According to the American Society of Addiction Medicine (ASAM, 2011), addiction can be defined as
“A primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviours.”
In other words, an individual introduced to a substance can become addicted over a period of time when he or she continues to use the substance to continuously achieve the same reward feeling. Addiction counselling is conducted by a qualified and/or licensed professional, usually in an office setting or in a rehabilitation facility. Addiction counselling is where a professional is teaching individuals some coping skills to minimise or discontinue the harmful substance usage and help them understand the consequences of continued use.
It is important to note that, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the term that is now being used is substance use disorder, rather than substance dependence or addiction. Thus, we will use the term substance use disorder predominantly. A licensed professional who focuses on helping those with substance use disorder is a substance use disorder counsellor.
Substance use forces certain changes in the brain. As the chemicals in the brain are altered, there is an effect on the individual’s ability to function and possibly, to make decisions.
Addiction and the Brain
Substances affect the brain and the chemical pathways of the neurotransmitters. Neurotransmitters are chemical messengers that communicate with the brain and affect bodily movement and cognitive functioning. Addictive substances alter the function of neurotransmitters, so counsellors must have a clear understanding of the function of each. Opiates and alcohol affect the dopamine neurotransmitter, which plays a major role within the pleasure and reward system in the brain. Stimulants and tobacco affect acetylcholine, which is in charge of learning and memory along with the stimulation of muscles. Norepinephrine is prevalent in the sympathetic nervous system and is responsible for increasing heart rate and blood pressure. When an individual uses an amphetamine, norepinephrine is released. Serotonin is known to have an effect on emotions and mood, and depending on the level of serotonin, an individual might show signs of depression or difficulty with anger control. Serotonin levels tend to increase with the usage of alcohol and cocaine. GABA (gamma aminobutyric acid) is involved in arousal, judgment, and impulse control. Drugs that are classified as depressants, including marijuana, affect the GABA neurotransmitter. Glutamate is an excitatory neurotransmitter. Long-term cocaine abuse affects this transmitter. Finally, endorphins are neurotransmitters related to pain relief and reward and punishment. Opioids, as well as depressants, affect endorphins.
Along with understanding how substances affect the brain and physical function, the counsellor must understand how to establish a foundation for the successful treatment of the client. Once clients make the decision to attend treatment, they need to have hope and reassurance of safety before the counselling begins. Addiction counselling is only successful when it is based on trust and within the comfort of a developing relationship. The first part of counselling is the development of a therapeutic relationship.
The therapeutic alliance is a continuously developing relationship between the client and the professional counsellor that involves non-judgmental verbal and non-verbal communication. This relationship promotes the client’s self-worth and strengthens the client’s belief that he or she can overcome challenges. For example, a counsellor can show respect for an individual by communicating a willingness to listen and provide genuine assistance. A firm handshake to the client upon greeting would be a step in the right direction of a therapeutic alliance.
After developing what is called the therapeutic relationship between the counsellor and the client, the counsellor has to make an accurate diagnosis to follow through with counselling or psychotherapy. Diagnosis includes completing assessments (gathering information) and evaluations (using scored tests to identify the severity of the drug use). Substance use disorder counsellors do not rely on their judgment or make guesses about a client’s issues; they refer to the DSM-5. The newest version of the DSM specifies the level of care that the individual will need.
The DSM-5’s section on substance-related and addictive disorders lists a combination of cognitive, behavioural, and physiological symptoms for each one of the 10 types of substances: alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, stimulants, tobacco, and other, unknown substances. There are 11 criteria, or circumstances, that the counsellor must address when developing the diagnosis:
- Whether the client was taking the substance in increasingly larger amounts over a period of time, and if the individual intended to continue using the substance.
- Any previous unsuccessful efforts to discontinue use.
- The amount of time using and obtaining the drug of choice.
- Whether the client craves the drug physically, psychologically, or both.
- Any inability for the individual to fulfil employment obligations.
- Interpersonal issues that are a result of the substance use.
- Instances when a person becomes disconnected with family and friends or have discontinued activities.
- Physical hazards that have resulted from substance use.
- Physical and psychological issues related to substance use.
- Whether or not tolerance has increased over time.
- Any physical symptoms that require medical management due to withdrawal.
Treatment is the external therapeutic process that an individual is exposed to through education in groups, individual sessions, and family sessions. The American Society of Addiction Medicine has a recommendation that includes six dimensions of treatment that will create an effective service plan for a client at the time of his or her assessment: acute intoxication and withdrawal, health history and complications, mental health stability, readiness to change, relapse, and recovery living environment.
Treatment for substance use disorder counselling can take place in different settings, including any place that is away from the client’s home. Treatment can occur either outside of a facility or within a facility for a designated amount of time.