has
been employed to provide counseling services in an AOD program for the
equivalent of forty (40) hours per week for a minimum of five (5) years between
April 1, 1995 and April 1, 2005 or provides an official diploma or written transcript
verifying that he/she has successfully completed an associate’s degree (A.A.), a
bachelor’s degree (B.A. or B.S.), or a master’s degree (M.A.) in the study of
chemical dependency; and
(c)
Achieves a score of at least seventy percent (70%) on an oral and/or written
examination, approved by the certifying organization. Achievement of a passing
score on an oral or written examination administered by any one of the certifying
organizations listed in Section 13035 does not mandate any other certifying
organization to certify the individual as an AOD counselor.
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§ 13030. Requirements for Counselors Certified or
Licensed in Other States or by Other Certifying Organizations.
(a)
Any certifying organization listed in Section 13035 may, at its option, certify by
reciprocity an individual, who is currently certified or licensed in another state to
provide counseling services in an AOD program, or is currently certified by an
organization other than those listed in Section 13035, if:
(1)
The individual registers with one of the certifying organizations listed in
Section 13035 and provides the certifying organization with verifiable
documentation of his/her current licensure or certification,
(2)
The certifying organization verifies that the registrant’s licensure or
certification is current, has never been revoked, and is not currently the
subject of an investigation by either the Department or the certifying
organization which granted it, and
(3)
The certifying organization determines to its satisfaction that the standards
by which the other state or certifying organization granted licensure or
certification were the same as or more stringent than the standards
contained in this Chapter.
(b)
The registrant/certified AOD counselor shall comply with all the requirements of
Subchapter 3 (commencing with Section 13040) of this Chapter.
(c)
This regulation shall not prohibit any certifying organization from establishing
additional terms and conditions for certification by reciprocity, so long as those
terms and conditions do not conflict with the provisions of this Chapter.
(d)
This regulation shall not require any certifying organization to grant certification
by reciprocity.
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Section 13035. Certifying Organizations
(a)
As of April 1, 2005, the following organizations are approved by the Department
to register and certify AOD counselors pursuant to this Chapter:
(1)
The Breining Institute,
(2)
The California Association of Addiction Recovery Resources,
(3)
The California Association for Alcohol/ Drug Educators,
(4)
The California Association of Alcoholism and Drug Abuse Counselors,
(5)
The California Association of Drinking Driver Treatment Programs,
(6)
The Forensic Addictions Corrections Treatment,
(7)
The Indian Alcoholism Commission of California, Inc.,
(8)
The American Academy of Health Care Providers,
(9)
The Association of Christian Alcohol & Drug Counselors, or
(10)
The California Certification Board of Chemical Dependency Counselors
(b)
The Department will also approve any other organization that certifies counselors
if it requests in writing that the Department recognize it and it provides written
documentation that it complies with all of the requirements of (c) of this
regulation, except that the accreditation required by (c)(2) must be in place by the
time the organization requests recognition, if the organization requests
recognition after April 1, 2007.
(c)
The certifying organizations listed in (a) of this regulation shall:
(1)
Maintain a business office in California, and
(2)
Become accredited with the National Commission for Certifying Agencies
(NCCA) by April 1, 2007 and shall continuously
maintain such accreditation. Certifying organizations may obtain
information on NCCA accreditation by contacting the NCCA at 2025 M
Street NW, Suite 800, Washington D.C. 20036-3309; telephone (202) 3671165; internet address www.noca.org;
(3)
Provide written documentation from the NCCA that the NCCA has
determined that the certifying organization complies with the requirements
of this Chapter ; and
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(4)
(d)
Comply with the requirements of this Chapter.
If any of the certifying organizations specified in this regulation fails to comply
with the requirements of this regulation, within five (5) working days following
receipt of written notification by the Department that it is no longer approved to
certify AOD counselors, the certifying organization shall send written notification
to each AOD counselor registered with or certified by the certifying organization,
informing him/her of his/her rights and responsibilities, including the following:
(1)
Before expiration of his/her certification or within six (6) months of the
notice (whichever is sooner), the counselor shall register with one of the
other certifying organizations listed in (a) of this regulation;
(2)
For purposes of this Chapter, the AOD counselor’s certification remains
valid until it expires only if the certified counselor re-registers as required
by (d)(1) of this regulation;
(3)
The new certifying organization shall give credit for any continuing
education credits earned while certified by the former certifying
organization; and
(4)
The new certifying organization shall give registrants sufficient credit for
education and experience completed to place the registrant at an
equivalent level in the new certifying organization.
(e)
If any of the certifying organizations specified in (a) of this regulation voluntarily
chooses to stop certifying AOD counselors, it shall notify the Department in
writing of its decision and follow the steps outlined in (d) of this regulation.
(f)
By October 1, 2005 or within six (6) months of the date of hire, whichever is
later, all non-licensed or non-certified individuals providing counseling services in
an AOD program shall be registered to obtain certification as an AOD counselor
by one of the certifying organizations specified in this regulation.
(1)
Registrants shall complete certification as an AOD counselor within five
(5) years of the date of registration.
(2)
The certifying organization may allow up to two (2) years additional time
for a leave of absence due to medical problem or other hardship,
consistent with the policy developed by the certifying organization.
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Subchapter 3. Requirements for Certification of AOD Counselors
§ 13040. Requirements for Initial Certification of AOD Counselors.
Prior to certification as an AOD counselor, the certifying organization shall require each
registrant to:
(a)
(b)
Complete a minimum of 155 documented hours of formal classroom AOD
education, which shall include at least the following subjects:
(1)
The curriculum contained in “Addiction Counseling Competencies: The
Knowledge, Skills, and Attitudes of Professional Practice”, Technical
Assistance Publication Series 21(TAP 21), published by the Substance
Abuse and Mental Health Services Administration, United States
Department of Health and Human Services, Reprinted 2002;
(2)
Provision of services to special populations such as aging individuals;
individuals with co-occurring disorders (e.g., alcoholism and mental
illness); individuals with post traumatic stress disorder [PTSD]); individuals
with disabilities; diverse populations; individuals with cultural differences,
individuals on probation/parole, etc.;
(3)
Ethics;
(4)
Communicable diseases including tuberculosis, HIV disease, and
Hepatitis C; and
(5)
Prevention of sexual harassment;
Complete a minimum of 160 documented hours of supervised AOD training
based on the curriculum contained in TAP 21 [as defined in (a) of this regulation]
and supervised on-site by an AOD counselor who has been licensed or certified
pursuant to this Chapter. As used in this regulation, “supervised” means that the
individual supervising the training shall:
(1)
Be physically present and available on site or at an immediately adjacent
site, but not necessarily in the same room at all times, and
(2)
Document in the registrant’s record that the registrant has completed the
supervised training required by this subsection.
(c)
Complete, an additional 2,080 or more documented hours of paid or unpaid work
experience providing counseling services in an AOD program prior to, after, or at
the same time as completion of the education required in (a) of this regulation
and the supervised AOD training required in (b) of this regulation.
(d)
Obtain a score of at least seventy percent (70%) on a written or oral examination
approved by the certifying organization;
(e)
Sign a statement documenting whether his/her prior certification as an AOD
counselor has ever been revoked; and
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(f)
Sign an agreement to abide by the certifying organization’s code of conduct,
developed pursuant to Section 13060.
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§ 13045. Issuance of Certification as an AOD Counselor.
(a)
Prior to certifying a registrant as an AOD counselor, the certifying organization shall
contact all other certifying organizations listed in Section 13035 to determine if the
registrant’s certification was ever revoked.
(b)
If previous certification was revoked, the certifying organization shall document in the
registrant’s file its reasons for granting or denying certification. The certifying
organization shall send written notification to the Department that it has granted
certification to a registrant whose previous certification was revoked within 48 hours of
granting such certification.
(c)
If the certifying organization denies certification it shall send the registrant a written
notice of denial. The notice shall specify the registrant’s right to appeal the denial in
accordance with the provisions of Section 13070.
(d)
If the certifying organization decides to grant certification, upon completion of all program
requirements, as specified in Section 13040, and payment of all fees charged by the
certifying organization, the certifying organization shall issue a written certificate to the
registrant, stating that he/she is certified as an AOD counselor.
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§ 13050. Length of Certification.
Certification as an AOD counselor shall be valid for two (2) years from the date of
certification, unless renewed pursuant to Section 13055 or revoked pursuant to Section
13065.
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§ 13055. Renewal of Certification.
(a)
In order to renew certification, the certifying organization shall require each
certified AOD counselor to complete a minimum of forty (40) hours of continuing
education, approved by the certifying organization, during each two-year period
of certification.
(b)
If a previously certified counselor’s certification expires prior to April 1, 2007, in
order to have his/her certification renewed, the counselor shall complete 1.6
hours of continuing education prorated for every month he/she was certified after
the effective date of this Chapter, and rounded to the nearest whole hour. For
example, if the counselor’s previous certification expires on September 30, 2005,
the counselor shall be required to complete ten (10) hours of continuing
education (i.e., 1.6 hours multiplied by six months) to renew certification.
(c)
The forty (40) hours of continuing education shall include any combination of the
following:
(1)
The curriculum contained TAP 21, as defined in Section 13040;
(2)
Provision of services to special populations including at least aging
individuals; individuals with co-occurring disorders (e.g., alcoholism and
mental illness); individuals with post traumatic stress disorder [PTSD]);
individuals with disabilities; diverse populations; individuals with cultural
differences, individuals on probation/parole, etc.;
(3)
Ethics;
(4)
Communicable diseases including tuberculosis, HIV disease and Hepatitis
C; and
(5)
Prevention of sexual harassment.
(d)
At the certifying organization’s discretion, the forty (40) hours of continuing
education may also include other topics related to the field of alcoholism and
drug abuse such as residential treatment, driving-under-the-influence, etc.
(e)
All certifying organizations (listed in Section 13035) shall accept as continuing
education credits hours of training in the areas specified in (c) and (d), provided
by any State, county, city, or other governmental agency or by any agency which
provides services through a contractual arrangement with a State and/or county
agency.
(f)
The certifying organization shall document completion of all continuing education
hours and the subject matter studied in each certified AOD counselor’s record
maintained pursuant to Section 13075.
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(g)
Prior to renewing certification, the certifying organization shall review the AOD
counselor’s record to determine if his/her certification has been revoked during
the previous certification period.
(h)
If previous certification was revoked, the certifying organization shall document in
the registrant’s file its reasons for granting or denying renewal of certification.
Within 48 hours of renewing certification, the certifying organization shall send
written notification to the Department that it has renewed certification of an AOD
counselor whose previous certification was revoked.
(i)
If the certifying organization denies renewal, it shall send the AOD counselor a
written notice of denial. The notice shall specify the counselor’s right to appeal
the denial in accordance with the provisions of Section 13070.
(j)
If the certifying organization decides to renew certification, upon completion of all
continuing education requirements and payment of all fees charged by the
certifying organization, the certifying organization shall issue a written certificate
to the registrant, stating that his/her certification as an AOD counselor has been
renewed.
(k)
If the AOD counselor’s previous certification was revoked, the certifying
organization shall deny renewal of certification and shall send the AOD counselor
a written notice of denial of renewal. The notice shall specify the AOD
counselor’s right to appeal the denial in accordance with the procedure
established in Section 13070.
(l)
If certification as an AOD counselor has not been revoked, the certifying
organization shall renew the AOD counselor’s certification upon documentation of
completion of a minimum of forty (40) hours of continuing education and payment
of a renewal fee as specified by the certifying organization.
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§ 13060. Code of Conduct.
(a)
Each certifying organization shall require registrants and certified AOD
counselors to comply with a code of conduct developed by the certifying
organization in compliance with the requirements of this regulation.
(b)
At a minimum, the code of conduct shall require registrants and certified AOD
counselors to:
(c)
(1)
Comply with a code of conduct developed by the certifying organization;
(2)
Protect the participant’s, patient’s, or resident’s rights to confidentiality in
accordance with Part 2, Title 42, Code of Federal Regulations;
(3)
Cooperate with complaint investigations and supply information requested
during complaint investigations unless such disclosure of information
would violate the confidentiality requirements of Subpart 2, Title 42, Code
of Federal Regulations.
At a minimum, the code of conduct shall prohibit registrants and certified AOD
counselors from:
(1)
Providing counseling services, attending any program services or
activities, or being present on program premises while under the influence
of any amount of alcohol or illicit drugs. As used in this subsection, “illicit
drugs” means any substance defined as a drug in Section 11014, Chapter
1, Division 10, Health and Safety Code, except:
(A)
Drugs or medications prescribed by a physician or other person
authorized to prescribe drugs, in accordance with Section 4036,
Chapter 9, Division 2, Business and Professions Code, and used in
the dosage and frequency prescribed; or
(B)
Over-the-counter drugs or medications used in the dosage and
frequency described on the box, bottle, or package insert.
(2)
Providing services beyond the scope of his/her registration or certification
as an AOD counselor, or his/her professional license, if the individual is a
licensed professional as defined in Section 13015;
(3)
Discriminating against program participants, patients, residents, or other
staff members, based on race, religion, age, gender, disability, national
ancestry, sexual orientation, or economic condition;
(4)
Engaging in social or business relationships for personal gain with
program participants, patients, or residents, their family members or other
persons who are significant to them;
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(5)
Engaging in sexual conduct with current participants, patients, residents,
their family members, or other persons who are significant to them;
(6)
Verbally, physically, or sexually harassing, threatening, or abusing any
participant, patient, resident, their family members, other persons who are
significant to them, or other staff members.
(d)
At its discretion, the certifying organization may chose to exclude any
conviction(s) for usage or possession of drugs or alcohol, which occurred prior to
the time of registration for certification as an AOD counselor, as a violation of the
code of conduct.
(e)
Each certifying organization shall notify registrants and AOD counselors, in
writing, of any changes to its code of conduct.
(f)
Certifying organizations and AOD programs may impose more stringent
standards at their discretion.
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§ 13065. Investigation of Complaints, Suspension, and Revocation.
(a)
Within 24 hours of the time an alleged violations of the code of conduct specified
in Section 13060 by a registrant or a certified AOD counselor becomes known
to an AOD program, the program shall report it to the Department and to the
registrant or counselor’s certifying organization. Such report may be made by
contacting the Department and the certifying organization in person, by
telephone, in writing, or by any automated or electronic means, such as e-mail or
fax.
(b)
The report shall include facts concerning the alleged violation.
(c)
The Department shall investigate each alleged violation.
(d)
Within ninety (90) days of receipt of the request for investigation, the Department
shall send a written order to the certifying organization specifying what corrective
action (if any) it shall take, based on the Department’s investigation and the
severity of the violation.
(e)
If the Department orders the certifying organization to temporarily suspend or
revoke a counselor’s certification or registration, the certifying organization shall
so inform the counselor and the AOD program employing the counselor or
registrant in person or by telephone, with written notification to follow,
immediately upon receipt of the written order from the Department. The written
notification shall inform the counselor or registrant of his/her right to
administrative review pursuant to Section 13070.
(f)
The same day that the certifying organization sends written notification to the
counselor or registrant, it shall document in its database (pursuant to Section
13075) the violation alleged, the outcome of the Department’s investigation, and
what action the certifying organization took based on the Department’s
investigation.
(h)
If the Department does not order temporary suspension or revocation, within ten
(10) days of receipt of the written order from the Department, the certifying
organization shall send written notification to the counselor or registrant and the
AOD program employing him/her, informing him/her of the results of the
investigation.
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§ 13070. Administrative Review.
(a)
The Department may initiate administrative review if a certifying organization
registers or certifies an individual whose previous registration or certification was
revoked.
(b)
A counselor or registrant whose registration or certification was denied,
temporarily suspended, or revoked may request an informal review by sending a
written request for review to the Director, Department of Alcohol and Drug
Programs, 1700 K Street, Sacramento, California 95814.
(c)
The written request for review shall be postmarked within fifteen (15) working
days of the date of the written notice of denial, temporary suspension, or
revocation. The written request for review shall state:
(1)
The alleged violation of the code of conduct which is at issue and the
basis for review.
(2)
The facts supporting the request for review.
(d)
Failure to submit the written request for review, pursuant to Subsections (b) and
(c) of this regulation, shall be deemed a waiver of administrative review.
(e)
Within fifteen (15) working days of receipt of the request for review, the Director
or the Director's designee shall schedule and hold an informal conference to
review the Department’s determination, unless:
(f)
(g)
(1)
The counselor or registrant waives the fifteen (15) day requirement, or
(2)
The Director or the Director's designee and the counselor or registrant
agree to settle the matter based upon the information submitted with the
request for review.
At the informal conference, the counselor or registrant shall have the right to:
(1)
Be represented by legal counsel,
(2)
Present oral and written evidence, and
(3)
Explain any mitigating circumstances.
The representatives of the Department who conducted the investigation shall and
their attorney may:
(1)
Attend the informal conference, and
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(2)
Present oral and/or written evidence and information substantiating the
alleged violation.
(h)
The informal conference shall be conducted as an informal proceeding.
(I)
Neither the counselor or registrant nor the Department shall have the right to
subpoena any witness to attend the informal conference. However, both the
counselor or registrant and the Department may call witnesses to present
evidence and information at the conference.
(j)
The proceedings of the informal conference may be recorded on audio tape by
either party.
(k)
The Department shall mail its decision to affirm, modify, or dismiss the notice of
denial, suspension, or revocation to the counselor or registrant. The decision
shall:
(l)
(m)
(1)
Be postmarked and mailed no later than fifteen (15) working days from the
date of the informal conference.
(2)
Specify the reason for affirming, modifying, or dismissing the suspension
or revocation.
(3)
Include a statement notifying the counselor or registrant of his/her right to
appeal the decision made at the informal conference in accordance with
Chapter 5 (commencing with Section 11500) Part 1, Division 3, Title 2 of
the Government Code.
The counselor or registrant may appeal the decision made at the informal
conference by submitting a written request to the Director of the Department of
Alcohol and Drug Programs, 1700 K Street, Sacramento, California, 95814,
postmarked no later than fifteen (15) working days from the date the decision
was mailed. Upon receipt of the request for appeal, the Department shall:
(1)
Request the Office of Administrative Hearings to set the matter for
hearing, and
(2)
Notify the counselor or registrant of the time and place of the hearing.
Failure of the counselor or registrant to submit a written request to appeal the
decision made at the informal conference postmarked within 15 working days
from the date the decision was mailed shall be deemed a waiver of further
administrative review and the decision of the Director or the Director's designee
shall be deemed final.
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§ 13075. Maintenance of Records.
(a)
The certifying organization shall maintain an automated electronic database ,
containing a record for each registrant or counselor the organization has certified.
The record shall document:
(1)
Completion of all education and work experience required pursuant to
Section 13040 and Section 13055;
(2)
Certification to provide counseling services in an AOD program;
(3)
Renewal of certification;
(4)
Investigation and outcome of the investigation of any complaints alleging
violations of the code of conduct developed pursuant to Section 13060;
and
(5)
Temporary suspension or revocation of certification pursuant to
Section13065; and
(6)
The final outcome of any appeal of temporary suspension or revocation
adjudicated pursuant to Section 13070.
(b)
The database shall be electronically accessible by the Department and by the
public.
(c)
The information contained in the database shall be updated each working day
and kept current at all times.
(d)
The certifying organization shall retain the information kept in the database for
five (5) years from the date of initial certification, denial, last renewal, temporary
suspension, or revocation, whichever occurs last.
*****
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THE CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS REGULATION
AND THE HIPAA PRIVACY RULE: IMPLICATIONS FOR ALCOHOL AND SUBSTANCE ABUSE PROGRAMS
June 2004
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TABLE OF CONTENTS
I. Applicability.................................................................................................................................3
A. Programs to which the Privacy Rule applies...........................................................................3
B. Information that is protected under Part 2 and the Privacy Rule.............................................3
C. When protections begin for someone seeking substance abuse treatment ..............................4
II. How the Privacy Rule affects disclosures of information ...........................................................4
A. The General Rule ....................................................................................................................4
B. When disclosures are permitted ..............................................................................................4
1. Part 2 Consent11 and Privacy Rule Authorization..............................................................5
2. Other permissible disclosures under Part 2........................................................................7
a. When little or no changes may be needed .......................................................................7
i. Internal program communications ..............................................................................7
ii. Crimes on program premises or against program personnel.......................................8
iii. Child abuse reporting..................................................................................................8
iv. Medical emergencies ..................................................................................................8
v. Subpoenas and court-ordered disclosures ...................................................................9
b. When some change is required .......................................................................................9
i. Disclosures that do not reveal patient-identifying information...................................9
ii. Disclosures to agencies that provide services to programs.......................................10
iii. Audit and evaluation.................................................................................................11
iv. Research....................................................................................................................12
III. Other Changes Required by the Privacy Rule18 .......................................................................12
A. Patient Notice/Notice of Privacy Practices ........................................................................12
1. Notice content................................................................................................................12
2. Distribution of the Notice ..............................................................................................14
B. Patient rights ......................................................................................................................15
1. Right to request a restriction of uses and disclosures ....................................................15
2. Right to access PHI ........................................................................................................15
3. The right to amend PHI..................................................................................................18
4. Right to an accounting of disclosures of PHI ................................................................19
C. Administrative Requirements.............................................................................................21
1. Complaints about the program’s privacy practices ........................................................21
2. Other administrative requirements.................................................................................22
D. Security of information ......................................................................................................23
Conclusion .....................................................................................................................................23
For more information about the HIPAA Standards .......................................................................24
This is an educational document from the Substance Abuse and Mental Health Services Administration
and the U.S. Department of Health and Human Services. It was prepared by SAMHSA staff and
contractors in consultation with the Office of the General Counsel, the Office for Civil Rights and other
offices and agencies within the U.S. Department of Health and Human Services, Washington, D.C.
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The Confidentiality of Alcohol and Drug Abuse Patient Records Regulation
and the HIPAA Privacy Rule:
Implications for Alcohol and Substance Abuse Programs
Introduction
In the early 1970’s, Congress recognized that the stigma associated with substance
abuse and fear of prosecution deterred people from entering treatment and enacted
legislation that gave patients a right to confidentiality. For the almost three decades
since the Federal confidentiality regulations (42 CFR Part 2 or Part 2) were issued,
confidentiality has been a cornerstone practice for substance abuse treatment programs
across the country.
In December, 2000, the Department of Health and Human Services (HHS) issued the
“Standards for Privacy of Individually Identifiable Health Information” final rule
(Privacy Rule), pursuant to the Administrative Simplification provisions of the Health
Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR Parts 160 and
164, Subparts A and E.1 Substance abuse treatment programs that are subject to HIPAA
must comply with the Privacy Rule.2 3 Substance abuse treatment programs that already
are complying with Part 2 should not have a difficult time complying with the Privacy
Rule, as it parallels the requirements of Part 2 in many areas. Programs subject to both
sets of rules must comply with both, unless there is a conflict between them. Generally,
this will mean that substance abuse treatment programs should continue to follow the
Part 2 regulations. In some instances, programs will have to establish new policies and
procedures or alter existing policies and practices. In the event a program identifies a
conflict between the rules, it should notify the Substance Abuse and Mental Health
Services Administration of HHS immediately for assistance in resolving the conflict.
This guidance is for substance abuse treatment programs that are subject to and already
complying with the confidentiality requirements of Part 2.4 It explains which programs
must also comply with the Privacy Rule and outlines what compliance will require. The
guidance is not a legal opinion. To comply with the Privacy Rule, programs should
apply this guidance to their individual situations; programs may also want to call upon
State agencies, provider organizations and legal counsel for assistance in establishing
and implementing the practices and policy changes required by the Privacy Rule.
1
In August 2002, HHS adopted modifications to the Privacy Rule. The compliance date for the Privacy Rule was April 14, 2003. However, small health plans, as defined by the Privacy Rule, are not required to be in compliance until April 14, 2004. 3
This guidance applies to substance abuse treatment programs that are also covered entities as defined by
the Privacy Rule. Programs should seek legal counsel for assistance in determining whether they are covered entities. 4
The Part 2 regulations apply to substance abuse treatment “programs” as defined by 42 CFR §2.11 that
are “federally assisted” as defined by 42 CFR §2.12(b). 2
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I.
Applicability
A.
Programs to which the Privacy Rule applies
The Privacy Rule applies to “covered entities” which are health plans, health care
clearinghouses and health care providers5 who transmit health information in electronic
form (i.e., via computer-based technology) in connection with transactions for which
HHS has adopted a HIPAA standard in 45 CFR Part 162. See 45 CFR §160.103.
HIPAA transactions that a substance abuse treatment program6 might engage in
include:
• Submission of claims to health plans
• Coordination of benefits with health plans
• Inquiries to health plans regarding eligibility, coverage or benefits or status of
health care claims
• Transmission of enrollment and other information related to payment to health
plans
• Referral certification and authorization (i.e., requests for review of health care
to obtain an authorization for providing health care or requests to obtain
authorization for referring an individual to another health care provider)
If a substance abuse treatment program transmits health information electronically in
connection with one or more of these Part 162 transactions, then it must comply with
the Privacy Rule. Part 162 may be amended in the future to cover additional
transactions.7
B.
Information that is protected under Part 2 and the Privacy Rule
Part 2 protects any and all information that could reasonably be used to identify an
individual and requires that disclosures be limited to the information necessary to carry
out the purpose of the disclosure. See 42 CFR §§2.11 and 2.13(a). Under the Privacy
Rule, a program may not use or disclose “protected health information” (PHI) except as
permitted or required by the Rule.8 See 45 CFR §164.502(a). Neither rule applies to
information that has been de-identified.9 See 45 CFR §164.514(a) (de-identification of
5
The Privacy Rule generally defines a health care provider to include a person or organization who
furnishes, bills or is paid for health care in the normal course of business, which would include substance
abuse treatment programs.
6
A substance abuse treatment program is defined as an individual or entity that provides alcohol or drug
abuse diagnosis, treatment or referral. For the purposes of this document, the term “program” includes
both individual substance abuse providers and substance abuse provider organizations.
7
Neither Part 2 nor the Privacy Rule protects employment records held by a program in its role as
employer. Note that while 42 CFR Part 2 arguably applies to substance abuse patient records covered by
the Family Educational Rights and Privacy Act (FERPA) (20 USC §1232g; 34 CFR Part 99), the Privacy
Rule does not.
8
PHI is defined as individually identifiable health information held or transmitted by a covered entity or
its “business associate,” with limited exceptions. See 45 CFR §160.103.
9
The Privacy Rule includes numerous elements that make information identifiable, such as, but not
limited to, information regarding employers, relatives and household members that are not necessarily
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PHI) and 42 CFR §2.11 (definition of “patient identifying information”). The Privacy
Rule permits programs to assign a code or other means of record identification to allow
information that has been de-identified to be re-identified, as provided in 45 CFR
§164.514(c).
The two regulations have some differences in the definition of what information is
protected. For instance, the Privacy Rule treats medical record numbers as PHI, subject
to all the same requirements as other PHI. Part 2 would permit a program to disclose a
medical record number because the regulation does not apply to “a number assigned to
a patient by a program, if that number does not consist of, or contain numbers . . .
which could be used to identify a patient with reasonable accuracy and speed from
sources external to the program.” See 42 CFR §2.11. Programs subject to both rules
must follow the Privacy Rule’s protection of a medical record number.
C.
When protections begin for someone seeking substance abuse treatment
Part 2 protects all information about any person who has applied for or been given
diagnosis or treatment for alcohol or drug abuse at a federally assisted program. See 42
CFR §2.11 (definition of a “patient”). Information is subject to the Privacy Rule if it is
individually identifiable information created, received, or maintained by the covered
entity. Former patients and deceased patients are protected under both Part 2 and the
Privacy Rule. See 42 CFR §§2.11 and 2.15 and 45 CFR §§164.501 and 164.502(f).
Programs should generally continue to follow Part 2, but note that if PHI is received
prior to a patient applying to a program, under the Privacy Rule, such information is
protected.
II.
How the Privacy Rule affects disclosures of information
A.
The General Rule
The “general rules” established by Part 2 and the Privacy Rule regarding uses and
disclosures of patient health information are very different.10
Substance abuse treatment programs must comply with both rules. Generally, this will
mean that they will continue to follow Part 2’s general rule and not disclose
information unless they can obtain consent or point to an exception to that rule that
specifically permits the disclosure. Programs must then make sure that the disclosure is
also permissible under the Privacy Rule.
B.
When disclosures are permitted
identifiable information under Part 2. Such information should be protected consistent with the Privacy
Rule requirements. 10
Part 2 uses the term “disclosure” to cover what the Privacy Rule refers to as “uses” and “disclosures.” See the definition of these terms in 45 CFR §160.103. Some Privacy Rule provisions differ for “uses”
and “disclosures.” For convenience, we generally use the Part 2 term “disclosure” throughout to
encompass both uses and disclosures under the Privacy Rule. In some instances, however, specific uses
or disclosures are discussed.
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1.
Part 2 Consent11 and Privacy Rule Authorization
42 CFR Part 2
The Privacy Rule
Programs may not use or disclose any
information about any patient unless the
patient has consented in writing (on a
form that meets the requirements
established by the regulations) or unless
another very limited exception specified
in the regulations applies. Any disclosure
must be limited to the information
necessary to carry out the purpose of the
disclosure.
The Privacy Rule permits uses and
disclosures for “treatment, payment and
health care operations” as well as certain
other disclosures without the individual’s
prior written authorization. Disclosures not
otherwise specifically permitted or required
by the Privacy Rule must have an
authorization that meets certain
requirements. With certain exceptions, the
Privacy Rule generally requires that uses and
disclosures of PHI be the minimum
necessary for the intended purpose of the use
or disclosure.
Substance abuse treatment programs most often make disclosures after a patient has
signed a consent form that meets the requirements of 42 CFR §2.31. Note that a
disclosure under Part 2 includes the acknowledgment that someone has applied to or is
enrolled in the program, and thus is only permitted if the patient has signed a consent
form (or another of the regulations’ narrow exceptions applies). See 42 CFR §§2.11 and
2.13. A Part 2 consent form must include the following elements:
• Name or general designation of the program or person permitted to make the
disclosure;
• Name or title of the individual or name of the organization to which disclosure
is to be made;
• Name of the patient;
• Purpose of the disclosure;
• How much and what kind of information is to be disclosed;
• Signature of patient (and, in some States, a parent or guardian);
• Date on which consent is signed;
• Statement that the consent is subject to revocation at any time except to the
extent that the program has already acted on it; and
• Date, event, or condition upon which consent will expire if not previously
revoked.
11
This document uses the term “consent” when referring to any written permission provided by a patient
for the use or disclosure of identifiable health information. The Privacy Rule uses the term
“authorization” for certain permissions, and also permits, but does not require, programs to obtain
“consent” for the use and disclosure of PHI for purposes of treatment, payment, or health care operations.
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When programs operating under Part 2 disclose information pursuant to a consent form,
they must include a written statement that the information cannot be redisclosed. See 42
CFR §2.32.
The core required elements for the Privacy Rule written authorization are similar to
those of Part 2. However, to comply with the Privacy Rule authorization requirements,
the Part 2 consent must also contain a statement reflecting the ability or inability of the
substance abuse treatment program to condition treatment on whether the patient signs
the form as described in 45 CFR §164.508(c)(2)(ii). In addition, the consent may be
signed by a personal representative, and if so, must include a description of such
representative’s authority to act for the patient. See 45 CFR §164.508(c)(1)(vi). Finally,
the consent must be written in plain language. See 45 CFR §164.508(c)(3).
The requirements above must be met with respect to the Part 2 consent form when the
purpose of the disclosure is not for “treatment, payment or health care operations” or
for any other permitted or required disclosure under the Privacy Rule. See 45 CFR
§164.502(a).12 The statements would have to be added when the consent form
authorizes a program to make a disclosure for which an authorization is required under
the Privacy Rule, e.g., those disclosures addressed by 45 CFR §164.508.
The Privacy Rule imposes three additional steps programs must take when disclosing
information pursuant to a patient’s written consent:
• Programs must ensure that the consent complies with the applicable
requirements of 45 CFR §164.508. • Programs must give patients a copy of the signed form (45 CFR §164.508(c)(4)). • Programs must keep a copy of each signed form for six (6) years from its
expiration date (45 CFR §164.508(b)(6)).
Therefore, substance abuse treatment programs should generally continue to use the
consent form for disclosures subject to Part 2. If the Privacy Rule requires authorization
for the disclosures, the substance abuse treatment program may use the Part 2 consent
form with additional elements required by the Privacy Rule as listed above.
Minors
12
See the Privacy Rule’s definitions of “treatment,” “payment,” and “health care operations” at 45 CFR
§164.501. When a substance abuse treatment program obtains information about a patient from a school,
relatives, health care providers and health plans for treatment or payment activities, when it refers a
patient to other providers and services and when it coordinates care with other health care providers, it
almost always makes an implicit disclosure that the patient has applied for or has received alcohol or
drug abuse treatment services and thus the program is required to treat these contacts as disclosures and
obtain patient consent prior to such contact. In most of these instances, the disclosure from the program is
for treatment purposes and the additional Privacy Rule statements would not have to be added to the
consent forms. Note that programs may add the Privacy Rule statements in all circumstances, and
programs may find it more convenient to use only one kind of consent form.
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The Privacy Rule defers to requirements in other applicable laws regarding the use or
disclosure of health information regarding minors and, thus, does not change the rules
in Part 2 regarding minors and consent. See 45 CFR §164.502(g). A minor must always
sign the consent form for a program to release information even to his or her parent or
guardian (42 CFR §2.14).13 Some States require programs to obtain parental permission
before providing treatment to a minor. In these States only, programs must get the
signatures of both the minor and a parent, guardian, or other person legally responsible
for the minor (42 CFR §2.14(c)(2)).
Revocation of Consent
Part 2 permits a patient to revoke consent orally (see 42 CFR §2.31(a)(8)); the Privacy
Rule requires written revocation of an authorization (45 CFR §164.508(b)(5)).
Substance abuse treatment programs must continue to honor verbal revocations but may
want to obtain written revocation when possible or at a minimum document the
revocation in the patient’s record. Both Part 2 and the Privacy Rule allow the program
to make a disclosure for services already rendered in reliance on a signed consent or
authorization form. See 42 CFR §2.31(a)(8) and 45 CFR §164.508(b)(5)(i).
2.
Other permissible disclosures under Part 2
Substance abuse treatment programs are accustomed to complying with Part 2’s general
rule prohibiting disclosure, unless the patient has consented in writing or the disclosure
falls within one of the regulations’ limited exceptions (e.g., child abuse reporting,
medical emergencies). In some instances, the Privacy Rule does not require a change in
these practices. In others, the Privacy Rule will require some modification of programs’
practices.
a.
When little or no changes may be needed
Programs should generally continue to follow the rules in Part 2 regarding:
i.
Internal program communications
Both Part 2 and the Privacy Rule allow for communications within programs on a
“need to know” basis. Part 2 requires that the communication of information within the
program (or to an entity with direct administrative control over the program)14 be
13
The only exception to this rule is when the program director determines that a minor applying for
services lacks capacity for rational choice and that the minor applicant’s situation poses a substantial
threat to life or physical well being of the minor or any other person that may be reduced by
communicating relevant facts to the minor’s parent or guardian. See 42 CFR §2.14(d).
14
In applying the Privacy Rule, programs should consider whether the program and the entity with
“direct administrative control” over the program are two separate legal entities. If they are two separate
legal entities, PHI flowing between the program and the other entity will generally be governed by the
Privacy Rule’s requirements regarding “disclosure” rather than “use” of PHI. However, the Privacy Rule
recognizes that health care providers may have different organizational arrangements and has established
different rules to reflect such arrangements. See the Privacy Rule’s provisions regarding hybrid entities
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limited to those persons who have a need for the information in connection with their
duties that arise out of the provision of diagnosis, treatment or referral for treatment of
alcohol or drug abuse. See 42 CFR §2.12(c)(3). Similarly, the Privacy Rule requires
programs to identify the staff persons or classes of persons in its workforce who need
access to PHI, the categories of PHI they need access to, and any conditions appropriate
to such access. See 45 CFR §164.514(d)(2)(i). The program must then make reasonable
efforts to limit access of such persons or classes of persons to PHI based on these
determinations. See 45 CFR §164.514(d)(2)(ii). Substance abuse treatment programs
subject to the Privacy Rule will have to establish written policies to comply with the
minimum necessary requirement of the Privacy Rule, although in practice, the
programs should be able to operate as they have under Part 2 in this regard.
ii.
Crimes on program premises or against program personnel
Part 2 permits programs to disclose limited information to law enforcement officers.
Such disclosures must be directly related to crimes and threats to commit crimes on
program premises or against program personnel and must be limited to the
circumstances of the incident and the patient’s status, name, address and last known
whereabouts. See 42 CFR §2.12(c)(5). The Privacy Rule permits programs to disclose
to law enforcement officials PHI that the program believes in good faith constitutes
evidence of a crime that occurred on the program’s premises. See 45 CFR
§164.512(f)(5). It also permits any member of the program’s staff who is the victim of a
crime to report certain information about the suspected perpetrator to law enforcement
officials. See 45 CFR §164.502(j)(2). Programs should continue to follow the rules
established by Part 2.
iii.
Child abuse reporting
Part 2 permits programs to comply with State laws that require the reporting of child
abuse and neglect. See 42 CFR §2.12(c)(6). The Privacy Rule also permits such
reporting. See 45 CFR §164.512(b)(1)(ii). However, Part 2 limits programs to making
only an initial report; it does not allow programs to respond to follow-up requests for
information or to subpoenas, unless the patient has signed a consent form or a court has
issued an order that complies with the rule (see “Subpoenas and court-ordered
disclosures,” below). Programs should continue to follow the rules established by Part
2.
iv.
Medical emergencies
Part 2 allows patient-identifying information to be disclosed to medical personnel who
have a need for the information about a patient for the purpose of treating a condition
which poses an immediate threat to the health of any individual and which requires
(45 CFR §164.105(a) and (c)), affiliated covered entities (45 CFR §164.105(b) and (c)), and organized
health care arrangements (OHCAs) (45 CFR §160.103 (definition of “business associate” and “OHCA”),
45 CFR §164.506(c)(5), and 45 CFR §164.520(d)).
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immediate medical intervention. See 42 CFR §2.51. A program can disclose
information only to medical personnel and must limit the amount of information to that
which is necessary to treat the emergency medical condition. Immediately following
the disclosure, the program must document the following in the patient’s records:
• The name and affiliation of the medical personnel to whom disclosure was
made;
• The name of the individual making the disclosure;
• The date and time of the disclosure; and
• The nature of the emergency.
These practices are not affected by the Privacy Rule.
v.
Subpoenas and court-ordered disclosures
Part 2 permits programs to release information in response to a subpoena if the patient
signs a consent permitting release of the information requested in the subpoena. When
the patient does not consent, Part 2 prohibits programs from releasing information in
response to a subpoena, unless a court has issued an order that complies with the rule.
See 42 CFR Part 2, Subpart E. Subpart E sets out the procedure the court must follow,
the findings it must make, and the limits it must place on any disclosure it authorizes.
The Privacy Rule permits a program to disclose PHI pursuant to a subpoena without a
prior written authorization, if it receives satisfactory assurance from the party seeking
the information that reasonable efforts have been made to ensure that the individual has
been given notice of the request for PHI and the opportunity to object, or reasonable
efforts have been made to secure a qualified protective order. See 45 CFR
§164.512(e)(1)(ii). The Privacy Rule has different requirements regarding court orders,
but programs can comply with both Part 2 and the Privacy Rule by continuing to follow
the Part 2’s court order requirements. Unless the disclosure requires authorization under
the Privacy Rule, the Part 2 consent form can be used.
b.
When some change is required
i.
Disclosures that do not reveal patient-identifying information
Part 2 permits a substance abuse treatment program to disclose information about a
patient if the disclosure does not identify the patient as an alcohol or drug abuser or as
someone who has applied for or received substance abuse assessment or treatment
services. See 42 CFR §§2.11 and 2.12(a). This allows a program that is part of a larger
entity, such as a hospital, to disclose information about a patient so long as it does not
explicitly or implicitly disclose the fact that the patient is an alcohol or drug abuser. For
example, a program that is part of a hospital could disclose to a public health
department that a named patient has TB by identifying itself only as part of the hospital
and not as a substance abuse treatment program and by taking care not to mention that
the patient is in substance abuse treatment.
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Many programs that are part of larger entities are accustomed to using this exception in
Part 2 to gather information about patients from, for example, other health care
providers, schools, and employers, or to refer patients to other providers.15 Some of
these practices by programs that are part of larger entities will continue to be
permissible under the Privacy Rule, which does not require patients to authorize
disclosures for purposes of treatment, payment or health care operations. The Privacy
Rule also permits programs to share information about an individual’s treatment or
payment related to the individual’s health care with persons involved in the individual’s
care. See 45 CFR §164.510(b).
The Privacy Rule also allows for certain disclosures to be made without authorization
that are not for treatment, payment or health care operations. See 45 CFR §164.512. For
example, the Privacy Rule permits a program to disclose, without the patient’s prior
authorization, to a public health department that the patient has TB when the health
department is authorized to collect such information. However, any program that is
accustomed to making “non-patient identifying” disclosures of information that do not
identify the subject as a substance abuser and that are not for treatment purposes should
consult the Privacy Rule directly to determine whether those disclosures continue to be
permissible.
Part 2 does not permit freestanding programs to make inquiries about patients or refer
patients to other providers without written consent. The Privacy Rule does not change
this prohibition.
ii.
Disclosures to agencies that provide services to programs
Disclosures to Qualified Service Organizations
Both Part 2 and the Privacy Rule recognize that substance abuse treatment programs
sometimes need to disclose information about patients to persons or agencies that
provide services to the program, such as legal or accounting services. The Part 2
regulations call such service providers “qualified service organizations” and permit
programs to sign “qualified service organization agreements” (QSOAs) allowing them
to disclose patient-identifying information needed by the organization to provide
services to the program. See 42 CFR §2.12(c)(4). In the agreements, the outside service
providers acknowledge that in receiving, storing, processing or otherwise dealing with
patients’ records they are fully bound by Part 2 and promise to safeguard the
information, including resisting in judicial proceedings any effort to obtain access to the
information, except as permitted by the Part 2 regulations.
Under the Privacy Rule, such outside service providers are “business associates” of the
substance abuse treatment program and the program must have a business associate
agreement with the business associate in order to share PHI needed by the organization
15
As noted above, when a program makes an inquiry about, or refers, a patient, it is often making an
implicit disclosure that the patient is in substance abuse treatment.
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to provide services (see 45 CFR §§160.103 and 164.502(e)).16 The Privacy Rule has
different requirements regarding the content of the business associate contract (the HHS
Office for Civil Rights has published sample contract language). See 67 Federal
Register 53264 (August 14, 2002).
Substance abuse treatment programs must meet the requirements of both Part 2 and the
Privacy Rule if they are going to continue to share information with lawyers,
accountants and others that provide services to the program.
Transition Provisions: The Privacy Rule permits programs to continue to use current
contracts with service providers until April 14, 2004, if the contract existed prior to
October 15, 2002, and the contract is not subsequently renewed or modified. Any
contract that is renewed or modified after October 15, 2002, must comply with the
business associate contract requirements. See 45 CFR §164.532(d).
Disclosures to accreditation bodies
Part 2 permits disclosures to accreditation bodies such as the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) under either the QSO provision or
the “audit and evaluation” exception, discussed below. The Privacy Rule, however,
considers accreditation bodies business associates conducting health care operations on
behalf of the covered entity. See 45 CFR §§160.103; 164.501. Substance abuse
treatment programs subject to the Privacy Rule who undergo accreditation will have to
sign business associate contracts with accreditation organizations. Additionally,
substance abuse treatment programs must comply with Part 2, either by ensuring that
the business associate contract contains all the requirements of a QSOA or by fulfilling
the mandates of the audit and evaluation provisions.
iii.
Audit and evaluation
Both Part 2 and the Privacy Rule permit programs to disclose patient-identifying
information to qualified persons who are conducting an audit or evaluation of the
program, without patient consent, provided that certain safeguards are met. The Privacy
Rule requires that uses and disclosures be limited to the minimum necessary to
accomplish the audit or evaluation. Each rule has its own additional requirements.
Substance abuse treatment programs subject to both Part 2 and the Privacy Rule must
combine those requirements. Three options result:
• If the audit or evaluation is conducted by a program or its employees, it is
permissible under both sets of regulations; no patient consent or authorization is
required. See 42 CFR §2.12(c)(3) and 45 CFR §164.502(a)(1)(ii).
16
A memorandum of understanding would generally be used between government entities rather than a
business associate contract.
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• If the audit or evaluation is conducted by a “health oversight agency,”17 the
program may disclose patient-identifying information so long as the health
oversight agency makes the written commitments required by 42 CFR §2.53(d)
and the disclosure meets the requirements in 45 CFR §164.512(d). If the health
oversight agency copies or removes patient records from the program, it must
agree in writing to abide by the requirements of 42 CFR §2.53(b).
• If an audit or evaluation is conducted by an outside entity on behalf of the
program as opposed to a “health oversight agency,” the program must have a
signed a business associate contract with the auditor or evaluator that satisfies
the requirements of both the Privacy Rule and Part 2 by incorporating either the
necessary QSO agreement requirements (as discussed above in II.B.2.b.ii) or the
appropriate provisions of 42 CFR §2.53.
iv.
Research
The Part 2 regulations and the Privacy Rule have different requirements for disclosures
of health information to researchers. See 42 CFR §2.52 and 45 CFR §164.512(i). This
will be the subject of additional guidance.
III.
Other Changes Required by the Privacy Rule18
A.
Patient Notice/Notice of Privacy Practices
Part 2 requires that programs notify patients that Federal law and regulations protect the
confidentiality of alcohol and drug abuse patient records and give them a written
summary of the regulations’ requirements. See 42 CFR §2.22. The Privacy Rule
requires that patients be given a notice of the program’s privacy practices as well as
their rights under the Privacy Rule. See 45 CFR §164.520. Programs subject to both
rules can combine their requirements into a single notice.
1.
Notice content
Accordingly, the combined notice must contain all the elements required by 42 CFR
§2.22, and in addition, contain the following:
17
Under the Privacy Rule, a “health oversight agency” is an agency or authority or the United States, a
State, a territory, a political subdivision of a State or a territory, or an Indian tribe, or a person or entity
acting under a grant of authority from or contract with such a public agency, including the employees or
agents of such public agency or its contractors or persons or entities to whom it has granted authority,
that is authorized by law to oversee the health care system (whether public or private) or government
programs in which health information is necessary to determine eligibility or compliance or to enforce
civil rights laws for which health information is relevant (45 CFR §164.501). Disclosures to health
oversight agencies when an individual is the subject of the investigation are prohibited under certain
circumstances by the Privacy Rule (45 CFR §164.512(d)(2)).
18
This last section addresses issues on which Part 2 is largely silent. Thus, these can be seen as new
requirements imposed by the Privacy Rule to which programs now must adhere.
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• A statement, prominently displayed stating: “THIS NOTICE DESCRIBES HOW
MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY;”
• A description in sufficient detail of the types of uses and disclosures that the
program may make without the patient’s consent or authorization.19 For
substance abuse treatment programs, these would include uses and disclosures:
o In connection with treatment, payment or health care operations (include
at least one example of each);
o To qualified service organizations or business associates who provide
services to the program’s treatment, payment or health care operations;
o In medical emergencies;
o Authorized by court order;
o To auditors and evaluators;
o To researchers if the information will be protected as required by
Federal regulations;
o To report suspected child abuse or neglect; and
o To report a crime or a threat to commit a crime on program premises or
against program personnel.
• A statement that other disclosures will be made only with the patient’s written
consent or authorization which can be revoked, unless the program has taken
action in reliance on the consent or authorization. ;20
• A statement that the program may contact the patient to provide appointment
reminders or information about treatment alternatives or other health-related
benefits and services that may be of interest to the patient;21
• A statement that it is required by law to maintain the privacy of PHI and to
notify patients of its legal duties and privacy practices, including any changes to
its policies;
• A statement that the program must abide by the terms of the notice currently in
effect; a statement that the program reserves the right to change the terms of its
notice and to make the new notice provisions effective for all information it
maintains;22 and a statement describing how it will provide patients with a
revised notice of its practices;
19
The Privacy Rule also requires that the notice contain information about any more restrictive law. For
example, if State law further limits disclosure of HIV-related information, that restriction should also
appear in the notice.
20
Programs often need to provide PHI to criminal justice agencies that mandate patients into treatment.
Under Part 2, such disclosures may be made pursuant to a non-revocable consent that complies with 42
CFR §2.35. Under the Privacy Rule, such disclosures may be made pursuant to an authorization or
pursuant to a court order. In order to comply with both rules, programs may find it helpful to ask the
court in such a situation to issue an order that the program disclose necessary information to the court
and other law enforcement personnel.
21
A substance abuse treatment program engaging in these kinds of activities must be careful in
contacting the patient that it does not make any patient-identifying disclosures to others. If the program
does not intend to contact the patient, they do not need to include this statement.
22
This is also voluntary. However, if this statement is not included, any changes in privacy practices
described in the notice will apply only to PHI the program created or received after issuing a revised
notice reflecting such changes. 45 CFR §164.520(b)(1)(v)(C).
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• The name or title and telephone number of a person or office the patient can
contact for further information;
• A statement of the patient’s rights with respect to PHI and a brief description of
how the patient may exercise those rights, including:
o The right to request restrictions on certain uses and disclosures of PHI,
including the statement that the program is not required to agree with
requested restrictions;
o The right to receive confidential communications of PHI (such as having
mail and telephone calls be limited to home or office location);
o The right to access and amend PHI;
o The right to receive an accounting of the program’s disclosures of PHI;
o The right to complain—free from retaliation—to the program and to the
Secretary of Health and Human Services (HHS) about violations of
privacy rights, and information on how to file a complaint with the
program; and
o The right to obtain a paper copy of the notice upon request.
• The effective date of the notice.
See 45 CFR §164.520(b).
2.
Distribution of the Notice
Part 2 requires that programs provide the notice at the time of admission or as soon
thereafter as the patient is capable of rational communication. See 42 CFR §2.22(a).
The Privacy Rule requires that the substance abuse treatment program must provide the
notice to a patient on the date of the first service delivery, including service delivered
electronically, after April 14, 2003.23 The program must also have the notice available
on site for patients to request to take with them and posted in a clear and prominent
location where it is reasonable to expect patients to be able to read it. Whenever there is
a material change to the notice, the notice must be promptly revised, made available
upon request, and re-posted as previously referenced. See 45 CFR §§164.520(c)(2);
164.530(i)(4)(i)(C).
The program must make a good faith effort to obtain patients’ written acknowledgment
of receipt of the notice, except in an emergency treatment situation, on the date of the
first service delivery. If written acknowledgment is not obtained, the program must
document its efforts and the reason it was not able to obtain the acknowledgement. See
45 CFR §164.520(c)(2)(ii).
Any program that maintains a web site that provides information about its services or
benefits must prominently post its notice on the site and make it available electronically
through the site. When patients agree, the program can provide the notice by e-mail.
See 45 CFR §164.520(c)(3).
23
There is an exception in emergency situations. If treatment is provided on an emergency basis, the
program must provide the notice as soon as practicable after the emergency is resolved. See 45 CFR
§164.520(c)(2)(i)(B).
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B.
Patient rights
The Privacy Rule provides patients with new Federal privacy rights, including the right
to request restrictions of uses and disclosures of PHI, and the right to access, amend,
and receive an accounting of disclosures of PHI. See 45 CFR §§164.522, 164.524,
164.526,164.528.
1.
Right to request a restriction of uses and disclosures
The Privacy Rule requires that programs allow patients to request that the program
restrict uses or disclosures of PHI for the purpose of treatment, payment or health care
operations and for involvement in the patient’s care and notification under 45 CFR
§164.510(b). The program is not required to agree to a requested restriction. If,
however, a program agrees to a restriction, the program may not then violate the
agreed-upon restriction, except for emergency treatment purposes, so long as the
program requests that the emergency treatment provider not further use or disclose the
PHI. A covered entity may terminate the agreement to a restriction, effective after the
patient has been informed of the termination. See 45 CFR §164.522(a).
The Privacy Rule gives the individual the right to request that communication of PHI
be done by alternative means or to alternative locations (confidential communications).
See 45 CFR §164.522(b)(1)(i). This might include the right to request that mail and
telephone calls be limited to home or office location. The Privacy Rule requires
programs to accommodate reasonable requests.
2.
Right to access PHI
Neither Part 2 nor the Privacy Rule requires programs to obtain written consent from
individuals before permitting them to see their own records. Likewise, neither rule
prohibits a program from giving a patient access to his or her own records, including
the opportunity to inspect and copy any records that the program maintains about the
patient. 42 CFR §2.23. However, the Privacy Rule permits programs to require that
such requests be in writing. See 45 CFR §164.524(b)(1). The Privacy Rule provides
patients with a right of access to inspect and obtain a copy of their PHI. See 45 CFR
§164.524(a)(1).24 Certain information, however, is exempt from this right of access:
24
The Privacy Rule requires access to information in a designated record set for as long as the PHI is
maintained in the designated record set. “Designated record set” is defined as “[a] group of records
maintained by or for a covered entity that is: (i) The medical records and billing records about individuals
maintained by or for a covered health care provider; (ii) The enrollment, payment, claims adjudication,
and case or medical management record systems maintained by or for a health plan; or (iii) Used, in
whole or in part, by or for the covered entity to make decisions about individuals.” 45 CFR §164.501.
The program must document the designated record sets that are subject to access and the titles of the
persons or offices responsible for receiving and processing requests for access (45 CFR §164.524(e)). It
must retain the documentation for six (6) years from the date it was last effective, whichever is later (45
CFR §164.530(j)). Under Part 2, the information need not be contained in a designated record set. Thus,
programs could permit access to all disclosable patient records.
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• Psychotherapy notes;25
• Information compiled in reasonable anticipation of or for use in a civil, criminal, or administrative action or proceeding; and • Information that may be subject to or exempt from certain Clinical Laboratory
Improvement Amendment (CLIA) provisions.
See 45 CFR §164.524(a)(1).
The Privacy Rule requires that programs respond to a patient’s request for access within
30 days after receipt of the request (within 60 days if the information is not maintained
or accessible on-site). The program may extend the deadline once by not more than 30
days, if within 30 days of the receipt of the request (or 60 days of receipt if the
information is not on-site), the patient is provided with a written statement containing
the reasons for the delay and the date by which it will permit access. See 45 CFR
§164.524(b). If the program does not maintain the requested information, but knows
where the requested information is maintained, it must inform the patient where to
direct his or her request. See 45 CFR §164.524(d)(3).
If a program grants the patient’s request for access to his or her records, it can charge
the patient a reasonable, cost-based fee, consistent with the restrictions on fees as
provided in the Privacy Rule. See 45 CFR §164.524(c)(4).26
Denial of Access
The Privacy Rule allows a program to deny a patient access without providing an
opportunity for review of the denial, on the following grounds:
• The information is specifically exempted from the right of access by the Privacy
Rule. See 45 CFR §164.524(a)(1);
• The program is a correctional institution or a provider acting under the direction
of the correctional institution and denies in whole or in part an inmate’s request
to obtain a copy of his or her records if doing so would jeopardize the health,
safety, security, custody, or rehabilitation of the individual or of other inmates,
or the safety of an officer, employee or other person at the correctional
institution or responsible for transporting the inmate. See §164.524(a)(2)(ii));
• The requested information was created or obtained by a program in the course
of research that includes treatment. The individual’s access to such information
25
The Privacy Rule defines “psychotherapy notes” as “notes recorded (in any medium) by a health care
provider who is a mental health professional documenting or analyzing the contents of conversation
during a private counseling session or a group, joint, or family counseling session and that are separated
from the rest of the individual’s medical record. Psychotherapy notes excludes medication prescription
and monitoring, counseling session start and stop times, the modalities and frequencies of treatment
furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status,
the treatment plan, symptoms, prognosis, and progress to date.” 45 CFR §164.501.
26
Information obtained by patient access to his or her own record is subject to Part 2’s restriction on use
of the information to initiate or substantiate any criminal charges against the patient or to conduct any
criminal investigation of the patient. See 42 CFR §2.23(b).
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may be temporarily suspended for as long as the research is in progress,
provided that the individual has agreed to the denial of access when consenting
to participate in the research and the program has informed him or her that the
right of access will be reinstated upon completion of the research. See 45 CFR
§164.524(a)(2)(iii);
• The requested information is subject to the Privacy Act and would be denied
under the access provisions of the Privacy Act, 5 USC §522a. See 45 CFR
§164.524(a)(2)(iv); or
• The requested information was obtained under a promise of confidentiality from
someone other than a health care provider and such access would be likely to
reveal the source of the information. See 45 CFR §164.524(a)(2)(v).
The Privacy Rule permits a program to deny patient access, provided that the patient is
given the right to have such a denial reviewed, on the following grounds:
• A licensed health care professional has determined, in the exercise of
professional judgment, that the access requested is reasonably likely to endanger
the life or physical safety of the patient or another person;
• The information makes reference to another person (other than a health care
provider) and a licensed health care professional has determined, in the exercise
of professional judgment, that the access is reasonably likely to cause
substantial harm to such other person; or
• The request for access is made by the patient’s personal representative and a
licensed health care professional has determined, in the exercise of professional
judgment, that the provision of access to such personal representative is
reasonably likely to cause substantial harm to the patient or another person.
See 45 CFR §164.524(a)(3).
If the program’s denial is based on one of the last three reasons, the patient has the right
to have that denial reviewed by a licensed health care professional who is designated by
the program to act as a reviewing official and who did not participate in the original
decision to deny access. See 45 CFR §164.524(a)(4).
If the program denies a patient access to all or parts of his or her PHI, it must give the
patient a timely denial written in plain language containing:
• The basis for the denial;
• If applicable, a statement of the patient’s review rights, including a description
of how the patient may exercise those rights; and
• A description of how the patient may complain to the program or to the
Secretary of HHS. The description must include information regarding how the
patient may complain to the program pursuant to the program’s complaint
procedures or to the Secretary, and must include the name or title, and telephone
number of the contact person or office designated by the program to receive
complaints.
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See 45 CFR §164.524(d)(2).
A program that denies a patient access in part must give the patient access to any other
PHI requested after excluding the information to which the program had reason to deny
access. See 45 CFR §164.524(d)(1).
3.
The right to amend PHI
The Privacy Rule gives patients the right to have the program amend their PHI or a
record about the patient in a designated record set. See 45 CFR §164.526. The program
must act on a patient’s request for amendment within 60 days after it receives the
request. The program may extend the deadline once by not more than 30 days if, within
the 60 days, the patient is provided with a written statement of the reasons for the delay
and the date by which it will respond. See 45 CFR §164.526(b)(2).
A program that accepts a patient’s request to amend PHI must:
• Timely inform the patient of its decision to accept the amendment;
• Make the appropriate amendment by identifying the records in the designated
record set that are affected by the amendment and appending or otherwise
providing a link to the location of the amendment; and
• If the patient agrees, make reasonable efforts to notify and provide the amendment within a reasonable period of time to: o Persons identified by the patient as having received the patient’s PHI
and needing the amendment; and
o Persons, including business associates, that the program knows to have
received the PHI that is the subject of the amendment and that may have
relied, or could foreseeably rely on such information to the detriment of
the patient.
See 45 CFR §164.526(c).
A program must obtain patient consent on forms that comply with 42 CFR §2.31 before
it provides any copies of the amendment to other persons or organizations.
Denial of Amendment
A program may deny a patient’s request for amendment if it determines that:
• It did not create the information, unless the patient provides a reasonable basis
to believe that the originator of the PHI is no longer available to act on the
requested amendment;
• The information or record is accurate and complete; or
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• The information that is the subject of the request is not part of a designated
record set or would not otherwise be available for inspection under the Privacy
Rule’s request for access provisions.
See 45 CFR §164.526(a)(2).
If a program denies a patient’s request to amend records, it must give him or her a
timely denial, written in plain language, and contain:
• The basis for the denial;
• Notice of the patient’s right to file a written statement of disagreement with the
denial and how the patient may file such a statement;
• Notice that, if the patient does not submit a statement of disagreement, the
patient may request that the program include his or her request for amendment
and its denial with any future disclosures of the PHI that is subject to the
amendment; and
• A description of how the patient may complain about the program’s actions to
the program or to the Secretary of HHS. The description must include
information regarding how the individual may complain to the program
pursuant to its complaint procedures or to the Secretary, and must include the
name or title, and telephone number of the contact person or office designated
by the program to receive complaints.
See 45 CFR §164.526(d)(1).
The program may prepare a written rebuttal to the patient’s statement of disagreement.
If it prepares such a rebuttal, it must provide a copy to the patient who submitted the
statement of disagreement. This information (e.g. the statement of disagreement and
rebuttal), or in some cases, a summary, must all be included in any subsequent
disclosures of the information to which the disagreement relates as provided in 45 CFR
§164.526(d)(3), (4), and (5).
The program must document the titles of the persons or offices responsible for
receiving and processing requests for amendment. It must retain the documentation for
six (6) years from the date it was created or last effective, whichever is later. See 45
CFR §164.526(f).
4.
Right to an accounting of disclosures of PHI
The Privacy Rule provides individuals with the right to obtain an accounting of certain
disclosures of PHI made by a program during the six (6) years prior to the request. See
45 CFR §164.528(a).
A program does not have to provide an accounting for any disclosures that were made:
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• For treatment, payment, and health care operations as provided in 45 CFR
§164.506;
• To the patient as provided in 45 CFR §164.502;
• Incident to a use or disclosure that is otherwise permitted as provided in 45 CFR
§164.502;
• Pursuant to the patient’s written consent (an “authorization” meeting the
Privacy Rule’s requirements at 45 CFR §164.508); • For the facility’s directory or to persons involved in the patient’s care or other
notification purposes as set forth by the rule at 45 CFR §164.510;
• For national security or intelligence purposes as provided by the rule at 45 CFR
§164.512(k)(2);
• To correctional institutions or law enforcement officials having custody of an
inmate or individual and as specified under 45 CFR §164.512(k)(5);
• As part of a limited data set in accordance with the rule at 45 CFR §164.514(e);
and
• Before April 14, 2003.
See 45 CFR §164.528(a)(1). In addition, a program must temporarily suspend a
patient’s right to receive an accounting of disclosures to a health oversight agency or
law enforcement official if the program receives notification that it would be
reasonably likely to impede the activities of the agency or official. See 45 CFR
§164.528(a)(2).
The accounting must be in writing27 and include:
•
•
•
•
The date of each disclosure;
The name and address (if known) of the entity or person who received the PHI;
A brief description of the PHI disclosed; and
A brief statement of the purpose of the disclosure that reasonably informs the
individual of the basis for the disclosure, or a copy of a written request for
disclosure, if any.
See 45 CFR §164.528(b)(2).
For substance abuse treatment programs, the following disclosures are typically made
without patient consent and must therefore be included in an accounting of disclosures:
• Disclosures to health oversight agencies;
• Disclosures to researchers that include patient-identifying information;28
• Disclosures to public health authorities;29
27
There are special provisions under the Privacy Rule that are applicable to accounting for recurrent
disclosures and certain research disclosures. See 45 CFR §§164.528(b)(3) and (b)(4).
28
There are special provisions under the Privacy Rule that are applicable to accounting for research. See
45 CFR §164.528(b)(4)).
29
When a program authorizes access to an entire universe of records, e.g., for public health surveillance
activities, the Privacy Rule’s accounting requirement can be met without the program having to make a
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• Court-ordered disclosures;
• Reports of patient crimes on program premises or against program personnel;
and
• Child abuse and neglect reports.
Programs should establish mechanisms to document all disclosures for which they must
account.
The accounting must be made within 60 days of the program’s receipt of the request.
The program may extend the deadline once by not more than 30 days if, within the 60
days, the patient is provided with a written statement of the reasons for the delay and
the date by which it will provide the accounting. A program must respond to a patient’s
request for one accounting within any 12-month period without charge. For any
subsequent request within a 12-month period, it may charge a patient a reasonable,
cost-based fee. If the program imposes a fee, it must inform the patient of the fee in
advance and give the patient an opportunity to withdraw or modify the request. See 45
CFR §164.528(c).
The program must also document the following:
• The information it was required to provide the patient;
• The written accounting it provided the patient; and
• The titles of the persons or offices responsible for receiving and processing
requests for an accounting.
This documentation must be retained for six (6) years from the date created or last
effective, which ever is later. See 45 CFR §164.528(d).
C.
Administrative Requirements
1.
Complaints about the program’s privacy practices
Part 2 allows violations of those regulations to be reported to the United States
Attorney for the judicial district in which the violation occurs. See 42 CFR §2.5.
The Privacy Rule establishes a process for individuals to file a complaint with the
Secretary of HHS if they believe a program violated the Privacy Rule. The complaint
must be written, either on paper or electronically, and filed with HHS’ Office for Civil
Rights within 180 days of when the complainant knew, or should have known, that the
act or omission complained of occurred, unless a waiver is granted. The complaint must
name the program and describe the violation of the Privacy Rule. See 45 CFR
§160.306. Programs must also establish a process for individuals to make complaints
about the program’s privacy policies and procedures or the program’s compliance with
notation in each medical record that has been accessed by public health authorities. See Office for Civil
Rights, Frequently Asked Questions, http://www hhs.gov/ocr/hipaa.
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such policies and procedures or with the requirements of the Privacy Rule. See 45 CFR
§164.530(d).
2.
Other administrative requirements
Programs subject to the Privacy Rule are required to meet administrative requirements
including:
• Designate a privacy official who is responsible for the development and
implementation of its policies and procedures and a contact person or office
responsible for receiving complaints and able to provide further information.
See 45 CFR §164.530(a).
• Train all members of the workforce on the program’s policies and procedures.
Each new member of the workforce must receive training within a reasonable
period of time after s/he joins the workforce. Whenever a workforce member’s
functions are affected by a material change in privacy policies or procedures,
that person must receive additional training within a reasonable period of time
after the material change becomes effective. The program must document all
training and retain the records for a period of six (6) years after the training. See
45 CFR §164.530(b).
• Have in place appropriate administrative, technical, and physical safeguards to
protect the privacy of PHI. See 45 CFR §164.530(c).
• Establish written policies and procedures that identify the staff persons or
classes of persons who need access to patients’ PHI, the categories of PHI they
need access to, and any conditions appropriate to such access. The program
must make reasonable efforts to limit access based on these determinations. See
45 CFR §164.514(d)(2).
• Establish policies and procedures to ensure that, for disclosures of information
that occur on a routine and recurring basis, reasonable efforts are made to limit
disclosures to the minimum necessary to accomplish the intended purpose of the
disclosure. See 45 CFR §§164.502(b) and 164.514(d)(3)(i). For “all other
disclosures,” the program must develop criteria designed to limit the
information it discloses to the information reasonably necessary to accomplish
the purpose for which disclosure is sought and review requests for disclosure on
an individual basis in accordance with those criteria. See 45 CFR
§164.514(d)(3)(ii). Programs must also develop policies, procedures and criteria
to ensure that requests to other entities subject to the Privacy Rule for PHI are
limited to information “which is reasonably necessary to accomplish the
purpose for which the request is made.” See 45 CFR §164.514(d)(4). The
written polices and procedures must be retained for six (6) years after the last
time they were effective. See 45 CFR §164.530(j).
• Establish and apply appropriate sanctions against members of its workforce who
fail to comply with its privacy policies and procedures. See 45 CFR
§164.530(e).
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• Mitigate, to the extent practicable, any harmful effect that is known to the
program that results from a use or disclosure in violation of its policies and
procedures. See 45 CFR §164.530(f).
• Refrain from taking intimidating, threatening, coercing, discriminating, or other
retaliatory action against any individual who exercises rights under the Privacy
Rule, including filing a complaint, assisting in an investigation, compliance
review, proceeding or hearing pursuant to the Privacy Rule, as well as any
individual who opposes any act or practice made unlawful by the Privacy Rule,
provided that he or she has a good faith belief that the practice is unlawful and
the manner of opposition is reasonable and does not invoke an impermissible
disclosure of PHI. See 45 CFR §164.530(g).
• Not require patients to waive their rights to complain to the Secretary of HHS or
their other rights under the Privacy Rule as a condition of treatment, payment,
enrollment in a health plan, or eligibility for benefits. See 45 CFR §164.530(h).
• Implement policies and procedures regarding PHI that are designed to comply
with the standards, implementation specifications, and other requirements of the
Privacy Rule, and maintain the policies and procedures in written or electronic
form for six years from the date the document was created, or last effective,
whichever is later. See 45 CFR §164.530(i) and (j).
D.
Security of information
Part 2 requires programs to maintain patient written records in a secure room, locked
file cabinet, safe or other similar container. The regulations also require programs to
adopt written procedures to regulate access to patients’ records. See 42 CFR §2.16.
Section 164.530(c) of the Privacy Rule requires programs to maintain reasonable and
appropriate administrative, technical and physical safeguards to protect the privacy of
PHI. The issue of security has been addressed in more detail through a separate
Security Rule issued by HHS on February 20, 2003 that established the physical and
technical security standards required to guard the integrity, confidentiality and
availability of confidential information that is electronically stored, maintained or
transmitted. See 68 Federal Register 8334. Covered entities must be in compliance with
the Security Rule by April 20, 2005, except small health plans which have until April
20, 2006.
Conclusion
Compliance with Part 2 has given the substance abuse treatment programs extensive
experience with protecting patient confidentiality. Although substance abuse programs
will need to make some changes to their business practices, they have a good starting
point to work from in achieving compliance with the HIPAA Privacy Rule. Substance
abuse treatment programs should contact their respective State substance abuse
agencies and/or provider organizations, as well as legal counsel for assistance in
implementing practices that will comply with both Part 2 and the Privacy Rule.
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For more information about the HIPAA Standards
http://www.hipaa.samhsa.gov is the SAMHSA website which provides information and
links for all HIPAA standards.
Standards for Privacy of Individually Identifiable Health Information (45 CFR
Parts 160 and 164)
More information can be obtained from the Office for Civil Rights HIPAA website
http://hhs.gov/ocr/hipaa
Standards for Electronic Transactions (45 CFR Parts 160 and 162)
The Standards for Electronic Transactions can be obtained from the Center for
Medicare and Medicaid Services (CMS) website at
http://cms.gov/hipaa/hipaa2/default.asp
Standard Unique Employer Identifier (45 CFR Parts 160 and 162)
Security Standards (45 CFR Parts 160, 162 and 164)
www.samhsa.gov
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JOURNAL
OF
ADDICTIVE DISORDERS
Professional and Ethical Standards of Case Management
1
Arron S. Hightower, MA
Ethics
Socrates devoted the better part of his life defining and better understanding moral values within
a cultural context and extending those values more broadly into the study of ethics. As such, he
laid the foundation of our understanding of an ethic as defined as “a set of principals of right
conduct” and “the study of the general nature of morals and of the specific moral choices to be
made by a person.” (Houghton 2009) So what does this mean to you, the reader today and how
can you apply ethics to your study and practice in the field of Recovery?
Purpose of Standards
Imagine a world with no laws or rules by which to govern. If you are a real thrill seeker, this may
sound exciting to you. However, for most we rely heavily on rules to give us guidance and a
sense of safety and security. I once traveled to China to study the culture and language. It was
a wonderful experience that I would highly recommend. However, beware of driving or even
riding a bike for that matter. The traffic is a nightmare. There are no traffic signals! For a
country with one-sixth of the earth’s population, can you imagine driving there with no traffic
signals? How would you know when to stop for others or when you have the right of way? In
most cities, cars driving opposite the flow of the intersection simply begin advancing together
slowly until they “choke off” the opposite flow and then it is their turn until they experience the
same. Can you imagine living in a major metropolitan area in which there were little or no rules
to driving? There would be complete chaos. The same is true for professional fields of practice.
The establishment of ethics as “a set of principals” allows for the proper governance of the field
and establishes a standard of care that protects both the professional and client alike. The
remainder of this article will discuss several important issues in the study of Professional &
Ethical Standards of Case Management and Counseling in the Addiction Treatment
Professions. While its intent is to be thorough in the discussion matter, it is not intended to be
all-inclusive. The best advice to offer is, when in doubt, consult with your clinical supervisor,
your Drug & Alcohol Certifying Board, the California Board of Behavioral Sciences or other
relevant parties as the situation may mandate.
1
properly referenced, and that the following citation is used in full: Hightower, A.S. (2010).
Professional and Ethical Standards of Case Management. Journal of Addictive Disorders.
Retrieved from http://www.breining.edu.
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Confidentiality
All clients are afforded the right to know that the information disclosed by them whether in a
counseling session or in a medical office is strictly confidential. To better understand how we
can protect our client’s confidentiality, we must begin to fully understand the boundaries and
limitations of confidentiality in a treatment environment. Two overarching laws and regulations
offer us guidance. The first is the Health Insurance Portability & Accountability Act (HIPAA) of
which most of us know. The second is 42 Code of Federal Regulations Part 2 which is largely
unknown. HIPAA was designed with four major purposes in mind. The first was to protect the
privacy of a patient’s personal and health information. The second was to provide for the
physical and electronic security of personal and health information. Third, was to simplify billing
and other transactions with Standardized Code Sets and Transactions. Fourth, was to specify
new rights for patients to approve access/use of their medical information. 42 Code of Federal
Regulations Part 2 was designed more specifically to protect persons seeking treatment. This
law forbids disclosure of any treatment related information to third parties unless one or more of
the following provisions are met: a court order is issued; valid written consent is received from
the patient, pursuant to an agreement for the qualified service organization or business
associate; for research audit or evaluation purpose; to report a crime on an institution’s
premises or against an institution’s personnel; to medical personnel in a medical emergency.
Mandated Reporting
California Penal Code 11166. Child Abuse and Neglect Reporting; Duty; Time
“Except as provided in subdivision (d), and in Section 11166.05, a mandated reporter shall
make a report to an agency specified in Section 11165.9 whenever the mandated reporter, in
his or her professional capacity or within the scope of his or her employment, has knowledge of
or observes a child whom the mandated reporter knows or reasonably suspects has been the
victim of child abuse or neglect. The mandated reporter shall make an initial report to the
agency immediately or as soon as is practicably possible by telephone and the mandated
reporter shall prepare and send, fax, or electronically transmit a written follow up report thereof
within 36 hours of receiving the information concerning the incident. The mandated reporter may
include with the report any non-privileged documentary evidence the mandated reporter
possesses relating to the incident.”(Board of Behavioral Sciences, 2009) Do you see any
potential conflicts with what we have learned already about reportable information contained
within HIPAA or 42 Code of Federal Regulations Part 2? The answer is yes. There is a
potential that in reporting child abuse we may disclose information that is treatment related and
thus strictly confidential under federal regulations.
Case Example: Sofia
Sofia is a 28 year-old single mother of two children ages 3 & 5. Sofia is currently pregnant and
has been struggling with staying “clean” and has turned in 3 consecutive heroin positive drug
tests. Sofia has missed several appointments with both the doctor and her primary caseload
manager. She was given a behavioral agreement that she is failing. Sofia finally meets with her
caseload manager and reports that the other day, she was so tired that she let her two children
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walk to a friend’s house 4 doors down so that she could get some rest.
Does any information in this case study rise to the level of a mandatory report? What about her
being pregnant and using, is that considered reportable or treatment related? If yes, then what
specific information? If no, then why not? The answer is yes, there is reportable information in
this scenario. Sofia allowing her 2 children ages 3 & 5 to walk unsupervised to a neighbor’s
house is reportable. All other information is related to treatment and may not be reported unless
one of the exclusionary reasons is met.
Case Example: Sam & Lisa
Sam is a 35 year-old who is in treatment with his wife Lisa, age 37, for opiate addiction with
poly-substance use as well. They have 2 children ages 10 & 15. During a counseling session,
Lisa’s counselor discusses her recent positive UA for heroin and amphetamines and works to
better understand the situation that led up to her use. Lisa discloses that Sam and she went to
a party last Friday night and the pressure was too much. They both used and got wasted. She
goes on to say that she also has guilt about leaving their 10 year-old in the custody of their older
daughter who is 15. While both girls were asleep and unharmed upon their return at 2 am, she
expresses that this was not okay. Does any information in this case study rise to the level of a
mandatory report? Is there any treatment related information that is protected? If yes, then
what specific information? If no, then why not? The answer is that it is unclear. Seek
consultation about the 10 year-old being left with her older 15 year-old sister. All other
information is treatment related and may not be disclosed unless one of the exclusionary
reasons are met.
California Welfare and Institution Code 15630. Elder Abuse Reporting
“Any person who has assumed full or intermittent responsibility for the care or custody of an
elder or dependent adult, whether or not he or she receives compensation, including
administrators, supervisors, and any licensed staff of a public or private facility that provides
care or services for elder or dependent adults, or any elder or dependent adult care custodian,
health practitioner, clergy member, or employee of a county adult protective services agency or
a local law enforcement agency, is a mandated reporter. (b) (1) Any mandated reporter who, in
his or her professional capacity, or within the scope of his or her employment, has observed or
has knowledge of an incident that reasonably appears to be physical abuse, as defined in
Section 15610.63 of the Welfare and Institutions Code, abandonment, abduction, isolation,
financial abuse, or neglect, or is told by an elder or dependent adult that he or she has
experienced behavior, including an act or omission, constituting physical abuse, as defined in
Section 15610.63 of the Welfare and Institutions Code, abandonment, abduction, isolation,
financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or
suspected instance of abuse by telephone immediately or as soon as practicably possible, and
by written report sent within two working days.” (Board of Behavioral Sciences, 2009)
Case Example: Bobby
Bobby is a 54 year-old who is a model patient. He attends all counseling appointments, and
has been illicit drug free for about 5 years now. He is also in good shape mentally & physically
except for the occasional stiff knee from an old football injury. In the course of a counseling
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session, Bobby discloses that his 23 year-old son has extreme anger issues and has been
beating him. Does any information in this case study rise to the level of a mandatory report? If
yes, then what specific information? If no, then why not? The answer is: No. Bobby would not
meet the traditional definition of elder abuse in that he is not 65 or older, developmentally
disabled, mentally ill/disabled, physically disabled or otherwise not able to care for his needs.
This is a matter for law enforcement.
Case Example: Bobby (part 2)
A week later, Bobby discloses in a counseling session that his 23 year-old son has been
screaming and cussing at his 83 year-old grandmother. Bobby has been present when this
occurred. Bobby is unsure if the son has ever hit her though. Does any information in this case
study rise to the level of a mandatory report? If yes, then what specific information. If no, then
why not? The answer is: Yes. The fact that Bobby’s 23 year-old son has been verbally abusing
his 83 year-old grandmother is considered a mandatory reporting issue. Bobby’s mere question
as to whether his mother has been physically abused by her grandson without any reasonable
suspicion (e.g. report, bruises, etc.) is most likely not. However, when in doubt, consult a
supervisor and call APS for a consultation without identifying confidential information until it is
determined that elder abuse is likely to exist.
Duty to Protect
Tarasoff v. Regents of University of California
In the fall of 1967, Prosenjit Poddar came to the University of California Berkley as a graduate
student studying naval architecture. During his studies, he became introduced to Tatiana
Tarasoff, a student at the University as well. The two saw each other regularly while attending a
class. Poddar developed feelings for Tatiana and felt they had a special relationship together.
The depths of his feelings were not reciprocated by Tatiana. Feeling rebuffed, Poddar stated in
a therapy session that he was going to kill Tarasoff. Poddar’s therapist requested that the
campus police detain Poddar and recommended that he be civilly committed as a dangerous
person. Poddar was detained but released shortly thereafter. No one warned Tarasoff or her
family of the threat and several months later on October 27, 1969, Poddar killed Tarasoff.
Tarasoff’s parents sued the Psychologist as well as the University Police, Regents and several
others for failing to warn them that their daughter was in danger. In 1974, the California
Supreme Court reversed the lower court’s decision to dismiss the case and ruled in favor of
Tarasoff stating that “When a therapist determines, or pursuant to the standards of his
profession should determine, that his patient presents a danger of violence to another, he incurs
an obligation to use reasonable care to protect the intended victim against such danger. The
discharge of this duty may require the therapist to take one or more of various steps. Thus, it
may call for him to warn the intended victim, to notify the police, or to take whatever steps are
reasonably necessary under the circumstances.” (Berger & Berger, 2009)
Tarasoff has been adopted throughout the country and exists as the standard of care in most
states. However, considerable confusion remains about the duty to warn. This is largely due to
the verbiage used in the ruling in 1974. However, Tarasoff II issued in 1976, now states that a
therapist actually has the duty to protect the intended victim by warning them or others who will
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likely warn them in addition to notifying the police and taking all reasonable steps to protect the
intended victim given the circumstances faced. Should a therapist be found to both make all
reasonable attempts to notify the intended victim as well as notify the police, there should be no
liability for the therapist. However, when in doubt, the best advice is to consult with the police.
This can be accomplished without identifying any confidential information until it is established
that the situation rises to the level of the Tarasoff ruling.
Transference versus Countertransference
It would be foolish to believe that a therapist would never encounter either transference or
countertransference. I recall a time in which I was a young professional working in a Masters &
Johnson Program for those with sexual trauma issues. I remember walking into the unit and
being approached by a new patient who told me that she hated me. I had never met her in my
life. Why would someone hate someone they had never met? In a word: transference. The
client was projecting onto me her own feelings, beliefs and attitudes based on her experiences
with men. It was a great lesson for me as it equipped me to better understand her behavior as a
symptom not the real problem. The real problem was that she had been molested as a child by
her father and generalized that pain and betrayal to the conclusion that all men were the same.
It wasn’t about me at all. Working in a treatment environment for substance abuse disorders is
similar. Patients will routinely project onto the case manager, clinic manager, doctor et al their
personal feelings, beliefs and attitudes because to them that is reality. I have found taking a
step back and asking myself the question, “what is this patient trying to communicate to me
behind this presentation” very helpful? In doing so, I am better able to understand the human
condition as well as detach my personal feeling from the moment. As we all know, the less we
allow our personal feelings to get involved the more we are able to assist our clients.
Countertransference onto a client can be equally destructive. We are all familiar with the
phrase, “Counselor, know thyself.” Simply put, this is so that we know what is ours and what is
our client’s, and why personal therapy is so vital for our on-going professional and personal
health. Countertransference is the idea that we project onto our clients our own feelings, beliefs
or attitudes. The danger in doing this is that the issues become clouded and, left unchecked,
can become more about the therapist than the client seeking help. In a treatment environment it
is important that we demonstrate a healthy boundary of our own issues as well, especially if
emerging from a similar addiction. While this may be a somewhat controversial statement, I
have yet to find indisputable proof that having “been there, done that” and projecting one’s own
way in recovery onto another has produced any better results than those working with people
suffering with addictions having a therapist or case manager with no personal experience in that
struggle. Having run a treatment program and now overseeing more than one-hundred forty
caseload managers, counselors and licensed clinicians, I have found the most critical elements
to assisting patients into recovery are having the ability to establish therapeutic rapport whereby
a client trusts the therapeutic relationship and secondly having an identity of professionalism. A
true professional understands that the issues a client or patient are suffering from and the
experiences that brought them to that place are as unique as a fingerprint. Hence, the
assumption of all addicts being the same and having a one-size fits all treatment paradigm is a
grave mistake. Counselors should approach every client as if they know nothing about them
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and allow the client to fill in the picture. After all, the client is the true expert on their own clinical
conditions.
Dual Relationships
Professional Boundaries
Sometimes it is next to impossible to avoid having some semblance of a relationship with a
client outside of the counseling session, but whenever possible, this should be strictly avoided.
So what does rise to the level of having a dual relationship with a client? A dual relationship is
generally understood as having another relationship, often known as a multiple relationship, with
a client outside of the therapeutic relationship. This could be having a sexual relationship with a
client, buying or selling products from or to a client, bartering for services or as simple as
accepting gifts from a client due to the inherent power a clinician has over those seeking
counseling. A general rule of thumb is to maintain no relationships whatsoever other than that
of a counselor and a client. This standard will allow for the counselor to assert more objectivity
during treatment and produce a better outcome for the client.
Dangers of Imposing Personal Values on Clients
The counselor-client relationship can be a tenuous one especially in treatment. With nearly
80% of clients suffering from co-occurring disorders in addition to a substance abuse disorder,
professionals should be especially sensitive to the power differential that is inherent in a
counseling relationship for the mere reason that our clients are vulnerable and susceptible to
abuse. Imagine a professional that has assisted a client through the most difficult part in his life.
Now imagine the respect and admiration that client has for the professional. The very nature of
this potential can open the door for even the most altruistic professional to begin imposing their
own personal values on their clients.
Self-Care
I once heard that the average life of a counseling professional was only ten years. What?
Those with advanced degrees spend nearly that much time in college, graduate school and
post-masters practicum. “Perhaps this wasn’t the best field in which to choose a career,” was
my thought. Ten years later, I am still going strong. The best advice I ever received regarding
my chosen profession is practice self-care. So what is self-care? It is whatever gives back to
you in such a way as to recharge you emotionally and physically so that you can be the best
professional you can be. I recall a time in which I was working in an inpatient psychiatric unit as
well as working with adolescents at a youth ranch. To hear the stories of neglect and abuse
would shake the most seasoned among us. My supervisor came to me and expressed concern
as she did not want me to take on more than I could handle. Being the Type-A personality I am,
I responded that I would be fine. Several months later, I noticed that I was having difficulty
sleeping and when I did sleep I dreamed about “my kids” as I came to speak of them. I was
irritable and otherwise little fun to be around. In meeting with one of my clinical mentors, he
suggested that I had developed secondary post-traumatic stress disorder by hearing and
internalizing “my kid’s” trauma. Whether the diagnosis was correct or not, the message was
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clear; I needed to balance my life in such a way as to be useful while in a professional role and
still healthy outside of that role. Simply put, whatever you choose to do to practice self-care,
your life outside of counseling should be larger than your life in it. If you find this to not be the
case, you will need to do what I did and introduce meaningful things into your life to help you
achieve this balance.
Counselor Responsibilities: A Different Look
From the AAMFT Code of Ethics to the individual State Drug & Alcohol Certifying Organization,
much has been written and re-written to express to counselors their responsibility in the helping
professions, and rightly so. We as case managers, counselors and therapists have a good
working knowledge of what we are not to do. For the true professional, we understand the
gravity and importance of our positions. We entered this field to make a difference and take
seriously the responsibilities entrusted to us. The problem is with all we have learned not to do,
we are sometimes ill-equipped in what we should do instead.
I remember the day my wife told me that we were expecting our first child; the joy, the pride and
the panic. As two well-educated individuals, we did what we always did and that was to buy
books and read them. We developed a small library with all the advice there was to be had.
Then came the relatives and their stories of times when little Timmy did this and that and how
they handled it. We went to labor coaching classes and practiced on that huge ball while
breathing in through the nose and out through the mouth. We exercised daily, went on an allorganic no meat diet and practiced calmness, whatever the heck that is. Then the day of our
daughter’s birth arrived. We felt good. We were confident and in the zone. 40 hours later we
had this little darling and had no idea of what to do with her. With all the preparation we had
done in what to expect in this situation and that, nothing had fully prepared us for having to be
solely responsible for this precious little gift. So it is true of being a counselor. With all of your
preparation through study and role plays, you are only partially equipped for the onset of your
professional career and the responsibilities therein. In that light, I would like to share with you
seven responsibilities I believe, if put in practice, will assist you in better meeting your goal of
becoming an effective counselor in the addiction treatment profession.
First, you must always remember that the client is the expert on their clinical condition, not you.
Over the years, I have had the privilege of interviewing literally hundreds of counselors wanting
to work in the company in which I do. As most are young in the field, I have a standard question
I ask them which is “what would you say to one of our clients who stated to you, why should I
listen to what you have to say, you’re the age of my daughter or you’ve never experienced what
I have?” I’m consistently amazed at the ones who ramble on about their practicum with this or
that agency or the ones that state I know exactly what they are going through because I have
been there myself. With all due respect, neither is a good answer in my opinion nor shows the
identity of someone who understands their role and responsibility as a counselor. As was
mentioned earlier in this article, we are as unique as a fingerprint and the fact that we share
similarities in a few areas does not permit us to discount the hundreds in which we do not. No
two people share the exact life experiences as the other. Even those that grow up in the same
home with the same environment will experience and interpret that experience through different
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lenses even if it is slightly. A true understanding of this principle allows us to answer the
question quite differently and state to the client “you’re right, but I was hoping that you would
teach me about you and your experiences.”
Second, you will be well-served to foster an environment in which a motivated client may
experience change. This is not meant to convey the idea that a counselor is solely responsible
for the outcome; quite to the contrary. However, the counselor is responsible for the process. I
recall a time in which I was providing therapy for a young girl who had witnessed her mother
attack her father resulting in her and her younger siblings being placed in out of home care. It
was really a heart-breaking case in which I could sense that she wanted to talk about what had
happened, but was scared to do so. I tried every therapeutic technique I knew to employ and
others I made up on the spot all to no avail. In meeting with my clinical supervisor and
explaining my own frustration with not being able to reach her, he gave me very solid advice.
He said, “Get in, shut up and hold on to where she wants to take the session, not the other way
around.” “Well, I’ve certainly never heard of that technique” was my first thought, but desperate
to see her progress I pledged to try it. So the next time I met with her I asked her what she
wanted to do in the session, to which she replied that she wanted to go on a treasure hunt. For
two solid months we went on treasure hunts weekly and found jewels and gold and all other
kinds of precious items until one day, she simply said, “you know that my mama tried to kill my
daddy?” Our moment of change had arrived. Now, I’m certainly not advocating that you take
your adult client on treasure hunts in the parking lot. However, I am saying that allowing a
motivated client to take his or her time in disclosing some of the most devastating and traumatic
moments of their life will take you fostering an environment in which they feel safe enough to do
so.
Third, a professional counselor has the responsibility to provide a therapeutic experience based
on authenticity and truth. It is not worth the time to try and pretend to be something you are not.
Your clients will smell you out a mile away. Living the life that your clients have and
experiencing those experiences has made them experts in many things, the least of which is to
possess the ability to sense their environment and the people within it. It is a survival skill long
since developed in most cases due to abuse and neglect whether from childhood, a spouse or
lover or by having to live on the streets. Our clients are true experts when it comes to who to
trust, who to manipulate and who to lie to. They possess a unique quality very similar to that of
a chameleon in that they can become who they need to in order to have their needs or desires
met. To possess that ability to change on a moment’s notice, takes someone who is truly in
tuned with human behavior. I once worked with clients who were court-ordered to see me for a
particular compulsive behavior disorder. In specializing with this population, I worked as long as
three years with some people and oh the stories and excuses I heard. Being a young therapist
at the time, I tried more subtle gestures such as reacting to the obvious lie disapprovingly or
simply trying to ignore their statement. One day I had heard enough and said to my client, “I
want you to know that I know you are lying, so let’s just cut the crap” to which I immediately
wished I could have retracted the statement. I had been trained better than that and I was
embarrassed by my outburst. Before I could apologize my client stated he was just seeing how
far I would let him go. It turned out to be the most therapeutic thing I could have done. My
client knew, or at least had a reasonable suspicion, that I knew he was lying. However, he was
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content not to address real issues when the make-believe ones could fill our sessions. While I
would not recommend on any regularity such crass conversation, I would challenge the
counselor not to expect the client to travel down a road (of truth) that the counselor is unwilling
to travel themselves.
The fourth responsibility of the professional counselor is to be fully present and engaged in the
client session regardless of life’s circumstances. There are few things that bother us more than
engaging someone in conversation only to receive half-hearted “uh, hums” in return. This pet
peeve of mine is so large that I will actually begin making up outrageous things just to see if the
person I am talking to will catch it. Now, if this is annoying during a casual dinner party or
conversation on the phone, imagine how a client must feel who is attempting to disclose or
convey events or emotions that perhaps they have never told anyone before and their counselor
is thinking about “life” outside the session. A professional counselor knows how to successfully
table their personal circumstances and focus solely on their client. They also know that if they
cannot, they should reschedule the session for a time in which they can.
Fifth, a counselor has the responsibility to offer hope to the patient beyond their present
circumstances. Perhaps some of you reading this will not agree thinking something to the effect
of, “How do you offer to the hopeless?” My response would be, “They’re in your office aren’t
they?” I have come to believe that the truly hopeless will not seek and maintain the services of
a counselor. The truly hopeless suffer oftentimes in silence. We will not be able to help them
because we will not know who they are in the first place. However, you will know and be able to
help those that seek treatment. Even the most resistant client can be said to have made
progress if they stay engaged in treatment and attend their counseling appointments. Our job is
to recognize and reinforce what they are doing well in the midst of difficult times with the belief
that in doing so we make it more likely they will continue this in the future. This type of
interaction with your client will allow for them to realize they have strengths that can be
employed to solve their own problems with the outcome being that hope is developed.
The sixth responsibility of the professional counselor is to respect the patient and know that his
or her choices and decisions are just that, his or hers. This is a tough one for some. We chose
this line of work to make a difference and there are few things more disappointing than working
with a client that continues to make poor choices for their lives. Our instinct is to continue trying
and trying until we arrive at the point that we are emotionally reactive against the patient. As
counselors, we should never place ourselves in a position in which we are working harder than
our clients. In doing so, we enable them to ourselves and can actually do more harm than
good. We must know when to let go knowing that we have done our jobs and we cannot be
responsible for something for which we have no control.
The seventh responsibility of a counselor is to maintain a professional identity even when those
around them falter. This is an especially important one to emphasize. Throughout my career
working in private psychiatric hospitals, non-profit agencies and now treatment centers, I have
had the distinct pleasure of working with some truly brilliant professionals. These people are
intrinsically motivated towards excellence and have high moral standards. Then there are those
that seem to be content with cutting corners, providing sub-par services and generally are
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difficult to be around. In my trainings I currently conduct with the more than 140 counselors in
my department, I offer instruction on many topics. However, no topic is covered with more
passion than this one. My advice to them is simple: if ever you feel that you cannot provide the
highest level of quality in patient care, then leave. This is not meant to be harsh, just honest.
Most patients voluntarily seek treatment and ask that we help them move on from their present
life of chaos, pain and trauma. Not being fully invested and committed to offer the highest
standards in patient care should never be an option.
References
Berger, S. & Berger, M. (2009). Tarasoff “duty to warn” clarified. The National Psychologist, 8,
2-3.
Board of Behavioral Sciences (2009). Statutes and Regulations Relating to the Practice of:
Marriage and Family Therapy Educational Psychology Clinical Social Work. Board of
Behavioral Sciences, 121-126.
Houghton Mifflin Company (2009). The American Heritage Dictionary of the English Language,
Fourth Edition. Houghton Mifflin Company.
This article was prepared by Arron S. Hightower, MA, who is Director of Clinical Services for
Aegis Medical Systems.
properly referenced, and that the following citation is used in full: Hightower, A.S. (2010).
Professional and Ethical Standards of Case Management. Journal of Addictive Disorders.
Retrieved from http://www.breining.edu.
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JOURNAL
OF
ADDICTIVE DISORDERS
Analyzing the Pros and Cons of Multiple Relationships Between Chemical Addiction
Therapists and their Clients. 1
ARTICLE
Abstract
The wording of the 1992 Ethics Code implied that multiple relationships were inherently
unethical, which essentially placed the burden of proof on the therapist (APA, 1992). In
contrast, the wording of the 2002 Ethics Code Standard 3.05 (Multiple Relationships) simply
begins with a neutral definition of a multiple relationship; the 2002 code does not contain the
implication that dual relationships are inherently unethical. Instead, the code clarifies that
multiple relationships that are not exploitive or harmful or cause impairment are not unethical
(Fisher, 2003). However, any boundary crossing has the potential to lead to a boundary
violation and must therefore be examined very closely. In those dual relationships in which
harm eventually results to a client, the burden of proof will always fall on the therapist
(Beauchamp & Childress, 2001).
Introduction
The New Ethics Code, Standard 3.05, explicitly states that multiple relationships that
reasonably would not be expected to cause impairment or risk exploitation or harm are not
inherently unethical (APA, 2002). The standard attempts to adopt a fair balance between the
interests of the public and the interests of Chemical Addiction Therapists. On one hand, the
Code was not designed to punish therapists who engage in benign multiple relationships. On
the other hand, it does want authority to punish those who create unethical dependency or who
engage in blatantly exploitative relationships (Fisher, 2003). According to this standard, it could
even be ethical to enter into a treatment relationship with a person with whom the therapist has
a current business or social relationship, as long as the relationship is not exploitative or
clinically contradicted, although from a risk-management perspective I would strongly
discourage that. Thus, maintaining healthy boundaries in relationships with clients does not
inherently require detached objectivity but does require professional judgment and a
commitment to the best interest of the client (Taylor & Gazda, 1991). As such, the intersections
of trust, boundaries, and appropriateness for both relationships are dependent on the therapist’s
knowledge that multiple relationships are going to occur; and just as importantly on the
therapist’s ability to effectively and ethically manage these relationships competently
(Beauchamp & Childress, 2001).
1
properly referenced, and that the following citation is used in full: Nardone, N.A. (2006).
Analyzing the Pros and Cons of Multiple Relationships Between Chemical Addiction Therapists
and their Clients. Journal of Addictive Disorders. Retrieved from http://www.breining.edu.
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Discussion
Definition
According to its preamble, the new APA Ethics Code has as its goals the welfare and
protection of the individuals and groups with whom therapists work and the education of
members, students and the public regarding ethical standards of therapy (APA, 2002).
Standard 3.05, on multiple relationships, is an excellent example of how the code achieves
these goals (APA, 2002). The first paragraph of the standard offers a definition that is new to
the code. The definition states that a multiple relationship arises when a therapist is in a
professional role with an individual, and that, in addition to this professional role one of three
other conditions is met. A multiple relationship occurs when a therapist is in a professional role
with a person and (1) at the same time is in another role with the same person, (2) at the same
time is in a relationship with a person closely associated with or related to the person with whom
the therapist has the professional relationship, or (3) promises to enter into another relationship
in the future with the person or a person closely associated with or related to the person (APA,
2002). The first paragraph of Standard 3.05 thus clearly informs therapists and the public what
constitutes a multiple relationship (Fisher, 2003).
The Test
One of the most frequent misconceptions surrounding Standard 3.05 is that multiple
relationships are, by definition, unethical (Taylor & Gazda, 1991). The second paragraph of
Standard 3.05 makes it clear that simply meeting the definition does not speak to the ethics of
multiple relationships (APA, 2002). In order to assess the ethical appropriateness of the
relationship, the second paragraph sets forth the following test: A therapist refrains from
entering into a multiple relationship if the multiple relationship could reasonably be expected to
impair the therapist's objectivity, competence, or effectiveness in performing his or her functions
as a therapist, or otherwise risks exploitation or harm to the person with whom the professional
relationship exists (APA, 2002).
Several things should be pointed out about this test. First, the test sets out criteria:
impairment in objectivity; competence or effectiveness; and a risk of exploitation or harm
(Fisher, 2003). In assessing whether the test is met, the therapist will therefore consider the
likelihood of impairment or the risk of exploitation or harm (Fisher, 2003). Second, the phrase
"reasonably expected" is central in determining what level of likelihood must be present, what a
reasonable psychologist would expect to occur (Fisher, 2003). Would a reasonable
psychologist expect that multiple relationships would cause impairment or risk of exploitation or
harm (Fisher, 2003)? If a reasonable psychologist would not, the test is not met (Fisher, 2003).
Third, there must be a causal connection between multiple relationships and the impairment
or risk. In other words, something about the relationship must reasonably lead a therapist to
expect that the relationship will cause impairment or risks exploitation and/or harm (Fisher,
2003). Thus, that a multiple relationship exists, in and of itself, does not meet the test, a
reasonable therapist must expect that the multiple relationship will lead somewhere problematic
(Fisher, 2003). The third paragraph in Standard 3.05 emphasizes this point: “Multiple
relationships that would not reasonably be expected to cause impairment or risk exploitation or
harm are not unethical” (APA, 2002).
The definition in Standard 3.05 educates therapists and the public about when a multiple
relationship is present. The test that follows protects those with whom psychologists work, and
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thereby promotes their welfare, by making a safe space available for the therapist and client to
proceed (Fisher, 2003).
Multiple relationships
How does a therapist know whether a multiple relationship will lead to impairment, or if the
relationship risks exploitation or harm? My feeling is that if a multiple relationship is likely to
lead to impairment or risks, the relationship should be avoided. Thus, the reasoning is not
about values, protecting from harm and promoting welfare, but is rather about what effect a
particular multiple relationship will have on a particular client (Beauchamp & Childress, 2001).
While the answer to this clinical question has profound ethical implications, the disagreement
remains on clinical and technical grounds. As therapists, we can agree upon and share the
underlying values (Beauchamp & Childress, 2001).
The APA Ethics Code recognizes that because of the many roles therapists assume in their
work, family, community and social lives, multiple relationships arise in unexpected ways. Some
of these multiple relationships are potentially harmful. The fourth paragraph in Standard 3.05
addresses potentially harmful, unanticipated multiple relationships. “If a therapist finds that, due
to unforeseen factors, a potentially harmful multiple relationship has arisen, the therapist takes
reasonable steps to resolve it with due regard for the best interests of the affected person and
maximal compliance with the Ethics Code” (APA, 2002).
The question is again what a reasonable therapist would do. The therapist's focus will be on
the affected person's best interests and on complying with the Ethics Code, which has as its
focus the individual's welfare and protection (Taylor & Gazda, 1991). Thus, the Ethics Code
continues to return to and emphasize its central values of doing good and not doing harm, found
in Principle A of the code's General Principles (Taylor & Gazda, 1991).
Multicultural competence
Multicultural competence is facilitated in this code by recognizing that in particular cultural
contexts, closer and more complex involvement in the lives of clients may facilitate appropriate
service and protection for the client (Fisher, 2003). This may be accomplished by the therapist’s
increased knowledge of the cultures involved in his/her clientele.
Clients in individual and group therapy
In most instances, treating clients/patients concurrently in individual and group therapy does
not represent a multiple relationship because the practitioner is working in a therapeutic role in
both contexts (Taylor & Gazda, 1991), and Standard 3.05 does not prohibit such practice (APA,
2002). Therapists providing individual and group therapy to the same clients should consider
instituting special protections against inadvertently revealing to a therapeutic group, information
shared by a client/patient in individual sessions (Taylor & Gazda, 1991). As in all types of
professional practice, psychologists should avoid recommending an additional form of therapy
based on the therapist’s financial interests rather than the client’s mental health needs (Taylor &
Gazda, 1991).
Avoiding multiple relationships
In some situations, it may not be possible or reasonable to avoid multiple relationships.
Therapists working in rural communities, small towns, military bases, or American Indian
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reservations, or therapists who are qualified to provide services to members of unique ethnic or
language groups for which alternative psychological services are not available, would not be in
violation of this standard if they took reasonable steps to protect their objectivity and
effectiveness and the possibility of exploitation and harm (Taylor & Gazda, 1991). Such steps
might include: seeking consultation by phone from a colleague to help ensure objectivity; taking
extra precautions to protect the confidentiality of each individual with whom the therapist works;
or explaining to individuals involved the ethical challenges of the multiple relationships. The
therapist will take steps to mitigate these risks, by encouraging individuals to alert the therapist
to relational situations of which the therapist might not be aware and that might place his or her
effectiveness at risk (Taylor & Gazda, 1991).
There will be instances in which therapists discover they are involved in a potentially harmful
multiple relationship of which they had been unaware. Standard 3.05b requires that therapists
take reasonable steps to resolve the potential harms that might arise from such relationships,
recognizing that in some instances the best interests of the affected person and maximal
compliance with other standards in the Ethics Code may require therapists to remain in the
multiple roles (Beauchamp & Childress, 2001).
For Example: a therapist in a chemical addiction program became aware that his neighbor
had begun dating one of the therapist’s addiction patients. The therapist could not reveal to his
neighbor that the patient was in therapy. Although telling the patient about the social
relationship could cause some distress, it was likely the patient would find out about the
relationship during conversations with the neighbor. The therapist considered reducing his
social exchanges with the neighbor but this proved infeasible. After seeking consultation from a
colleague, the therapist decided that he could not ensure therapeutic objectivity or effectiveness
if the situation continued. He decided to explain the situation to the patient, provide a referral,
and assist the transition to a new therapist during pre-termination counseling (Fisher, 2003).
Multiple Roles
In its fifth and final paragraph, Standard 3.05 recognizes that therapists are sometimes
required to serve in more than one role in judicial or administrative proceedings, and so cannot
always avoid or fully resolve a potentially harmful multiple relationship. When a therapist
encounters such a situation, the Ethics Code focuses the therapist on informing those affected
about the change in expectations (Fisher, 2003). The reasoning behind the code's language is
that if a therapist must take on a potentially harmful multiple role, the best way to help protect
those affected is to inform them of the change in circumstances (Fisher, 2003). Standard 3.05c
applies to instances when therapists are required to serve in more than one role in judicial or
administrative proceedings or because of extraordinary circumstances (APA, 2002). This
standard does not permit therapists to take on these multiple roles if such a situation can be
avoided (Fisher, 2003). Standard 3.05c requires that when such multiple roles cannot be
avoided, as soon as possible and thereafter as changes occur, therapists clarify to all parties
involved the roles the therapist is expected to perform and the extent and limits of confidentiality
that can be anticipated by taking on these multiple roles (Fisher, 2003).
In most situations, therapists are expected to avoid entering multiple relationships in
forensically relevant situations or to resolve such relationships when they unexpectedly occur
(Standards 3.05 a and b) (APA, 2002). When such circumstances arise (e.g., such as
performing a custody evaluation and then providing court-mandated family therapy for the
couple involved), the conflict may sometimes be resolved by explaining to a judge or institutional
administrator the problematic nature of the multiple relationship (Taylor & Gazda, 1991).
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For example, a judge asked a therapist who had conducted a custody evaluation to provide
6-month mandated family counseling for the couple involved followed by a re-evaluation for
custody. The therapist explained to the judge that providing family counseling to individuals
who’s parenting skills the therapist would later have to evaluate could reasonably be expected
to impair her ability to form an objective opinion independent of knowledge gained and the
professional investment made in the counseling sessions (Taylor & Gazda, 1991). She also
explained that such a multiple relationship would likely impair her effectiveness as a counselor if
the parents refrained from honest engagement in the counseling sessions out of fear that
comments made would be used against them during the custody assessment (Taylor & Gazda,
1991). The judge agreed to assign the family to another therapist for counseling.
”When therapists are required by law, institutional policy, or extraordinary circumstances to
serve in more than one role in judicial or administrative proceedings, at the outset they clarify
role expectations and the extent of confidentiality and thereafter as changes occur” (APA,
2002).
Relationships that are not unethical
Individual therapists perform a variety of roles and work with a variety of individuals.
Standard 3.05 was crafted to define multiple relationships and to help therapists distinguish
between those that are ethical and those that are unethical (Fisher, 2003).
For example, a client with a fluctuating sense of reality coupled with strong romantic
transference feelings for a treating therapist misinterpreted two incidental encounters with his
therapist as planned romantic meetings (Beauchamp & Childress, 2001). The client
subsequently raised these incidents in a sexual misconduct complaint against the therapist.
The therapist’s recorded notes made immediately following these encounters were effective
evidence against the invalid accusations (Beauchamp & Childress, 2001).
Multiple relationships that would not reasonably be expected to cause impairment or risk
exploitation or harm are not unethical (APA, 2002). Standard 3.05 does not prohibit attendance
at a client’s, student’s, employee’s, or employer’s family funeral, wedding, or graduation; the
participation of a therapist’s child in an athletic team coached by a client; gift giving or receiving
with those with whom one has a professional role; or from entering into a social relationship with
a colleague as long as these relationships would not reasonably be expected to lead to role
impairment, exploitation, or harm (Fisher, 2003). Incidental encounters with clients at religious
services, school events, restaurants, health clubs, or similar places are not unethical
(Beauchamp & Childress, 2001). Nonetheless, therapists should always consider whether the
particular nature of a professional relationship might lead to misperceptions regarding the
encounter. If so, it may be wise to keep a record of such encounters (Beauchamp & Childress,
2001).
The standard does not have an absolute prohibition against post-termination nonsexual
relationships with persons with whom therapists have had a previous professional relationship
(APA, 2002). However, such relationships are prohibited if the post-termination relationship was
promised during the course of the therapeutic relationship or if the individual was exploited or
harmed by the intent to have the post-termination relationship. If the personal knowledge
acquired during therapy becomes relevant to the new relationship then the new relationship
would be prohibited (Fisher, 2003).
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Relationships that are potentially unethical
Therapists may encounter situations in which the opportunity to enter a new relationship
emerges with a person with whom they already have an established professional role. Many
relationships would be prohibited by Standard 3.05a because these situations could reasonably
be expected to impair a therapists’ ability to competently and objectively perform their roles and
could lead to exploitation or harm (Fisher, 2003).
For example: a company hired a therapist for consultation on how to prepare employees for
a shift in management anticipated by the failing mental health of the chief executive officer
(CEO). A few months later, the therapist agreed to a request by the board of directors to
counsel the CEO about retiring. The CEO did not want to retire and told the therapist about the
coercive tactics used by the board. The therapist realized too late that this second role
undermined both treatment and consultation effectiveness because the counseling role-played
by the therapist would be viewed as either exploitative by the CEO or as disloyal by the board of
directors (Fisher, 2003).
Therapists may also encounter situations in which a person closely associated with someone
with whom they have a professional role seeks to enter into a similar professional relationship
(Fisher, 2003).
For example, the roommate of a addiction therapy client might ask the therapist for an
appointment to begin addiction herapy. With few exceptions, entering into such relationships
would risk a violation of Standard 3.05a because it could reasonably be expected that the
therapist’s ability to make appropriate and objective judgments would be impaired, which in turn
would jeopardize the effectiveness of services provided and result in harm (Fisher, 2003).
Therapists may also encounter situations in which they are asked to be in a professional role
with someone with whom they have a preexisting personal relationship. These multiple
relationships are frequently unethical because the preexisting relationship would reasonably be
expected to impair the therapist’s objectivity and effectiveness (Fisher, 2003). The phrase
“could reasonably be expected” indicates that violations of Standard 3.05a may be judged not
only on the basis of whether actual impairment, harm, or exploitation has occurred but whether
most therapists engaged in similar activities in similar circumstances would determine that
entering into the multiple relationship would be expected to lead to such harms (Taylor &
Gazda, 1991).
Here are two examples of what I am talking about: relatives ask a therapist to help his
nephew overcome his dependence on alcohol; a colleague asks a therapist to administer a
battery of tests to assess whether she has a drinking problem.
Conclusion
Standard 3.05 defines a multiple relationship and provides a test for when therapists refrain
from entering into a multiple relationship (APA, 2002). The Standard also indicates what
therapists should do when an unanticipated and/or unavoidable multiple relationship arises in
their professional lives (APA, 2002).
The goal of Standard 3.05, like the goal of the code as a whole, set forth in the preamble, is
"the welfare and protection of the individuals and groups with whom therapists work and the
education of members, students and the public regarding ethical standards of the discipline”
(APA, 2002). Standard 3.05 illustrates that an excellent way to protect our clients and promote
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their welfare is to educate the public about our profession's core values and to inform therapists
about how these values can be implemented in everyday practice (Fisher, 2003).
A therapist should refrain from entering into a multiple relationship if the multiple relationship
could reasonably be expected to impair the therapist’s objectivity, competence, or effectiveness
in performing his or her functions as a therapist, or otherwise risks exploitation or harm to the
person with whom the professional relationship exists (Fisher, 2003). Multiple relationships that
would not reasonably be expected to cause impairment or risk exploitation or harm are not
unethical (APA, 2002).
Adjudication of complaints under the 2002 Ethics Code is likely to be determined by the way
disciplinary boards interpret the meaning of the phrase "could reasonably be expected" (Fisher,
2003). The word “reasonably” does not define itself. What is reasonable to one therapist may
not be reasonable to another. These considerations highlight the importance of consulting with
colleagues in situations involving dual roles or boundary crossings (Fisher, 2003). Of course,
the best way to stay out of potentially dangerous situations is to avoid them in the first place
(Fisher, 2003).
REFERENCES AND ADDITIONAL RESOURCES
American Psychological Association, APA (1992). Ethical Principles of Psychologists and Code
of Conduct. American Psychologist, 47, 1597-1611.
American Psychological Association, APA (2002). Ethical Principles of Psychologists and Code
of Conduct. American Psychologist, 57, 1060 – 1073.
Beauchamp, T., & Childress, J. (2001). Principles of ethics. (5th ed.). New York: Oxford
University Press.
Fisher, C. B. (2003), Decoding the Ethics Code: A Practical Guide for Psychologists. Thousand
Oaks, CA: Sage Publication Company.
Taylor, R. E., & Gazda, G. M. (1991). Concurrent individual and group therapy: The ethical
issues. Journal of Group Psychotherapy, Psychodrama, & Sociometry, 44, 51-59.
This article was prepared by Nicholas A. Nardone, Dr.AD, who earned his Doctor of Addictive
Disorders (Dr.AD) degree from Breining Institute. Dr. Nardone also holds a Master of Science in
Addiction Psychology from Capella University.
properly referenced, and that the following citation is used in full: Nardone, N.A. (2006).
Analyzing the Pros and Cons of Multiple Relationships Between Chemical Addiction Therapists
and their Clients. Journal of Addictive Disorders. Retrieved from http://www.breining.edu.
WWW.BREINING.EDU
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COLLEGE FOR THE ADVANCED STUDY OF ADDICTIVE DISORDERS
CONTINUING EDUCATION (CE) COURSE MATERIAL
Course No. CE1311P2 – HIV / ARC / AIDS / Hepatitis
COURSE OBJECTIVE
This course examines the current state of human immunodeficiency virus (HIV), AIDS-related
complex (ARC), autoimmune deficiency syndrome (AIDS) and hepatitis for the addiction
practitioner.
COURSE MATERIAL
People have been using and abusing substances since the dawn of time. Some physical
illnesses have been connected to alcohol and drug use. Alcohol affects the liver and other vital
organs. Cocaine can affect the heart, and smoking causes cancer. In the early days of
America, smoking was viewed as glamorous, and many people smoked. Even after diseases
such as emphysema and cancer were directly connected to smoking, people still smoked. It
took generations before society became aware of the severity of the problem, and then to make
changes in the way America viewed smoking. The substance and illnesses go hand in hand.
Substance abuse and human immunodeficiency virus (HIV) infection often coexist in the same
individual. Both diseases are chronic, with remissions and exacerbations or relapses. There are
risks in contracting other diseases such as Hepatitis and Sexually transmitted diseases while
using addictive substances. Not all addicts will contract the disease and there are those that
have never abused substance that will. HIV/AIDS is a serious epidemic, affecting many
American’s and people in other nations through out our world. At the end of 1999, an estimated
320,282 people in the United States were living with AIDS (Centers for Disease Control and
Prevention HIV/AIDS Surveillance report 2000; 12(no.1):1-44). AIDS is the 5th leading cause of
death in America among people from the age of 25 to 44 with 438,795 deaths recorded June
30, 2000 (CDC and Prevention Surveillance report 2000;12(no.1). HIV ARC and AIDS will be
described as well as hepatitis. The links between substance abuse and these diseases will be
identified, and ways of treating and preventing such diseases will be discussed. (Centers for
Disease Control and Prevention HIV/AIDS Surveillance report 2000; 12(no.1):1-44.)
Early signs of HIV
Joe could not imagine what was wrong with him. He was not able to figure out why he
felt so fatigued all of the time. He thought maybe it was the stress of his job, or his poor diet.
Joe thought he would just shake it off, and figured that it would pass. The fatigue did not pass
however, and more symptoms surfaced. He started to have a low grade fever and he would
wake up in the middle of the night drenched with sweat. Little did he know at that time, that he
acquired HIV.
The HIV virus was identified in 1984. HIV is a precursor to AIDS. If some one has HIV it
does not mean that they have AIDS. Many symptoms will appear that are debilitating but not life
threatening (“The Persistent Threat of AIDS” David W. Sifton, 2003). AIDS is the final stage of
HIV infection and it can take many years to develop. As this disease grew, and physicians
were educated, a list identifying the warning symptoms of HIV was developed. The following
symptoms are the early signs of HIV; Chronic fever, extreme fatigue, diarrhea, persistent night
sweats, weight loss swollen lymph glands, headaches, skin rashes and fungal infections (“The
Persistent Threat of AIDS” David W. Sifton, 2003). Seroconversion is the detectability of HIV
antibodies in the blood. The infection can normally be detected from 6 to 12 weeks, but can
show up anywhere between 1 week to 1 year. The time between infection and identification of
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HIV is called that window period. (Nursing Diagnoses in Psychiatric Nursing 5th edition Mary
Townsend 2001). (Nursing Diagnoses in Psychiatric Nursing 5 h edition Mary Townsend 2001).
(“The Persistent Threat of AIDS” David W. Sifton, 2003).
During the asymptomatic infection stage, which is in the early stage of HIV there are no
manifestations of illness. Blood test may show some abnormalities however, such as
leukopenia and anemia. This period may last 5 to 10 years or longer (Nursing Diagnoses in
Psychiatric Nursing 5th edition Mary Townsend 2001).
In the Middle stage of HIV the T4 Cells are from 200-500mm. Generalized
Lymphadenopathy is an infection that affects the lymph nodes. The swelling of the lymph nodes
will show up in different locations in the body, such as the neck, armpit and groin. The swelling
can remain for months. Other symptoms in this stage are fever, night sweats, and chronic
diarrhea.
AIDS was first observed in 1981 by physicians in San Francisco and New York City.
Quite a few homosexual men were showing up in hospitals and Doctors offices with a group of
signs and symptoms that were unexplainable. Some of the symptoms were often, resistant to
treatment. The sickest of the individuals had Pneumocystis carinii pneumonia. That type of
pneumonia is a common organism that most people are able to fight off. Another symptom that
showed up was Kaposi’s sarcoma (The Persistent Threat of AIDS David W. Sifton, 2003).
Kaposi’s sarcoma is a type of cancer that generally in seen in older men. The cancer shows up
as purple blotches on the skin. Intensive laboratory testing was done and found that the patients
had severely impaired immune systems.
The human body has cells that are responsible for fighting infection. In a normal healthy
organism the cells work to destroy invasive organisms and facilitate repair of the cells.1 If the
cells do not do there job in fighting the infection, specific immune mechanism cells take over.
The elements of the cellular response include the T4 lymphocytes, called T-cells (Nursing
Diagnoses in Psychiatric Nursing 5th edition Mary Townsend 2001). When the body is invaded,
the T4 cells divide many times, producing antigen-specific T4 cells with other functions. One
function of the T4 cell is to help destroy the antigen. HIV infects and depletes the T4
lymphocyte, destroying the very cell that the body needs to attack the virus. A person with a
healthy immune system may have a T4 cell count of between 600 to 1200mm. In the late stage
of HIV the T4 Cells drop to 200mm. AIDS is a very debilitating and deadly disease. I was
working at a treatment center about six years ago. One aspect of my job was to help the
patients with a continuing care plan. The after care plan was usually an out patient treatment or
a sober living. One of the patient’s was in the late stages of AIDS. His aftercare plan was
referred to a Hospice nurse who set him up in hospice.
Types of Hepatitis
Hepatitis is a virus that causes illnesses and affects the liver. There are different types
of hepatitis, with various signs and symptoms. The different types of hepatitis are as follows:
Nursing Diagnoses in Psychiatric Nursing 5th edition Mary Townsend 2001). (The Persistent
Threat of AIDS David W. Sifton, 2003.
1
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Hepatitis A
Hepatitis A virus (HAV) was at one time known as infectious hepatitis because it is spread so
easily. HAV is an inflammation of the liver caused by the Hepatitis A virus. The symptoms of this
virus start within 2 to 6 weeks after contact with HAV.2
The virus runs its course in two to three months. When the infection ends, it is over. There are
no chronic phases of the illness. Most people recover fully and develop immunities to the virus
(Encyclopedia of Medicine “Hepatitis A Larry I. Lutwick 2001). The Hepatitis A virus is
transmitted through food, water or improper hand washing after a bowel movement. Children
seem to be the most likely victims, but they very often have mild flu like symptoms. Adults
however are more likely to have move sever symptoms. Epidemics of HAV infection can affect
hundreds of people at a time. I have heard of a cruise ship with contaminated food and all the
passengers were infected. Food-handlers who have no symptoms themselves can start a
widespread epidemic. There are other groups that can be at risk besides cruise ship
passengers. For instance; Troops living under crowed conditions and people who live in
populated areas that have poor sanitation. It is estimated that between 14-40 % of all cases of
HAV come from children in day care centers in The United States (Encyclopedia of Medicine
“Hepatitis A Larry I. Lutwick 2001). This happens because toys can become contaminated and
remain that way for some time.
Travelers pick up the virus when traveling to an infected area. Homosexual men are at risk if
they engage in oral or anal sexual contact.
The symptoms in the Hepatitis A virus are fatigue, body aches, mild fever and loss of appetite.
HAV can affect the liver causing enlargement and jaundice (yellowing of the skin) (Encyclopedia
of Medicine “Hepatitis A Larry I. Lutwick 2001).
Once the symptoms appear there is little that can be done, as far a medications or antibiotics
go.3 The HIV patient should get a lot of bed rest, and eat a healthy diet, avoiding alcohol or
other medications that can exacerbate the liver damage.
In preventing the spread of Hepatitis A one should take care to wash hands after using the
toilet. Precautions should be used with sexual partners, in avoiding transmission of the virus.
Travelers should boil water for one minute before drinking.
Hepatitis B
Hepatitis B (HBV) was known at one time as serum hepatitis, because it was sometimes
transmitted in blood products, before screen tests were implemented (Encyclopedia of Medicine
“Hepatitis B David A Cramer, MD 2001). Some people can be carriers of this virus having no
symptoms. They may pass the infection to others however. There are two different forms of
HBV acute and chronic. Acute HBV does not persist longer then two or three months. One in
five patients infected with HBV develop severe symptoms of jaundice (Encyclopedia of Medicine
“Hepatitis B David A Cramer, MD 2001). There are rare cases (1%), when the liver will fail.
Encyclopedia of Medicine “Hepatitis A Larry I. Lutwick 2001. Nursing Diagnoses in Psychiatric
Nursing 5th edition Mary Townsend 2001.
2
3
Encyclopedia of Medicine “Hepatitis A Larry I. Lutwick 2001.
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Some patients will develop flu like symptoms and not even know they have the virus unless
testing is done to identify it. With chronic Hepatitis B the infection last longer than 6 months. Not
all persons with chronic HBV develop liver disease but one in four will. (Encyclopedia of
Medicine “Hepatitis B David A Cramer, MD 2001). The liver becomes scarred (cirrhosis) and is
unable to carry out its normal functions. Liver cancer is another serious complication of chronic
HBV. Those who drink and smoke are more likely to develop cancer.4
People at risk to contract the HBV are; Health care workers who may come into contact with
infected blood, homosexuals or heterosexuals who have multiple partners, drug abusers who
use needles, and those living in crowed institutions. There are no treatments for acute HBV
(Encyclopedia of Medicine “Hepatitis B David A. Cramer, MD 2001). Like Hepatitis A, if
infected one should get a lot of bed rest and eat a health diet, avoiding alcohol. The best way to
prevent HBV is to avoid contact with blood and other bodily fluids and use condoms during sex.
There is a vaccination against Hepatitis B, those at risk such as hospital workers, should get the
3 recommended doses.
Hepatitis C
Hepatitis C has affected an estimated 3.9 million Americans and 2.7 million are
chronically infected, according to the Center for Disease Control (CDC.gov/hepatitis 2003).
Hepatitis C is a blood born virus that causes a form of liver inflammation. HCV is mild in the
early stages and with that; it can go undetected allowing the virus to spread. More than half of
all people who have Hepatitis C have no symptoms or signs of liver disease (Encyclopedia of
Medicine “Hepatitis C Larry I. Lutwick 2001). Some individuals will have minor flu like
symptoms. Hepatitis affects how the liver functions, and it affects the way the liver processes
certain color pigmentation. Therefore, some patients develop jaundice, a yellowing of the skin.
About 20% of Hepatitis patients develop cirrhosis of the liver (Encyclopedia of Medicine
“Hepatitis A Larry I. Lutwick 2001).5 The virus damages a large number of liver cells and then
the cell becomes scarred (cirrhosis), preventing normal functioning of the liver. Hepatitis C is
one of the most common reasons for liver transplants in the United States of America. Other
serious conditions that may occur in patients with chronic HCV are; joint pain, weakness, and
extreme sensitivity to light. This disease can effect the kidneys and brain and liver cancer may
develop, which could be life threatening. Interferon is a natural body protein. Scientist can
make interferon by genetic engineering. The interferon protein can lessen the symptoms and
improve the liver functioning (Encyclopedia of Medicine “Hepatitis C Larry I. Lutwick 2001).
This treatment can provide hope to those suffering with Hepatitis C, although not everyone
responds positively to the treatments.
Another medication used to treat Hepatitis C called ribavirin, this is used in combination with
interferon. The combination therapy can get rid of the virus in up to 5 out of 10 persons that
have genotype 1 and 8 out of 10 in persons with the genotype 2 and 3 (CDC.gov/hepatitis 2003)
Hepatitis C is a blood born infection and it is acquired by the following routes of
transmission; IV drug users and recipients of blood before 1992 are high risk (CDC.gov/hepatitis
2003). Health care workers who come into contact with infected blood either by a cut or a
contaminated needle. Sexual contact is low risk (CDC.gov/hepatitis 2003). Anyone who gets a
4
Encyclopedia of Medicine “Hepatitis B David A Cramer, MD 2001.
5
Encyclopedia of Medicine “Hepatitis C Larry I. Lutwick 2001. CDC.gov/hepatitis 2003.
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tattoo or gets a piercing could be at risk of Hepatitis C if the needle is infected. At one time
blood transfusions were a common cause of the spread of HCV, but testing for the virus in the
blood was implemented in the 1990s, which decreased the risk.6
In order to prevent Hepatitis C one should practice the following precautions; Do not
use IV drugs, if you do, use clean needles, and do not share needles with others. Do not share
personal items such as razors and toothbrushes. Make sure if you get a tattoo or body piercing
that the artist has clean equipment. Health care workers should use care when handling
needles and anything with patient’s blood on it (CDC.gov/hepatitis 2003). One should use
condoms if they are having sex with more then one partner.
Hepatitis D
Hepatitis D is a liver inflammation, which is only acquired, if one is infected with Hepatitis
B virus. Hepatitis D or Delta was discovered in the late 1970’s by Italian physicians
(Encyclopedia of Medicine “Hepatitis D David A Cramer, MD 2001).
They discovered that another type of infection was present in the liver cells, of those infected
with hepatitis B. The infection tends to be more severe when both viruses are present. One is
more likely to develop chronic liver disease when both infections are present, than if one is
infected with Hepatitis B virus only (Encyclopedia of Medicine “Hepatitis D David A Cramer, MD
2001).
Three million people worldwide are infected with Hepatitis B, and at least 5 % also have
Hepatitis D. Hepatitis D can not cause infection on its own because it is so small7 and has an
incomplete viral particle. Hepatitis B is a companion virus because it forms a covering, which
allows the D virus to develop. This combination is called a superinfection (Encyclopedia of
Medicine “Hepatitis D David A Cramer, MD 2001).
Symptoms of the infection are like other forms for Hepatitis; nausea, loss of appetite, joint pains.
Symptoms in the later stages are an enlarged liver and Jaundice. In the acute stage bed rest,
a healthy diet and avoiding alcohol would be recommended. Since Hepatitis D can only occur
when the B virus is present, vaccination against Hepatitis B is a positive method of prevention.
Hepatitis E
Hepatitis E virus is a form of hepatitis that is transmitted in the intestinal tract. This virus was
discovered in 1987 and it is spread by fecal-oral route (Encyclopedia of Medicine “Hepatitis E
David A. Cramer, MD 2001). In developing countries where human waste is allowed to get into
drinking water, hepatitis E can become an epidemic. Although no outbreaks have occurred in
the United States or Canada, large outbreaks have been reported in Asia and South America.
The virus is short lived illness but it can sometimes cause liver failure. The HEV starts in the
gastrointestinal tract it grows mainly in the liver. It may take two to eight weeks for the
symptoms to appear. The infected person may experience nausea, fever, loss of appetite and
pain in the upper part of the abdomen where the liver is located (Encyclopedia of Medicine
“Hepatitis E David A Cramer, MD 2001). The majority of the time the illness is mild and
6
Ibid.
7
Encyclopedia of Medicine “Hepatitis D David A Cramer, MD 2001. CDC.gov/hepatitis 2003.
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disappears within a few weeks. The HEV stimulates the body’s immune system which produces
an antibody that can destroy the virus. On rare occasions however the virus may destroy the
liver cells which prevent the liver from functioning (Encyclopedia of Medicine “Hepatitis E David
A Cramer, MD 2001).
The best way to prevent Hepatitis E virus is to provide safe, clean drinking water and create
proper sanitation. When traveling to other countries one should bring bottled water.
STDs and Substance Abuse
There are some connections between sexually transmitted diseases and abuse of
alcohol and drugs. One factor is that when one is under the influence of drugs and /or alcohol it
decreases one’s inhibitions. Judgment can be affected when using. While drinking alcohol or
using drugs, some people engage in high- risk behaviors. Sexual encounters are more likely to
happen when drinking and less likely that condoms will be used (Loosening the Grip, Kinney &
Leaton 1995). Sexually transmitted diseases can be contracted when one chooses to have sex,
and makes those decisions while impaired. Heavy Alcohol abuse can interfere with the immune
system disrupting the bodies’ natural ability to fight infections allowing viruses to grow
(Loosening the Grip, Kinney & Leaton 1995).
Another connection between sexually transmitted diseases and substance abuse is that some
people will use drugs to enhance the sexual experience. Some men will use drugs as an
aphrodisiac. I have worked with quite a few gay men, and they shared that they use Meth
amphetamines to prolong the sexual experience, and engage in “marathon sex”. The gay men
that I have spoken to reported that they use Meth anally. 8
Some of them are sex addicts, and their compulsive sexual behavior is the primary issue.
Others reported that if they did not have the methamphetamines they would not be having the
risky sex. Some of these men shared that they would go to gay bars looking for sex partners
with little thought of protecting themselves from sexually transmitted diseases. One other
connection between sexually transmitted diseases and chemical dependency is that some
people will trade sex for drugs. They call this the oldest profession, or prostitution. Some addicts
become hooked on drugs and they are unable to hold a job, or function in society so they turn to
prostitution. The can be seen in the poorer areas of the country such as the inner cities.
Prevention
Education is the key when it comes to prevention. HIV, Hepatitis and other transmitted
disease are preventable, but still prevalent in society. In the chemically dependent and the
behaviorally addicted individuals, denial can be strong. They may think, “It could never happen
to me”. They may see their using-buddy or partner as a clean healthy individual, and have no
idea, that they are infected with a disease. One could have the HIV and/or hepatitis C virus and
have no symptoms, and then pass on the virus, unaware to others. There are some different
methods of preventing these diseases. The general public needs to be educated on the
methods for prevention as well as those who engage in risky behaviors. Education should start
with our youth, some High Schools have prevention programs where they educated students on
abstinence and safe sex practices. In order to avoid transmitting HIV/AIDS the IV Drug user
Encyclopedia of Medicine “Hepatitis E David A Cramer, MD 2001. Loosening the Grip, Kinney
& Leaton 1995.
8
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should, use clean needles, and not share needles with others. There are clinics that have
instituted a needle exchange program where IV user and get a supply of clean needles. For
prevention of blood born illness the following precautions should be followed. One should not
share personal items such as razors and toothbrushes. If one gets a tattoo or body piercing they
should make sure that the artist has clean equipment. Health care workers should use care
when handling needles and anything with patient’s blood on it (CDC.gov/hepatitis 2003). One
should use condoms if they are having sex with more then one partner. There is no vaccination
at this time for HIV, but there is for Hepatitis B, and this is a positive method of prevention, for
that illness. Working in hospitals and in the chemical dependency treatment field universal
precautions are taught. Universal precautions are safety measures you take to avoid
contracting an infection or virus. In practicing universal precautions you treat everyone the same
whether or not they have an infectious disease. Hand washing with antibacterial soap often and
avoiding blood products are a way to use universal precautions.
Treatment plan
Here is a case study of a couple who is affected by substance abuse and HIV illness.
Bill and Mary are married. Mary is the breadwinner in the house. She has a full time job, and
they are living comfortably. Bill on the other hand is unemployed. Bill is also a heroin addict and
is HIV positive. Since Bill has been diagnosed HIV positive they have been practicing safe sex
by using condoms. Mary wants desperately to have a baby, but is conflicted because of the HIV
status. Mary came to see me with this problem and she stated that Bill is willing to go along
with any suggestions that I may have as a professional. The first thing I would do is to have a
conjoint session with both Mary and Bill. Mary did say that Bill was willing to do whatever was
suggested, but I would need to meet with him face to face to get a real idea of his motivation
level.
After the first meeting it was clear that Mary seemed more motivated then Bill, but he was
willing to take direction. Because Bill is in an active addiction to Heroin the first
recommendation is to go to an inpatient treatment program. Bill needs to have a safe medical
detoxification. Bill will need education on the disease process of chemical dependency and
acquire tools for relapse prevention. I would recommend that Mary attend a family program
where she can be educated on the disease process, co-dependency, enabling behaviors and
Al-Anon.
The treatment plan is an important tool and one of the 12 core functions of counselors.
The treatment plan is the blueprint for recovery. The treatment plan is built around the problems
that the patient brings into treatment (Chemical Dependency Counseling Robert R. Perkinson
1997). These are the treatment plans that I would recommend. First it is important that each
person have an individual treatment plan, and then a treatment plan as a couple. Before the
issue of the possibility of a baby can be discussed, the addiction and HIV status must be
addressed. Counselors must be aware of their abilities to treat individuals. In being a substance
abuse counselor, one must know, what is in and out of their scope of practice. One of the other
12- core functions of counseling is referral. Some of the problems are to be referred to other
professionals of the interdisciplinary treatment team.
First for Bill, Bill has two issues that are separate but must be addressed simultaneously.
While Bill is in the inpatient treatment, he will work on the following treatment plan items.9 The
9
Chemical Dependency Counseling Robert R. Perkinson 1997.
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first thing Problem 1; is his active addiction to heroin. Bill will have a safe medical detoxification.
During the detox the nursing staff will monitor his vital signs and appropriately medicate his
withdrawal symptoms. It’s important to make the patient comfortable during the detox, but to
inform them that there will be some level of discomfort. As soon as he gets through the physical
withdraw symptoms he would start to attend lectures and groups. Problem 2; Bill is HIV
positive; the short term goal is for him to exhibit no new symptoms of infection. He will be seen
by a physician and will continue his medication as prescribed for HIV. The intervention that the
nursing staff would initiate to prevent infection, in the immunocompromised patient, are the
following: Patient (Pt) will be educated on self-care for his HIV. Pt will take medications. Pt will
protect himself from contraction of colds or influenza by washing hands, and wear a mask when
he is around individuals with infections (Nursing Diagnoses in Psychiatric Nursing 5th edition
Mary Townsend 2001). Patient’s vital signs will be monitored at regular intervals. Blood tests
will be conducted to monitor blood counts.
Problem 3; Patient lacks knowledge of the disease of chemical dependency, and has
been unable to remain abstinent from drugs. Goal for problem 3; Bill is to recognize how the
disease of addiction has impacted his life and why abstinence is necessary. Patient will do this
by writing 10 consequences of his addiction and then share it in the group. Bill will complete a
first step assignment and will make a list of areas of powerlessness and unmanageability. The
patient will learn the skills necessary to maintain a sober lifestyle, such as anger management
and communication skills. (Chemical Dependency Counseling Robert R. Perkinson 1997).
The patient will learn to identify triggers of relapse and learn new coping skills for relapse
prevention. Some of the identified relapse triggers are; using people, anger, depression and
fear regarding his health and HIV status. The coping skills developed are that Bill will avoid
using people and places, keep a journal of feelings and build a sober support system.
Problem 4: Patient is exhibiting signs of depression that could be connected to the
chemical dependency and HIV status. This is evidenced by patient’s isolation, expressed
feelings of hopelessness and sadness. Bill will meet with a psychiatrist to evaluate depression
and possibly be given anti-depressants. Bill needs to deal with grief and loss issues he will do
that by attending a HIV/AIDS support group where he can safely share feeling about his illness.
It will be suggested that Bill explore his spirituality and consider attending a church, temple or
synagogue of his choice for additional support.
Bill will be educated on ongoing recovery. Upon discharge from the inpatient level of care,
an aftercare/continuing care plan will be implemented. While in treatment he will be educated on
the 12-step recovery program, such as how to get a sponsor and work the 12 steps. Upon
discharge patient will attend NA meetings daily, obtain a sponsor and work the 12-steps. Bill will
also attend the weekly aftercare groups.
The treatment plans change as goals are met and then new problems could be added,
(Chemical Dependency Counseling Robert R. Perkinson 1997) such as the unemployment
status. Pt should first focus on his recovery. 1. To become free of his active addiction, 2. Being
able to maintain his sobriety. Pt must also continue to take his HIV and anti-depressant
medication. When these are accomplished, I would suggest that he see an occupational
therapist and work on developing a career. Pt was interested in computers, so he could take
some classes on computer programming to get an education and then become employed. This
will help patient with self-esteem and help him develop a sense of purpose.
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Mary’s treatment plan will consist of education on the disease of chemical dependency. I
would recommend that she attend an intense family program where she will attend lectures and
participate in family group activities. Mary will be educated on co-dependency, enabling
behaviors and family roles and dynamics.
Problem 1; Co-dependency, a co-dependent person is obsessed with controlling the person
that is out of control (Beatti, 1987; Weinhold& Weinhold 1998, Perkinson 1997). Mary has been
so focused on Bill that she has lost the ability to take care of her own needs. Mary is to learn to
stop focusing on Bill and explore her own thoughts and feelings. She will do this by keeping a
daily journal exploring her own feeling and pain. Mary will learn to communicate her feelings
and needs. Education in developing boundaries and role play exercises will assist Mary in
identifying and practicing new behaviors. Problem 2; Enabling behaviors, Mary has a history of
enabling Bill by protecting him from the consequences of his using. Mary has lied for Bill and
has even made a purchase of heroin for Bill, at his insistence. Mary will be educated on how
enabling behavior allows the chemical dependency to progress. Mary will learn to stop the
enabling behaviors and stop protecting Bill from the consequences of his use. (Beatti, 1987;
Weinhold& Weinhold 1998, Perkinson 1997).
Problem 3; Mary has been isolated, dealing with the feelings of shame connected to living
with the addiction and the HIV status. Mary will develop a support system in a support group for
families living with HIV/AIDS. Mary will be able to get the support she needs and be able to
share in a safe environment. Mary will attend Al-Anon meetings where she will find a sponsor
and work the 12-steps.
The treatment plan for them as a couple and the desire to have a baby are as follows.
First is for them to each commit to their own individual treatment plans, and to support each
other in achieving individual treatment goals. They will participate in couples counseling with a
Marriage and Family Therapist. Now regarding the idea of having a baby, I would suggest that
they postpone this for at least two years. I would instruct them to continue practicing safe sex.
This would give them time to stabilize, complete treatment goals, and build the foundation for
their recovery. I would inform them that there are risks in pregnancy with the HIV status. Such
as 20 % to 40% of babies born to HIV infected mothers become infected with the virus
(HIV,AIDS and Pregnancy McKesson Health Solution LLC 2002). Bill is the one with HIV but if
they have unprotected sex in an attempt to have a baby there is a chance of Mary becoming
infected. Other options would be offered for consideration, such as adoption. There is a way for
the male sperm to be tested for HIV and even washed, but because this is out of my scope of
my practice. The recommendation would be for them to consult a physician that specializes in
this area.
There are many diseases out there that effect peoples lives, but recovery is possible.
Educating oneself is the key to prevention.
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REFERENCES AND SUGGESTED ADDITIONAL RESOURCES
HIV, AIDS and Pregnancy McKesson Health Solution LLC 2002
CDC.gov/hepatitis 2003
Centers for Disease Control and Prevention HIV/AIDS Surveillance report 2000; 12(no.1):1-44
Chemical Dependency Counseling Robert R. Perkinson 1997
Nursing Diagnoses in Psychiatric Nursing 5 h edition Mary Townsend 2001
“The Persistent Threat of AIDS” The PDR Family Guide to Women’s Health and Prescription
Drugs. David W. Sifton, 2003
Encyclopedia of Medicine “Hepatitis A Larry I. Lutwick 2001
Encyclopedia of Medicine “Hepatitis B David A Cramer, MD 2001
Loosening the Grip, Kinney & Leaton 1995
ACKNOWLEDGEMENTS
The information contained in this Course Material was prepared by Kelly M. Ryan, who is a
counselor at the Betty Ford Center, and is a candidate for the Master of Arts in Addictive
Disorders degree from Breining Institute. Breining Institute has edited the original material for
the purpose of presentation in this course. The Examination Questions were developed and are
copyrighted by Breining Institute, and cannot be distributed or reproduced without permission
from Breining Institute.
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The
Supervisor
Training Manual for Clinical Supervisor Competency in the Addic:on Treatment Se;ng Breining Research and Educa:on Founda:on The
Supervisor
Training Manual for Clinical Supervisor
Competency in the Addic:on Treatment Se;ng
Breining Research and Educa:on Founda:on
8894 Greenback Lane, Orangevale, California USA 95662-‐4019
www.breining.edu/BREFounda:on.htm
The Clinical Supervisor:
Training Manual for Clinical Supervisor Competency in the Addiction Treatment Setting
Copyright © 2010 by Breining Research and Education Foundation
All rights reserved. No part of this publication may be reproduced or transmitted in any form
or by any means, electronic or mechanical, including photocopying and recording, or by an
information storage and retrieval system, except as may be expressly permitted by the
Breining Research and Education Foundation or the publisher.
For additional copies to purchase, comments, or permission to reprint material, contact the
publisher at:
Breining Institute
8894 Greenback Lane
Orangevale, California USA 95662-‐4019
Printed in the United States of America.
Training Manual for Clinical Supervisor Competency in the Addic:on Treatment Se;ng
Table of Contents
Forward...........................................................................................................................................3
Contributing Authors ................................................................................................................5
Introduction ..................................................................................................................................7
Section
1
Background Information
1.1 Effect of the Management Role on Managers: A Study .....................................11
1.2 Financial Cost of Addictive Disorders ......................................................................23
Section
2
Foundation Areas
2.1 Models of Supervision: A Brief Overview ..............................................................41
2.2 Management Styles ..........................................................................................................51
2.3 Faith-‐based Modalities ...................................................................................................61
2.4 The Supervisor: An Historical Perspective ............................................................73
2.5 Leadership in Clinical Supervision............................................................................85
2.6 Challenges of Clinical Supervision: A Case Study .............................................101
2.7 Strategic Planning Tools .............................................................................................117
2.8 Preventing Sexual Harassment ................................................................................123
Section
3
Performance Domains
3.1 Counselor Development .............................................................................................135
3.2 Transference and Countertransference................................................................145
3.3 Developing Competent Counselors ........................................................................151
3.4 Professional / Ethical Standards of Case Management .................................165
3.5 Program Description Policy ......................................................................................175
3.6 Supervising Recovering Counselors ......................................................................183
3.7 Policy and Organizational Design ...........................................................................197
Section
4
Appendices
A. Professional Quality of Life Scale (ProQOL) .........................................................207
B. TAP 21-‐A Section III ........................................................................................................211
C. TAP 21-‐A Section IV .........................................................................................................217
D. ConZidentiality of AODA Patient Records (42 CFR part 2)..............................223
Copyright © 2010 Breining Research and Educa:on Founda:on
1
Forward
We wish to acknowledge and thank the California Association of Addiction Recovery Resources,
California Association of Alcoholism and Drug Abuse Counselors, California Association of
Drinking Driver Treatment Programs, California Association for Alcohol / Drug Educators,
NAADAC – The Association for Addiction Professionals, and Breining Institute for their
assistance in identifying the capable authors who contributed to this Manual.
We also wish to speciZically thank the following individuals for their respective reviews of this
Manual prior to Zinal publication:
• Shirley Beckett Mikell, NCAC II, CAC II, SAP, Director of CertiZication and Education, NAADAC
The Association for Addiction Professionals; Staff Liaison, National CertiZication Commission
• Susan Blacksher, MSW, MCA, Executive Director, California Association of Addiction Recovery
Resources
• Warren Daniels III, BA, M-‐RAS, CADC II, ICADC II, Executive Director, Community Recovery
Resources; Chair, California Foundation for the Advancement of Addiction Professionals
• Luky Maldonado, CAODC, Senior Vice President, Safety Center, Inc.; Chair, California
Association of Drinking Driver Treatment Programs
• Armond Urbano, CAS II, RAS, Director, Education and Training, California Association of
Addiction Recovery Resources
• Carole Warshaw, EdD, Adjunct Professor, Kaplan University
We hope that this Manual provides valuable information for the individual desiring to improve
his/her competency as a clinical supervisor in an addiction treatment setting.
Editors
Michael J. Breining, JD, M-‐RAS
President, Breining Institute
Kathy L. Christopher, JD, M-‐RAS
Dean of Academic Affairs, Breining Institute
Theresa J. Russell, DrAD, MCA
Dean of Instruction, Breining Institute
3
Contributing Authors
Barbara Aday-Garcia, CSC, AODC
DUI Program Manager
Occupational Health Services (dba MHN)
Alexis Hernandez-Hons, PsyD, LMFT
Program Manager
Mental Health Systems, Inc.
Jessica Apfel, PsyD
Alcohol and Other Drug (AOD) Specialist
Director of Clinical Services
Aegis Medical Systems
Jodie S. Arrington, BA, CAP
Substance Abuse Counselor
Michael P. Belzman, PhD, MDAAC, M-RAS
Chief Executive OfZicer
Association of Christian Alcohol and Drug
Counselors
Mary Cook, MA, RAS
Author, Speaker, Private practice and
retired Professor
Mary Crocker Cook, DMin, LMFT
Instructor / Program Coordinator
San Jose City College Alcohol & Drug Studies
Program
John Fulan, LMFT, M-RAS
Clinical Supervisor
Mental Health Systems, Inc.
Ivey Ike Grozier III, MA, CCJAP, CADCA
Executive Director
Recovery Connections Treatment Services
Brian W. Jackson, MS, CAP, CGAC, ICADC
Program Director
GreenZield Center IOP
Teri R. Kerns, MBA, CSC, CADC II
Director of Operations / Direct Clinical
Services
Occupational Health Services (dba MHN)
Jenna M. McAdam, MS, RAS
Program Director
California Human Development / Athena
House
James R. McKinney, PhD
Coordinator, Criminal Justice Addictions
Programs
Loyola Marymount University
Rick E. Thomas, MS, CATC
Consultant
IDEA Consulting
Sally Wynn, MA, MCA, CSC, CAS II
Consultant
5
Introduction
Breining Research and Education Foundation is a 501(c)(3) nonproZit, tax-‐exempt, public
beneZit corporation, dedicated to the education and research of addictions and disseminating
results of that research to the public and professionals involved in the addictions Zield.
With the goal of developing a meaningful training manual to assist addiction professionals
become clinical supervisors, or to improve their skills in clinical supervision, the FOUNDATION
has developed this publication, The Clinical Supervisor: Training Manual for Clinical
Supervisor Competency in the Addiction Treatment Setting, with the generous academic
contributions of a number of clinicians, supervisors, program managers and educators in the
Zield of addictions.
This Manual uses as a guide the recommendations suggested within the “Competencies for
Substance Abuse Treatment Clinical Supervisors” Technical Assistance Publication Series 21-‐A
(also known as the “TAP 21-‐A Supervisor Competencies”), primarily the Section III Foundation
Areas, and the Section IV Performance Domains.
Disclaimer
The opinions expressed herein are the views of the respective authors, and do not necessarily
reZlect the opinion of the FOUNDATION or Breining Institute.
Copyright
The materials contained within this publication are copyrighted by the FOUNDATION, except for
that material copyrighted by other sources and used with permission. Copying and/or printing
of isolated articles for noncommercial classroom distribution and/or library reserve use is
permitted, provided a fee is not charged for the material, and the material is fully and properly
cited.
Recommended Citation
Breining Research and Education Foundation (2010). The Clinical Supervisor: Training Manual
for Clinical Supervisor Competency in the Addiction Treatment Setting. Sacramento, CA: Breining
Institute.
7
2.8 Preventing Sexual Harassment13
Teri R. Kerns, MBA, CSC, CADC-II
Barbara Aday-Garcia, CSC, AODC
As Clinical Supervisors, it’s our obligation and responsibility to our associates, organizations,
and clientele to ensure that we provide an atmosphere of the highest professional and ethical
standards. Part of this responsibility is our obligation to provide clear supervision that creates
a counseling environment that is free of harassment. This includes role-‐modeling appropriate
behaviors, developing and enforcing policies, and providing clear training and direction.
Harassment can take many forms, including verbal, physical, and sexual harassment. In this
article, we will focus on sexual harassment, the Equal Employment Opportunity Commission
sections pertaining to sexual harassment, and the laws speciZic to the State of California.
Sexual harassment claims are a reality in workplaces across America, and that this most
certainly includes the counseling workplace. Sexual harassment in the workplace can take many
forms. Our personal experience shows that mandated clientele may not be ready for the issues
that arise as they explore their own substance abuse history. This leads to increased
responsibility on the part of the supervisor to ensure the environment and counseling
relationship is of the highest standards. Sexual Harassment is a serious threat that can put the
counselor and agency at risk Zinancially; also the professional reputations of both the agency
and the counselor can be permanently damaged. The U.S. Equal Employment Opportunity
Commission’s data compiled by the OfZice of Research, Information and Planning, shows that
51.5 million was paid out in monetary beneZits in 2009, and this does not include settlements in
response to litigation. There are laws that prohibit harassment in agencies that receive federal
funding, and individuals as well as agencies may be held Zinancially liable for the consequences
of sexual harassment. U.S. Equal Employment Opportunity Commission states that Sexual
harassment is a form of sex discrimination that violates Title VII of the Civil Rights Act of 1964;
Title VII applies to employers with 15 or more employees, including state and local
governments.
When we look closer to home here in California, we have Assembly Bill 1825, sponsored by
Assemblywoman Sarah Reyes and signed into law by Governor Schwarzenegger on September
29, 2004. This bill clearly outlines the responsibilities of employers. California employers are
required to provide training and instruction to supervisors on preventing unlawful
discrimination and harassment in the workplace. This law, the Zirst of its kind, requires
employers with 50 or more associates, including independent contractors and temporary
workers to provide training to supervisors speciZically on sexual harassment every two years. If
an agency promotes a counselor to the supervisory position, or hires a new supervisor
externally, the training must be provided within their Zirst six months in their new role. In our
own State Counselor Regulations, Section § 13040. Requirements for Initial CertiZication of AOD
Counselors, speciZically requires training on the Prevention of Sexual Harassment, and this is
also required in Section § 13055 (5) for the renewal of AOD Counselor CertiZication.
13
This section was submitted by Teri R. Kerns, Director of Operations / Direct Clinical Services,
for Occupational Health Services (dba MHN), in San Marcos, California, and Barbara Aday-‐
Garcia, DUI Program Manager for Occupational Health Services (dba MHN), also in San Marcos,
California. It was edited by the FOUNDATION for inclusion within this Manual.
123
THE CLINICAL SUPERVISOR
We feel it would be prudent for agencies with less than 50 associates provide internal guidance,
both as a customer service tool, and to mitigate the potential risk. In our agencies, we provide
training on harassment to all associates, including line and clerical staff, as we believe we have
an obligation to provide them with the information and tools necessary to address unwelcome
behavior. Supervisors are then provided with additional training, speciZic to their role and
responsibilities on an annual basis.
Sexual harassment is a form of discrimination that violates Title VII of the Civil Rights Act of
1964, as well as other federal, state, and local laws. The following elements show how the Equal
Employment Opportunity Commission (EEOC) and the courts have deZined sexual harassment.
When we see the words employment, work performance, workplace we need to understand
that although the deZinition refers to the working environment the counseling relationship falls
into this category.
Sexual Harassment can arise in several different types of relationships and in several different
contexts, and is not tied to gender. Both male-‐to-‐female and female-‐to-‐male harassment are
prohibited, as is same-‐sex harassment. The harasser can be the victim's supervisor, a
supervisor in another area, a co-‐worker, a counselor, or someone who is not an employee of the
employer, such as a client or customer.
The EEOC deZines a supervisor as follows:
“If the individual has the authority to recommend tangible employment decisions affecting the
employee or if the individual has the authority to direct the employee's daily work activities. A
tangible employment action means a signiRicant change in employment status. Examples
include hiring, Riring, promotion, demotion, undesirable reassignment, a decision causing a
signiRicant change in beneRits, compensation decisions, and work assignment.”
In many of the counseling arenas, especially mandated programs, the counselor operates from a
position of authority, and is in the position to make tangible decisions regarding the status of a
client. Entering into the counseling relationship can in itself be a difZicult but necessary
situation for our clients, and it’s our responsibility to ensure it’s a healthy one. For example, a
counselor in a Driving Under the InZluence (DUI) program has the authority to recommend a
client be dismissed from the DUI program for violation of a rule. A dismissal from the Driving
Under the InZluence (DUI) program can in turn, negatively impact the client’s driving privileges,
result in jail time, and in additional fees. The impact of these types of decisions is great, and
deZinitely puts the AOD Counselor in a position of authority in the mandated environment.
Based on the potential impact, and positional authority of the counselor, Clinical Supervisors
have an increased responsibility to ensure that counselors provide a safe harbor for all clients.
As a Clinical Supervisor, we are tasked with both role-‐modeling appropriate behavior, ensuring
the counselors under our supervision understand the impact of their behaviors, and their
responsibility to uphold the agencies policies that prevent sexual harassment claims, and
ensuring an atmosphere free of sexual harassment for all clientele.
Sexual Harassment denies its victims a safe counseling experience, impedes the counseling
relationship, and the client’s ability to move forward. Clients who experience sexual harassment
are likely to stop coming to treatment, and may experience stressors that compound their
reasons for seeking treatment in the Zirst place. As counselors in the Zield, we have observed
124
that there are a higher proportion of individuals seeking treatment for substance abuse that are
or have been victims of sexual harassment or abuse, than in the general public. As Managers we
have personally seen the devastation that clients, agencies and counselors go through when a
claim of sexual harassment is made. The road to a harassment-‐free setting is both the internal
knowledge of not only the ramiZications of sexual harassment but also more importantly what
can be done to prevent it.
Sexual Harassment is:
Unwelcome Conduct that is Sexual In Nature and would offend a Reasonable Person and is
used as a basis for making employment decisions; or unreasonably interferes with an
individuals work performance; or creates an intimidating, hostile or offensive work
environment.
What is especially important for all to understand is that you do not have to intend to harass
someone for it to be illegal. Sexual harassment is judged by the impact on its victim not on the
harasser's intent. If unwelcome conduct of a sexual nature is sufZicient to alter the victim's
working (counseling) conditions, whether intentional or not, it meets the deZinition of sexual
harassment. A controversial example of this is the practice of hugging clients; the counselor may
not intend this act to be sexual but the client may interpret it as unwelcome sexual conduct.
Unwelcome Conduct is deZined as:
• Uninvited
• Uninitiated
• Unwanted
• Sexual harassment must be sexual in nature
The standard used by the courts for assessing whether particular conduct constitutes sexual
harassment is whether a reasonable woman or man would Zind it offensive. In determining
whether conduct is offensive, the sensitivities of a "reasonable person" are considered. Some
people are overly sensitive about sex; such individuals do not set the standard. Rather, the law
looks at whether a reasonable person would be offended. Courts recognize that men and
women interpret sexual harassment differently (hence the “reasonable man” and “reasonable
woman” standard.) Therefore, if a woman is the victim of harassment, it must be asked whether
the conduct would offend a reasonable woman. It is not a defense for a male to say that the
conduct complained of would not bother him if he were in the victim's shoes. Nor will a history
of always having talked of sex at work, or having had "pin ups" on the walls for many years
excuse sexually offensive behavior. As we become more aware of the potential impact, and
damage an inappropriate counseling relationship can cause, the importance of our role as
clinical supervisors can not be taken lightly.
Important: Someone does not have to suffer unduly before they can complain of sexual
harassment. The conduct need only be offensive to a reasonable person.
Sexual harassment can take different forms, ranging from blatant requests for sexual favors to
unintentionally offensive comments. The Equal Employment Opportunity Commission (EEOC)
regulations describe two kinds of sexual harassment:
125
• Quid Pro Quo Sexual Harassment
Quid pro quo is the Latin term meaning "this for that." Quid pro quo sexual harassment arises
when employment decisions are based on whether or not an employee gives in to sexual
advances. If anyone ever conditions a beneZit in return for something sexual, it constitutes
quid pro quo harassment. As discussed above, we can see that with Quid Pro Quo counselors
are placed in a position of power, especially if the court had mandated the counseling
program, and speciZic actions are tied to compliance. For example, the return of a driver’s
license in the case of a DUI program, or the reduction of drug charges in the case of PC-‐1000
or PC-‐1210.
• Hostile Environment Harassment
A second type of sexual harassment is "hostile environment" harassment. It is different from
quid pro quo harassment, as it does not require a counselor or person in power to trade
beneZits in return for sex. Rather, if there is enough sexually oriented conduct in the setting
that a reasonable person would be uncomfortable, there may be an illegal hostile
environment. Conduct that creates a hostile environment can take many different forms and
may be intentionally or unintentionally offensive. A hostile environment could be considered,
if a counselor tells sexually explicit jokes in-‐group, or allows sexually explicit jokes to be told
in-‐group, creating/allowing a sexually hostile environment.
The courts have established standards for evaluating the characteristics of conduct which could
result in a sexually hostile work environment, including:
• Severe or Pervasive -‐ There either has to be a single instance of serious sexual misconduct or
enough separate instances of sexually oriented conduct that it creates an uncomfortable
working (or counseling) environment.
• Pattern of Offensive Conduct – There needs to be a pattern of such conduct before it violates
the law; two or three incidents can create a pattern.
• Offensive to a Reasonable Person -‐ In determining whether conduct is offensive, the
sensitivities of a "reasonable person" are considered.
You be the Judge
How would you evaluate the following situations?
• Example 1: Otis, a counselor, always requires the women in his mandated Drug Diversion
group to sit next to him, going so far to “save seats,” for them, and tells the women how nice
they look, commenting on new outZits they are wearing, etc. Is he guilty of sexual harassment?
Authors’ comments: Could be, he is commenting on their physical appearance that is tipping the
scales towards sexual harassment. And, saving seats for speciRic clients is never a good idea, and
could be seen as a pattern of offensive conduct.
• Example 2: Mario, a clinical supervisor in your agency from Europe always greets his
associates with series of kisses on the cheek. In Mario's culture, this is the way friends are
greeted. If a co-‐worker is uncomfortable with his greetings, could it be sexual harassment
126
even though his actions are innocent and well intentioned?
Authors’ comments: Yes, remember sexual harassment is judged on the impact to the victim, not
on the intent of the harasser; in this case, the females under Mario’s supervision may not
welcome this behavior, but be unable to tell him, as he is in a position of authority, quid pro quo.
• Example 3: Bill, a clinical supervisor, tells Paula, a counselor under his supervision that he
Zinds her attractive and would like to go out with her. When Paula tells Bill she is not
interested, Bill recommends that she explore opportunities to Zind a new supervisor, because
it is now too difZicult for them to continue working together. Could this be quid pro quo sexual
harassment?
Authors’ comments: Yes, remember the EEOC deRines a supervisor as follows: “If the individual
has the authority to recommend tangible employment decisions affecting the employee or if the
individual has the authority to direct the employee's daily work activities.”
• Example 4: While conducting a mandated DUI Counseling session, Ron, a counselor, tells one
of his female clients that he attends an AA meeting that she would enjoy on Thursday nights
after the group. The client politely thanks him but declines the invitation, to which Ron
replies, “you better be careful of your absences or I will have to dismiss you, and you’ll be
seeing the Judge.”
Authors’ comments: While Ron has not said anything overtly sexual, the impression the client
may have is that he is asking for a date, and that if she does not comply, her program compliance
is in jeopardy, giving the impression of quid pro quo, this for that.
• Example 5: An all female PC1210 (Proposition 36) group, ending at 6:30 p.m. walks past the
group of male clients waiting to attend the next group. As the women are leaving, the men
waiting make suggestive sexual comments as the women walk by; the counselor is the last to
leave the room and does not hear the comments. The next week the female clients tell the
counselor what happened. Could the women claim sexual harassment?
Authors’ comments: Yes, this is a clear situation of hostile environment sexual harassment, it’s
the counselor, and agency’s responsibly to immediately stop the behaviors by addressing the
male clients on the behavior, with the Clinical Supervisor joining the group to educate them on
sexual harassment, and clearly outlining the consequences of any future harassment. Another
important point for the agency is to “close the loop,” with the Clinical Supervisor joining the
group to let the female clients know that the behavior has been addressed, and that any further
incidents should be reported immediately.
• Example 6: Sally greets her clients, who are participants in a court-‐ordered Driving Under the
InZluence (DUI) program, with a big welcoming hug at the beginning of each session. Is she
engaging in sexually harassing conduct?
Authors’ comments: Yes – this could meet several of the deRinition of sexual harassment. The
behavior is pervasive, as it happens at the beginning of each group and may also creates an
uncomfortable counseling environment, and given that the attendance is mandated, the
repeated hugging could be seen as offensive to a reasonable person, given that they are required
127
to attend. We recognize that historically hugging is an acceptable part of the Rield, but that
times have changed, and Clinical Supervisors have an obligation to ensure all counseling
interactions are professional, especially in a mandated program.
Two legal case reviews are included for your consideration below:
In the case of Spencer v. General Electric, 697 F. Supp. 204 (E.D. Va. 1988), the supervisor of an
ofZice engaged in virtually daily horseplay of a sexual nature with female subordinates. This
behavior included sitting on their laps, touching them in an intimate manner, and making lewd
comments. The subordinates joined in and generally found the horseplay funny and inoffensive.
With the exception of one incident (which may have been time-‐barred and was not critical to
the court's decision), none of the horseplay was directed at the plaintiff. The supervisor
additionally engaged in consensual relations with at least two of his subordinates. The court
found that the supervisor's conduct would have interfered with the work performance and
would have seriously affected the psychological well-‐being of a reasonable employee, and on
that basis it found a violation of Title VII.14 Although Spencer did not involve sexual favoritism,
the case supports the proposition that pervasive sexual conduct can create a hostile work
environment for those who Zind it offensive even if he targets of the conduct welcome it and
even if no sexual conduct is directed at the persons bringing the claim.15 You do not have to
intend to harass someone for it to be illegal; sexual harassment is judged by the impact on its
victim, not on the harasser’s intent.
The US Equal Employment Opportunity Commission (EEOC) recently announced the settlement
of two lawsuits against Landwin Management, Inc., a San Gabriel, California-‐based hotel
operator,16 for $500,000 and signiZicant remedial relief in cases alleging national origin
discrimination and sexual harassment. Both suits were Ziled under Title VII of the Civil Rights
Act of 1964. In the sexual harassment suite, the EEOC alleged that the San Gabriel Hilton
subjected female employees to a sexually hostile work environment, including verbal sexual
harassment by the housekeeping department supervisor, who referred to the women as
“whores” and “prostitutes” in addition to other offensive language. The supervisor also allegedly
reprimanded the female employees if they even spoke to men, and Landwin failed to respond to
the employees’ complaints of harassment.
In addition to the $500,000 in monetary relief, the EEOC reported that a three-‐year consent
decree settling the two lawsuits will also ensure that (1) Landwin will implement hiring and
recruiting goals for Hispanic employees; (2) Landwin will revise its written policies on
discrimination, sexual harassment and recruitment and hiring; (3) employees will receive
annual training regarding discrimination, including national origin discrimination and sexual
harassment; (4) Landwin will retain an EEO monitor / consultant named by the Commission to
14
Ibid, 697 F. Supp. at 218.
US Equal Employment Opportunity Commission (1990), Policy Guidance on Employer Liability
under Title VII for Sexual Favoritism. Retrieved February 20, 2010 from http://www.eeoc.gov/
policy/docs/sexualfavor.html
15
16
Case No. CV 07-‐05916 PA, settled February 3, 2010.
128
assist with recruiting, hiring, training, revision of policies and record-‐keeping procedures; and
(5) the company will provide annual reports to the EEOC regarding its employment practices.
“The days when employers make decisions based on stereotypes and assumptions shaped by
the race or national origin of their employees should be far behind us,” said Anna Y. Park, the
regional attorney for the EEOC’s Los Angeles District OfZice. “Further, sexual harassment should
no longer be tolerated in any workplace, and employers should never condone or overlook the
mistreatment of vulnerable victims, such as monolingual Spanish-‐speaking women.”17
If you are a Clinical Supervisor, we recommend that you ensure your company has clear, written
policies in place, and that you provide refresher training on an annual basis. If you are a
Counselor, we recommend that you step back and take a look at your own patterns of behavior.
Can any of your behaviors be misconstrued? We also recommend that Group Counselors be
aware of the potential for sexual harassment in group, and step in quickly to address any
perceived implications of harassment.
It is crucial that as Clinical Supervisors we carefully screen the counselors we hire, and
subsequently place in a position of responsibility. Our hiring practices should include both a
reference check, inquiry into past offenses for harassment, and upon hire, training on internal
policies, including sexual harassment be conducted in a timely manner. Part of the counseling
relationship is the underlying premise that all people deserve to be treated with fairness and
respect. To ensure that a positive, respectful counseling environment is maintained, counselors
must understand the ramiZications of sexual harassment and agencies must develop clear,
written guidelines and provide training establishing their policy against harassment.
Most companies are committed to providing a harassment-‐free work environment for all
employees and clients. It is your responsibility to refrain from harassing behavior and to
promptly report any inappropriate conduct, even if you are not the target of the harassment or
discrimination. If you have knowledge of any potential harassment, you have an obligation to
the Zield, your clientele, and your agency to investigate immediately. Maintaining a harassment-‐
free workplace is essential to keeping a positive and productive counseling environment for all
involved. If you do suspect harassment, as a Clinical Supervisor, it is your obligation to stop the
behavior.
Additionally, State of California Code of Regulations (CCR), Title 9, section 13065 requires any
State licensed agency employing an Alcohol Other Drug (AOD) counselor to notify the
Department of Alcohol and Drug Programs of knowledge of a violation of said AOD Counselor’s
certifying agency’s code of conduct.18 Section 13065 also requires ADP to investigate all alleged
violations of the code of conduct by a registrant or a certiZied alcohol and other drug counselor.
Within ninety (90) days of receipt of the request ADP is required to send a written order to the
certifying organization specifying what corrective action (if any) it shall take based on ADP’s
investigation and the severity of the violation. Section 13065(f) requires the certifying
US Equal Employment Opportunity Commission, press release, “Landwin Management to Pay
$500,000 for National Origin Bias and Sexual Harassment,” issued February 3, 2010, retrieved
from http://www.eeoc.gov/eeoc/newsroom/release/2-‐3-‐10c.cfm
17
18
California Code of Regulations (CCR), Title 9, Division 4, Chapter 8, section 13000, et seq.
129
organization to document in its database the violation alleged, the outcome of ADP’s
investigation, and what action the certifying organization took based on ADP’s investigation the
same day that the certifying organization sends written notiZication to the counselor or
registrant.
The Breining Institute Clinical Supervisor Code of Ethics states:
I will not verbally, physically, or sexually harass, threaten or abuse any program participant,
patient, client or fellow addiction professional…. I have an individual responsibility for myself
in regard to sexual conduct and/or contact with clients, and shall not engage in sexual conduct
with current program participants, patients or clients.
As a Clinical Supervisor employed in any agency within the State of California that is licensed by
the State Department of Alcohol and Drug programs, you are mandated to report the violation of
the Breining Code of Ethics to ADP, along with the Breining Institute. At the time of notiZication,
an independent investigation will be conducted by the ADP Program Licensing Branch, and a
recommendation with be made to the Certifying Organization regarding the Counselor’s
certiZication:
§ 13065. Investigation of Complaints, Suspension, and Revocation.
(a) Within 24 hours of the time an alleged violations of the code of conduct speciRied in Section
13060 by a registrant or a certiRied AOD counselor becomes known to an AOD program, the
program shall report it to the Department and to the registrant or counselor's certifying
organization. Such report may be made by contacting the Department and the certifying
organization in person, by telephone, in writing, or by any automated or electronic means,
such as e-mail or fax.
(b) The report shall include facts concerning the alleged violation.
(c) The Department shall investigate each alleged violation.
(d) Within ninety (90) days of receipt of the request for investigation, the Department shall
send a written order to the certifying organization specifying what corrective action (if any) it
shall take, based on the Department's investigation and the
severity of the violation.
(e) If the Department orders the certifying organization to temporarily suspend or revoke a
counselor's certiRication or registration, the certifying organization shall so inform the
counselor and the AOD program employing the counselor or registrant in person or by
telephone, with written notiRication to follow, immediately upon receipt of the written order
from the Department. The written notiRication shall inform the counselor or registrant of his/
her right to administrative review pursuant to Section 13070.
(f) The same day that the certifying organization sends written notiRication to the counselor or
registrant, it shall document in its database (pursuant to Section 13075) the violation alleged,
the outcome of the Department's investigation, and what action the certifying organization
took based on the Department's investigation.
130
(h) If the Department does not order temporary suspension or revocation, within ten (10) days
of receipt of the written order from the Department, the certifying organization shall send
written notiRication to the counselor or registrant and the AOD program employing him/her,
informing him/her of the results of the
investigation.
Conclusion
As Clinical Supervisors with over 40 years combined experience in the Zield, we have observed
an increasing number of sexual harassment claims, and realized that dealing with this issue,
although uncomfortable, was a vital component of our role. Educating ourselves was the Zirst
step towards providing an environment for our staff to openly discuss sexual harassment,
allowing us to take the steps necessary to provide a safe and productive counseling
environment.
References
Checklist for a Comprehensive Approach to Addressing Harassment, OfZice for Civil Rights, U.S.
Department of Education, available at http://www.ed.gov/about/ofZices/list/ocr/
checklist.html
Do the Right Thing: Understanding, Addressing, and Preventing Sexual Harassment in Schools,
National Women’s Law Center (1998). http://www.nwlc.org/pdf/Final
NIDA InfoFacts: Understanding Drug Abuse and Addiction. http://www.drugabuse.gov/
infofacts/understand.html
Further guidance on harassment can be found in the 1999 Guidance on Employer Liability for
Unlawful Harassment by Supervisors; the 1980 Guidelines on Sexual Harassment; the 1990
Policy Statement on Current Issues in Sexual Harassment; the 1990 Policy Statement on
Sexual Favoritism; http://www.eeoc.gov/
The EEOC Training Institute provides a wide variety of training to assist employers in educating
their managers and employees on the laws enforced by EEOC and how to prevent and
correct discrimination in the workplace. More information is available at http://
www.eeoc.gov/Zield/washington/training.cfm.
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS, Adoption of Chapter 8 (commencing with
Section 13000), and Amendment of Sections 9846, 10125, and 10564, Division 4, Title 9,
California Code of Regulations, COUNSELOR CERTIFICATION http://www.adp.ca.gov/
Licensing/LCBhome.shtml
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3.4 Professional / Ethical Standards of Case Management22
Ethics
Socrates devoted the better part of his life deZining and better understanding moral values
within a cultural context and extending those values more broadly into the study of ethics. As
such, he laid the foundation of our understanding of an ethic as deZined as “a set of principals of
right conduct” and “the study of the general nature of morals and of the speciZic moral choices to
be made by a person.” (Houghton 2009) So what does this mean to you, the reader today and
how can you apply ethics to your study and practice in the Zield of Recovery?
Purpose of Standards
Imagine a world with no laws or rules by which to govern. If you are a real thrill seeker, this
may sound exciting to you. However, for most we rely heavily on rules to give us guidance and a
sense of safety and security. I once traveled to China to study the culture and language. It was a
wonderful experience that I would highly recommend. However, beware of driving or even
riding a bike for that matter. The trafZic is a nightmare. There are no trafZic signals! For a
country with one-‐sixth of the earth’s population, can you imagine driving there with no trafZic
signals? How would you know when to stop for others or when you have the right of way? In
most cities, cars driving opposite the Zlow of the intersection simply begin advancing together
slowly until they “choke off” the opposite Zlow and then it is their turn until they experience the
same. Can you imagine living in a major metropolitan area in which there were little or no rules
to driving? There would be complete chaos. The same is true for professional Zields of practice.
The establishment of ethics as “a set of principals” allows for the proper governance of the Zield
and establishes a standard of care that protects both the professional and client alike. The
remainder of this article will discuss several important issues in the study of Professional &
Ethical Standards of Case Management and Counseling in the Addiction Treatment Professions.
While its intent is to be thorough in the discussion matter, it is not intended to be all-‐inclusive.
The best advice to offer is, when in doubt, consult with your clinical supervisor, your Drug &
Alcohol Certifying Board, the California Board of Behavioral Sciences or other relevant parties
as the situation may mandate.
ConRidentiality
All clients are afforded the right to know that the information disclosed by them whether in a
counseling session or in a medical ofZice is strictly conZidential. To better understand how we
can protect our client’s conZidentiality, we must begin to fully understand the boundaries and
limitations of conZidentiality in a treatment environment. Two overarching laws and
regulations offer us guidance. The Zirst is the Health Insurance Portability & Accountability Act
(HIPAA) of which most of us know. The second is 42 Code of Federal Regulations Part 2 which is
largely unknown. HIPAA was designed with four major purposes in mind. The Zirst was to
protect the privacy of a patient’s personal and health information. The second was to provide
This section was submitted by Arron S. Hightower, Director of Clinical Services, Aegis Medical
Systems, Inc. It was edited by the FOUNDATION for inclusion within this Manual.
22
165
for the physical and electronic security of personal and health information. Third, was to
simplify billing and other transactions with Standardized Code Sets and Transactions. Fourth,
was to specify new rights for patients to approve access/use of their medical information. 42
Code of Federal Regulations Part 2 was designed more speciZically to protect persons seeking
treatment. This law forbids disclosure of any treatment related information to third parties
unless one or more of the following provisions are met: a court order is issued; valid written
consent is received from the patient, pursuant to an agreement for the qualiZied service
organization or business associate; for research audit or evaluation purpose; to report a crime
on an institution’s premises or against an institution’s personnel; to medical personnel in a
medical emergency.
Mandated Reporting
California Penal Code 11166. Child Abuse and Neglect Reporting; Duty; Time
“Except as provided in subdivision (d), and in Section 11166.05, a mandated reporter shall
make a report to an agency speciZied in Section 11165.9 whenever the mandated reporter, in his
or her professional capacity or within the scope of his or her employment, has knowledge of or
observes a child whom the mandated reporter knows or reasonably suspects has been the
victim of child abuse or neglect. The mandated reporter shall make an initial report to the
agency immediately or as soon as is practicably possible by telephone and the mandated
reporter shall prepare and send, fax, or electronically transmit a written follow up report
thereof within 36 hours of receiving the information concerning the incident. The mandated
reporter may include with the report any non-‐privileged documentary evidence the mandated
reporter possesses relating to the incident.”(Board of Behavioral Sciences, 2009) Do you see
any potential conZlicts with what we have learned already about reportable information
contained within HIPAA or 42 Code of Federal Regulations Part 2? The answer is yes. There is a
potential that in reporting child abuse we may disclose information that is treatment related
and thus strictly conZidential under federal regulations.
Case Example: SoRia
SoZia is a 28 year-‐old single mother of two children ages 3 & 5. SoZia is currently pregnant and
has been struggling with staying “clean” and has turned in 3 consecutive heroin positive drug
tests. SoZia has missed several appointments with both the doctor and her primary caseload
manager. She was given a behavioral agreement that she is failing. SoZia Zinally meets with her
caseload manager and reports that the other day, she was so tired that she let her two children
walk to a friend’s house 4 doors down so that she could get some rest.
Does any information in this case study rise to the level of a mandatory report? What about her
being pregnant and using, is that considered reportable or treatment related? If yes, then what
speciZic information? If no, then why not? The answer is yes, there is reportable information in
this scenario. SoZia allowing her 2 children ages 3 & 5 to walk unsupervised to a neighbor’s
house is reportable. All other information is related to treatment and may not be reported
unless one of the exclusionary reasons is met.
Case Example: Sam & Lisa
Sam is a 35 year-‐old who is in treatment with his wife Lisa, age 37, for opiate addiction with
poly-‐substance use as well. They have 2 children ages 10 & 15. During a counseling session,
Lisa’s counselor discusses her recent positive UA for heroin and amphetamines and works to
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better understand the situation that led up to her use. Lisa discloses that Sam and she went to a
party last Friday night and the pressure was too much. They both used and got wasted. She
goes on to say that she also has guilt about leaving their 10 year-‐old in the custody of their older
daughter who is 15. While both girls were asleep and unharmed upon their return at 2 am, she
expresses that this was not okay. Does any information in this case study rise to the level of a
mandatory report? Is there any treatment related information that is protected? If yes, then
what speciZic information? If no, then why not? The answer is that it is unclear. Seek
consultation about the 10 year-‐old being left with her older 15 year-‐old sister. All other
information is treatment related and may not be disclosed unless one of the exclusionary
reasons are met.
California Welfare and Institution Code 15630. Elder Abuse Reporting
“Any person who has assumed full or intermittent responsibility for the care or custody of an
elder or dependent adult, whether or not he or she receives compensation, including
administrators, supervisors, and any licensed staff of a public or private facility that provides
care or services for elder or dependent adults, or any elder or dependent adult care custodian,
health practitioner, clergy member, or employee of a county adult protective services agency or
a local law enforcement agency, is a mandated reporter. (b) (1) Any mandated reporter who, in
his or her professional capacity, or within the scope of his or her employment, has observed or
has knowledge of an incident that reasonably appears to be physical abuse, as deZined in Section
15610.63 of the Welfare and Institutions Code, abandonment, abduction, isolation, Zinancial
abuse, or neglect, or is told by an elder or dependent adult that he or she has experienced
behavior, including an act or omission, constituting physical abuse, as deZined in Section
15610.63 of the Welfare and Institutions Code, abandonment, abduction, isolation, Zinancial
abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected
instance of abuse by telephone immediately or as soon as practicably possible, and by written
report sent within two working days.” (Board of Behavioral Sciences, 2009)
Case Example: Bobby
Bobby is a 54 year-‐old who is a model patient. He attends all counseling appointments, and has
been illicit drug free for about 5 years now. He is also in good shape mentally & physically
except for the occasional stiff knee from an old football injury. In the course of a counseling
session, Bobby discloses that his 23 year-‐old son has extreme anger issues and has been beating
him. Does any information in this case study rise to the level of a mandatory report? If yes, then
what speciZic information? If no, then why not? The answer is: No. Bobby would not meet the
traditional deZinition of elder abuse in that he is not 65 or older, developmentally disabled,
mentally ill/disabled, physically disabled or otherwise not able to care for his needs. This is a
matter for law enforcement.
Case Example: Bobby (part 2)
A week later, Bobby discloses in a counseling session that his 23 year-‐old son has been
screaming and cussing at his 83 year-‐old grandmother. Bobby has been present when this
occurred. Bobby is unsure if the son has ever hit her though. Does any information in this case
study rise to the level of a mandatory report? If yes, then what speciZic information. If no, then
why not? The answer is: Yes. The fact that Bobby’s 23 year-‐old son has been verbally abusing
his 83 year-‐old grandmother is considered a mandatory reporting issue. Bobby’s mere question
as to whether his mother has been physically abused by her grandson without any reasonable
suspicion (e.g. report, bruises, etc.) is most likely not. However, when in doubt, consult a
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supervisor and call APS for a consultation without identifying conZidential information until it is
determined that elder abuse is likely to exist.
Duty to Protect
Tarasoff v. Regents of University of California
In the fall of 1967, Prosenjit Poddar came to the University of California Berkley as a graduate
student studying naval architecture. During his studies, he became introduced to Tatiana
Tarasoff, a student at the University as well. The two saw each other regularly while attending a
class. Poddar developed feelings for Tatiana and felt they had a special relationship together.
The depths of his feelings were not reciprocated by Tatiana. Feeling rebuffed, Poddar stated in a
therapy session that he was going to kill Tarasoff. Poddar’s therapist requested that the campus
police detain Poddar and recommended that he be civilly committed as a dangerous person.
Poddar was detained but released shortly thereafter. No one warned Tarasoff or her family of
the threat and several months later on October 27, 1969, Poddar killed Tarasoff. Tarasoff’s
parents sued the Psychologist as well as the University Police, Regents and several others for
failing to warn them that their daughter was in danger. In 1974, the California Supreme Court
reversed the lower court’s decision to dismiss the case and ruled in favor of Tarasoff stating that
“When a therapist determines, or pursuant to the standards of his profession should determine,
that his patient presents a danger of violence to another, he incurs an obligation to use
reasonable care to protect the intended victim against such danger. The discharge of this duty
may require the therapist to take one or more of various steps. Thus, it may call for him to warn
the intended victim, to notify the police, or to take whatever steps are reasonably necessary
under the circumstances.” (Berger & Berger, 2009)
Tarasoff has been adopted throughout the country and exists as the standard of care in most
states. However, considerable confusion remains about the duty to warn. This is largely due to
the verbiage used in the ruling in 1974. However, Tarasoff II issued in 1976, now states that a
therapist actually has the duty to protect the intended victim by warning them or others who
will likely warn them in addition to notifying the police and taking all reasonable steps to
protect the intended victim given the circumstances faced. Should a therapist be found to both
make all reasonable attempts to notify the intended victim as well as notify the police, there
should be no liability for the therapist. However, when in doubt, the best advice is to consult
with the police. This can be accomplished without identifying any conZidential information until
it is established that the situation rises to the level of the Tarasoff ruling.
Transference versus Countertransference
It would be foolish to believe that a therapist would never encounter either transference or
countertransference. I recall a time in which I was a young professional working in a Masters &
Johnson Program for those with sexual trauma issues. I remember walking into the unit and
being approached by a new patient who told me that she hated me. I had never met her in my
life. Why would someone hate someone they had never met? In a word: transference. The
client was projecting onto me her own feelings, beliefs and attitudes based on her experiences
with men. It was a great lesson for me as it equipped me to better understand her behavior as a
symptom not the real problem. The real problem was that she had been molested as a child by
her father and generalized that pain and betrayal to the conclusion that all men were the same.
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It wasn’t about me at all. Working in a treatment environment for substance abuse disorders is
similar. Patients will routinely project onto the case manager, clinic manager, doctor et al their
personal feelings, beliefs and attitudes because to them that is reality. I have found taking a step
back and asking myself the question, “what is this patient trying to communicate to me behind
this presentation” very helpful? In doing so, I am better able to understand the human
condition as well as detach my personal feeling from the moment. As we all know, the less we
allow our personal feelings to get involved the more we are able to assist our clients.
Countertransference onto a client can be equally destructive. We are all familiar with the
phrase, “Counselor, know thyself.” Simply put, this is so that we know what is ours and what is
our client’s, and why personal therapy is so vital for our on-‐going professional and personal
health. Countertransference is the idea that we project onto our clients our own feelings, beliefs
or attitudes. The danger in doing this is that the issues become clouded and, left unchecked, can
become more about the therapist than the client seeking help. In a treatment environment it is
important that we demonstrate a healthy boundary of our own issues as well, especially if
emerging from a similar addiction. While this may be a somewhat controversial statement, I
have yet to Zind indisputable proof that having “been there, done that” and projecting one’s own
way in recovery onto another has produced any better results than those working with people
suffering with addictions having a therapist or case manager with no personal experience in
that struggle. Having run a treatment program and now overseeing more than one-‐hundred
forty caseload managers, counselors and licensed clinicians, I have found the most critical
elements to assisting patients into recovery are having the ability to establish therapeutic
rapport whereby a client trusts the therapeutic relationship and secondly having an identity of
professionalism. A true professional understands that the issues a client or patient are suffering
from and the experiences that brought them to that place are as unique as a Zingerprint. Hence,
the assumption of all addicts being the same and having a one-‐size Zits all treatment paradigm is
a grave mistake. Counselors should approach every client as if they know nothing about them
and allow the client to Zill in the picture. After all, the client is the true expert on their own
clinical conditions.
Dual Relationships
Professional Boundaries
Sometimes it is next to impossible to avoid having some semblance of a relationship with a
client outside of the counseling session, but whenever possible, this should be strictly avoided.
So what does rise to the level of having a dual relationship with a client? A dual relationship is
generally understood as having another relationship, often known as a multiple relationship,
with a client outside of the therapeutic relationship. This could be having a sexual relationship
with a client, buying or selling products from or to a client, bartering for services or as simple as
accepting gifts from a client due to the inherent power a clinician has over those seeking
counseling. A general rule of thumb is to maintain no relationships whatsoever other than that
of a counselor and a client. This standard will allow for the counselor to assert more objectivity
during treatment and produce a better outcome for the client.
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Dangers of Imposing Personal Values on Clients
The counselor-‐client relationship can be a tenuous one especially in treatment. With nearly
80% of clients suffering from co-‐occurring disorders in addition to a substance abuse disorder,
professionals should be especially sensitive to the power differential that is inherent in a
counseling relationship for the mere reason that our clients are vulnerable and susceptible to
abuse. Imagine a professional that has assisted a client through the most difZicult part in his life.
Now imagine the respect and admiration that client has for the professional. The very nature of
this potential can open the door for even the most altruistic professional to begin imposing their
own personal values on their clients.
Self-Care
I once heard that the average life of a counseling professional was only ten years. What? Those
with advanced degrees spend nearly that much time in college, graduate school and post-‐
masters practicum. “Perhaps this wasn’t the best Zield in which to choose a career,” was my
thought. Ten years later, I am still going strong. The best advice I ever received regarding my
chosen profession is practice self-‐care. So what is self-‐care? It is whatever gives back to you in
such a way as to recharge you emotionally and physically so that you can be the best
professional you can be. I recall a time in which I was working in an inpatient psychiatric unit
as well as working with adolescents at a youth ranch. To hear the stories of neglect and abuse
would shake the most seasoned among us. My supervisor came to me and expressed concern as
she did not want me to take on more than I could handle. Being the Type-‐A personality I am, I
responded that I would be Zine. Several months later, I noticed that I was having difZiculty
sleeping and when I did sleep I dreamed about “my kids” as I came to speak of them. I was
irritable and otherwise little fun to be around. In meeting with one of my clinical mentors, he
suggested that I had developed secondary post-‐traumatic stress disorder by hearing and
internalizing “my kid’s” trauma. Whether the diagnosis was correct or not, the message was
clear; I needed to balance my life in such a way as to be useful while in a professional role and
still healthy outside of that role. Simply put, whatever you choose to do to practice self-‐care,
your life outside of counseling should be larger than your life in it. If you Zind this to not be the
case, you will need to do what I did and introduce meaningful things into your life to help you
achieve this balance.
Counselor Responsibilities: A Different Look
From the AAMFT Code of Ethics to the individual State Drug & Alcohol Certifying Organization,
much has been written and re-‐written to express to counselors their responsibility in the
helping professions, and rightly so. We as case managers, counselors and therapists have a good
working knowledge of what we are not to do. For the true professional, we understand the
gravity and importance of our positions. We entered this Zield to make a difference and take
seriously the responsibilities entrusted to us. The problem is with all we have learned not to do,
we are sometimes ill-‐equipped in what we should do instead.
I remember the day my wife told me that we were expecting our Zirst child; the joy, the pride
and the panic. As two well-‐educated individuals, we did what we always did and that was to buy
books and read them. We developed a small library with all the advice there was to be had.
Then came the relatives and their stories of times when little Timmy did this and that and how
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they handled it. We went to labor coaching classes and practiced on that huge ball while
breathing in through the nose and out through the mouth. We exercised daily, went on an all-‐
organic no meat diet and practiced calmness, whatever the heck that is. Then the day of our
daughter’s birth arrived. We felt good. We were conZident and in the zone. 40 hours later we
had this little darling and had no idea of what to do with her. With all the preparation we had
done in what to expect in this situation and that, nothing had fully prepared us for having to be
solely responsible for this precious little gift. So it is true of being a counselor. With all of your
preparation through study and role plays, you are only partially equipped for the onset of your
professional career and the responsibilities therein. In that light, I would like to share with you
seven responsibilities I believe, if put in practice, will assist you in better meeting your goal of
becoming an effective counselor in the addiction treatment profession.
First, you must always remember that the client is the expert on their clinical condition, not you.
Over the years, I have had the privilege of interviewing literally hundreds of counselors wanting
to work in the company in which I do. As most are young in the Zield, I have a standard question
I ask them which is “what would you say to one of our clients who stated to you, why should I
listen to what you have to say, you’re the age of my daughter or you’ve never experienced what I
have?” I’m consistently amazed at the ones who ramble on about their practicum with this or
that agency or the ones that state I know exactly what they are going through because I have
been there myself. With all due respect, neither is a good answer in my opinion nor shows the
identity of someone who understands their role and responsibility as a counselor. As was
mentioned earlier in this article, we are as unique as a Zingerprint and the fact that we share
similarities in a few areas does not permit us to discount the hundreds in which we do not. No
two people share the exact life experiences as the other. Even those that grow up in the same
home with the same environment will experience and interpret that experience through
different lenses even if it is slightly. A true understanding of this principle allows us to answer
the question quite differently and state to the client “you’re right, but I was hoping that you
would teach me about you and your experiences.”
Second, you will be well-‐served to foster an environment in which a motivated client may
experience change. This is not meant to convey the idea that a counselor is solely responsible
for the outcome; quite to the contrary. However, the counselor is responsible for the process. I
recall a time in which I was providing therapy for a young girl who had witnessed her mother
attack her father resulting in her and her younger siblings being placed in out of home care. It
was really a heart-‐breaking case in which I could sense that she wanted to talk about what had
happened, but was scared to do so. I tried every therapeutic technique I knew to employ and
others I made up on the spot all to no avail. In meeting with my clinical supervisor and
explaining my own frustration with not being able to reach her, he gave me very solid advice. He
said, “Get in, shut up and hold on to where she wants to take the session, not the other way
around.” “Well, I’ve certainly never heard of that technique” was my Zirst thought, but desperate
to see her progress I pledged to try it. So the next time I met with her I asked her what she
wanted to do in the session, to which she replied that she wanted to go on a treasure hunt. For
two solid months we went on treasure hunts weekly and found jewels and gold and all other
kinds of precious items until one day, she simply said, “you know that my mama tried to kill my
daddy?” Our moment of change had arrived. Now, I’m certainly not advocating that you take
your adult client on treasure hunts in the parking lot. However, I am saying that allowing a
motivated client to take his or her time in disclosing some of the most devastating and traumatic
171
moments of their life will take you fostering an environment in which they feel safe enough to
do so.
Third, a professional counselor has the responsibility to provide a therapeutic experience based
on authenticity and truth. It is not worth the time to try and pretend to be something you are
not. Your clients will smell you out a mile away. Living the life that your clients have and
experiencing those experiences has made them experts in many things, the least of which is to
possess the ability to sense their environment and the people within it. It is a survival skill long
since developed in most cases due to abuse and neglect whether from childhood, a spouse or
lover or by having to live on the streets. Our clients are true experts when it comes to who to
trust, who to manipulate and who to lie to. They possess a unique quality very similar to that of
a chameleon in that they can become who they need to in order to have their needs or desires
met. To possess that ability to change on a moment’s notice, takes someone who is truly in
tuned with human behavior. I once worked with clients who were court-‐ordered to see me for a
particular compulsive behavior disorder. In specializing with this population, I worked as long
as three years with some people and oh the stories and excuses I heard. Being a young therapist
at the time, I tried more subtle gestures such as reacting to the obvious lie disapprovingly or
simply trying to ignore their statement. One day I had heard enough and said to my client, “I
want you to know that I know you are lying, so let’s just cut the crap” to which I immediately
wished I could have retracted the statement. I had been trained better than that and I was
embarrassed by my outburst. Before I could apologize my client stated he was just seeing how
far I would let him go. It turned out to be the most therapeutic thing I could have done. My
client knew, or at least had a reasonable suspicion, that I knew he was lying. However, he was
content not to address real issues when the make-‐believe ones could Zill our sessions. While I
would not recommend on any regularity such crass conversation, I would challenge the
counselor not to expect the client to travel down a road (of truth) that the counselor is unwilling
to travel themselves.
The fourth responsibility of the professional counselor is to be fully present and engaged in the
client session regardless of life’s circumstances. There are few things that bother us more than
engaging someone in conversation only to receive half-‐hearted “uh, hums” in return. This pet
peeve of mine is so large that I will actually begin making up outrageous things just to see if the
person I am talking to will catch it. Now, if this is annoying during a casual dinner party or
conversation on the phone, imagine how a client must feel who is attempting to disclose or
convey events or emotions that perhaps they have never told anyone before and their counselor
is thinking about “life” outside the session. A professional counselor knows how to successfully
table their personal circumstances and focus solely on their client. They also know that if they
cannot, they should reschedule the session for a time in which they can.
Fifth, a counselor has the responsibility to offer hope to the patient beyond their present
circumstances. Perhaps some of you reading this will not agree thinking something to the effect
of, “How do you offer to the hopeless?” My response would be, “They’re in your ofZice aren’t
they?” I have come to believe that the truly hopeless will not seek and maintain the services of a
counselor. The truly hopeless suffer oftentimes in silence. We will not be able to help them
because we will not know who they are in the Zirst place. However, you will know and be able to
help those that seek treatment. Even the most resistant client can be said to have made
progress if they stay engaged in treatment and attend their counseling appointments. Our job is
to recognize and reinforce what they are doing well in the midst of difZicult times with the belief
172
that in doing so we make it more likely they will continue this in the future. This type of
interaction with your client will allow for them to realize they have strengths that can be
employed to solve their own problems with the outcome being that hope is developed.
The sixth responsibility of the professional counselor is to respect the patient and know that his
or her choices and decisions are just that, his or hers. This is a tough one for some. We chose
this line of work to make a difference and there are few things more disappointing than working
with a client that continues to make poor choices for their lives. Our instinct is to continue
trying and trying until we arrive at the point that we are emotionally reactive against the
patient. As counselors, we should never place ourselves in a position in which we are working
harder than our clients. In doing so, we enable them to ourselves and can actually do more
harm than good. We must know when to let go knowing that we have done our jobs and we
cannot be responsible for something for which we have no control.
The seventh responsibility of a counselor is to maintain a professional identity even when those
around them falter. This is an especially important one to emphasize. Throughout my career
working in private psychiatric hospitals, non-‐proZit agencies and now treatment centers, I have
had the distinct pleasure of working with some truly brilliant professionals. These people are
intrinsically motivated towards excellence and have high moral standards. Then there are those
that seem to be content with cutting corners, providing sub-‐par services and generally are
difZicult to be around. In my trainings I currently conduct with the more than 140 counselors in
my department, I offer instruction on many topics. However, no topic is covered with more
passion than this one. My advice to them is simple: if ever you feel that you cannot provide the
highest level of quality in patient care, then leave. This is not meant to be harsh, just honest.
Most patients voluntarily seek treatment and ask that we help them move on from their present
life of chaos, pain and trauma. Not being fully invested and committed to offer the highest
standards in patient care should never be an option.
References
Berger, S. & Berger, M. (2009). Tarasoff “duty to warn” clariRied. The National Psychologist, 8,
2-‐3.
Board of Behavioral Sciences (2009). Statutes and Regulations Relating to the Practice of:
Marriage and Family Therapy Educational Psychology Clinical Social Work. Board of
Behavioral Sciences, 121-‐126.
Houghton MifZlin Company (2009). The American Heritage Dictionary of the English Language,
Fourth Edition. Houghton MifZlin Company.
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3.5 Program Description Policy23
Ivey Ike Grozier, MA, CADCA, CCJAP
Mary Crocker Cook, DMin, LMFT, CADC II
It is important that clinical supervisors be aware of the operations functions of the agency to
assist their supervisees to keep their focus on the actual purpose of the agency.
Service Delivery is the primary operation task in Chemicals Dependency treatment. Service
delivery organizations are affected by many things; introducing type and quantity of services
needed, availability of service providers, range of services offered, acceptability of services to
patients and others, environmental limitations, regulatory conditions, scheduling and logistics,
task efZiciency and general and superZicial costs.
This is the policy that speciZically outlines WHAT YOU DO in your agency. You will need a
Program Description page for each program you offer, for example, Outpatient Services or
Residential Treatment.
SERVICES OFFERED POLICY
You will need a policy that outlines the services offered in each component of your program. For
example Residential services:
• Initial assessment and treatment planning
• Individualized Treatment planning, individual and group Counseling
• Psycho education classes
• Multi-‐family group
• Social skills and Life Skills development
• Transport to outside medial, court, and therapy appointments
• Introduction to community support and resources
• Continuing Care planning
• Referrals
Finally, you want a program philosophy statement at the bottom: For example, Recovery
Connections believes that clients are to be treated with dignity and respect, should be involved and
have a voice from treatment planning to recovery maintenance. Treatment is a team effort,
utilizing all available recourses to provide the best possible care. We believe in working toward
substance-free, healthy lifestyles, as well as being positive members of our families and the
community
GOALS AND OBJECTIVES POLICY
This policy refers to the measurable goals you are claiming for your agency.We would not
recommend that pick more than 3 or 4, because these goals will eventually be the focus of your
This section was submitted by Ivey Ike Grozier, Executive Director, Recovery Connections
Treatment Services, and Mary Crocker Cook, Director of Clinical Services for Recovery
Connections Treatment Services, and Instructor / Program Coordinator for the San Jose City
College Alcohol & Drug Studies Programs. It was edited by the FOUNDATION for inclusion
within this Manual.
23
175
outcome studies for the effectiveness of your treatment program. You want them to be speciZic,
so picture them in the form of a follow-‐up questionnaire:
Services will assist clients in their ability to maintain abstinence.
A. 85% of clients will successfully complete Phase I of treatment
B. 75% of clients will successfully complete the six month program
C. 60% of clients will achieve twelve months continuous sobriety.
Follow-‐up questions would be easy to create. Did complete all the requirements of Phase I and
transition to the Outpatient Phase of treatment successfully?
Services will assist clients in reducing substance related problems.
A.75% of clients will report improvement in family relations
B. 90% of clients will report a reduction of physical health problems
C. 90% of clients will report a reduction of legal problems
D.80% of clients will report an increase in ability to manage emotions.
As a result of treatment, did you Rind that your relationship with your family members has
improved?
YOUR PROGRAM will experience continuing growth as a result of delivering quality
services
A. Client census will increase by 30% annually
This is easy to measure simply by intake numbers.
CONTROL POLICIES
You can plan, create an efZicient structure, direct and motivate employees, but there still needs
to be a way to measure achievement.
The Control process consists of:
• Measuring actual performance
• Comparing actual performance against standards
• Taking managerial action to correct deviations and inadequate standards
Much of what we are measuring is determined by the goals we have set. They should be
tangible, veriZiable, and measurable. This makes progress easy to measure and compare.
Four common sources of information used to measure actual performance are personal
observation, statistical reports, oral reports, and written reports.
Management by walking around – pick up omissions, facial expression, tones of voice. While
this method is vulnerable to manager bias – and the least scientiZic, it is one of our favorites.
Actually, observation by taking a participating role is better, because you are less an observer
and hopefully less intimidating to your staff.
Statistical reports are usually computer output. Graphs, bar charts, numerical displays are all
gages of improvement. We can use these to measure rate of program entry, length of stay, length
of sobriety following treatment, demographic data, etc.
176
Oral reports are conferences, meetings, telephone calls. This includes creating surveys to be
completed by program participants, program stakeholders, satisfaction surveys, etc.
Written reports – these can be feedback summaries provided by your staff or clients regarding
their experiences.
What are we measuring?
• Information
• Operations
• Finances
How do managers determine discrepancies between actual performance and planned goals?
Range of variation needs to be established because some degree of variation is natural. For
example, a counselor case load may be unusually high or low one month, affecting the level of
detail in their charting.
So, we need to look for variations that become pattern indicating performance problems.
Managerial action:
• We can do nothing and hope it will self-‐correct.
• We can correct the actual performance
• Revise the standard we are measuring performance against.
If the source of deviation is deZicient performance, the manager will want to take corrective
action – like make changes in strategy or structure, institute training programs, redesign the job,
or even replace the personnel.
We have two choices here.
Immediate corrective action means to correct a problem at once to get performance back on
track (putting out Zires)
Basic Corrective action determine how or why performance has deviated and then correction
the source of the deviation.
Maybe the deviation is a result of an unrealistic standard –and you may need to revise or
redesign the standard to more accurately reZlect the result being measured.
Management can implement controls before an activity begins, while the activity is going on, or
after the activity has been completed.
Feedforward Control anticipates and prevents problems.
Concurrent control – takes place while work is being performed. Direct supervision can
monitor the employee’s actions and correct problems as they occur.
177
Feedback Control – this provides managers information about how effective they have planned.
It can also enhance employee motivation and give people information about how well they have
performed. This includes satisfaction surveys, follow up surveys, exit interviews.
Qualities of an Effective Control System
Accuracy: A control system that generates inaccurate information can result in a manager’s
failing to take action when it should or responding to a problem that doesn’t exist. An accurate
control system is reliable and produces good control data.
Timeliness: Controls should call management’s attention to variations in time to prevent
serious infringement on an employee’s performance. The best information has little value if it is
dated. Therefore, an effective control system must provide timely information.
Economy: A control system must be economically reasonable to operate. Any system of control
has to justify the beneZits it gives in relation to the costs it incurs. To minimize costs,
management should try to impose the least amount of control that is necessary to produce the
desired effects.
Flexibility: Effective controls must be Zlexible enough to adjust to adverse change or take
advantage for new opportunities. Few organizations face environments so stable that there is no
need for Zlexibility. Even highly mechanistic structures require controls that can be adjusted as
time and conditions change.
Understandability: Controls that cannot be understood have no value. it is sometimes
necessary, therefore, to substitute lass complex controls for sophisticated devices. A control
system that is difZicult to understand can cause unnecessary mistakes, frustrate employees, and
eventually will be ignored.
Reasonable criteria: Control standards must be reasonable and attainable. If they are too high
or unreasonable, they no longer motivate. Because most employees don’t want to risk begin
labeled incompetent by accusing superiors of asking too much, employees may resort to
unethical or illegal shortcuts. Controls should, therefore, enforce standards that challenge and
stretch people to reach higher performance levels without being demotivating or encouraging
deceptions.
Strategic placement: Management can’t control everything that goes on in a an organization.
Even if it could, the beneZits couldn’t justify the costs. As a result, mangers should place controls
on those factors that are strategic to the organizations performance. Controls should cover the
critical activities, operations and events within the organization. That is, theory should focus on
places where variations from standard are most likely to occur or where a variation would do
the greatest harm.
Emphasis on the exception: Because managers can’t control all activities, they should palace
their strategic control devices where those devices can call attention only to the exceptions. An
exception system ensures that a manager is not overwhelmed by information on variations from
standard.
178
Multiple Criteria: Managers and employees alike will seek to “look good” on criteria that are
controlled. If management controls by using a single measure such as agency proZit, effort will
be focused solely on looking good on that standard. Multiple measures of performance decrease
this narrow focus. Multiple criteria have a dual positive effect. Because they are more difZicult to
manipulate than a single measure, they can discourage efforts to merely look good. In addition,
because performance can rarely be objectively evaluated from a single indicator, multiple
criteria make possible more accurate assessments of performance.
Corrective action: An effective control system not only indicates when a signiZicant deviation
from standard occurs but also suggests what action should be taken to correct the deviation.
That is, it ought to both point out the problem and specify the solution. This form of control is
frequently accomplished by establishing if-‐then guidelines; for instance, if agency’s revenues
drop more than 5 percent, then costs should be reduced by a similar amount.
Keep in mind that the generalized actions above about effective controls are inZluenced by the
size of the organization, one’s position in the agency hierarchy, degree of decision making,
agency culture and importance of the activity that you might consider controlling.
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3.6 Supervising Recovering Counselors24
In this chapter we begin to address the “Big Kahumna” of concerns identiZied by our
management subjects in the Zirst chapter of this Manual.25 The information that follows would
have been helpful to them as new supervisors in their early career.
To connect staff behavior with recovery status, we will utilize the developmental stages of
recovery as outlined by Terence Gorski in Passages Through Recovery. It is Gorski’s premise that
recovery is a developmental process during which we go through a series of stages. It is a
gradual effort to learn new and progressively more complex skills. For Gorski, sobriety is more
than just healing the damage of addiction; it is living a lifestyle that promotes continued
physical, psychological, social, and spiritual health.
The skills necessary for long-‐term sobriety are all directed at Zinding the meaning and purpose
in life. Sobriety is a way of thinking, a way of acting, a way of relating to others. It is a philosophy
of living. It requires the daily effort of working a recovery program. The longer we stay sober,
the more we need to know to maintain a sense of meaning, purpose, and comfort. The things we
did to stay comfortable at thirty days of sobriety may no longer work for us at sixty days or two
years. It is as if the recovery process forces us to keep growing, learning, and changing.
For Gorski, the developmental model of recovery is based on a series of beliefs:
• Recovery is a long-‐term process that is not easy.
• Recovery requires total abstinence from alcohol and other drugs, plus active efforts toward
personal growth.
• There are underlying principles that govern the recovery process.
• The better we understand these principles, the easier it will be for us to recover.
• Understanding alone will not promote recovery; the new understanding must be put into
action.
• The actions that are necessary to produce full recovery can be clearly and accurately
described as recovery tasks.
• It is normal and natural to periodically get stuck on the road to recovery. It is not whether you
get stuck that determines success or failure, but it is how you cope with the stuck point that
counts.
Staff members employed in recovery treatment centers can be hired from six months clean to
many years clean and sober. It is our premise that the staff member’s developmental stage in
recovery will directly impact their behavior as an employee, and it would be helpful to
within this Manual.
24
25
Effect of the Management Role on Managers: A Study.
183
Substance Abuse Managers to utilize Gorski’s concepts when evaluating the behavior for their
staff, including guidance in developing work performance plans.
Transition. During the Zirst recovery stage, addicts recognize that they have problems with
chemicals, but think the problem can be solved by learning how to control their use. This stage
ends when the addict recognizes that they are not capable of control—that they are “powerless”
over alcohol or other drugs—and will need to abstain to regain control of their lives. The addict
doesn’t yet know why they are out of control or how to stay sober; but knows life cannot
continue the way it has been. In AA this is called “being sick and tired.” Staff members will not
be in this transition stage, though issues around power and control will surface in other areas of
their lives, including the workplace, for quite some time. Transition issues will reappear when
recovering people begin to work the “Sixth Step” of the Twelve Step program. This step applies
these same Transitional developmental tasks to what are referred to as “character defects” or
defense mechanisms we have adopted, often since childhood. These defenses are now outdated
and are interfering with our recovery program.
Tasks of the Transition Stage:
• Develop history of problems related to addiction
• Experience motivational crisis
• Recognize pattern
• Recognize need for help
• Treatment
Stabilizing. Recovering addicts now know they have a serious problem with alcohol and drug
use and they need to stop completely, but are unable to do so. During this time we recuperate
from acute withdrawal and from long-‐term or post-‐acute withdrawal (six to eighteen months).
Tasks of the Stabilization stage:
• Interrupt addiction use
• Recovery from intoxication
• Manage Acute withdrawal symptoms
• Manage Post Acute Withdrawal
• Recover from additional related issues
• Stabilize major life crisis
• Initial admission of addiction
• Motivational Counseling
In the Zirst year of recovery staff is still stabilizing. They are biologically healing, and may be still
be suffering from intermittent Post Acute Withdrawal Symptoms, like sleeping poorly,
overreacting or under reacting emotionally, and occasional confusion and memory problems.
They tend to still be stabilizing their immediate “wreckage” and still adjusting to a new identity
as a recovering person. Why is this so important?
When administrators hire someone with less than a year sobriety, we are often hiring them as a
house manager, or putting them on a night shift or “baby sitting” shift on the weekends. We are
taking someone who is still stabilizing themselves, and putting them in charge of other
stabilizing addicts. Is it any wonder we have management issues like boundary violations with
other staff and clients, and conZlict between staff and clients? We need to think long and hard
184
before deciding to hire someone so new in their own recovery, even though these new
employees are so willing to do service that they would work for free (a tempting situation for a
struggling treatment center to be in). Ultimately, we may be doing an enormous disservice to
recovering counselors in their recovery journey and may be inviting more chaos into the
treatment center than the Zinancial ‘bargain” was worth.
Early recovery is a time of internal change. During early recovery addicts learn how to become
more comfortable abstinent. The physical compulsion to use chemicals is relieved and addicts
learn more about their addiction and its effects. They also learn to overcome their feelings of
shame, guilt, and remorse. and become capable of coping with their problems without chemical
use. Early recovery ends when recovering addicts are ready to begin practicing what they
learned by straightening our other areas of their lives.
Tasks of the Early Recovery stage:
• Externally regulated recovery program
• Education
• Self-assessment
• Reversal of nutritional deRiciencies
• Proper diet and exerciseNon-addictive stress management
• Recovery from Post Acute Withdrawal
• Recovery from addiction related health disorders
• Recovery from addiction related psycho-social disorders
• Management of the urge to use (relapse prevention)
In Early Recovery, the Zirst twelve to eighteen months, addicts are still highly dependent on an
external structure for recovery. This is a high motivation for someone new in recovery to want
to work in treatment. It is a common belief in early recovery that working in a recovery
structure supports their personal recovery. However, what employees do not bargain for is that
in the rooms of AA/NA, they get to choose their companions in recovery, whereas treatment is
comprised of people who have varying degrees of motivation to get clean ranging from none at
all to very motivated. If the recovering employee is vulnerable in their own program, they can
get bit with the “euphoric recall” bug and start swapping drunk-‐a-‐logues with clients while
having a cigarette on break. In fact, the line between client and counselor can get a little blurry
in those moments. They may still be having occasional drinking dreams themselves; and may
still be stabilizing their own health and life wreckage. Newcomers in recovery can be very
triggered in treatment centers, and it is key to provide these employees with very strong
supervision and support.
Middle Recovery. During Middle Recovery addict learn how to repair past damage and put
balance in their lives. Recovering addicts learn that full recovery means “practicing these
principles (the sober living skills we learned in early recovery) in all of our affairs” (in the real
world of daily living). During middle recovery, it becomes a priority to straighten out our
relationships with people. It is a time to reevaluate their signiZicant relationships—including
their relationships with family and friends—as well as career choices. If the recovering addict
Zinds they are unhappy in any of these areas, and admit it, it is time to make plans to do
something about it.
185
Tasks of the Middle Recovery Stage:
• Resolving demoralizations crisis
• Values clariRication
• Internally regulate recovery
• Develop sobriety-centered lifestyle
• Overcome barriers to self-esteem
• Acceptance of loss of old lifestyle
In Middle Recovery, about two to three years, recovering addicts are integrating recovery into
their lifestyle, and the program is more internally regulated at this point. This is the point when
our self-‐esteem issues will begin to surface more strongly, and we see them surface at work in
the counselors interactions with each other, and most especially with management. Gorski
points out that many of us will still carry demoralization issues into this point, meaning
unpleasant, distressing feelings of personal failure and inadequacies. This may make it difZicult
for employees in this phase of recovery to accept feedback regarding their performance or
counseling style. Recovering employees may still carry a myriad of defenses constructed in the
course of their lifetime to protect their soft underbelly; in recovery we often refer to these traits
as “character defects”—Step Six and Seven issues.
Staff with an extensive criminal justice background may still struggle with the value system
developed in incarceration settings, and may even demonstrate “criminal thinking” at the
workplace under stress. Managers need to monitor their own reactivity in the face of employee
defenses, or criminal thinking maneuvers. When counseling employees at this stage of their
recovery, behavioral speciZics and speciZic strategies to change these behaviors will be key.
Employees may make attempts to shift the blame
In his article on leadership (2000), Mr. Clark points out that Confrontation Counseling is not
yelling or hostile, but rather making the employee “face the evidence of their performance or
behavior and requiring them to decide about their future.” He advises that we begin this
confrontation process prior to a serious incident, and catch the employee as they are beginning
to deteriorate in their performance. One of the primary complaints employees often have about
management is that they have not communicated their concerns about employee performance
prior to a taking formal action, such as a write up or even a termination. This is often due to the
fact that managers, like most people, are avoidant of confrontation. We just hope the situation
turns itself around without us having to risk any kind of negative interaction. It rarely does, in
our experience.
Mr. Clark advises that we consider four factors when making the decision to sit down with an
employee and confront their poor work performance.
Personal Belief System
Am I having trouble with this employee’s performance based on a personal preference or bias,
or is it an objective problem? This reminds me of my comment earlier about how I always
judged self-‐interested co-‐workers as lazy or somehow lacking ambition. In actuality, there was
nothing wrong with their job performance. Not everyone wants to be in charge and lose control
over his or her personal time!
186
Organizational Belief Systems
Different Managers or Supervisors will have different expectations about confrontational style,
as well as have their own biases and beliefs. So, YOUR supervisor may be conZlict avoidant, while
your personal style may be more direct. There is also an overall agency culture. Is the culture of
your agency more supportive and nurturing, or does it tend to focus more on efZiciency and task
completion? You may need to adjust your style accordingly.
Objective Standards
These are the factual laws and regulations in your Policies and Procedures manual, as well as
the certifying agencies who oversee your agency. For example, the State Department of Alcohol
and Drugs who licenses the operation of treatment centers. There are work performance
standards that are not negotiable—pretty cut-‐and-‐dried and not a result of company preference
or culture. In some ways, safety issues or ethics standards are the easiest to confront because
they are so straightforward.
Factual Reference Base
The Confrontation Process includes providing the employee with some factual material to move
forward with after the meeting has concluded.
Mr. Clark recommends that the employee be made aware of the following:
• Realistic understanding of consequences for the employee if the poor performance continues.
• To make the employee aware of resources available to the employee to help them meet the
increased performance standards.
• Make sure they have the factual knowledge to make the required improvements—do they
need additional training? Is there someone in your agency who might be a good mentor?
• Express conZidence in the process and conZidence in their ability to meet the improved work
performance standards.
Late Recovery. Recovering addicts focus on overcoming obstacles to healthy living that were
learned as children, before addiction even developed. Many chemically dependent people come
from dysfunctional families. Because their parents may not have done a very good job at
teaching solid self-‐care and life management skills, recovering addicts may never have learned
the skills necessary to be happy.
Tasks of Late Recovery:
• Resolution of family of origin issues
• Personality change
• Development of healthy self-esteem
• Development of healthy intimacy
• Development of balanced functional lifestyle
• Productive life planning
In Late Recovery, three to Zive years, Gorski points out that the need to resolve our Family of
Origin issues becomes more prominent. It is at this point unresolved family role issues (like
being the family scapegoat or hero), or authority issues, or ingrained family relationship
patterns may be surfacing in the workplace. Recovering people at this point in their recovery
have hopefully been developing a more healthy and balanced lifestyle, and have developed some
realistic and attainable goals for their future.
187
However, those family patterns and issues can be strong road blocks, and it is our observation
that any group will bring out our family roles and issues—especially the workplace because we
have so many “siblings” and “parental Zigures” to bounce off of! Recommending more meeting
attendance or another round of the steps may not be what is called for at this point in time. It
may be that the staff member really needs personal therapy. This is tricky, because you cannot
mandate personal therapy for employees.
However, you can gently point out the patterns you are seeing and encourage them to consider
seeking the personal support and counseling they deserve. Ultimately, they can choose not to
follow your advice, and your only recourse is to address their work performance regardless of
where the problem is stemming from. As a manager, the fact that they had an abusive childhood
and therefore have issues with authority Zigures is not your problem. Your focus has to be work
performance, and that they are required to be respectful and responsive to direction in the
workplace.
What is the employee’s problem that is not related to their skill level but to their desire to do the
job? It then becomes a discipline problem. You can handle this through Employee Counseling or
taking disciplinary actions.
Discipline includes verbal and written warning, suspension, even termination. These are actions
taken by a manager to enforce an organizations standards and regulations.
The Employee Counseling process is designed to help employees overcome performance-‐related
problems. It is an attempt to uncover why employees have lost their desire to work productively
and to Zind ways to resolve the problem and retain the employee. However, employee
counseling is not designed to lessen the effect of poor performance or reduce his or her
responsibility to change inappropriate work
behavior. If the employee can’t or won’t accept help then disciplinary actions will be appropriate
and necessary.
Maintenance. During maintenance, recovering addicts recognize a need for continued growth
and development as people. The addict recognizes that alcohol and other drug use is not going
to be a safe option, and they must practice a daily recovery program to keep addictive thinking
from returning. It is vital to live in a way that allows them to enjoy the journey of life.
Tasks of Maintenance Stage:
• Recovery program
• Periodic sobriety checks
• Relapse prevention planning
• Daily problem solving skills
• Productive living
Maintenance has to do with ongoing self-‐care. This is very hard for recovering people and
codependents, which seem to lack the “moderate” gene, and management will see employees
making unwise time commitments or relationship choices that will begin to affect their work
performance. Having ongoing relationship drama creates fatigue and distractions for the
employee, just like their decision to take on a couple of jobs, go back to school, and take on three
188
service positions all at the same time! It may be that you will have to make the link between
their lack of self-‐care and job performance for them. Many of us struggle with denial about our
limitations and we may really believe that we are juggling everything “just Zine.” Sometimes it
takes an objective party to point out our behaviors for us to see them for ourselves.
This relates to the issue of burnout. This is a very real employee problem, often related to our
untreated Codependency issues. In his book, The Codependent Counselor, Philip Beebe points out
that both the client and the counselor bring their own interpersonal issues and histories into
the therapy relationship, just like they do the workplace. This means that the same
developmental issues of trust, intimacy and respect that are found in non-‐therapeutic
relationships are also found in the counseling situation. Regardless of theoretical orientation,
therapists are susceptible to codependent attitudes and behaviors, as deZined by Beebe:
• Investment of self-esteem in patient change. This is the belief that the counselor should have
the ability to make a client change, and is in denial of the innate powerlessness and fallibility
an individual has in ANY relationship.
• Assumption of Responsibility for clients. The therapist suppresses personal feelings, reactions
and needs in favor of those of the client to avoid angering them or to keep them “happy” with
the therapeutic relationship.
• Anxiety and boundary distortions in the therapeutic relationship. As rapport develops the
counselor may begin to experience confusion, anxiety, and even loss of will. Boundaries
between individuals involved will begin to shift as the counselor identiZies with the client.
• Enmeshment in the relationship with clients. The counselor doesn’t confront the client’s denial,
is tolerant of client projections, and accepts and offers rationalizations to the client. The
counselor mirrors those same unacknowledged behaviors, and the client’s behavior is never
challenged.
Three or More of the Following:
• Excessive reliance on denial
• Constriction of emotions
• Depression
• Hyper-‐vigilance
• Compulsions
• Anxiety
• Substance abuse
• Victim of emotional abuse
• Stress related medical illness
• Remains in a therapeutic relationship with unchanging clients
It is beyond the scope of this book to explore this issue more in depth. We HIGHLY recommend
Beebe’s book as mandatory reading for counselors.
Performance Evaluations
Most agencies have a requirement of yearly performance evaluations, and there are many
evaluations forms available in management books and on the Internet. In this section, we want
to brieZly address your management responsibilities in giving a performance evaluation rather
than specifying which form you should use.
189
Assessment
Effective preparation for performance evaluations requires the ability to assess the needs of the
employee and the organization. Your job is to help the employee set career goals that are
consistent with their knowledge, experience and interests by providing feedback based on your
observations and assessment of their abilities, readiness and potential. The assessment should
be based on your actual experience and observation of employee behavior rather than on
assumptions and personal biases. This is one of the reasons some management systems have an
evaluations review by another manager prior to sitting down with the actual employee. The
“other pair of eyes” may see bias when you are blind to it yourself.
Providing information
Managers support employee career development when they inform an employee about options
for possible barriers to career movement. For example, you may tell your employee about
upcoming positions or opening for which they may be qualiZied, or about budgetary constraints
which may inhibit career options or development opportunities in the department.
Referral
Refer your employee to others who can assist them in achieving their goals. You may refer
employees to books, journals, professional associations or other sources of information. You
may also want to put them in touch with people who might be willing to serve as mentors or
with those who might provide an informational interview in which employees can learn more
about the Zield or position they would like to obtain.
Guidance
Encourage your employees to focus on clear, speciZic, and attainable career goals. Share your
knowledge and experience with your employee. Provide guidance to your employees about
steps they might take to improve existing skills and knowledge or develop in new functional
areas.
Develop
Supervisors support employee development when they assign employees roles or tasks that
challenge them and provide the opportunity to grow. Base decisions about assigning new tasks
on your assessment of the employee’s readiness to accept additional or new responsibility or
challenges. Consider delegating a responsibility of your own which is appropriate to the
employee’s job description. You can recommend employees to sit on teams or committees that
may help them grow in conZidence and skill set.
Management-Employee Communication Barriers
Many communications problems can be directly attributed to misunderstanding and
inaccuracies. We can summarize these barriers to effective communication:
Filtering: The deliberate manipulation of information to make it appear more favorable to the
receiver.
Selective perception: Receiving communications on the basis of what one selectively sees and
hears depending on his or her needs, motivation, experience, background, and other personal
characteristics.
190
Emotions: Messages will often be interpreted differently depending on our emotions when the
message is being communicated.
Language: Words have different meanings to different people. Receivers will use their deZinition
of words communicated, which may be different from what the sender intended.
Nonverbal cues: Body language or intonation that sends the receiver another message. When the
two are not aligned, the communication is distorted.
These problems are less likely to occur if the manager uses a feedback loop in the
communication process. This loop is often referred to Active Listening.
Active listening is deZined as listening for full meaning without making premature judgments or
interpretations. As we tell clients, there is major difference between hearing, which is an organ
function, and listening, which is an attention function. Active Listening is an actual process.
1. Listen to what the person is saying, along with the feelings underneath their words. You
want to listen to how they FEEL about what they are saying
2. Think about what you hear and see
3. Acknowledge their feelings by giving the feel a name. For example, ”It sounds like you were
frustrated with your boss”, or “You sound angry”
4. Tell the other person what you think you heard them say. “For example, “Are you saying
that. . . ? “ If you did not hear them correctly, have them tell you again until you DO fully
understand what they are communicating.
Feedback is also happening non-‐verbally. For example when the staff does not follow through
with a request, does or does not change problematic behavior, etc.
There are some techniques you can use to overcome the communications barriers listed earlier.
Use feedback. Check the accuracy of what has been communicated – or what you think you
heard.
Simplify language: Use words that the intended audience understands.
Listen actively: Listen or the full meaning of the message without making premature judgments
or thinking about what you are going to say in response.
Constrain emotions. Recognize when your emotions are running high. When they are, don’t
communicate until you have calmed down.
Watch nonverbal cues. Be aware that our actions speak louder than your words. Keep the two
consistent.
ConWlict Management
Working in a Chemical dependency programs automatically assumes the presence of conZlict.
The clients themselves are needy and emotionally reactive and the counselors may have varying
degrees of personal recovery and struggle with reactivity themselves.
191
However, as a manager your approach to resolving a conZlict is likely to be determined largely by
its causes, so you need to determine the sources of the conZlict. Research indicates they
generally can be separated into three categories:
Communication differences –disagreements arising from word choice, misunderstandings and
confusion in the communication channels
Structural differences -‐ disagreements arising from role assignments, unit goals, decision
alternatives, performance criteria, and resource use.
Personal differences – disagreements arising from value systems and personalities. Chemistry
can sometimes make it hard for people to work together.
Managers essentially draw upon 5 conZlict resolution options to reduce conZlict when it is high.
STRATEGY
BEST USED WHEN:
Avoidance
Conflict is trivial, when emo:ons are running high and :me is needed to cool them
down, or when the poten:al disrup:on from an asser:ve ac:on outweighs the
benefits of resolu:on.
Accommoda:on
The issue under dispute isn’t that important to you or when you want to build up
credits for later issues
Forcing
You need a quick resolu:on on important issues that require unpopular ac:ons to
be taken and when commitment by others to your solu:on is not cri:cal.
Compromise
Conflic:ng par:es are about equal in power, when is it desirable to achieve a
temporary solu:on to a complex issue, or when :me pressure demands
expediency.
Collabora:on
Time pressures are minimal, when all par:es seriously want a win-‐win solu:on, and
when the issue is too important to be compromised.
Negotiation
Negotiation – the process in which two or more parties that have different preference must
make a joint decision or come to an agreement.
How can you develop effective negotiation skills? We have six recommendations.
Research the other party. Acquire as much information as you can about their interests and
goals. Who must they answer to? What is their Strategy? This information will help you to better
192
understand the other person’s behavior and predict his or her responses, and to frame solutions
in term of his or her interests.
Begin with a positive overture. Research shows that concessions then are reciprocated and
lead to agreements. As a result begin bargaining with a positive overture – perhaps a small
concession – and then reciprocate the other person’s concessions.
Address problems, not personalities. This is where are recovery program comes into play –
principles before personalities. Concentrate on the negotiation issues, not on the personal
characteristics of the other person. When negotiations get tough, avoid the tendency to attack
the other party. It is their ideas or positions that you disagree with, not him or her personality.
Separate the people from the problem, and don’t personalize differences.
Pay little attention to initial offers. Treat an entail offer as merely a point of departure.
Everyone has to have an initial position, and initial positions tend to be extreme and idealistic.
Treat them as such.
Emphasize win-win solutions. If conditions are supportive, look for an integrative solution.
Frame options in terms of the other person; interests and look for solutions that can allow the
other person as well as yourself, to declare a victory.
Be open to accepting third-party assistance. When stalemates are reached consider the use of
a neutral third party – a mediator, a counselor. Mediators can help parties come to an
agreement, but they don’t impose a settlement. They can act as a communication conduit,
passing information between the parties, interpreting messages, and clarifying
misunderstandings.
References
Independent Press.
193
PDF/251.pdf
194
(31), 173-‐180.
24, 129-‐135.
Inquiry, 77(2), 166-‐193.
1821-‐1837.
195
196
3.7 Policy and Organizational Design26
Clinical supervisors juggle a variety of hats, and it is especially challenging to remain being up-‐
to-‐date and monitor changes and developments in policy and procedure at the agency level.
What follows are key areas to be developed if you are developing your own program, or are
evaluating the strength of the program you have been hired to manage.
Whether you are applying for State licensure, CARF accreditation, grants, or Requests for
Proposals you will need to have develop or refer to a set of Policies and Procedures for your
agency that provide standards of operation.
First, some vocabulary:
Procedures are a series of interrelated steps that can be used to respond to a structured
problem. Following procedure simply entails following the steps.
Rules are an explicit statement that tells Managers what they can and can’t do. These are
particularly clear in employee personnel and hiring.
Policies are general guidelines that establish parameters for making decisions. Policy requires
judgment and interpretation. For example, the Ten Commandments are Rules; the U.S.
Constitution is Policy.
Many decisions cannot be programmed; they have to be customized to solve unique and non-‐
recurring problems. Agencies can get rule and procedure-‐bound if they try to eliminate
uncertainty and risk by attempting to create rules for every possible contingency. Treatment is a
dynamic process, and we are always coming up against an issue that we haven’t seen before or
we don’t have a written policy to address.
In The Beginning. . . .
You will need to either develop, or become acquainted with, your agency Mission statement. You
Mission statement and Agency Philosophy will drive everything you do in your organization.
When used properly, it is the benchmark you measure all decisions against.
What are the opportunities or needs we exists to address? (Our purpose) For example:
Recovery Connections Treatment Services was formed to offer quality, compassionate, state-of-the-
art treatment to alcoholics and addicts who want to recover from their disease.
within this Manual.
26
197
What are we doing to address those needs? (the business itself)We offer various levels of care,
and several specialized treatment tracks designed to acknowledge that everyone enters treatment
with various goals and a need for individualized treatment planning.
What principles or beliefs guide our work (the values of the organizations) It is our goal that
every resident that leaves our facility will leave with a memory of support and dignity, regardless
of their commitment to ongoing sobriety.
Mission Statement
Recovery Connections Treatment Services was formed to offer quality, compassionate, state-of-the-
art treatment to alcoholics and addicts who want to recover from their disease. We offer various
levels of care, and several specialized treatment tracks designed to acknowledge that everyone
enters treatment with various goals and a need for individualized treatment planning. It is our
goal that every resident that leaves our facility will leave with a memory of support and dignity,
regardless of their commitment to ongoing sobriety.
Absence of an understanding of the mission statement can lead to a narrowing of the scope of
an employee and resistance to necessary changes. “That’s not my job” is more likely to be said
by someone who understands their job description, but not in relation to the mission of the
agency. A mission statement that is not translated into every day activities of employees is
meaningless.
Organizational Structure
This is the agency structural design that will best help us achieve our strategic goals and
mission statement. There are six key elements of agency structure to consider as you look at the
organizational chart of your agency.
Work Specialization
In essence, individuals specialize in doing part of an activity rather than the entire activity. This
is why a cardiac surgeon does not “close up” after surgery. Aspects of Chemical dependency
treatment delivery are provided by staff with the sufZicient training and specialization to
complete the task. For example your graveyard shift employee is usually just beginning in the
Zield, or “getting their feet wet” and not completing treatment plans and assessments on their
shift.
Chain of Command
This is the management principle that no person should report to more than one boss. This
eliminates staff struggle between competing demands and priorities and clariZies decision
making.
Centralization
At what level are decisions made? This is a function is how much decision making authority is
pushed down to lower levels in an organization; the more centralized an organization is, the
higher is the level at which decisions are made.
Decentralization refers to the pushing down of decision making authority to the lowest levels of
the organization.
198
Span of Control
This refers to the number of employees a manager can direct effectively, and refers to the level
training and experience of your employees. The more seasoned your employees, the larger span
of control you can assume. The less skilled or conZident your employees, the smaller span of
control you should assume. It reminds us of sponsorship. Sponsoring “newcomers” is time
consuming and would suggest you take on fewer sponsees. As your sponsees age in recovery
and stabilized, you can add more sponsees.
Authority
The rights inherent in a managerial position to give direction and have the direction followed.
Authority is relates to your position in an agency and not your personal characteristics. The
authority lies in the position itself.
Different kinds of authority
Line authority entitles a manager to direct the work of an employee. It is an employer-‐employee
relationship which is hierarchical. When an agency gets large enough the line managers Zind
they do not have the time, expertise or resources to get their job done effectively and they
create, . . .
Staff authority functions to support, assist, advise, and generally reduce some of the
informational burdens the line staff carries.
For example, in a county contract alcohol and drug agency, the line supervisor will refer
employees to a union representative, clerical, or human resources to assist them with their
speciZics needs.
Authority and power are different. Power refers to an individual’s capacity to inZluence
decisions. Max Weber (1947) deZined power as follows, “Power is the probability that one actor
within a social relationships will be in a position to carry out his own will despite resistance,
regardless of the basis on which this probability exists.” Very often agencies have very
inZluential and powerful employees who do not have managerial authority status.
John French and Bertram Raven have identiZied Zive sources, or bases of power:
• Coercive power: Power based on fear
• Reward power: Power based on the ability to distribute something of value
• Legitimate power: Power based on one’s position in the formal hierarchy
• Expert power: Power based on one’s expertise, special skills, or knowledge
• Referent power: Power based on identiZication with a person who has desirable resources or
personal traits.
It might be an interesting exercise for you to go through your organizational chart and identify
who has which type of power. Identifying types of power is very important if you want to be
politically aware of what is happening at all levels of management in your agency.
In a Chemical Dependency agency, most tactical decisions are made by line supervisors who
then inform or consult with upper management. This is often referred to an as organic
organization vs. mechanistic.
199
Mechanistic organizations are bureaucratic, and have a structure that is high in specialization,
formalization and centralization of decision making.
An organic agency is called an adhocacy, and has a division of labor, but the jobs people do are
not standardized. Employees tend to be professional who are well trained to meet their job
requirements and handle diverse problems. They need very few formal rules and little direct
supervision because their training instilled in them standards of professional conduct. This is a
more Zlexible structure, Zlat with more informal communication. The professional can handle
most problems alone or by conferring with colleagues.
Size will affect structure. The larger the agency, the more it will push toward standardization
and become more mechanistic. This is why some people move from “start up” to “start up”.
Research shows that once an organization has around 2,000 employees it will be fairly
mechanistic.
Organization Design
A Table of Organization (TO) presents one’s position in the hierarchy as well as lines of
authority and reporting. Dotted lines indicate that there is a communication between positions
but authority resides with those in the solid lines. This table is often referred to as the
“Org.Chart”.
Simple Structure
Work specialization is low, few rules govern the operation, and authority is centralized in a
single person – the owner. It is a “Zlat” organization, usually only 2 or 3 vertical levels and
empowered employees.
It is fast, Zlexible, and inexpensive to maintain and accountability is clear. However, as the
organization grows decision making becomes slower as a single executive tries to continue
making all the decisions. The agency may lose momentum because everything depends on one
person – the owner.
As we grow, agencies tend to form a Functional Structure.
Functional structure
Similar and related occupational specialties are grouped together. While this can minimize
duplication of personnel and equipment, and make employees comfortable it can lead to
departmental isolation – no one department has responsibility for the end result of the strategic
plan, and does not know what the other departments are doing.
Divisional Structure
The organization is made up of self-‐contained units. Each division is autonomous in strategy
and operational decision making. Central headquarters provides support services such as legal
and Zinancial support, and is the external overseers to coordinate and control the various
divisions. This advantage is it is results driven and central headquarters can focus on long term
strategy and planning. The downside of the divisional structure is duplication of activities and
resources. It increases the organizations costs and reduces efZiciency.
200
Matrix Structure
The structure that combines the advantages of functional specialization with the focus on
accountability that product departmentalization provides.
Matrix is an organization is which specialists from functional departments are assigned to work
on one or more projects led by a project manager. These employees have 2 managers – a
functional department manager and a project manager. Authority is shared between the two
managers.
Boundary-less structure
These are not deZined or limited by boundaries or categories imposed by traditional structures.
Rather than have functional specialties in distinct departments. The organizational culture
usually reZlects the vision or values of the agency founder. They project an image of what the
agency should be. It results from the interaction between the founder’s biases and assumptions
and what the Zirst employees learn subsequently from their own experience.
Once you have clariZied your agency mission and structure, you will need to clarify the services
your agency will be providing. This is called the Program Description.
References
Independent Press.
201
PDF/251.pdf
(31), 173-‐180.
202
24, 129-‐135.
Inquiry, 77(2), 166-‐193.
1821-‐1837.
203
Appendix D
Title 42 Code of Federal Regulations Part 2 (edited)30
ConZidentiality of Alcohol and Drug Abuse Patient Records
2.3 Purpose and effect.
(a) Purpose. Under the statutory provisions quoted in §§2.1 and 2.2, these regulations impose
restrictions upon the disclosure and use of alcohol and drug abuse patient records which are
maintained in connection with the performance of any federally assisted alcohol and drug abuse
program. The regulations specify:
(1) DeZinitions, applicability, and general restrictions in subpart B (deZinitions applicable to
§2.34 only appear in that section);
(2) Disclosures which may be made with written patient consent and the form of the written
consent in subpart C;
(3) Disclosures which may be made without written patient consent or an authorizing court
order in subpart D; and
(4) Disclosures and uses of patient records which may be made with an authorizing court order
and the procedures and criteria for the entry and scope of those orders in subpart E.
(b) Effect. (1) These regulations prohibit the disclosure and use of patient records unless certain
circumstances exist. If any circumstances exists under which disclosure is permitted, that
circumstance acts to remove the prohibition on disclosure but it does not compel disclosure.
Thus, the regulations do not require disclosure under any circumstances.
(2) These regulations are not intended to direct the manner in which substantive functions such
as research, treatment, and evaluation are carried out. They are intended to insure that an
alcohol or drug abuse patient in a federally assisted alcohol or drug abuse program is not made
more vulnerable by reason of the availability of his or her patient record than an individual who
has an alcohol or drug problem and who does not seek treatment.
(3) Because there is a criminal penalty (a Zine—see 42 U.S.C. 290ee–3(f), 42 U.S.C. 290dd–3(f)
and 42 CFR 2.4) for violating the regulations, they are to be construed strictly in favor of the
potential violator in the same manner as a criminal statute (see M. Kraus & Brothers v. United
States, 327 U.S. 614, 621–22, 66 S. Ct. 705, 707–08 (1946)).
§ 2.4 Criminal penalty for violation.
United States Code of Federal Regulations, Title 42: Public Health, Chapter 1: Public Health
Service, Department of Health and Human Services, Subchapter A: General Provisions, Part 2:
ConZidentiality of Alcohol and Drug Abuse Patient Records.
30
223
Under 42 U.S.C. 290ee–3(f) and 42 U.S.C. 290dd–3(f), any person who violates any provision of
those statutes or these regulations shall be Zined not more than $500 in the case of a Zirst
offense, and not more than $5,000 in the case of each subsequent offense.
§ 2.5 Reports of violations.
(a) The report of any violation of these regulations may be directed to the United States
Attorney for the judicial district in which the violation occurs.
(b) The report of any violation of these regulations by a methadone program may be directed to
the Regional OfZices of the Food and Drug Administration.
Subpart B—General Provisions
§ 2.11 DeZinitions.
For purposes of these regulations:
Alcohol abuse means the use of an alcoholic beverage which impairs the physical, mental,
emotional, or social well-‐being of the user.
Drug abuse means the use of a psychoactive substance for other than medicinal purposes which
impairs the physical, mental, emotional, or social well-‐being of the user.
Diagnosis means any reference to an individual's alcohol or drug abuse or to a condition which
is identiZied as having been caused by that abuse which is made for the purpose of treatment or
referral for treatment.
Disclose or disclosure means a communication of patient identifying information, the
afZirmative veriZication of another person's communication of patient identifying information,
or the communication of any information from the record of a patient who has been identiZied.
Informant means an individual:
(a) Who is a patient or employee of a program or who becomes a patient or employee of a
program at the request of a law enforcement agency or ofZicial: and
(b) Who at the request of a law enforcement agency or ofZicial observes one or more patients or
employees of the program for the purpose of reporting the information obtained to the law
enforcement agency or ofZicial.
224
Patient means any individual who has applied for or been given diagnosis or treatment for
alcohol or drug abuse at a federally assisted program and includes any individual who, after
arrest on a criminal charge, is identiZied as an alcohol or drug abuser in order to determine that
individual's eligibility to participate in a program.
Patient identifying information means the name, address, social security number, Zingerprints,
photograph, or similar information by which the identity of a patient can be determined with
reasonable accuracy and speed either directly or by reference to other publicly available
information. The term does not include a number assigned to a patient by a program, if that
number does not consist of, or contain numbers (such as a social security, or driver's license
number) which could be used to identify a patient with reasonable accuracy and speed from
sources external to the program.
Person means an individual, partnership, corporation, Federal, State or local government
agency, or any other legal entity.
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 identiZied 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 identiZied as such providers. (See §2.12(e)(1) for examples.)
Program director means:
(a) In the case of a program which is an individual, that individual:
(b) In the case of a program which is an organization, the individual designated as director,
managing director, or otherwise vested with authority to act as chief executive of the
organization.
QualiZied service organization means a person which:
(a) Provides services to a program, such as data processing, bill collecting, dosage preparation,
laboratory analyses, or legal, medical, accounting, or other professional services, or services to
prevent or treat child abuse or neglect, including training on nutrition and child care and
individual and group therapy, and
(b) Has entered into a written agreement with a program under which that person:
225
(1) Acknowledges that in receiving, storing, processing or otherwise dealing with any patient
records from the progams, it is fully bound by these regulations; and
(2) If necessary, will resist in judicial proceedings any efforts to obtain access to patient records
except as permitted by these regulations.
Records means any information, whether recorded or not, relating to a patient received or
acquired by a federally assisted alcohol or drug program.
Third party payer means a person who pays, or agrees to pay, for diagnosis or treatment
furnished to a patient on the basis of a contractual relationship with the patient or a member of
his family or on the basis of the patient's eligibility for Federal, State, or local governmental
beneZits.
Treatment means the management and care of a patient suffering from alcohol or drug abuse, a
condition which is identiZied as having been caused by that abuse, or both, in order to reduce or
eliminate the adverse effects upon the patient.
Undercover agent means an ofZicer of any Federal, State, or local law enforcement agency who
enrolls in or becomes an employee of a program for the purpose of investigating a suspected
violation of law or who pursues that purpose after enrolling or becoming employed for other
purposes.
[52 FR 21809, June 9, 1987, as amended by 60 FR 22297, May 5, 1995]
§ 2.12 Applicability.
(a) General —(1) Restrictions on disclosure. The restrictions on disclosure in these regulations
apply to any information, whether or not recorded, which:
(i) Would identify a patient as an alcohol or drug abuser either directly, by reference to other
publicly available information, or through veriZication of such an identiZication by another
person; and
(ii) Is drug abuse information obtained by a federally assisted drug abuse program after March
20, 1972, or is alcohol abuse information obtained by a federally assisted alcohol abuse
program after May 13, 1974 (or if obtained before the pertinent date, is maintained by a
federally assisted alcohol or drug abuse program after that date as part of an ongoing treatment
episode which extends past that date) for the purpose of treating alcohol or drug abuse, making
a diagnosis for that treatment, or making a referral for that treatment.
(2) Restriction on use. The restriction on use of information to initiate or substantiate any
criminal charges against a patient or to conduct any criminal investigation of a patient (42 U.S.C.
290ee–3(c), 42 U.S.C. 290dd–3(c)) applies to any information, whether or not recorded which is
drug abuse information obtained by a federally assisted drug abuse program after March 20,
1972, or is alcohol abuse information obtained by a federally assisted alcohol abuse program
after May 13, 1974 (or if obtained before the pertinent date, is maintained by a federally
assisted alcohol or drug abuse program after that date as part of an ongoing treatment episode
226
which extends past that date), for the purpose of treating alcohol or drug abuse, making a
diagnosis for the treatment, or making a referral for the treatment.
(b) Federal assistance. An alcohol abuse or drug abuse program is considered to be federally
assisted if:
(1) It is conducted in whole or in part, whether directly or by contract or otherwise by any
department or agency of the United States (but see paragraphs (c)(1) and (c)(2) of this section
relating to the Veterans' Administration and the Armed Forces);
(2) It is being carried out under a license, certiZication, registration, or other authorization
granted by any department or agency of the United States including but not limited to:
(i) CertiZication of provider status under the Medicare program;
(ii) Authorization to conduct methadone maintenance treatment (see 21 CFR 291.505); or
(iii) Registration to dispense a substance under the Controlled Substances Act to the extent the
controlled substance is used in the treatment of alcohol or drug abuse;
(3) It is supported by funds provided by any department or agency of the United States by
being:
(i) A recipient of Federal Zinancial assistance in any form, including Zinancial assistance which
does not directly pay for the alcohol or drug abuse diagnosis, treatment, or referral activities; or
(ii) Conducted by a State or local government unit which, through general or special revenue
sharing or other forms of assistance, receives Federal funds which could be (but are not
necessarily) spent for the alcohol or drug abuse program; or
(4) It is assisted by the Internal Revenue Service of the Department of the Treasury through the
allowance of income tax deductions for contributions to the program or through the granting of
tax exempt status to the program.
(c) Exceptions— (1) Veterans' Administration. These regulations do not apply to information on
alcohol and drug abuse patients maintained in connection with the Veterans' Administration
provisions of hospital care, nursing home care, domiciliary care, and medical services under
title 38, United States Code. Those records are governed by 38 U.S.C. 4132 and regulations
issued under that authority by the Administrator of Veterans' Affairs.
(2) Armed Forces. These regulations apply to any information described in paragraph (a) of this
section which was obtained by any component of the Armed Forces during a period when the
patient was subject to the Uniform Code of Military Justice except:
(i) Any interchange of that information within the Armed Forces; and
(ii) Any interchange of that information between the Armed Forces and those components of
the Veterans Administration furnishing health care to veterans.
(3) Communication within a program or between a program and an entity having direct
administrative control over that program. The restrictions on disclosure in these regulations do
not apply to communications of information between or 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 alcohol or drug abuse if the communications are
(i) Within a program or
(ii) Between a program and an entity that has direct administrative control over the program.
(4) QualiZied Service Organizations. The restrictions on disclosure in these regulations do not
apply to communications between a program and a qualiZied service organization of
information needed by the organization to provide services to the program.
(5) Crimes on program premises or against program personnel. The restrictions on disclosure
and use in these regulations do not apply to communications from program personnel to law
enforcement ofZicers which—
227
(i) Are directly related to a patient's commission of a crime on the premises of the program or
against program personnel or to a threat to commit such a crime; and
(ii) Are limited to the circumstances of the incident, including the patient status of the
individual committing or threatening to commit the crime, that individual's name and address,
and that individual's last known whereabouts.
(6) Reports of suspected child abuse and neglect. The restrictions on disclosure and use in these
regulations do not apply to the reporting under State law of incidents of suspected child abuse
and neglect to the appropriate State or local authorities. However, the restrictions continue to
apply to the original alcohol or drug abuse patient records maintained by the program including
their disclosure and use for civil or criminal proceedings which may arise out of the report of
suspected child abuse and neglect.
(d) Applicability to recipients of information— (1) Restriction on use of information. The
restriction on the use of any information subject to these regulations to initiate or substantiate
any criminal charges against a patient or to conduct any criminal investigation of a patient
applies to any person who obtains that information from a federally assisted alcohol or drug
abuse program, regardless of the status of the person obtaining the information or of whether
the information was obtained in accordance with these regulations. This restriction on use bars,
among other things, the introduction of that information as evidence in a criminal proceeding
and any other use of the information to investigate or prosecute a patient with respect to a
suspected crime. Information obtained by undercover agents or informants (see §2.17) or
through patient access (see §2.23) is subject to the restriction on use.
(2) Restrictions on disclosures — Third party payers, administrative entities, and others. The
restrictions on disclosure in these regulations apply to:
(i) Third party payers with regard to records disclosed to them by federally assisted alcohol or
drug abuse programs;
(ii) Entities having direct administrative control over programs with regard to information
communicated to them by the program under §2.12(c)(3); and
(iii) Persons who receive patient records directly from a federally assisted alcohol or drug abuse
program and who are notiZied of the restrictions on redisclosure of the records in accordance
with §2.32 of these regulations.
(e) Explanation of applicability— (1) Coverage. These regulations cover any information
(including information on referral and intake) about alcohol and drug abuse patients obtained
by a program (as the terms “patient” and “program” are deZined in §2.11) if the program is
federally assisted in any manner described in §2.12(b). Coverage includes, but is not limited to,
those treatment or rehabilitation programs, employee assistance programs, programs within
general hospitals, school-‐based programs, and private practitioners who hold themselves out as
providing, and provide alcohol or drug abuse diagnosis, treatment, or referral for treatment.
However, these regulations would not apply, for example, to emergency room personnel who
refer a patient to the intensive care unit for an apparent overdose, unless the primary function
of such personnel is the provision of alcohol or drug abuse diagnosis, treatment or referral and
they are identiZied as providing such services or the emergency room has promoted itself to the
community as a provider of such services.
(2) Federal assistance to program required. If a patient's alcohol or drug abuse diagnosis,
treatment, or referral for treatment is not provided by a program which is federally conducted,
regulated or supported in a manner which constitutes Federal assistance under §2.12(b), that
patient's record is not covered by these regulations. Thus, it is possible for an individual patient
to beneZit from Federal support and not be covered by the conZidentiality regulations because
the program in which the patient is enrolled is not federally assisted as deZined in §2.12(b). For
228
example, if a Federal court placed an individual in a private for-‐proZit program and made a
payment to the program on behalf of that individual, that patient's record would not be covered
by these regulations unless the program itself received Federal assistance as deZined by §2.12
(b).
(3) Information to which restrictions are applicable. Whether a restriction is on use or
disclosure affects the type of information which may be available. The restrictions on disclosure
apply to any information which would identify a patient as an alcohol or drug abuser. The
restriction on use of information to bring criminal charges against a patient for a crime applies
to any information obtained by the program for the purpose of diagnosis, treatment, or referral
for treatment of alcohol or drug abuse. (Note that restrictions on use and disclosure apply to
recipients of information under §2.12(d).)
(4) How type of diagnosis affects coverage. These regulations cover any record of a diagnosis
identifying a patient as an alcohol or drug abuser which is prepared in connection with the
treatment or referral for treatment of alcohol or drug abuse. A diagnosis prepared for the
purpose of treatment or referral for treatment but which is not so used is covered by these
regulations. The following are not covered by these regulations:
(i) Diagnosis which is made solely for the purpose of providing evidence for use by law
enforcement authorities; or
(ii) A diagnosis of drug overdose or alcohol intoxication which clearly shows that the individual
involved is not an alcohol or drug abuser (e.g., involuntary ingestion of alcohol or drugs or
reaction to a prescribed dosage of one or more drugs).
[52 FR 21809, June 9, 1987; 52 FR 42061, Nov. 2, 1987, as amended at 60 FR 22297, May 5,
1995]
§ 2.13 ConZidentiality restrictions.
(a) General. The patient records to which these regulations apply may be disclosed or used only
as permitted by these regulations and may not otherwise be disclosed or used in any civil,
criminal, administrative, or legislative proceedings conducted by any Federal, State, or local
authority. Any disclosure made under these regulations must be limited to that information
which is necessary to carry out the purpose of the disclosure.
(b) Unconditional compliance required. The restrictions on disclosure and use in these
regulations apply whether the holder of the information believes that the person seeking the
information already has it, has other means of obtaining it, is a law enforcement or other
ofZicial, has obtained a subpoena, or asserts any other justiZication for a disclosure or use which
is not permitted by these regulations.
(c) Acknowledging the presence of patients: Responding to requests. (1) The presence of an
identiZied patient in a facility or component of a facility which is publicly identiZied as a place
where only alcohol or drug abuse diagnosis, treatment, or referral is provided may be
acknowledged only if the patient's written consent is obtained in accordance with subpart C of
these regulations or if an authorizing court order is entered in accordance with subpart E of
these regulations. The regulations permit acknowledgement of the presence of an identiZied
patient in a facility or part of a facility if the facility is not publicy identiZied as only an alcohol or
drug abuse diagnosis, treatment or referral facility, and if the acknowledgement does not reveal
that the patient is an alcohol or drug abuser.
229
(2) Any answer to a request for a disclosure of patient records which is not permissible under
these regulations must be made in a way that will not afZirmatively reveal that an identiZied
individual has been, or is being diagnosed or treated for alcohol or drug abuse. An inquiring
party may be given a copy of these regulations and advised that they restrict the disclosure of
alcohol or drug abuse patient records, but may not be told afZirmatively that the regulations
restrict the disclosure of the records of an identiZied patient. The regulations do not restrict a
disclosure that an identiZied individual is not and never has been a patient.
§ 2.14 Minor patients.
(a) DeZinition of minor. As used in these regulations the term “minor” means a person who has
not attained the age of majority speciZied in the applicable State law, or if no age of majority is
speciZied in the applicable State law, the age of eighteen years.
(b) State law not requiring parental consent to treatment. If a minor patient acting alone has the
legal capacity under the applicable State law to apply for and obtain alcohol or drug abuse
treatment, any written consent for disclosure authorized under subpart C of these regulations
may be given only by the minor patient. This restriction includes, but is not limited to, any
disclosure of patient identifying information to the parent or guardian of a minor patient for the
purpose of obtaining Zinancial reimbursement. These regulations do not prohibit a program
from refusing to provide treatment until the minor patient consents to the disclosure necessary
to obtain reimbursement, but refusal to provide treatment may be prohibited under a State or
local law requiring the program to furnish the service irrespective of ability to pay.
(c) State law requiring parental consent to treatment. (1) Where State law requires consent of a
parent, guardian, or other person for a minor to obtain alcohol or drug abuse treatment, any
written consent for disclosure authorized under subpart C of these regulations must be given by
both the minor and his or her parent, guardian, or other person authorized under State law to
act in the minor's behalf.
(2) Where State law requires parental consent to treatment the fact of a minor's application for
treatment may be communicated to the minor's parent, guardian, or other person authorized
under State law to act in the minor's behalf only if:
(i) The minor has given written consent to the disclosure in accordance with subpart C of these
regulations or
(ii) The minor lacks the capacity to make a rational choice regarding such consent as judged by
the program director under paragraph (d) of this section.
(d) Minor applicant for services lacks capacity for rational choice. Facts relevant to reducing a
threat to the life or physical well being of the applicant or any other individual may be disclosed
to the parent, guardian, or other person authorized under State law to act in the minor's behalf
if the program director judges that:
(1) A minor applicant for services lacks capacity because of extreme youth or mental or physical
condition to make a rational decision on whether to consent to a disclosure under subpart C of
these regulations to his or her parent, guardian, or other person authorized under State law to
act in the minor's behalf, and
(2) The applicant's situation poses a substantial threat to the life or physical well being of the
applicant or any other individual which may be reduced by communicating relevant facts to the
230
minor's parent, guardian, or other person authorized under State law to act in the minor's
behalf.
§ 2.15 Incompetent and deceased patients.
(a) Incompetent patients other than minors —(1) Adjudication of incompetence. In the case of a
patient who has been adjudicated as lacking the capacity, for any reason other than insufZicient
age, to manage his or her own affairs, any consent which is required under these regulations
may be given by the guardian or other person authorized under State law to act in the patient's
behalf.
(2) No adjudication of incompetency. For any period for which the program director determines
that a patient, other than a minor or one who has been adjudicated incompetent, suffers from a
medical condition that prevents knowing or effective action on his or her own behalf, the
program director may exercise the right of the patient to consent to a disclosure under subpart
C of these regulations for the sole purpose of obtaining payment for services from a third party
payer.
(b) Deceased patients —(1) Vital statistics. These regulations do not restrict the disclosure of
patient identifying information relating to the cause of death of a patient under laws requiring
the collection of death or other vital statistics or permitting inquiry into the cause of death.
(2) Consent by personal representative. Any other disclosure of information identifying a
deceased patient as an alcohol or drug abuser is subject to these regulations. If a written
consent to the disclosure is required, that consent may be given by an executor, administrator,
or other personal representative appointed under applicable State law. If there is no such
appointment the consent may be given by the patient's spouse or, if none, by any responsible
member of the patient's family.
§ 2.16 Security for written records.
(a) Written records which are subject to these regulations must be maintained in a secure room,
locked Zile cabinet, safe or other similar container when not in use; and
(b) Each program shall adopt in writing procedures which regulate and control access to and
use of written records which are subject to these regulations.
§ 2.17 Undercover agents and informants.
(a) Restrictions on placement. Except as speciZically authorized by a court order granted under
§2.67 of these regulations, no program may knowingly employ, or enroll as a patient, any
undercover agent or informant.
(b) Restriction on use of information. No information obtained by an undercover agent or
informant, whether or not that undercover agent or informant is placed in a program pursuant
to an authorizing court order, may be used to criminally investigate or prosecute any patient.
231
[52 FR 21809, June 9, 1987; 52 FR 42061, Nov. 2, 1987]
§ 2.18 Restrictions on the use of identiZication cards.
No person may require any patient to carry on his or her person while away from the program
premises any card or other object which would identify the patient as an alcohol or drug abuser.
This section does not prohibit a person from requiring patients to use or carry cards or other
identiZication objects on the premises of a program.
§ 2.19 Disposition of records by discontinued programs.
(a) General. If a program discontinues operations or is taken over or acquired by another
program, it must purge patient identifying information from its records or destroy the records
unless—
(1) The patient who is the subject of the records gives written consent (meeting the
requirements of §2.31) to a transfer of the records to the acquiring program or to any other
program designated in the consent (the manner of obtaining this consent must minimize the
likelihood of a disclosure of patient identifying information to a third party); or
(2) There is a legal requirement that the records be kept for a period speciZied by law which
does not expire until after the discontinuation or acquisition of the program.
(b) Procedure where retention period required by law. If paragraph (a)(2) of this section
applies, the records must be:
(1) Sealed in envelopes or other containers labeled as follows: “Records of [insert name of
program] required to be maintained under [insert citation to statute, regulation, court order or
other legal authority requiring that records be kept] until a date not later than [insert
appropriate date]”; and
(2) Held under the restrictions of these regulations by a responsible person who must, as soon
as practicable after the end of the retention period speciZied on the label, destroy the records.
§ 2.20 Relationship to State laws.
The statutes authorizing these regulations (42 U.S.C. 290ee–3 and 42 U.S.C. 290dd–3) do not
preempt the Zield of law which they cover to the exclusion of all State laws in that Zield. If a
disclosure permitted under these regulations is prohibited under State law, neither these
regulations nor the authorizing statutes may be construed to authorize any violation of that
State law. However, no State law may either authorize or compel any disclosure prohibited by
these regulations.
Section 2.22
232
§ 2.22 Notice to patients of Federal conZidentiality requirements.
(a) Notice required. At the time of admission or as soon threreafter as the patient is capable of
rational communication, each program shall:
(1) Communicate to the patient that Federal law and regulations protect the conZidentiality of
alcohol and drug abuse patient records; and
(2) Give to the patient a summary in writing of the Federal law and regulations.
(b) Required elements of written summary. The written summary of the Federal law and
regulations must include:
(1) A general description of the limited circumstances under which a program may
acknowledge that an individual is present at a facility or disclose outside the program
information identifying a patient as an alcohol or drug abuser.
(2) A statement that violation of the Federal law and regulations by a program is a crime and
that suspected violations may be reported to appropriate authorities in accordance with these
regulations.
(3) A statement that information related to a patient's commission of a crime on the premises of
the program or against personnel of the program is not protected.
(4) A statement that reports of suspected child abuse and neglect made under State law to
appropriate State or local authorities are not protected.
(5) A citation to the Federal law and regulations.
(c) Program options. The program may devise its own notice or may use the sample notice in
paragraph (d) to comply with the requirement to provide the patient with a summary in writing
of the Federal law and regulations. In addition, the program may include in the written
summary information concerning State law and any program policy not inconsistent with State
and Federal law on the subject of conZidentiality of alcohol and drug abuse patient records.
(d) Sample notice.
ConZidentiality of Alcohol and Drug Abuse Patient Records
The conZidentiality of alcohol and drug abuse patient records maintained by this program is
protected by Federal law and regulations. Generally, the program may not say to a person
outside the program that a patient attends the program, or disclose any information identifying
a patient as an alcohol or drug abuser Unless:
(1) The patient consents in writing:
(2) The disclosure is allowed by a court order; or
(3) The disclosure is made to medical personnel in a medical emergency or to qualiZied
personnel for research, audit, or program evaluation.
Violation of the Federal law and regulations by a program is a crime. Suspected violations may
be reported to appropriate authorities in accordance with Federal regulations.
Federal law and regulations do not protect any information about a crime committed by a
patient either at the program or against any person who works for the program or about any
threat to commit such a crime.
233
Federal laws and regulations do not protect any information about suspected child abuse or
neglect from being reported under State law to appropriate State or local authorities.
(See 42 U.S.C. 290dd–3 and 42 U.S.C. 290ee–3 for Federal laws and 42 CFR part 2 for Federal
regulations.)
(Approved by the OfZice of Management and Budget under control number 0930–0099)
§ 2.23 Patient access and restrictions on use.
(a) Patient access not prohibited. These regulations do not prohibit a program from giving a
patient access to his or her own records, including the opportunity to inspect and copy any
records that the program maintains about the patient. The program is not required to obtain a
patient's written consent or other authorization under these regulations in order to provide
such access to the patient.
(b) Restriction on use of information. Information obtained by patient access to his or her
patient record is subject to the restriction on use of his information to initiate or substantiate
any criminal charges against the patient or to conduct any criminal investigation of the patient
as provided for under §2.12(d)(1).
Subpart C—Disclosures With Patient's Consent
§ 2.31 Form of written consent.
(a) Required elements. A written consent to a disclosure under these regulations must include:
(1) The speciZic name or general designation of the program or person permitted to make the
disclosure.
(2) The name or title of the individual or the name of the organization to which disclosure is to
be made.
(3) The name of the patient.
(4) The purpose of the disclosure.
(5) How much and what kind of information is to be disclosed.
(6) The signature of the patient and, when required for a patient who is a minor, the signature of
a person authorized to give consent under §2.14; or, when required for a patient who is
incompetent or deceased, the signature of a person authorized to sign under §2.15 in lieu of the
patient.
(7) The date on which the consent is signed.
(8) A statement that the consent is subject to revocation at any time except to the extent that the
program or person which is to make the disclosure has already acted in reliance on it. Acting in
reliance includes the provision of treatment services in reliance on a valid consent to disclose
information to a third party payer.
(9) The date, event, or condition upon which the consent will expire if not revoked before. This
date, event, or condition must insure that the consent will last no longer than reasonably
necessary to serve the purpose for which it is given.
(b) Sample consent form. The following form complies with paragraph (a) of this section, but
other elements may be added.
1. I (name of patient) o Request o Authorize:
234
2. (name or general designation of program which is to make the disclosure)
____________________
3. To disclose: (kind and amount of information to be disclosed)
____________________
4. To: (name or title of the person or organization to which disclosure is to be made)
____________________
5. For (purpose of the disclosure)
____________________
6. Date (on which this consent is signed)
____________________
7. Signature of patient
____________________
8. Signature of parent or guardian (where required)
____________________
9. Signature of person authorized to sign in lieu of the patient (where required)
____________________
10. This consent is subject to revocation at any time except to the extent that the program which
is to make the disclosure has already taken action in reliance on it. If not previously revoked,
this consent will terminate upon: (speciZic date, event, or condition)
(c) Expired, deZicient, or false consent. A disclosure may not be made on the basis of a consent
which:
(1) Has expired;
(2) On its face substantially fails to conform to any of the requirements set forth in paragraph
(a) of this section;
(3) Is known to have been revoked; or
(4) Is known, or through a reasonable effort could be known, by the person holding the records
to be materially false.
§ 2.32 Prohibition on redisclosure.
Notice to accompany disclosure. Each disclosure made with the patient's written consent must
be accompanied by the following written statement:
235
This information has been disclosed to you from records protected by Federal conZidentiality
rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of this
information unless further disclosure is expressly permitted by the written consent of the
person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization
for the release of medical or other information is NOT sufZicient for this purpose. The Federal
rules restrict any use of the information to criminally investigate or prosecute any alcohol or
drug abuse patient.
[52 FR 21809, June 9, 1987; 52 FR 41997, Nov. 2, 1987]
§ 2.33 Disclosures permitted with written consent.
If a patient consents to a disclosure of his or her records under §2.31, a program may disclose
those records in accordance with that consent to any individual or organization named in the
consent, except that disclosures to central registries and in connection with criminal justice
referrals must meet the requirements of §§2.34 and 2.35, respectively.
§ 2.34 Disclosures to prevent multiple enrollments in detoxiZication and maintenance
treatment programs.
(a) DeZinitions. For purposes of this section:
Central registry means an organization which obtains from two or more member progams
patient identifying information about individuals applying for maintenance treatment or
detoxiZication treatment for the purpose of avoiding an individual's concurrent enrollment in
more than one program.
DetoxiZication treatment means the dispensing of a narcotic drug in decreasing doses to an
individual in order to reduce or eliminate adverse physiological or psychological effects incident
to withdrawal from the sustained use of a narcotic drug.
Maintenance treatment means the dispensing of a narcotic drug in the treatment of an
individual for dependence upon heroin or other morphine-‐like drugs.
Member program means a detoxiZication treatment or maintenance treatment program which
reports patient identifying information to a central registry and which is in the same State as
that central registry or is not more than 125 miles from any border of the State in which the
central registry is located.
(b) Restrictions on disclosure. A program may disclose patient records to a central registry or to
any detoxiZication or maintenance treatment program not more than 200 miles away for the
purpose of preventing the multiple enrollment of a patient only if:
236
(1) The disclosure is made when:
(i) The patient is accepted for treatment;
(ii) The type or dosage of the drug is changed; or
(iii) The treatment is interrupted, resumed or terminated.
(2) The disclosure is limited to:
(i) Patient identifying information;
(ii) Type and dosage of the drug; and
(iii) Relevant dates.
(3) The disclosure is made with the patient's written consent meeting the requirements of
§2.31, except that:
(i) The consent must list the name and address of each central registry and each known
detoxiZication or maintenance treatment program to which a disclosure will be made; and
(ii) The consent may authorize a disclosure to any detoxiZication or maintenance treatment
program established within 200 miles of the program after the consent is given without naming
any such program.
(c) Use of information limited to prevention of multiple enrollments. A central registry and any
detoxiZication or maintenance treatment program to which information is disclosed to prevent
multiple enrollments may not redisclose or use patient identifying information for any purpose
other than the prevention of multiple enrollments unless authorized by a court order under
subpart E of these regulations.
(d) Permitted disclosure by a central registry to prevent a multiple enrollment. When a member
program asks a central registry if an identiZied patient is enrolled in another member program
and the registry determines that the patient is so enrolled, the registry may disclose—
(1) The name, address, and telephone number of the member program(s) in which the patient is
already enrolled to the inquiring member program; and
(2) The name, address, and telephone number of the inquiring member program to the member
program(s) in which the patient is already enrolled. The member programs may communicate
as necessary to verify that no error has been made and to prevent or eliminate any multiple
enrollment.
237
(e) Permitted disclosure by a detoxiZication or maintenance treatment program to prevent a
multiple enrollment. A detoxiZication or maintenance treatment program which has received a
disclosure under this section and has determined that the patient is already enrolled may
communicate as necessary with the program making the disclosure to verify that no error has
been made and to prevent or eliminate any multiple enrollment.
§ 2.35 Disclosures to elements of the criminal justice system which have referred patients.
(a) A program may disclose information about a patient to those persons within the criminal
justice system which have made participation in the program a condition of the disposition of
any criminal proceedings against the patient or of the patient's parole or other release from
custody if:
(1) The disclosure is made only to those individuals within the criminal justice system who have
a need for the information in connection with their duty to monitor the patient's progress (e.g.,
a prosecuting attorney who is withholding charges against the patient, a court granting pretrial
or posttrial release, probation or parole ofZicers responsible for supervision of the patient); and
(2) The patient has signed a written consent meeting the requirements of §2.31 (except
paragraph (a)(8) which is inconsistent with the revocation provisions of paragraph (c) of this
section) and the requirements of paragraphs (b) and (c) of this section.
(b) Duration of consent. The written consent must state the period during which it remains in
effect. This period must be reasonable, taking into account:
(1) The anticipated length of the treatment;
(2) The type of criminal proceeding involved, the need for the information in connection with
the Zinal disposition of that proceeding, and when the Zinal disposition will occur; and
(3) Such other factors as the program, the patient, and the person(s) who will receive the
disclosure consider pertinent.
(c) Revocation of consent. The written consent must state that it is revocable upon the passage
of a speciZied amount of time or the occurrence of a speciZied, ascertainable event. The time or
occurrence upon which consent becomes revocable may be no later than the Zinal disposition of
the conditional release or other action in connection with which consent was given.
(d) Restrictions on redisclosure and use. A person who receives patient information under this
section may redisclose and use it only to carry out that person's ofZicial duties with regard to the
patient's conditional release or other action in connection with which the consent was given.
Subpart D—Disclosures Without Patient Consent
§ 2.51 Medical emergencies.
(a) General Rule. Under the procedures required by paragraph (c) of this section, patient
identifying information may be disclosed to medical personnel who have a need for information
about a patient for the purpose of treating a condition which poses an immediate threat to the
health of any individual and which requires immediate medical intervention.
(b) Special Rule. Patient identifying information may be disclosed to medical personnel of the
Food and Drug Administration (FDA) who assert a reason to believe that the health of any
238
individual may be threatened by an error in the manufacture, labeling, or sale of a product
under FDA jurisdiction, and that the information will be used for the exclusive purpose of
notifying patients or their physicians of potential dangers.
(c) Procedures. Immediately following disclosure, the program shall document the disclosure in
the patient's records, setting forth in writing:
(1) The name of the medical personnel to whom disclosure was made and their afZiliation with
any health care facility;
(2) The name of the individual making the disclosure;
(3) The date and time of the disclosure; and
(4) The nature of the emergency (or error, if the report was to FDA).
§ 2.52 Research activities.
(a) Patient identifying information may be disclosed for the purpose of conducting scientiZic
research if the program director makes a determination that the recipient of the patient
identifying information:
(1) Is qualiZied to conduct the research;
(2) Has a research protocol under which the patient identifying information:
(i) Will be maintained in accordance with the security requirements of §2.16 of these
regulations (or more stringent requirements); and
(ii) Will not be redisclosed except as permitted under paragraph (b) of this section; and
(3) Has provided a satisfactory written statement that a group of three or more individuals who
are independent of the research project has reviewed the protocol and determined that:
(i) The rights and welfare of patients will be adequately protected; and
(ii) The risks in disclosing patient identifying information are outweighed by the potential
beneZits of the research.
(b) A person conducting research may disclose patient identifying information obtained under
paragraph (a) of this section only back to the program from which that information was
obtained and may not identify any individual patient in any report of that research or otherwise
disclose patient identities.
[52 FR 21809, June 9, 1987, as amended at 52 FR 41997, Nov. 2, 1987]
§ 2.53 Audit and evaluation activities.
(a) Records not copied or removed. If patient records are not copied or removed, patient
identifying information may be disclosed in the course of a review of records on program
premises to any person who agrees in writing to comply with the limitations on redisclosure
and use in paragraph (d) of this section and who:
(1) Performs the audit or evaluation activity on behalf of:
(i) Any Federal, State, or local governmental agency which provides Zinancial assistance to the
program or is authorized by law to regulate its activities; or
(ii) Any private person which provides Zinancial assistance to the program, which is a third
party payer covering patients in the program, or which is a quality improvement organization
performing a utilization or quality control review; or
239
(2) Is determined by the program director to be qualiZied to conduct the audit or evaluation
activities.
(b) Copying or removal of records. Records containing patient identifying information may be
copied or removed from program premises by any person who:
(1) Agrees in writing to:
(i) Maintain the patient identifying information in accordance with the security requirements
provided in §2.16 of these regulations (or more stringent requirements);
(ii) Destroy all the patient identifying information upon completion of the audit or evaluation;
and
(iii) Comply with the limitations on disclosure and use in paragraph (d) of this section; and
(2) Performs the audit or evaluation activity on behalf of:
(i) Any Federal, State, or local governmental agency which provides Zinancial assistance to the
program or is authorized by law to regulate its activities; or
(ii) Any private person which provides Zinancial assistance to the program, which is a third part
payer covering patients in the program, or which is a quality improvement organization
performing a utilization or quality control review.
(c) Medicare or Medicaid audit or evaluation. (1) For purposes of Medicare or Medicaid audit or
evaluation under this section, audit or evaluation includes a civil or administrative investigation
of the program by any Federal, State, or local agency responsible for oversight of the Medicare
or Medicaid program and includes administrative enforcement, against the program by the
agency, of any remedy authorized by law to be imposed as a result of the Zindings of the
investigation.
(2) Consistent with the deZinition of program in §2.11, program includes an employee of, or
provider of medical services under, the program when the employee or provider is the subject
of a civil investigation or administrative remedy, as those terms are used in paragraph (c)(1) of
this section.
(3) If a disclosure to a person is authorized under this section for a Medicare or Medicaid audit
or evaluation, including a civil investigation or administrative remedy, as those terms are used
in paragraph (c)(1) of this section, then a quality improvement organization which obtains the
information under paragraph (a) or (b) may disclose the information to that person but only for
purposes of Medicare or Medicaid audit or evaluation.
(4) The provisions of this paragraph do not authorize the agency, the program, or any other
person to disclose or use patient identifying information obtained during the audit or
evaluation for any purposes other than those necessary to complete the Medicare or Medicaid
audit or evaluation activity as speciZied in this paragraph.
(d) Limitations on disclosure and use. Except as provided in paragraph (c) of this section,
patient identifying information disclosed under this section may be disclosed only back to the
program from which it was obtained and used only to carry out an audit or evaluation purpose
or to investigate or prosecute criminal or other activities, as authorized by a court order entered
under §2.66 of these regulations.
Subpart E—Court Orders Authorizing Disclosure and Use
§ 2.61 Legal effect of order.
240
(a) Effect. An order of a court of competent jurisdiction entered under this subpart is a unique
kind of court order. Its only purpose is to authorize a disclosure or use of patient information
which would otherwise be prohibited by 42 U.S.C. 290ee–3, 42 U.S.C. 290dd–3 and these
regulations. Such an order does not compel disclosure. A subpoena or a similar legal mandate
must be issued in order to compel disclosure. This mandate may be entered at the same time as
and accompany an authorizing court order entered under these regulations.
(b) Examples. (1) A person holding records subject to these regulations receives a subpoena for
those records: a response to the subpoena is not permitted under the regulations unless an
authorizing court order is entered. The person may not disclose the records in response to the
subpoena unless a court of competent jurisdiction enters an authorizing order under these
regulations.
(2) An authorizing court order is entered under these regulations, but the person authorized
does not want to make the disclosure. If there is no subpoena or other compulsory process or a
subpoena for the records has expired or been quashed, that person may refuse to make the
disclosure. Upon the entry of a valid subpoena or other compulsory process the person
authorized to disclose must disclose, unless there is a valid legal defense to the process other
than the conZidentiality restrictions of these regulations.
[52 FR 21809, June 9, 1987; 52 FR 42061, Nov. 2, 1987]
§ 2.62 Order not applicable to records disclosed without consent to researchers, auditors and
evaluators.
A court order under these regulations may not authorize qualiZied personnel, who have received
patient identifying information without consent for the purpose of conducting research, audit or
evaluation, to disclose that information or use it to conduct any criminal investigation or
prosecution of a patient. However, a court order under §2.66 may authorize disclosure and use
of records to investigate or prosecute qualiZied personnel holding the records.
§ 2.63 ConZidential communications.
(a) A court order under these regulations may authorize disclosure of conZidential
communications made by a patient to a program in the course of diagnosis, treatment, or
referral for treatment only if:
(1) The disclosure is necessary to protect against an existing threat to life or of serious bodily
injury, including circumstances which constitute suspected child abuse and neglect and verbal
threats against third parties;
(2) The disclosure is necessary in connection with investigation or prosecution of an extremely
serious crime, such as one which directly threatens loss of life or serious bodily injury, including
homicide, rape, kidnapping, armed robbery, assault with a deadly weapon, or child abuse and
neglect; or
(3) The disclosure is in connection with litigation or an administrative proceeding in which the
patient offers testimony or other evidence pertaining to the content of the conZidential
communications.
241
(b) [Reserved]
§ 2.64 Procedures and criteria for orders authorizing disclosures for noncriminal purposes.
(a) Application. An order authorizing the disclosure of patient records for purposes other than
criminal investigation or prosecution may be applied for by any person having a legally
recognized interest in the disclosure which is sought. The application may be Ziled separately or
as part of a pending civil action in which it appears that the patient records are needed to
provide evidence. An application must use a Zictitious name, such as John Doe, to refer to any
patient and may not contain or otherwise disclose any patient identifying information unless
the patient is the applicant or has given a written consent (meeting the requirements of these
regulations) to disclosure or the court has ordered the record of the proceeding sealed from
public scrutiny.
(b) Notice. The patient and the person holding the records from whom disclosure is sought
must be given:
(1) Adequate notice in a manner which will not disclose patient identifying information to other
persons; and
(2) An opportunity to Zile a written response to the application, or to appear in person, for the
limited purpose of providing evidence on the statutory and regulatory criteria for the issuance
of the court order.
(c) Review of evidence: Conduct of hearing. Any oral argument, review of evidence, or hearing
on the application must be held in the judge's chambers or in some manner which ensures that
patient identifying information is not disclosed to anyone other than a party to the proceeding,
the patient, or the person holding the record, unless the patient requests an open hearing in a
manner which meets the written consent requirements of these regulations. The proceeding
may include an examination by the judge of the patient records referred to in the application.
(d) Criteria for entry of order. An order under this section may be entered only if the court
determines that good cause exists. To make this determination the court must Zind that:
(1) Other ways of obtaining the information are not available or would not be effective; and
(2) The public interest and need for the disclosure outweigh the potential injury to the patient,
the physician-‐patient relationship and the treatment services.
(e) Content of order. An order authorizing a disclosure must:
(1) Limit disclosure to those parts of the patient's record which are essential to fulZill the
objective of the order;
(2) Limit disclosure to those persons whose need for information is the basis for the order; and
(3) Include such other measures as are necessary to limit disclosure for the protection of the
patient, the physician-‐patient relationship and the treatment services; for example, sealing from
public scrutiny the record of any proceeding for which disclosure of a patient's record has been
ordered.
§ 2.65 Procedures and criteria for orders authorizing disclosure and use of records to
criminally investigate or prosecute patients.
242
(a) Application. An order authorizing the disclosure or use of patient records to criminally
investigate or prosecute a patient may be applied for by the person holding the records or by
any person conducting investigative or prosecutorial activities with respect to the enforcement
of criminal laws. The application may be Ziled separately, as part of an application for a
subpoena or other compulsory process, or in a pending criminal action. An application must use
a Zictitious name such as John Doe, to refer to any patient and may not contain or otherwise
disclose patient identifying information unless the court has ordered the record of the
proceeding sealed from public scrutiny.
(b) Notice and hearing. Unless an order under §2.66 is sought with an order under this section,
the person holding the records must be given:
(1) Adequate notice (in a manner which will not disclose patient identifying information to
third parties) of an application by a person performing a law enforcement function;
(2) An opportunity to appear and be heard for the limited purpose of providing evidence on the
statutory and regulatory criteria for the issuance of the court order; and
(3) An opportunity to be represented by counsel independent of counsel for an applicant who is
a person performing a law enforcement function.
(c) Review of evidence: Conduct of hearings. Any oral argument, review of evidence, or hearing
on the application shall be held in the judge's chambers or in some other manner which ensures
that patient identifying information is not disclosed to anyone other than a party to the
proceedings, the patient, or the person holding the records. The proceeding may include an
examination by the judge of the patient records referred to in the application.
(d) Criteria. A court may authorize the disclosure and use of patient records for the purpose of
conducting a criminal investigation or prosecution of a patient only if the court Zinds that all of
the following criteria are met:
(1) The crime involved is extremely serious, such as one which causes or directly threatens loss
of life or serious bodily injury including homicide, rape, kidnapping, armed robbery, assault
with a deadly weapon, and child abuse and neglect.
(2) There is a reasonable likelihood that the records will disclose information of substantial
value in the investigation or prosecution.
(3) Other ways of obtaining the information are not available or would not be effective.
(4) The potential injury to the patient, to the physician-‐patient relationship and to the ability of
the program to provide services to other patients is outweighed by the public interest and the
need for the disclosure.
(5) If the applicant is a person performing a law enforcement function that:
(i) The person holding the records has been afforded the opportunity to be represented by
independent counsel; and
(ii) Any person holding the records which is an entity within Federal, State, or local government
has in fact been represented by counsel independent of the applicant.
(e) Content of order. Any order authorizing a disclosure or use of patient records under this
section must:
(1) Limit disclosure and use to those parts of the patient's record which are essential to fulZill
the objective of the order;
(2) Limit disclosure to those law enforcement and prosecutorial ofZicials who are responsible
for, or are conducting, the investigation or prosecution, and limit their use of the records to
investigation and prosecution of extremely serious crime or suspected crime speciZied in the
application; and
(3) Include such other measures as are necessary to limit disclosure and use to the fulZillment of
only that public interest and need found by the court.
243
[52 FR 21809, June 9, 1987; 52 FR 42061, Nov. 2, 1987]
§ 2.66 Procedures and criteria for orders authorizing disclosure and use of records to
investigate or prosecute a program or the person holding the records.
(a) Application. (1) An order authorizing the disclosure or use of patient records to criminally or
administratively investigate or prosecute a program or the person holding the records (or
employees or agents of that program or person) may be applied for by any administrative,
regulatory, supervisory, investigative, law enforcement, or prosecutorial agency having
jurisdiction over the program's or person's activities.
(2) The application may be Ziled separately or as part of a pending civil or criminal action
against a program or the person holding the records (or agents or employees of the program or
person) in which it appears that the patient records are needed to provide material evidence.
The application must use a Zictitious name, such as John Doe, to refer to any patient and may not
contain or otherwise disclose any patient identifying information unless the court has ordered
the record of the proceeding sealed from public scrutiny or the patient has given a written
consent (meeting the requirements of §2.31 of these regulations) to that disclosure.
(b) Notice not required. An application under this section may, in the discretion of the court, be
granted without notice. Although no express notice is required to the program, to the person
holding the records, or to any patient whose records are to be disclosed, upon implementation
of an order so granted any of the above persons must be afforded an opportunity to seek
revocation or amendment of that order, limited to the presentation of evidence on the statutory
and regulatory criteria for the issuance of the court order.
(c) Requirements for order. An order under this section must be entered in accordance with,
and comply with the requirements of, paragraphs (d) and (e) of §2.64 of these regulations.
(d) Limitations on disclosure and use of patient identifying information: (1) An order entered
under this section must require the deletion of patient identifying information from any
documents made available to the public.
(2) No information obtained under this section may be used to conduct any investigation or
prosecution of a patient, or be used as the basis for an application for an order under §2.65 of
these regulations.
§ 2.67 Orders authorizing the use of undercover agents and informants to criminally
investigate employees or agents of a program.
(a) Application. A court order authorizing the placement of an undercover agent or informant in
a program as an employee or patient may be applied for by any law enforcement or
prosecutorial agency which has reason to believe that employees or agents of the program are
engaged in criminal misconduct.
(b) Notice. The program director must be given adequate notice of the application and an
opportunity to appear and be heard (for the limited purpose of providing evidence on the
statutory and regulatory criteria for the issuance of the court order), unless the application
asserts a belief that:
244
(1) The program director is involved in the criminal activities to be investigated by the
undercover agent or informant; or
(2) The program director will intentionally or unintentionally disclose the proposed placement
of an undercover agent or informant to the employees or agents who are suspected of criminal
activities.
(c) Criteria. An order under this section may be entered only if the court determines that good
cause exists. To make this determination the court must Zind:
(1) There is reason to believe that an employee or agent of the program is engaged in criminal
activity;
(2) Other ways of obtaining evidence of this criminal activity are not available or would not be
effective; and
(3) The public interest and need for the placement of an undercover agent or informant in the
program outweigh the potential injury to patients of the program, physician-‐patient
relationships and the treatment services.
(d) Content of order. An order authorizing the placement of an undercover agent or informant in
a program must:
(1) SpeciZically authorize the placement of an undercover agent or an informant;
(2) Limit the total period of the placement to six months;
(3) Prohibit the undercover agent or informant from disclosing any patient identifying
information obtained from the placement except as necessary to criminally investigate or
prosecute employees or agents of the program; and
(4) Include any other measures which are appropriate to limit any potential disruption of the
program by the placement and any potential for a real or apparent breach of patient
conZidentiality; for example, sealing from public scrutiny the record of any proceeding for which
disclosure of a patient's record has been ordered.
(e) Limitation on use of information. No information obtained by an undercover agent or
informant placed under this section may be used to criminally investigate or prosecute any
patient or as the basis for an application for an order under §2.65 of these regulations.
245
Breining Research and Education Foundation is a 501(c)(3) nonproVit, tax-‐
exempt, public beneVit corporation, dedicated to the education and research of addictions and disseminating results of that research to the public and professionals involved in the addictions Vield. With the goal of developing a meaningful training manual to assist addiction professionals become clinical supervisors, or to improve their skills in clinical supervision, the FOUNDATION has developed this publication, The Clinical Supervisor: Training Manual for Clinical Supervisor Competency in the Addiction Treatment Setting, with the generous academic contributions of a number of clinicians, supervisors, program managers and educators in the Vield of addictions. This Manual uses as a guide the recommendations suggested within the “Competencies for Substance Abuse Treatment Clinical Supervisors” Technical Assistance Publication Series 21-‐A (also known as the “TAP 21-‐A Supervisor Competencies”), primarily the Section III Foundation Areas, and the Section IV Performance Domains. We hope that this Manual provides valuable information for the individual desiring to improve his/her competency as a clinical supervisor in an addiction treatment setting. Breining Research and Educa:on Founda:on 8894 Greenback Lane, Orangevale, California USA 95662-‐4019 www.breining.edu/BREFounda:on.htm BREINING INSTITUTE
40-hour Continuing Education (CE) Packet – Global Bundle
These Exam Questions are based upon the information presented in the Course Material. You
should choose the best answer based upon the information contained within the Course
Material. Answers which are not consistent with the information provided within the Course
Material will be marked incorrect. A score of at least 70% correct answers is required to receive
Course credit. GOOD LUCK!
The following questions are based upon the material contained in
Codependency among Health Care Professionals
1. Within the section titled “Codependency in the Therapeutic Process,” the author
suggests which of the following?
a. Nature instills in most humans an innate desire to help others who are in
need of assistance.
b. Nature instills in most humans an innate defense mechanism to avoid
danger and getting too close to others who are perceived as weak.
c. Both A and B above.
d. Neither A nor B above.
2. Within the section titled “Counselor safeguards against codependency,” the
author suggests that a counselor’s dilemma is that the therapeutic strategy that
must be employed to actually help a client is which of the following?
a. Counterintuitive to their initial logical and emotional reaction to the client’s
presenting issues.
b. Intuitive to their initial logical and emotional reaction to the client’s
presenting issues.
3. This article suggests a number of counseling practices to safeguard against
codependency. Which of the following describes setting boundaries?
a. Be aware of certain personality types, physical appearance, and gender
issues to which the counselor may be attracted.
b. The counselor can step back when limits are being approached and, thus,
avoid being drawn into difficulty.
c. While having regard and concern for their clients, counselors need to
remain emotionally detached as a safeguard against drifting into
codependency.
d. Establish clear ground rules for conduct of the counseling interaction.
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Relapse Prevention
4. Durfee’s “Practicing Farm” was well known in the early 1900’s for treatment with
alcoholics. Efforts at early relapse prevention included Durfee helping his clients
define “zero hour” which was:
a. 12 o’clock midnight.
b. Times and situations most likely to elicit cravings and lead to drinking.
c. The time you are fired from your employment.
d. The time that you first stop drinking.
5. A fifty year study of 660 men reported more subjects who recovered from alcohol
dependence began abstinence at AA than in treatment. This study concluded
that “changing an addiction required four elements.” Which of the following
elements was NOT included:
a. Ritual reminders that one drink could cause relapse.
b. Repair of social and medical damage.
c. Initial and sustainable economic support.
d. Self esteem.
6. The survey included a number of activities that were rated as helpful to staying
clean and sober. Each of the following were noted by both men and women,
EXCEPT:
a. Spend more time with family.
b. Spend more quality time at your job.
c. Learn to speak your truth clearly.
d. Work to change negative thinking.
Anger Management for Substance Abuse and Mental Health Clients
7. The inappropriate expression of anger initially has many “apparent” payoffs,
which, in the long term, tend to lead to negative consequences. Which of the
following “apparent” payoffs were identified in the course material?
a. Being able to manipulate and control others through aggressive and
intimidating behavior.
b. The release of tension that occurs when one loses his or her temper and
acts aggressively.
c. Both A and B.
d. Neither A nor B.
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8. An important aspect of anger monitoring is to identify the cues that occur in
response to the anger-provoking event. These cues serve as warning signs that
you have become angry and that your anger is continuing to escalate. They can
be broken down into four cue categories: physical, behavioral, emotional, and
cognitive (or thought) cues. Which of the following describes “Behavioral” cues?
a. Involves the way our bodies respond when we become angry. For
example, our heart rates may increase, we may feel tightness in our
chests, or we may feel hot and flushed.
b. Involves the behaviors we display when we get angry, which are observed
by other people around us.
c. Involves other feelings that may occur concurrently with our anger.
d. Refers to the thoughts that occur in response to the anger-provoking
event.
9. In the final session of this twelve-session program, what should the Group
Leader get the participants to do?
a. Review their respective anger control plans.
b. Rate the treatment components for their usefulness and familiarity.
c. Complete a closing exercise.
d. All of the above.
SUD in People with Physical and Sensory Disabilities
10. To improve outcomes, it is important that clients with disabilities and SUDs:
a. Receive services for the disabilities first, before addressing the SUD
conditions.
b. Receive services for the SUD issues first, before addressing the disability
conditions.
c. Received services for both conditions and that the disabilities do not
prevent clients from receiving treatment for SUDs.
d. None of the above.
11. Both substance abuse and substance dependence refer to maladaptive patterns
of substance use. Substance dependence:
a. Usually refers to using any substance in a way that leads to a failure to
fulfill major responsibilities at work, school, or home, or to substancerelated legal or interpersonal problems. It also includes using substances
in situations that put one’s physical safety at risk.
b. Usually manifests as continued use of a substance despite negative
physical or psychological effects, inability to cut down or control the use of
the substance, tolerance (using more of the substance to get the same
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effect), and withdrawal symptoms when the substance is no longer
consumed.
12. Across all age groups, more women than men are disabled. Women with cooccurring disabilities and SUDs are at high risk for experiencing physical abuse
and domestic violence. One study of people with disabilities and SUDs found
that:
a. 75% of women reported histories physical, sexual or domestic violence,
compared with 25% of men with disabilities reporting abuse experiences.
b. 20% of women reported histories physical, sexual or domestic violence,
c. 47% of women reported histories physical, sexual or domestic violence,
d. Women and men report about the same percentage of histories of
physical, sexual or domestic violence experiences.
Professional Ethics: Counselor Certification in California
13. Section 13005 includes a number of activities which are considered “Counseling
services” that include which of the following?
a. Evaluating participants’, patients’, or residents’ AOD treatment or recovery
needs, including screening prior to admission, intake, and assessment of
need for services at the time of admission.
b. Conducting individual counseling sessions, group counseling sessions,
face-to-face interviews, or counseling for families, couples, and other
individuals significant in the life of the participants, patients, or residents.
c. Documenting counseling activities, assessment, treatment and recovery
planning, clinical reports related to treatment provided, progress notes,
discharge summaries, and all other client related data.
14. Section 13055 provides that the certified counselor must complete a minimum of
how many hours of continuing education during each two-year period of
certification?
a. 20 hours.
b. 30 hours.
c. 40 hours.
d. 60 hours.
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15. Section 13060 provides that the code of conduct applies to registered and
certified AOD counselors, and prohibits which of the following conduct:
a. Providing counseling services while under the influences of any amount of
alcohol or illicit drugs.
b. Providing services beyond the scope of the counselor’s registration or
certification or license.
c. Discriminating against program participants, patients, residents, or other
staff members, based on race, religion, age, gender, disability, national
ancestry, sexual orientation, or economic condition.
Confidentiality of Alcohol and Drug Abuse Patient Records
16. A Part 2 consent form must include all of the following, except:
a. Name of patient / client.
b. Purpose of the disclosure.
c. Date on which consent is signed.
d. General information regarding patient fees and costs.
17. When a disclosure is directly related to crimes and threats to commit crimes on
program premises or against program personnel, Part 2:
a. PERMITS programs to disclose limited information to law enforcement
officers.
b. REQUIRES programs to disclose limited information to law enforcement
officers.
18. Regarding the release of information in response to a subpoena, Part 2:
a. ALLOWS a program to release information in response to a subpoena,
whether or not the client / patient has signed a consent permitting the
release of information requested in the subpoena.
b. REQUIRES a program to release information in response to a subpoena,
whether or not the client / patient has signed a consent permitting the
c. PROHIBITS a program from releasing information in response to a
subpoena if the client / patient has not signed a consent permitting the
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Professional and Ethical Standards of Case Management
19. The Health Insurance Portability & Accountability Act (HIPAA) was designed with
four major purposes in mind. Which of the following was NOT identified as one
of those purposes in the Course Material?
a. To protect the privacy of a counselor’s personal and health information.
b. To provide for the physical and electronic security of personal and health
information.
c. To simplify billing and other transactions with Standardized Code Sets and
Transactions.
d. To specify new rights for patients to approve access/use of their medical
information.
20. Which of the cases cited in the material provides that the therapist has a duty to
warn an intended victim and/or the police when the therapist determines that a
patient / client presents a danger of violence to another?
a. Berger v. Berger.
b. Roe v. Wade.
c. Tarasoff v. Regents of University of California.
d. Brown v. Board of Education.
21. A dual relationship is generally understood as having another relationship, often
known as a multiple relationship, with a client outside of the therapeutic
relationship. The author provided examples of dual relationships, which included
all of the following except:
a. Sexual relationship.
b. Bartering for services.
c. Accepting gifts from a client.
d. Driving a client to a doctor’s appointment.
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Analyzing the Pros and Cons of Multiple Relationships
22. A “multiple relationship” occurs when a therapist is in a professional role with a
person and which of the following is present?
a. At the same time is in another role with the same person.
b. At the same time is in a relationship with a person closely associated with
or related to the person with whom the therapist has the professional
relationship.
c. Promises to enter into another relationship in the future with the person or
a person closely associated with or related to the person.
23. A therapist should refrain from entering into a multiple relationship if which of the
following is present?
a. If the multiple relationship could reasonably be expected to impair the
therapist's objectivity, competence, or effectiveness in performing his or
her functions as a therapist.
b. If the multiple relationship otherwise risks exploitation or harm to the
person with whom the professional relationship exists.
24. There are situations that will require a therapist to serve in more than one role in
judicial or administrative proceedings, thus creating a potentially harmful multiple
relationship. When a therapist encounters such a situation, the author suggests
that the therapist should focus on:
a. Protecting the integrity of the therapist’s professional practice by keeping
this confidential information to him or herself.
b. Protecting the equal standing of the client and the judicial or administrative
authorities by charging the identical consulting fees to each.
c. Clarifying to all parties involved the roles that the therapist is expected to
perform and the extent and limits of confidentiality that can be anticipated
by taking on these multiple roles.
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HIV / ARC / AIDS / Hepatitis
25. During the asymptomatic infection stage, which is in the early stage of HIV, which
of the following is true:
a. There are no manifestations of illness.
b. Blood test may show some abnormalities such as leukopenia and anemia.
c. This period may last 5 to 10 years or longer.
d. All of the above is correct.
26. People generally at risk to contract the Hepatitis B virus (HBV) are:
a. Health care workers who come into contact with infected blood.
b. Homosexuals or heterosexuals who have multiple partners.
c. Individuals living in crowded institutions.
27. Connections between sexually transmitted diseases (STDs) and the abuse of
alcohol and drugs include which of the following:
a. A person’s inhibition to engage in risky behavior may be affected when
abusing drugs and/or alcohol.
b. Heavy alcohol abuse can interfere with the immune system disrupting the
body’s natural ability to fight infections allowing viruses to grow.
The Clinical Supervisor
Chapter 2.8 – Preventing Sexual Harassment
28. The U.S. Equal Employment Opportunity Commission provides that sexual
harassment is a form of sex discrimination that violates which of the following?
a. Common decency and manners.
b. Title VII of the Civil Rights Act of 1964.
c. Title IX of the California Code of Regulations.
d. Title X of the U.S. Code of Health and Human Services.
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29. The authors describe “sexual harassment” unwelcome conduct that can be all of
the following except:
a. Conduct that is sexual in nature and would offend a reasonable person
and used as a basis for making employment decisions.
b. Conduct that unreasonably interferes with an individual’s work
performance.
c. Conduct that can be considered offensive by an unreasonable person.
d. Conduct that creates an intimidating, hostile or offensive work
environment.
30. The authors identify “quid pro quo sexual harassment” and “hostile environment
harassment.” Which of the following describes “quid pro quo sexual
harassment”?
a. Arises when employment decisions are based on whether or not an
employee gives in to sexual advances.
b. Requires the offer of payment or other direct compensation in order to
avoid the sexual harassment.
c. It does not require a counselor or person in power to trade benefits in
return for sex.
Chapter 3.4 – Professional / Ethical Standards of Case Management
31. The Health Insurance Portability & Accountability Act (HIPAA) was designed with
four major purposes in mind. Which of the following was NOT identified as one
of those purposes in the Course Material?
a. To protect the privacy of a counselor’s personal and health information.
b. To provide for the physical and electronic security of personal and health
information.
c. To simplify billing and other transactions with Standardized Code Sets and
Transactions.
d. To specify new rights for patients to approve access/use of their medical
information.
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32. In the section regarding Transference and Countertransference, the author, while
working with patients with sexual trauma issues, recounted an experience of
being approached by a new patient whom he had never met. The patient told the
author something that he used as an example of “transference.” What did the
patient tell him?
a. She liked him.
b. She hated him.
c. She despised him.
d. She worshiped him.
Chapter 3.5 – Program Description Policy
33. Which of the following is identified by the authors of this chapter as the primary
operation task in chemical dependency treatment?
a. Service delivery.
b. Sales and marketing.
c. Customer service.
34. This chapter identifies “qualities of an effective control system” which suggests
that a control system that generates inaccurate information can result in a
manager’s failing to take action when it should or responding to a problem that
doesn’t exist. This refers to which quality?
a. Accuracy.
b. Timeliness
c. Flexibility.
d. Reasonable criteria.
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Chapter 3.6 – Supervising Recovering Counselors
35. This chapter advises that supervisors consider four factors when making the
decision to sit down with an employee and confront their poor work performance.
The factor that addresses “personal belief system” considers which of the
following?
a. Different managers or supervisors will have different expectations about
confrontational style, as well as have their own biases and beliefs. Is the
culture of the agency more supportive and nurturing, or does it tend to
focus more on efficiency and task completion?
b. Consider the agency policy and procedures, as well as laws and
regulations with which your agency must comply.
c. The confrontation process includes providing the employee with factual
material to move forward with after the meeting has concluded.
d. Consider whether you are having trouble with this employee’s
performance based on a personal preference or bias, or whether it is
based upon an objective problem.
36. Within the “factual reference base” consideration, this chapter suggests that the
employee be made aware of which of the following?
a. Realistic understanding of consequences for the employee if the poor
performance continues.
b. Make sure they have the factual knowledge to make the required
improvements.
c. Express confidence in the process and confidence in their ability to meet
the improved work performance standards.
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Chapter 3.7 – Policy and Organizational Design
37. Organizational policies, procedures and rules are key areas to consider in the
development and evaluation of your program. “Policies”:
a. Are a series of interrelated steps that can be used to respond to a
structured problem.
b. Are explicit statements that tell managers what they can and cannot do.
c. Are general guidelines that establish parameters for making decisions.
38. Organizational policies, procedures and rules are key areas to consider in the
development and evaluation of your program. “Rules”:
a. Are a series of interrelated steps that can be used to respond to a
structured problem.
b. Are explicit statements that tell managers what they can and cannot do.
c. Are general guidelines that establish parameters for making decisions.
Appendix D – Title 42 CFR Part 2
39. Title 42 Code of Federal Regulations Part 2 deals with the confidentiality of
alcohol and drug abuse patient records. Which of the following statements is
true, regarding the effect of this Regulation?
a. These regulations prohibit the disclosure and use of patient records unless
certain circumstances exist.
b. If any circumstances exists under which disclosure is permitted, that
circumstance acts to remove the prohibition on disclosure but it does not
compel disclosure.
c. The regulations do not require disclosure under any circumstances.
40. Disclosures of information without patient consent may be made in which of
following circumstances?
a. Medical emergencies.
b. Research activities.
c. Audit and evaluation activities.
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breining institute - The Register of Addiction Specialists

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