|
SpeedyCeus
Treatment of Substance Users with Depressive Symptoms cont'd...
Chapter 7.1
Approaches and Psychosocial Interventions for Working With Depressive Symptoms
Many psychological therapies (e.g., cognitive– behavioral therapies [CBT], psychoeducation) help the client build adaptive strategies for coping with depressive symptoms. The literature reports that the therapies substance abuse counselors are generally trained in (such as CBT, supportive counseling, and psychoeducation), are effective in relieving depressive symptoms (Carroll, 1998). Counselors therefore do not need to learn a whole new skill set, but rather to translate what they already know to the language of depression. Some drug therapies (such as antidepressants) are effective in relieving depressive symptoms.
As stated above, depressive symptoms exist on a continuum. The difference between having depressive symptoms and having clinical depression can be the presence of a single symptom or the degree to which a specific symptom limits a person’s ability to function. There is also no current evidence that the causes of depressive symptoms differ from those of significant depressive illness. Until further research is available, it is sensible to assume that those interventions and counseling approaches that work for depressive illnesses will likely be of help to persons with depressive symptoms.
Interventions Used in This TIP—Chapter 2 provides the application of a number of interventions for depression, including:
• Educating clients about depression and depression recovery.
• Integrating counseling for substance abuse and depressive symptoms.
• Understanding depression.
• Reframing negative thoughts.
• Testing negative beliefs against reality.
• Helping clients identify and change maladaptive behaviors.
• Developing coping strategies.
• Exploring and understanding emotions related to substance abuse and depression.
• Providing support and encouragement to the client.
• Motivating the client to change.
Many of these strategies are described in the work of Miller and Rollnick on motivational interviewing (2002). All these interventions seek to break the cycle of maladaptive thoughts, beliefs, behaviors, and emotional reactions that are characteristic of depression.
Brief descriptions of the major intervention techniques used in this TIP follow:
• Behavioral interventions—Behavioral interventions focus on helping clients change problematic behaviors or take on new behaviors that will benefit and sustain recovery. Behavioral interventions assume that as an individual changes behavior, more productive thinking and feelings will follow. For example, behavioral activation is an intervention that, by identifying behaviors that maintain or worsen depression and then scheduling rewarding activities, assists clients with depressive symptoms in overcoming inertia and avoidance despite their depressed mood or lack of motivation (Jacobson, Martell, & Dimidjian, 2001). When clients with depressive symptoms become more active, they focus less on painful feelings, and because of this respite, tend to feel more motivated and energetic. Behavioral activation using activity scheduling is an effective treatment for depression and should be of specific use in clients with depressive symptoms (Cuijpers, van Straten, & Warmerdam, 2007b).
• Cognitive–behavioral therapy—CBT integrates principles derived from both cognitive and behavioral theories. Cognitive theory suggests that cognitions or thoughts mediate between environmental demands and an individual’s attempts to respond to them effectively. Behavioral theory suggests that changing behavior can be a powerful influence on both the acceptance of changes in cognitions about self or a situation and on the establishment of a newly learned pattern of cognitive–behavioral interactions. A large number of clinical trials have demonstrated that cognitive therapy is efficacious for depression (Dobson, 1989). Analyses of other controlled studies show that CBT has a significant impact on depressive symptoms (Cuijpers, Smit, & van Straten, 2007a). In practice, CBT makes use of a wide range of coping strategies, not all of which are cognitive in nature (e.g., having individuals change behaviors directly rather than focusing on change in thinking). CBT is often the basis of relapse prevention counseling in substance abuse treatment.
• Supportive therapy—Supportive psychotherapy, the most frequently used psychological treatment in the United States, uses direct measures to reduce or eliminate symptoms and to help the client maintain, restore, or improve self-esteem, adaptive skills, and psychological functioning. These positive changes in the client are a result of
therapist interventions such as active expression of interest and empathy, offering appropriate praise and reassurance, a general focus on here-and-now relationships, modeling adaptive behavior and anticipatory guidance, and respect for defenses (Winston, 2004).
• Expressive (affectively based) therapies— Expressive therapies focus on assisting clients in experiencing and modulating feelings that have been disavowed or distorted. The goal of expressive or supportive/expressive therapy is to have feelings be a productive rather than limiting component of recovery and, by accessing feelings, to change cognitions, behaviors, and self-esteem.
• Motivational interviewing—The goal of motivational interviewing and related motivational strategies is to assist clients in mobilizing, seeking, and benefiting from a variety of change approaches, as well as to sustain the energy required to achieve lasting change.
Choosing Among Interventions—There is no cookbook that will tell you which interventions to use with a given client at a given point in his or her recovery. Rather, the interventions described above and demonstrated in chapter 2 constitute a toolkit on which you can draw.
Different substance abuse treatment counselors emphasize different interventions and approaches depending on their skills, preferences, and counseling styles. Effective counselors also adapt their toolkits to the specific needs of the client. If you are not comfortable with a given intervention, it is not likely to help your client. Thus, it may be best initially to use a limited number of techniques and expand your toolkit as you gain experience, confidence, and competence.
As discussed later in this chapter under Client-Centered, Integrated Treatment Planning (p. 22), your client’s values and patterns of relating to others will also dictate the strategies you use. Specific elements of your client’s culture may make some interventions inappropriate.
Evidence-Based Thinking—Some counselors may find it useful to think of their work in terms of “evidence-based thinking” (Hyde, Falls, Morris, & Schoenwald, 2003). Evidence-based thinking means picking the best clinical option available for a given client in a given context based on the best current information.
The information that is used in evidence-based thinking includes:
• Research and the experience and recommendations of clinical experts.
• Your past experience.
• Your personal preferences and style.
• Advice from your clinical supervisor.
• The needs, values, preferences, and characteristics of the client.
• Constraints such as the number of sessions you have available.
Evidence-based thinking mixes science and clinical experience with a large measure of common sense. Counselors who use evidence-based thinking are flexible—always looking out for changes in the client’s needs, and constantly adjusting their approach to make use of new information.
Special Considerations Related to the Substance Abuse Treatment Setting in Which You Work
Most information presented in this TIP is applicable to any setting in which clients with substance abuse problems receive treatment. However, different kinds of substance abuse treatment settings may place limits on what you can do. The vignettes in chapter 2 take place in a variety of settings including inpatient, intensive outpatient (day treatment), and outpatient to demonstrate issues that may arise in each type of setting.
Sometimes, responding to the needs of clients with depressive symptoms may require a departure from the way your program normally provides services. For example, clients with depressive symptoms may require more individual attention, and some of these clients will have trouble participating in groups. If your program does not currently provide for extra individual sessions, new arrangements may need to be made. Similarly, some clients may initially feel too low or blue to participate in recreational activities, occupational therapy, or other program components. If participation is currently mandatory, some changes to accommodate people who are depressed might be considered.
As you learn from this TIP and gather ideas for working with clients with depressive symptoms, share your thoughts with your clinical supervisor, your treatment team members, and, where appropriate, with program administrators. See whether there is room for the changes you think are needed, and collaborate with supervisors and administrators to find the best ways to meet the needs of your clients with depressive symptoms. Refer them to Part 2 of this TIP, Managing Depressive Symptoms: An Implementation Guide for Administrators, for further information on changes in your substance abuse treatment program that may be important to meet client needs.
Special Considerations Related to the Cultures of Your Clients
Individuals from different cultures and ethnic groups will experience and report symptoms of depression differently. General observations can be made, but it is of the utmost importance that you seek to understand each individual with whom you work. Some ethnic groups speak of depressive symptoms in terms of physical symptoms (headache, fatigue, gastrointestinal discomfort) and therefore seek the assistance of a medical doctor. This is common among some Asians, Hispanics/Latinos, and some non-Hispanic whites (especially from families where emotions are denied or minimized).
Another phenomenon is that depression is collectively denied by an ethnic group or subculture and therefore is not discussed or reported. For instance, African-American women are often socialized to deny the existence of their own needs and feelings and do not acknowledge depression. They may say things like, “well, that’s just the way life is; life is hard.” These statements may reflect feelings of hopelessness and frustration associated with external situations such as financial stress, family dysfunction, and racism. However, these statements may also reflect the presence of undiagnosed depression. Additionally, having been raised to believe that one has “no needs,” seeking the assistance of a treatment program (by choice or through mandate) is likely to evoke intense shame, increasing the difficulty in opening up and getting support. Lastly, if children are involved, women are, understandably, afraid to report difficulties for fear the local child protective services agency will become involved. All these issues can make engaging in treatment and trusting the counselor difficult (Jackson & Greene, 2000).
Some older Americans will talk of having had a “nervous breakdown,” which for some is another word for depression. But for others, “nervous breakdown” may mean other psychiatric disorders, such as anxiety disorder or an exacerbation of schizophrenic illness. It is therefore important to explore not only the symptoms experienced in the “breakdown,” but also the environment in which the “breakdown” occurred, how long the symptoms lasted, and what happened that resulted in the remission of symptoms.
Some cultures, particularly Latino and Caribbean cultures, talk in terms of nerves. An “ataque de nervios” has similarities to a panic attack but is often triggered by a significant loss or distress. The fear of recurrence that is characteristic of panic disorder may not be present. When some people talk about “nerves,” it is likely that they are referring to thoughts and feelings associated with a mix of anxiety and depression. It should be emphasized that a person’s belief about the cause of depression is key to helping the client address it.
An important precursor to cultural competence is self-knowledge: how have your beliefs about functional and dysfunctional behavior been shaped by your own culture? How have racism, discrimination, and cultural stereotyping affected you personally and professionally? How do your beliefs about other cultural groups affect your relationships with clients who belong to those groups?
Having knowledge of the culture of the clients served by your organization demonstrates respect for their experiences and ways of life. Particularly valuable in your interactions with clients whose culture differs from yours is a familiarity with immigration, acculturation, and assimilation issues; socioeconomic, religious or spiritual, and political influences; sex role expectations and family structure; and communication styles.
Culturally competent counselors are skilled in—
- Framing issues in culturally specific ways (e.g., “How does your family respond when you are sad?”).
- Recognizing complexity in client issues based on cultural context (e.g., “How do your experiences leaving your homeland and coming to the United States affect your depression?”).
- Making allowances for variations in relating to others and in the use of personal space (e.g., a client’s preference for sitting beside a counselor rather than being separated by a table).
- Displaying sensitivity to culturally specific meanings of touch (e.g., hugging and holding hands).
- Exploring culturally based experiences of power and powerlessness (e.g., “How does feeling depressed affect how you see your status in your community?”).
- Adjusting communication styles to accommodate the client’s culture (e.g., permitting comfortable silence in conversations with American Indians).
- Interpreting emotional expressions in light of the client’s culture (e.g., “How do people know when you’re feeling depressed; what do you do?”).
- Expanding roles and practices as needed (e.g., participating in cultural ceremonies, facilitating indigenous support systems and healing systems).
Clinical supervisors must distinguish cultural sensitivity and cultural competence among staff members. To have empathic regard for another’s culture is one thing, but to have cultural competence to help the person grow within and/or beyond their cultural strengths and limits is another.
The DSM-IV-TR recognizes several culture-bound syndromes (APA, 2000) and lists several examples of how mental disorders may be manifested differently by individuals of different ethnic groups.
The work of Sue and Sue, Counseling the Culturally Diverse: Theory and Practice (2007), is a basic text on cultural competency and includes some discussion on the issues of substance abuse and depression.
Your Professional Role and Responsibilities in Relation to Clients With Depressive Symptoms
As a substance abuse counselor, your professional responsibilities include facilitating and guiding clients in their recoveries through the clinical evaluation of substance use and related issues, treatment planning, counseling (individual, group, and/or family), education, and relapse prevention. If you hold other credentials, you may have broader roles and responsibilities related to mental health issues.
If you are a clinical social worker, licensed professional counselor, licensed psychologist, psychiatric nurse, or physician, you may hold a national credential in addiction disorders issued by your professional association. The specific duties you may undertake with a client depend on the licenses and/or certifications you hold. Licenses and certifications define the scope of practice for your discipline, and they differ by State and profession.
Figure 1.4 provides information on common certifications and licenses for substance abuse counselors and other related professionals, including information related to substance abuse and depressive symptoms. This table is intended as a guideline only. It is your responsibility, in collaboration with your clinical
supervisor, to determine the exact nature and scope of services you can provide within the laws of your State and within your profession’s ethical requirements for competency.
End of Section
|
