____________________________________ Substance Use Disorders: Assessment and Treatment, 2nd Edition
More extensive information regarding SBIRT can be found in the Resources section. It is imperative to maintain a nonjudgmental stance during assessment. There is an incredible stigma related to substance use, and individuals who engage in substance use are not doing so because they lack willpower to stop; they are addicted and may be coming to treatment to get help. In many instances, clients with addictions have severe feelings of worthlessness and self-hatred or expect scorn and rejection from others, such that they may present as grandiose in an effort to protect themselves from these experiences. It is helpful for clinicians to remember that, once addicted, clients have a serious medical condition, similar to other medical conditions, and should not be subjected to blame or condemnation. Some provid- ers use a judgmental tone, which can be detrimental to the therapeutic alliance and may hinder an individual from being able to reduce his or her substance use. Instead, such a tone may make the client feel guilty or ashamed, which may result in increased use. Through a clinician’s nonjudgmental stance, individuals will be more likely to open up and explore the possibility of reducing their substance use. The biopsychosocial effects of different substances are also an important element of assessment. For example, the brief high and immediate craving for crack cocaine has social, legal, financial, and emotional ramifications that are different from the effects of a legal alcoholic beverage (Straussner, 2011). Additionally, determining what symptoms are related to substance use and what symptoms are related to other mental health disorders is an essential component of assessment. As discussed earlier, several substances can mimic psychosis, while withdrawal from others can mimic depression. It is impera- tive to assess substance use as related to other mental health symptoms to determine if symptoms are substance-induced or if they are not related to substances. Furthermore, the course of SUDs and other disorders can be interrelated, and it is important not to assume that one disorder preceded the other without thorough assessment. For example, it may be possible for an individual with co-occurring PTSD and SUD to have developed either the PTSD or the SUD first, and the course of each disorder can look different based on which began first. (Additional points will be made about co-occurring and coex- isting diagnoses later in the course. See also Scheffler, 2014, listed in the References section of this course.) ASSESSING MOTIVATION Substance use assessment should also include assessment of clients’ willingness to change their substance use. It is also essential to understand a client’s motivations for treatment, which can include the wish to reduce negative consequences of substance use or engage in more productive behaviors or perhaps involuntarily entering treatment as a result of the effects of the addiction or through a legal mandate (although classic studies reveal that even clients who are initially coerced into treatment can have good outcomes; Lawental et al., 1996). It is imperative to understand that treatment is unlikely to be
effective if individuals are not interested in changing their behavior. The use of motivational interviewing techniques can help an individual increase motivation for treatment. The stages of change can be helpful to the clinician in understand- ing where the client is in terms of readiness to change his or her substance use. Figure 3 is a depiction of what the stages of change may look like with a client who has a problem with alcohol consumption. This model was first developed in smoking cessation (Prochaska et al., 1992) to describe the process by which motivation for change occurs gradually. In the precontemplation stage, indi- viduals are unaware of the problem or not ready for change and do not believe they have a problem even if they are expe- riencing consequences from use. In the contemplation stage, they are considering a change but are not yet ready to commit to change. Preparation and action stages are typically when providers see clients who voluntarily come in to work on their SUDs. However, if providers engage in universal screening, they may encounter more clients in the precontemplation and contemplation stages. In this case, they can use motiva- tional interviewing techniques to help clients progress to the next stage of change. After undergoing treatment for SUDs, individuals often move to the maintenance stage to continue behaviors that are resulting in substance use reductions or abstinence. Relapses are often considered to be part of the process and occur when an individual uses a substance after successfully reducing use. A relapse can occur at any stage of treatment, and it is important to prepare clients for relapse and plan for it, so they do not feel shame and engage in more substance use to cope with the shame. This perspective helps to minimize unrealistic expectations of quick change and is more effective in keeping clients in treatment and supporting their efforts toward recovery. The view of recovery from substance abuse as a process that occurs over time rather than a single event marked in time is sometimes a helpful concept to share with clients and their families who are new to treatment. THE USE OF DSM-5-TR DIAGNOSTIC CRITERIA In the fifth edition of the American Psychiatric Association’s (APA’s) Diagnostic and Statistical Manual of Mental Disorders ( DSM-5-TR ; APA, 2023), the terminology of substance-related disorders (APA, 2023) has changed to substance-related and addictive disorders ( SRAD ) and includes an additional diagnosis of gambling disorder . In the future, SRAD is likely to include other addictive disorders as more disorders are deemed to have scientific bases. One new disorder being researched for future inclusion is Internet addiction . The substances included in DSM-5-TR are alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives/hypnotics, stimulants, tobacco, and unknown substances. The biggest differences between the SUDs criteria in the revised fourth edition of DSM (APA, 2023) and DSM-5-TR SUDs criteria are the elimination of the separate diagnostic terms “substance abuse” and “substance dependence” and the addition of a severity specifier , as discussed subsequently.
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