SpeedyCeus

Treatment of Substance Users with Depression Final Section!!!

Chapter 7.4 Treatment

Treatment

This section presents the principles, skills, techniques, and resources you can use in implementing these strategies with your clients.

Principles

Principles that you should apply in your work with clients with substance use disorders and depressive symptoms have been presented throughout this chapter. Figure 1.7 (p. 25) summarizes them for easy reference.

Skills and Techniques

A number of skills and techniques can be used while applying any of the treatment approaches and interventions discussed earlier. You probably use many of these already, but the brief descriptions below are a reminder of their importance.

The Therapeutic or Working Alliance—This refers to a mutual bond between the substance abuse counselor and the client. It includes elements of trust, rapport, and faith in the counselor’s ability to help and the client’s ability to change, and agreement on treatment tasks and goals. An early and strong therapeutic alliance is critical to successful treatment. Specific techniques that facilitate the development of a therapeutic or working alliance are:

•             Maintaining a respectful, welcoming, accepting, warm, empathic, hope-inspiring, confident, non-judgmental, trustworthy, and open stance.

•             Setting appropriately frequent and consistent appointments.

•             Listening reflectively (see Active Listening, below).

•             Providing accurate feedback and interpretation.

•             Expressing interest, empathy, and understanding.

•             Actively addressing a misstep or conflict.

•             Setting appropriate limits and boundaries.

•             Being sensitive to the client’s ethnic identity, cultural values, and beliefs.

•             Being a good role model.

 Motivational Techniques—Motivational techniques emphasize the client’s responsibility to talk about ambivalence toward making a change, to voice personal goals and values, and to make choices among options for change. The counselor’s stance is to understand and respond to the client’s statements in a non-judgmental way. For example, when working with a client who is not thinking about making a change, the counselor can help identify ways in which the client’s current behaviors have created problems. When working with a client who is ambivalent about making a change, the counselor can seek to identify discrepancies between the client’s current behavior and the client’s values. When working with a client who is preparing to make a change, the counselor can identify not only potential barriers to change, but also the resources available to the client to overcome those barriers. Motivational techniques are client-centered and strengths-based and use acceptance, support, and understanding to help a client move from one stage of change to another. These techniques help clients resolve their reluctance and resistance as they learn alternative ways to satisfy their total well-being. (See Figure 2.2 in TIP 35 [CSAT, 1999] for more on strategies for enhancing motivation.)

Cognitive–Behavioral Techniques—Cognitive–behavioral techniques are directive and educational in nature and aim to help clients learn to think and act more adaptively and thus experience improvements in mood, motivation, and behavior. Clients with depressive symptoms are caught in a vicious cycle of negative expectations and attributions about themselves and others, and then make choices based on these assumptions that reinforce these dysfunctional beliefs. Clients can be taught to monitor and record instances of their negative thoughts and mental images so as to realize the connection between their thoughts, feelings, and behavior. Inaccurate thoughts associated with depressive symptoms can be identified and modified using the counselor’s more objective understanding of the client’s history, current experience, and future opportunities.

Clients also learn to make their problems seem less catastrophic by breaking them down into smaller, more manageable components. This reduces dysphoria and anxiety and builds self-efficacy. Assignments that have tasks of increasing difficulty help clients get moving and provide rewarding experiences that will directly refute their negative attributions. Over time, clients learn to recognize, assess, and change the underlying assumptions and maladaptive beliefs that have rendered them vulnerable to depressive symptoms.

Individualized Care—In programs treating large numbers of people with similar problems, there is a tendency to diminish the focus on individualized care. Everyone, in effect, gets the same treatment. Programs offering individualized care have flexible program policies that allow counselors to focus on specific client needs and then target treatment to meet those specific needs. The concept of individualized care is particularly important for individuals with co-occurring disorders and other special needs. Individualized care allows treatment to be client centered, involving the client in treatment planning and sharing responsibility for treatment outcome.

Active Listening—Also called reflective listening, active listening involves listening attentively to client statements and reflecting them back in different words so that the client can confirm or clarify their meaning. Active listening allows the client with substance abuse problems who is depressed to hear what he or she is saying, thus encouraging self-exploration of problems and feelings. Active listening deepens the counselor’s understanding of the client’s statements and can be used to elicit a client’s concerns about problems without asking questions that can activate resistance.

Empathy—Empathy is central to helping the client feel understood, accepted, and safe to explore painful emotions and experiences. People with substance use disorders and depressive symptoms often have trouble feeling understood or believing that someone else can understand their experiences. Empathy is communicated through verbal and nonverbal signals that say “I understand.” In some sense, it is wrong to say that empathy is a skill or technique. Rather, it is best understood as a way of being or staying in tune with your client. Certainly, when counselors have had some of the same experiences as their clients (such as recovering from substance abuse or depression), the capacity for empathy is heightened. Just as in 12Step programs where individuals are taught to identify with feelings rather than compare the particulars of a situation, counselors can empathize with clients’ feelings because they know what it is like to experience pain and loss.

In some instances, having a similar background to a client can interfere with empathy because you think you know what the client is going through and therefore fail to listen effectively. Being empathic is more than simply relating to a client. Empathy includes having patience and being supportive and understanding. As always, appropriate supervision and self-reflection are key to being an effective counselor.

People sometimes confuse empathy with sympathy. Sympathy does not involve placing yourself in the client’s shoes. Rather, sympathy is an expression of compassion, concern, or sorrow for the client’s experience. A good distinction between sympathy and empathy is that sympathy is feeling for the client, while empathy is feeling with the client. It is common for inexperienced counselors to confuse sympathy and empathy, and often people with substance use disorders who are depressed look for sympathy in lieu of empathy. Sympathy can, at times, be helpful. However, when you are carried away by your sympathy for clients, you may feel the need to rescue, which can interfere with their self-healing. Figure 1.8 provides some useful contrasts between empathy and sympathy.

Resolving Conflicts—Maintaining a therapeutic alliance requires skill in resolving the conflicts that arise between client and counselor. (You will see an example of such a conflict in vignette 4 in chapter 2.) Resolving conflict requires: 

Treatment of Depressive Symptoms With Antidepressant Medications

• Any given medication has about a 50 percent chance of working well, and a 50 percent chance of failing.
• No method or test will predict the best medication for a patient.
• It often takes at least 4 to 6 weeks of treatment and the achievement of an adequate dose before an antidepressant medication begins to work.
• Depression symptoms should be monitored regularly and systematically during antidepressant treatment.
• If one medication fails to result in a significant improvement in depression symptoms after an adequate trial (generally 6 weeks of treatment at an adequate dose), then a different medication should be tried by the prescribing clinician.

• Counselors should be alert to possible adverse interactions between an antidepressant medication and the substances a patient is abusing (such as the potential for increased sedation or intoxication).

Continuing Care and Treatment Termination

In most cases, your work with a client on his or her depressive symptoms will be time-limited. There are some special considerations related to treatment termination with a (formerly) depressed client as well as some special considerations for continuing care.

Perhaps to a greater extent than with your clients who are not depressed, you will have engaged in a client-counselor relationship involving emotional sharing, support, and encouragement. As demonstrated in vignette 3 in chapter 2, the client may have shared experiences with you that he or she has never shared with anyone else. For these reasons, the client (and you) may experience sadness at the prospect of saying goodbye. It is especially important that you help the (formerly) depressed client view this sadness as a normal grief process rather than as a return of depressive symptoms. Indeed, distinguishing appropriate sadness from depression is one of the lessons you hope your client has learned in your time together. Other considerations related to treatment termination are discussed below.

Reactivation

For some clients, the termination experience will mirror or reactivate experiences that were fundamental to their depressive symptoms (abandonment or feeling alone or without support). These feelings can be addressed directly using the skills the client has learned in counseling. They can also serve as practice in dealing with future situations that may cause depressive feelings to surface.

Preparation

This means preparation both for the treatment termination experience and for “life after counseling.” Part of the preparation for life after counseling is avoiding early termination when the client begins to feel better. It is important for the client to understand that ups and downs are normal and that these are likely to occur throughout life. Learning the differences between a short remission and a more stable adjustment will be key to assisting the client in deciding when termination is appropriate. Sometimes, a “partial termination” can be accomplished by increasing the interval between sessions or by a trial period without therapy. If it is not possible to continue counseling, even though depressive symptoms continue, make every effort to assist the client in arranging other services that will help with the depressive symptoms.

Near the end of treatment, you should consider anticipatory guidance with the client for a host of situations. Anticipatory guidance is a core supportive psychotherapy technique, but it is consistent with CBT in that it rehearses what the client should do in high-risk situations or in situations where the client used to have your help to work things out. The counselor reviews the accomplishments achieved and uses anticipatory guidance to outline issues to explore in the future. Clients will have a range of feelings about the end of treatment and about the counselor after treatment, so it is also useful to help the client anticipate how he or she will deal with them (Rosenthal, 2008).

Because depressive symptoms can recur, it is necessary at some point to educate the client about this possibility. Just as people with substance use disorder lapse while in recovery, so people with depressive symptoms re-experience feelings of despair. Clients should be educated about this possibility, the likelihood that they may need to seek services again, and the fact that recurrence is not an indicator that they have “done something wrong.”

Your Reaction to Treatment Termination

As already noted, you may experience sadness at the prospect of termination with your client. This sadness is a normal result of the therapeutic alliance you have forged. Another result of this alliance may be an investment in the client’s future adjustment. After all, you have worked very hard to gain the client’s trust and to use that trust productively in treatment. Although counselors want their work to be successful, the client’s future is the client’s responsibility. For you, the task is now to let go.

Continuing Care Plans

The symptoms of depression, like those of many other illnesses, come and go. The absence of symptoms doesn’t mean the tendency toward depressive symptoms is necessarily gone. In addition, the potential for relapse with depressive symptoms is quite high, and significant improvement and remission of symptoms do not mean that ongoing care and monitoring should be discarded. Clients should be educated about the nature of depressive illnesses, relapse symptoms, and procedure to follow if symptoms do reappear. It is important for clients leaving treatment to know that they can telephone you or the agency if symptoms reappear, either to reactivate treatment or for referral. Finally, it is important for clients to understand that reoccurrence of depressive symptoms does not mean failure on their part, nor does it mean that the onset of another depressive episode has to be as difficult and painful as previous episodes. Like most other illnesses, if caught early, depressive symptoms can be treated more efficaciously and effectively than if symptoms linger for an extended period.

End of Chapter

motivation to change and of their belief in their ability to change. A person’s belief about his or her ability to do something is related to the ability to actually do it. A client’s belief that he or she cannot change (e.g., cannot feel better, cannot alter circumstances that are leading to depressed feelings) needs to be dealt with proactively. Useful techniques for building feelings of self-efficacy include:

• Partializing a large task into smaller, manageable tasks.
• Setting a modest, if less important, goal that is achievable rather than repeatedly trying and failing at something that is very important but not currently achievable.
• Mentally rehearsing a task and visualizing success.

Because depressive symptoms often include feelings of helplessness, self-efficacy issues may be particularly salient for clients who are experiencing these symptoms. Supportive techniques such as offering reassurance, encouragement, and appropriate praise for recovery-related accomplishments bolster self-esteem and help motivate further adaptive change in clients (Rosenthal, 2008).

The 12 Steps as a Tool

Many substance abuse counselors use the 12 Steps of Alcoholics Anonymous (AA) and similar organizations as part of their work with people who abuse substances. Many of the curative factors inherent in 12Step programs also can be helpful to people with depressive symptoms.

Some of these factors include:

• The support, comfort, acceptance, and hope people find when they enter AA can directly confront some depressive symptoms of alienation, hopelessness, and despair.
•  The 12 Steps themselves can be applied to many aspects of healing depressive symptoms. For instance, doing a self-inventory of limitations, as well as strengths and assets, taking action to address wrongs of the past, and the act of reaching out to others can both be curative steps.
• The slogans and “folk wisdom” of AA and similar 12-Step programs confront “stinking thinking” that keeps people with depressive symptoms trapped in a cycle of fear and hopelessness.

•     Finally, the nonjudgmental acceptance of others in the program provides an environment in which depressed people can examine themselves in a more nonjudgmental and accepting manner.