Getting Ready To Test Supplement PDF
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Since 1995 we’ve been offering our study guide to assist counselors in their preparation
for their state drug and alcohol credentialing exam. A great deal of care and effort has
gone into the materials contained in the manual in order to make sure that we are
providing the type of information counselors will need to be successful in the completion
of their credentialing requirements. With this in mind, we do strive to maintain up-to-
date information, updating any statistical information we include as it comes available
and adding new revisions or additions to our content information as it is warranted. As
such the current edition of the study guide is our sixth revision, completed in March of
2008.
When major changes like this occur, we do realize that some students have yet to
complete their testing requirement and as a result will benefit from having any new
information or content we have developed. So, we’ve created this supplemental guide
as a courtesy to our students, helping to ensure that they will have the most up-to-date
information we can provide them.
Kevin Scheel
Director of Educational Services
DLC, LLC
What It Means To Be a
Culturally Competent Clinician
It is agreed widely in the health care field that an individual's culture is a
critical factor to be considered in treatment. The Surgeon General's report,
Mental Health: Culture, Race, and Ethnicity, states, “Substantive data from
consumer and family self-reports, ethnic match, and ethnic-specific services
outcome studies suggest that tailoring services to the specific needs of these
[ethnic] groups will improve utilization and outcomes” (U.S. Department of Health
and Human Services 2001, p. 36). The Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association
1994) calls on clinicians to understand how their relationship with the client is
affected by cultural differences and sets up a framework for reviewing the effects
of culture on each client.
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Mental Health: Culture, Race, and Ethnicity is the first comprehensive
report on the status of mental health treatment for minority groups in the United
States. This report synthesizes research data from a variety of disciplines and
concludes that
! Disparities in mental health services exist for racial and ethnic minorities.
These groups face many barriers to availability, accessibility, and use of
high-quality care.
! The gap between research and practice is worse for racial and ethnic
minorities than for the general public, with problems evident in both
research and practice settings. No ethnic-specific analyses have been
done in any controlled clinical trials aimed at developing treatment
guidelines.
! In clinical practice settings, racial and ethnic minorities are less likely than
Whites to receive the best evidence-based treatment. (It is worth noting,
however, that given the requirements established by funders and
managed care, clients at publicly funded facilities are perhaps more likely
than those at many private treatment facilities to receive evidence-based
care.)
Because verbal communication and the therapeutic alliance are
distinguishing features of treatment for both substance use and mental disorders,
the issue of culture is significant for treatment in both fields. The therapeutic
alliance should be informed by the clinician's understanding of the client's cultural
identity, social supports, self-esteem, and reluctance about treatment resulting
from social stigma. A common theme in culturally competent care is that the
treatment provider — not the person seeking treatment — is responsible for
ensuring that treatment is effective for diverse clients.
Meeting the needs of diverse clients involves two components: (1)
understanding how to work with persons from different cultures and (2)
understanding the specific culture of the person being served (Jezewski and
Sotnik 2001). In this respect, being a culturally competent clinician differs little
from being a responsible, caring clinician who looks past first impressions and
stereotypes, treats clients with respect, expresses genuine interest in clients as
individuals, keeps an open mind, asks questions of clients and other providers,
and is willing to learn.
Principles in Delivering
Culturally Competent Services
The Commonwealth Fund Minority Health Survey found that 23 percent of
African-Americans and 15 percent of Latinos felt that they would have received
better treatment if they were of another race. Only 6 percent of Whites reported
the same feelings (La Veist et al. 2000). Against this backdrop, it clearly is
important for providers to have a genuine understanding of their clients from
other cultures, as well as an awareness of how personal or professional biases
may affect treatment.
Most counselors who provide treatment services are White and come from
the dominant Western culture, but nearly half of clients seeking treatment are not
White (Mulvey et al. 2003). This stark fact supports the argument that clinicians
consider treatment in the context of culture. Counselors often feel that their own
social values are the norm — that their values are typical of all cultures. In fact,
U.S. culture differs from most other cultures in a number of ways. Clinicians and
program staff members can benefit from learning about the major areas of
difference and from understanding the common ways in which clients from other
cultures may differ from the dominant U.S. culture.
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Treatment Principles
Members of racial and ethnic groups are not uniform. Each group is highly
heterogeneous and includes a diverse mix of immigrants, refugees, and
multigenerational Americans who have vastly different histories, languages,
spiritual practices, demographic patterns, and cultures (U.S. Department of
Health and Human Services 2001).
For example, the cultural traits attributed to Hispanics/Latinos are at best
generalizations that could lead to stereotyping and alienation of an individual
client. Hispanics/Latinos are not a homogeneous group. For example, distinct
Hispanic/Latino cultural groups — Cuban Americans, Puerto Rican Americans,
Mexican Americans, and Central and South Americans — do not think and act
alike on every issue. How recently immigration occurred, the country of origin,
current place of residence, upbringing, education, religion, and income level
shape the experiences and outlook of every individual who can be described as
Hispanic/Latino.
Many people also have overlapping identities, with ties to multiple cultural
and social groups in addition to their racial or ethnic group. For example, a
Chinese American also may be Catholic, an older adult, and a Californian. This
individual may identify more closely with other Catholics than with other Chinese
Americans. Treatment providers need to be careful not to make facile
assumptions about clients' culture and values based on race or ethnicity.
To avoid stereotyping, clinicians must remember that each client is an
individual. Because culture is complex and not easily reduced to a simple
description or formula, generalizing about a client's culture is a paradoxical
practice. An observation that is accurate and helpful when applied to a large
group of people may be misleading and harmful if applied to an individual. It is
hoped that the utility of offering broad descriptions of cultural groups outweighs
the potential misunderstandings. When using the information in this chapter,
counselors need to find a balance between understanding clients in the context
of their culture and seeing clients as merely an extension of their culture. Culture
is only a starting point for exploring an individual's perceptions, values, and
wishes. How strongly individuals share the dominant values of their culture varies
and depends on numerous factors, including their education, socioeconomic
status, and level of acculturation to U.S. society.
Differences in Worldview
A first step in mediating among various cultures in treatment is to
understand the Anglo-American culture of the United States. When compared
with much of the rest of the world, this culture is materialistic and competitive and
places great value on individual achievement and on being oriented to the future.
For many people in U.S. society, life is fast paced, compartmentalized, and
organized around some combination of family and work, with spirituality and
community assuming less importance.
Some examples of this worldview that differ from that of other cultures
include
6
! Multidimensional learning styles. The Anglo-American culture
emphasizes learning through reading and teaching. This method
sometimes is described as linear learning that focuses on reasoned facts.
Other cultures, especially those with an oral tradition, do not believe that
written information is more reliable, valid, and substantial than oral
information. Instead, learning often comes through parables and stories
that interweave emotion and narrative to communicate on several levels at
once. The authority of the speaker may be more important than that of the
message. Expressive, creative, and nonverbal interventions that are
characteristic of a specific cultural group can be helpful in treatment.
Cultures with this kind of rich oral tradition and learning pattern include
Hispanics/Latinos, African-Americans, American Indians, and Pacific
Islanders.
Common issues affecting the counselor-client relationship include the
following:
! Respect and dignity. For most cultures, particularly those that have been
oppressed, being treated with respect and dignity is supremely important.
The Anglo-American culture tends to be informal in how people are
addressed; treating others in a friendly, informal way is considered
respectful. Anglo Americans generally prefer casual, informal interactions
even when newly acquainted. However, some other cultures view this
informality as rudeness and disrespect. For example, some people feel
disrespected at being addressed by their first names.
Clinical Implications of
Culturally Competent Treatment
Programs should take the following steps to ensure culturally competent
treatment for their clients:
! Assess the program for policies and practices that might pose barriers to
culturally competent treatment for diverse populations. Removing these
barriers could entail something as simple as rearranging furniture to
accommodate clients in wheelchairs or as involved as hiring a counselor
who is from the same cultural group as the population the program serves.
Section 2 provides more information about assessing program needs.
! Ensure that all program staff receives training about the meaning and
benefits of cultural competence in general and about the specific cultural
beliefs and practices of client populations that the program serves.
! Incorporate family and friends into treatment to support the client.
Although family involvement is often a good idea in any program, it may
be particularly effective given the importance of family in many cultures.
Some clients left families and friends behind when they came to the
United States. Helping these clients build support systems is critical.
! Provide program materials on audiotapes, in Braille, or in clients' first
languages. All materials should be sympathetic to the culture of clients
being served.
! Ensure that client materials are written at an appropriate reading level.
People who are homeless and those for whom English is a second
language may need materials written at an elementary school reading
level.
! Include a strong outreach component. People who are unfamiliar with U.S.
culture may be unaware that substance abuse treatment is available or
how to access it.
! Hire counselors and administrators and appoint board members from the
diverse populations that the program serves. Section 2 provides more
information about recruiting and hiring diverse staff members.
! Incorporate elements from the culture of the populations being served by
the program (e.g., Native-American healing rituals or Talking Circles).
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! Partner with agencies and groups that deliver community services to
provide enhanced services, such as child care, transportation, medical
screening and services, parenting classes, English-as-a-second-language
classes, substance-free housing, and vocational assistance. These
services may be necessary for some clients to be able to stay in
treatment.
! Provide meals at the program facility. This may bring some clients (e.g.,
those who are elderly or homeless) into treatment and induce them to
stay.
! Make case management services available for clients who need them.
! Emphasize structured programming, as opposed to open-ended
discussion, in group therapy settings.
! Base treatment on clients' strengths. Experienced providers report that
this approach works well with clients from many cultures and is the
preferred approach for clients struggling with self-esteem or
empowerment.
! Use a motivational framework for treatment, which seems to work well
with clients from many cultures. Basic principles of respect and
collaboration are the basis of a motivational approach, and these qualities
are valued by most cultures.
! Encourage clients to participate in mutual-help programs to support their
recovery. Although the mutual-help movement's roots are in White,
Protestant, middle-class American culture, data show that members of
minorities benefit from mutual-help programs to the same extent as do
Whites (Tonigan 2003).
Hispanics/Latinos
Hispanics/Latinos include individuals from North, Central, and South
America, as well as the Caribbean. Hispanic people can be of any race, with
forebears who may include American Indians, Spanish-speaking Caucasians,
and people from Africa. Great disparities exist among these subgroups in
education, economic status, and labor force participation. In 2002, the
Hispanic/Latino population totaled 37.4 million, more than 13 percent of the total
U.S. population, and it is now the largest ethnic group in the Nation. Mexican
Americans are the largest subgroup, representing more than two-thirds of all
Hispanics/Latinos in the United States (Ramirez and de la Cruz 2003).
Two-thirds of the Hispanic/Latino people in the United States were born
here. As a group, they are the most urbanized ethnic population in the country.
Although poverty rates for Hispanics/Latinos are high compared with those of
Whites, by the third generation virtually no difference in income exists between
Hispanic/Latino and non-Hispanic/Latino workers who have the same level of
education (Bean et al. 2001).
Celebrations and religious ceremonies are an important part of the culture,
and use of alcohol is expected and accepted in these celebrations and
ceremonies. In the interest of family cohesion and harmony, traditional
Hispanic/Latino families tend not to discuss or confront the alcohol problems of
family members. Among Hispanics/Latinos with a perceived need for treatment of
substance use disorders, 23 percent reported the need was unmet — nearly
twice the number of Whites who reported unmet need (Wells et al. 2001). Studies
show that Hispanics/Latinos with substance use disorders receive less care and
often must delay treatment, relative to White Americans (Wells et al. 2001). De
La Rosa and White's (2001) review of the role social support systems play in
substance use found that family pride and parental involvement are more
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influential among Hispanic/Latino youth than among White or African-American
youth. The 2000 Substance Abuse and Mental Health Services Administration's
(SAMHSA's) National Household Survey on Drug Abuse (NHSDA) found that
nearly 40 percent of Hispanics/Latinos reported alcohol use. Five percent of
Hispanics reported use of illicit substances, with the highest rate occurring
among Puerto Ricans and the lowest rate among Cubans (Office of Applied
Studies 2001). Hispanics/Latinos accounted for 9 percent of admissions to
substance abuse treatment in 2000 (Office of Applied Studies 2002).
Spanish-language treatment groups are helpful for recently arrived
Hispanic/Latino immigrants. Programs in areas with a large population of foreign-
born Hispanics/Latinos should consider setting up such groups, using Spanish-
speaking counselors. AA has Spanish-language meetings in many parts of the
country, especially in urban areas.
African-Americans
African-Americans make up 13 percent of the U.S. population and include
36 million residents who identify themselves as Black, more than half of whom
live in a metropolitan area (McKinnon 2003). The African-American population is
extremely diverse, coming from many different cultures in Africa, Bermuda,
Canada, the Caribbean, and South America. Most African-Americans share the
experience of the U.S. history of slavery, institutionalized racism, and
segregation (Brisbane 1998).
Foreign-born Africans living in America have had distinctly different
experiences from U.S.-born African-Americans. As one demographer points out,
“Foreign-born African-Americans and native-born African-Americans are
becoming as different from each other as foreign-born and native-born Whites in
terms of culture, social status, aspirations and how they think of themselves”
(Fears 2002, p. A8). Nearly 8 percent of African-Americans are foreign born;
many have grown up in countries with majority Black populations ruled by
governments consisting of mostly Black Africans.
The 2000 NHSDA found that 34 percent of African-Americans reported
alcohol use, compared with 51 percent of Whites and 40 percent of
Hispanics/Latinos. Only 9 percent of African-American youth reported alcohol
use, compared with at least 16 percent of White, Hispanic/Latino, and Native-
American youth (Office of Applied Studies 2001). Six percent of African-
Americans reported use of illicit substances, compared with 6 percent of Whites
and 5 percent of Hispanics/Latinos (Office of Applied Studies 2001). African-
Americans accounted for 24 percent of admissions to substance abuse treatment
in 2000 (Office of Applied Studies 2002). Among African-Americans with a
perceived need for substance abuse treatment, 25 percent reported the need
was unmet — more than twice the number of Whites who reported unmet need
(Wells et al. 2001).
Native Americans
The Bureau of Indian Affairs recognizes 562 different Native-American
tribal entities. (The term “Native American” as it is used here encompasses
American Indians and Alaska Natives.) Each tribe has unique customs, rituals,
languages, beliefs about creation, and ceremonial practices. On the 2000
census, about 2.5 million Americans listed themselves as Native Americans and
1.6 million Americans listed themselves as at least partly Native American,
accounting for 4.1 million people or 1.5 percent of the U.S. population (Ogunwole
2002).
Currently only 20 percent of American Indians and Alaska Natives live on
reservations or trust lands, where they have access to treatment from the Indian
Health Service. More than half live in urban areas (Center for Substance Abuse
Prevention 2001). The 2000 NHSDA found that 35 percent of Native Americans
reported alcohol use. Thirteen percent of Native Americans reported use of illicit
substances (Office of Applied Studies 2001). Among all youth ages 12 to 17, the
use of illicit substances was most prevalent among Native Americans — 22
percent (Office of Applied Studies 2001). Native Americans begin using
substances at higher rates and at a younger age than any other group (U.S.
Government Office of Technology Assessment 1994). Native Americans
accounted for 3 percent of admissions to substance abuse treatment in 2000
(Office of Applied Studies 2002). More than three-quarters of all Native-American
admissions for substance use are due to alcohol. Alcoholism, often
intergenerational, is a serious problem among Native Americans (CSAT 1999b).
One study found that rates for alcohol dependence among Native Americans
were higher than the U.S. average (Spicer et al. 2003) but not as high as often
had been reported. Thirty percent of men in culturally distinct tribes from the
Northern Plains and the Southwest were alcohol dependent, compared with the
national average of 20 percent of men. Among the Northern Plains community,
20 percent of women were alcohol dependent, compared with the national
average of 8.5 percent. Only 8.7 percent of all women in the Southwest were
found to be alcohol dependent.
Among Native Americans, there is a movement toward using Native
healing traditions and healers for the treatment of substance use disorders.
Spiritually based healing is unique to each tribe or cultural group and is based on
that culture's traditional ceremonies and practices.
Asian Americans and Pacific Islanders
Asian Americans and Pacific Islanders are the fastest growing minority
group in the United States, making up more than 4 percent of the U.S. population
and totaling more than 12 million. They account for more than one-quarter of the
U.S. foreign-born population. The vast majority live in metropolitan areas
(Reeves and Bennett 2003); more than half live in three States: California,
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New York, and Hawaii (Mok et al. 2003). Nearly 9 out of 10 Asian Americans
either are foreign born or have at least one foreign-born parent (U.S. Census
Bureau 2003). Asian Americans represent many distinct groups and have
extremely diverse cultures, histories, and religions.
Pacific Islanders are peoples indigenous to thousands of islands in the
Pacific Ocean. Pacific Islanders number about 874,000 or 0.3 percent of the
population. Fifty-eight percent of these individuals reside in Hawaii and California
(Grieco 2001).
Grouping Asian Americans and Pacific Islanders together can mask the
social, cultural, linguistic, and psychological variations that exist among the many
ethnic subgroups this category represents. Very little is known about interethnic
differences in mental disorders, seeking help, and use of treatment services
(U.S. Department of Health and Human Services 2001).
The 2000 NHSDA found that 28 percent of Asian Americans and Pacific
Islanders reported alcohol use. Only 7 percent of adolescent Asian Americans
and Pacific Islanders reported alcohol use, compared with at least 16 percent of
White, Hispanic/Latino, and Native-American youth (Office of Applied Studies
2001). Three percent of Asian Americans and Pacific Islanders reported use of
illicit substances (Office of Applied Studies 2001). As a group Asian Americans
and Pacific Islanders have the lowest rate of illicit substance use, but significant
intragroup differences exist. Koreans (7 percent) and Japanese (5 percent) use
illicit substances at much greater rates than Chinese (1 percent) and Asian
Indians (2 percent) (Office of Applied Studies 2001). Asian Americans and Pacific
Islanders accounted for less than 1 percent of admissions to substance abuse
treatment in 2000 (Office of Applied Studies 2002).
Persons With HIV/AIDS
In the United States, more than 918,000 people are reported as having
AIDS (Centers for Disease Control and Prevention 2004). HIV is still largely a
disease of men who have sex with men and people who inject drugs; these
groups together account for nearly four-fifths of all cases of HIV/AIDS (Centers
for Disease Control and Prevention 2004). Minorities have a much higher
incidence of infection than does the general population. Although African-
Americans make up only 13 percent of the U.S. population, they accounted for
50 percent of new HIV infections in 2004 (Centers for Disease Control and
Prevention 2004). HIV is spreading most rapidly among women and adolescents.
In 2000, females accounted for nearly half of new HIV cases reported among 13-
to 24-year-olds. Among 13- to 19-year-olds, females accounted for more than 60
percent of new cases (Centers for Disease Control and Prevention 2002).
HIV/AIDS is increasing rapidly among African-American
and Hispanic/Latino women. Although they represent less than a quarter of U.S.
women, these groups account for more than four-fifths of the AIDS cases
reported among women; African-American women account for 64 percent of this
total (Centers for Disease Control and Prevention 2004). Gay people who abuse
substances also are at high risk because they are more likely to engage in risky
sex after alcohol or drug use (Greenwood et al. 2001).
The development of new medications — and combinations of medications
— has had a significant effect on the length and quality of life for many people
who live with HIV/AIDS. However, these new treatment protocols require clients
to take multiple medications on a complicated regimen. Clients with HIV often
present with a cluster of problems, including poverty, indigence, homelessness,
mental disorders, and other medical problems.
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Those with cognitive or physical disabilities are more likely than the
general population to have a substance use disorder but less likely to receive
effective treatment (Moore and Li 1998). Many community-based treatment
programs do not currently meet the Federal requirements of the Americans with
Disabilities Act. Any treatment program is likely to have clients who present with
a variety of disabilities. Experienced clinicians report that an appreciable number
of individuals with substance use disorders have unrecognized learning
disabilities that can impede successful treatment. People who have the same
disability may have differing functional capacities and limitations.
Treating substance use disorders in persons with disabilities is an
emerging field of study. Culture brokering is a treatment approach that was
developed to mediate between the culture of a foreign-born person and the
health care culture of the United States. This model helps rehabilitation providers
understand the role that culture plays in shaping the perception of disabilities and
treatment (Jezewski and Sotnik 2001). Culture brokering is an extension of
techniques that providers already practice, including assessment and problem
solving.
Rural Populations
In 2000, nearly 20 percent of the U.S. population (55.4 million people)
lived in nonmetropolitan areas; the nonmetropolitan population increased 10.2
percent from 1990 to 2000 (Perry and Mackun 2001). The economic base and
ethnic diversity of these populations, not just their isolation, are critical factors.
This population includes people of Anglo-European heritage in Appalachia and in
farming and ranching communities of the Midwest and West, Hispanic/Latino
migrant farm workers across the South, and Native Americans on reservations.
Despite this diversity, rural communities from different parts of the country
have commonalities: low population density, limited access to goods and
services, and considerable familiarity with other community members. People
living in rural situations also share broad characteristics that affect treatment.
These characteristics are
! Overall higher resistance to seeking help because of pride in self-
sufficiency
! Concerns about confidentiality and resistance to participating in group
work because in small communities “everyone knows everyone else”
! A sense of strong individuality and privacy, sometimes coupled with
difficulty in expressing emotions
! A culturally embedded suspicion of treatment for substance use and
mental disorders, although this varies widely by area
Among adults older than age 25, the rate of alcohol use is lower in rural
areas than in metropolitan areas. But rates of heavy alcohol use among youth
ages 12 to 17 in rural areas are almost double those seen in metropolitan areas
(Office of Applied Studies 2001). Women in rural areas have higher rates of
alcohol use and alcoholism than women in metropolitan areas (American
Psychological Association 1999). However, in one study, urban residents
received substance abuse treatment at more than double the rate of their rural
counterparts (Metsch and McCoy 1999). Researchers attribute this disparity to
the relative unavailability and unacceptability of substance abuse treatment in
rural areas of the United States (Metsch and McCoy 1999).
Homeless Populations
Approximately 600,000 Americans are homeless on any given night. One
census count of people who are homeless found about 41 percent were White,
40 percent were African- American, 11 percent were Hispanic, and 8 percent
were Native American. Compared with all U.S. adults, people who are homeless
are disproportionately African-American and Native American (Urban Institute et
al. 1999). Homeless populations include groups of people who are
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and in treatment have co-occurring disorders, compared with 20 percent who are
not homeless (Office of Applied Studies 2003b). People who are homeless are
more than three times as likely to receive detoxification services as people who
are not homeless (45 percent vs. 14 percent) (Office of Applied Studies 2003b).
In addition to the resources found in Appendix A, the following clinical
guidelines will assist providers in treating people who are homeless:
! Clients who are homeless often drop out of treatment early. Meeting
survival needs of clients who are homeless is integral to successful
outcomes. A treatment program needs to provide safe shelter, warmth,
and food, in addition to the components of effective treatment provided to
other clients who use substances, including extensive continuing care
(Milby et al. 1996).
! Individuals who are homeless benefit from intensive contact early in
treatment. Clients who attend treatment an average of 4.1 days per week
are more successful than those attending fewer days (Schumacher et al.
1995).
! The Alcohol Dependence Scale, the Alcohol Severity Index, and the
personal history form have been found to be reliable and valid screening
tools for this population (Joyner et al. 1996). Reliability is higher when
items are factual and based on a recent time interval and when individuals
are interviewed in a protected setting.
! Case management must be available to ease access to and coordinate
the variety of services needed by clients who are homeless and abuse
substances. Case management should arrange for stable, safe, and drug-
free housing. The availability of housing is a powerful influence on
recovery. Making such housing contingent on abstinence has been shown
to be a useful strategy (Milby et al. 1996). Case management also should
coordinate medical care, including psychiatric care, with vocational training
and education to help individuals sustain a self-sufficient life.
! Providers should work with homeless shelters to provide treatment
services. Strategies include (1) working with staff members at shelters and
with public housing authorities to find and arrange for housing, (2) locating
the program within a homeless shelter or at least providing core elements
of treatment at the shelter, and (3) placing a substance abuse treatment
specialist at the shelter as a liaison with the program.
Older Adults
The number of older adults needing treatment for substance use disorders
is expected to increase from 1.7 million in 2001 to 4.4 million by 2020. This
increase is the result of a projected 50-percent increase in the number of older
adults as well as a 70-percent increase in the rate of treatment need among older
adults (Gfroerer et al. 2003). America's aging cohort of baby boomers (people
born between 1946 and 1964) is expected to place increasing demands on the
substance abuse treatment system in the coming years, requiring a shift in focus
to address their special needs. This older generation will be more ethnically and
racially diverse and have higher substance use and dependence rates than
current older adults (Korper and Council 2002).
As a group, older people tend to feel shame about substance use and are
reluctant to seek out treatment. Many relatives of older individuals with substance
use disorders also are ashamed of the problem and rationalize the substance
use or choose not to address it. Diagnosing and treating substance use disorders
are more complex in older adults than in other populations because older people
have more — and more interconnected — physical and mental health problems.
Barriers to effective treatment include lack of transportation, shrinking social
support networks, and financial constraints.
Oslin and colleagues (2002) find that older adults had greater attendance
and lower incidence of relapse than younger adults in treatment and conclude
that older adults can be treated successfully in mixed-age groups, provided that
they receive age-appropriate individual treatment. When treating older clients,
programs need to be involved actively with the local network of aging services,
including home- and community-based long-term care providers. Older
individuals who do not see themselves as abusers — particularly those who
misuse over-the-counter or prescription drugs or do not understand the problems
caused by alcohol and drug interactions — need to be reached through wellness,
health promotion, social service, and other settings that serve older adults. In
addition, programs can broaden the multicultural resources available to them by
working through the aging service network to link up with diverse language,
cultural, and ethnic resources in the community.
Programs that develop geriatric expertise can provide an essential service
by making consultation available to staff members at programs that face similar
challenges, along with inservice training, coordination of interventions, and care
conferences designed to solve problems and develop care plans for individuals.
There also may be opportunities to make this expertise available to caregivers
and participants in settings where older adults receive interdisciplinary care (e.g.,
a support group for family caregivers or a discussion group for participants at a
social daycare or adult day health center).
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Exhibit 1. Glossary of
Cultural Competence Terms
Adapted from Administration for Children and Families 1994, pp. 108–109.
20
Stage 5. Cultural Competence
• Shows acceptance of and respect for differences.
• Expands cultural knowledge and resources.
• Provides continuous self-assessment.
• Pays attention to the dynamics of difference to meet client needs better.
• Adapts service models to needs.
• Seeks advice and consultation from minority communities.
• Is committed to policies that enhance services to diverse clientele.
Stage 6. Cultural Proficiency
• Holds all cultures in high esteem.
• Seeks to add to knowledge base.
• Advocates continuously for cultural competence.
Chapter 4, “Preparing a Program To Treat Diverse Clients,” in TIP 46, Substance Abuse:
Administrative Issues in Outpatient Treatment (CSAT 2006f) — This chapter includes an
introduction to cultural competence and why it matters to treatment programs, as well as
information on assessing a diverse population's treatment needs and conducting
outreach to attract clients and involve the community. This chapter also includes a list of
resources for assessment and training, in addition to culture-specific resources.
“Alcohol Use Among Special Populations” (National Institute on Alcohol Abuse and
Alcoholism 1998) — This special issue of the journal Alcohol Health & Research World
(now called Alcohol Research & Health) includes articles on alcohol use in Asian
Americans and Pacific Islanders, African-Americans, Alaska Natives, Native Americans,
and Hispanics/Latinos. Authors also address such topics as alcohol availability and
advertising in minority communities, special populations in AA, and alcohol consumption
in India, Mexico, and Nigeria. Visit pubs.niaaa.nih.gov/publications/arh22-4/toc22-4.htm
to download the articles.
Mental Health: Culture, Race, and Ethnicity (U.S. Department of Health and Human
Services 2001) — This publication describes the disparities in mental health services
that affect minorities, presents evidence of the need to address those disparities, and
documents promising strategies to eliminate them. Visit
www.mentalhealth.samhsa.gov/cre/default.asp to download a copy of this publication.
Counseling the Culturally Different: Theory and Practice, Third Edition (Sue and Sue
1999) — This book offers a conceptual framework for counseling across cultural lines
and includes treatment recommendations for specific cultural groups, with individual
chapters on counseling Hispanics/Latinos, African-Americans, Asian Americans, and
Native Americans and special sections on women, gay and lesbian people, and persons
who are elderly and disabled.
22
The Cultural Context of Health, Illness, and Medicine (Loustaunau and Sobo 1997) —
This book, written by a sociologist and an anthropologist, examines the ways in which
cultural and social factors shape understandings of health and medicine. Although its
discussions are not specific to substance abuse, they address the effect of social
structures on health, differing conceptions of wellness, and cross-cultural
communication.
Pocket Guide to Cultural Health Assessment, Third Edition (D'Avanzo and Geissler
2003) — This quick reference guide has individual sections on 186 countries, each of
which lists demographic information (e.g., population, ethnic and religious descriptions,
languages spoken), political and social information, and health care beliefs.
“Acculturation and Latino Adolescents' Substance Use: A Research Agenda for the
Future” (De La Rosa 2002) — This article reviews literature on the effects of
acculturation to Western values on Hispanic/Latino adolescents' mental health and
substance use, discusses the role that acculturation-related stress plays in substance
use, and suggests directions for treatment and further research.
African-Americans
Chemical Dependency and the African American: Counseling and Prevention Strategies,
Second Edition (Bell 2002) — This book from the co-founder of the Institute on Black
Chemical Abuse explores the dynamics of race, culture, and class in treatment and
examines substance abuse and recovery in the context of racial identity.
Substance Abuse Resource Guide: American Indians and Native Alaskans (Center for
Substance Abuse Prevention 1998b) — A substance abuse resource guide for American
Indians and Alaska Natives, including books, articles, classroom materials, posters, and
Web sites. Order from SAMHSA's NCADI.
Promising Practices and Strategies To Reduce Alcohol and Substance Abuse Among
American Indians and Alaska Natives (American Indian Development Associates 2000)
— This report collects descriptions of successful substance abuse prevention efforts by
Native-American groups. It also includes a literature review and list of Federal resources.
Visit www.ojp.usdoj.gov/americannative/promise.pdf to download the report.
“Morning Star Rising: Healing in Native American Communities” (Nebelkopf et al. 2003)
— This special issue of the Journal of Psychoactive Drugs is devoted to healing in
Native-American communities, with 13 articles on various aspects of prevention and
treatment. Contact Haight-Ashbury Publications at (415) 565–1904.
Walking the Same Land — This videotape presents young Indians who are returning to
traditional cultural ways to strengthen their recovery from substance abuse. It includes
aboriginal men from Australia and Mohawk men from New York. Order from SAMHSA's
NCADI.
24
Asian Americans and Pacific Islanders
Asian and Pacific Islander American Health Forum
(www.apiahf.org/resources/index.htm) — This site provides links to information and
resources.
Asian Community Mental Health Services (www.acmhs.org) — This site provides links to
information and describes a substance abuse treatment program in Oakland, California.
Substance Abuse Resource Guide: Asian and Pacific Islander Americans (Center for
Substance Abuse Prevention 1996a; www.ncadi.samhsa.gov/govpubs/MS408) — This
guide contains resources appropriate for use in Asian and Pacific Islander communities.
It also contains facts and figures about substance use and prevention within this diverse
group.
“Communicating Appropriately With Asian and Pacific Islander Audiences” (Center for
Substance Abuse Prevention 1997) — This Technical Assistance Bulletin discusses
population characteristics, lists cultural factors related to substance use in nine distinct
ethnic groups, and presents guidelines on developing effective prevention materials for
these populations. Visit www.ncadi.samhsa.gov/govpubs/MS701 to download the
bulletin.
Opening Doors: Techniques for Talking With Southeast Asian Clients About Alcohol and
Other Drug Issues — This program is available on videocassette in Vietnamese and
Khmer with English subtitles. Order from SAMHSA's NCADI, and visit
http://ncadistore.samhsa.gov/catalog/productDetails.aspx?ProductID=15136 to view it
on the Web.
Persons With HIV/AIDS
TIP 37, Substance Abuse Treatment for Persons With HIV/AIDS (CSAT 2000c) — This
TIP discusses the medical aspects of HIV/AIDS (epidemiological data, assessment,
treatment, and prevention), the legal and ethical implications of treatment, the
counseling of patients with HIV/AIDS, the integration of treatment and enhanced
services, and funding sources for programs.
The Hawaii AIDS Education and Training Center has numerous resources available for
download at www.hawaii.edu/hivandaids/links.htm.
LGB Populations
The Web site of the National Association of Lesbian and Gay Addiction Professionals is
a clearinghouse for information and resources, including treatment programs and
mutual-help groups, organized by State. Visit www.nalgap.org.
Addictions in the Gay and Lesbian Community (Guss 2000) — This volume includes
personal experiences of substance use and recovery and research into the sources of
and treatment for substance use disorders in gay and lesbian clients. The book also
includes techniques for assessing and treating LGB clients, including adolescents.
Persons With Physical and Cognitive Disabilities
Programs should link with local groups that offer specialized housing, vocational training,
and other supports for people who are disabled. The Centers for Independent Living
(CILs) are organizations run by and for persons with disabilities to provide mutual-help
and advocacy. CILs and Client Assistance Programs were developed to provide a third
party to broker the interaction between clients and the service system. The Special
Olympics may be able to help locate recreational activities appropriate for individual
clients.
Coping With Substance Abuse After TBI — This report answers basic questions about
substance use and traumatic brain injury (TBI) and includes recommendations from
clients with TBI who are now abstinent. Download the publication at
www.mssm.edu/tbicentral/resources/publications/tbi_consumer_reports.shtml.
TIP 29, Substance Use Disorder Treatment for People With Physical and Cognitive
Disabilities (CSAT 1998e) — This volume discusses screening, treatment planning, and
counseling for clients with disabilities. The book includes a compliance guide for the
Americans with Disabilities Act, a list of appropriate terms to use when referring to
people with disabilities, and screening instruments for use with this population, including
an Education and Health Survey and an Impairment and Functional Limitation Screen.
Substance Abuse Resources and Disability Issues Program at Wright State School of
Medicine (www.med.wright.edu/citar/sardi) — This Web site offers products for
professionals and persons with disabilities, including a training manual with an
introduction on substance abuse and the deaf culture, as well as a Web course on
substance abuse and disability.
26
Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals
(www.mncddeaf.org) — This Web site includes links to articles on substance abuse
treatment of individuals who are deaf and to manuals and videotapes for use in
treatment.
TAP 20, Bringing Excellence to Substance Abuse Services in Rural and Frontier
America (CSAT 1996) — The papers in this volume examine innovative strategies and
policies for treating substance use disorders in rural and frontier America. Topics include
rural gangs and crime, needs assessment approaches, coalitions and partnerships, and
minorities and women in treatment.
Rural Substance Abuse: State of Knowledge and Issues (Robertson et al. 1997) — This
NIDA Research Monograph examines rural substance abuse from many perspectives,
looking at substance use among youth and at the health, economic, and social
consequences of substance use. The final section of the book addresses ethnic and
migrant populations, including rural Native Americans, African-Americans, and Mexican
Americans. Visit www.nida.nih.gov/PDF/Monographs/Monograph168/Download168.html
to download the monograph.
Homeless Populations
National Resource Center on Homelessness and Mental Illness
(www.nrchmi.samhsa.gov/pdfs/bibliographies/Cultural_Competence.pdf) — This Web
site has an annotated, online bibliography of journal articles, resource guides, reports,
and books that address cultural competence. Many resources discuss substance use
disorders.
The U.S. Department of Housing and Urban Development has compiled a list of local
agencies by State and other resources to assist people who are homeless. Visit
www.hud.gov/homeless/index.cfm.
The U.S. Department of Health and Human Services offers assistance and resources for
people who are homeless. For example, the Health Care for the Homeless Program
provides grants to community-based organizations in urban and rural areas for projects
aimed at improving access for the homeless to primary health care, mental health care,
and substance abuse treatment. Visit www.aspe.hhs.gov/homeless/index.shtml.
Substance Abuse Treatment: What Works for Homeless People? A Review of the
Literature (Zerger 2002) — This report links research on homelessness and substance
abuse with clinical practice and examines various treatment modalities, types of
interventions, and methods for engaging and retaining people who are homeless.
Download the report from National Health Care for the Homeless Council's Web site at
www.nhchc.org/Publications/SubstanceAbuseTreatmentLitReview.pdf.
Substance Abuse Relapse Prevention for Older Adults: A Group Treatment Approach
(CSAT 2005c) — This manual presents a relapse prevention intervention that uses a
cognitive-behavioral and self-management approach in a counselor-led group setting to
help older adults overcome substance use disorders. Order from SAMHSA's NCADI.
28
Substance Abuse by Older Adults: Estimates of the Future Impact on the Treatment
System (Korper and Council 2002) — This report examines substance abuse treatment
services for older adults in the context of increased demand in the future and calls for
better documentation of substance abuse among older adults and prevention and
treatment strategies that are tailored to subgroups of older adults, such as immigrants
and racial and ethnic minorities. Download the report at
www.drugabusestatistics.samhsa.gov/aging/toc.htm.
Alcohol and Aging (Beresford and Gomberg 1995) — This book for clinicians covers
topics such as diagnosis and treatment, mental disorders, interactions of alcohol and
prescription medications, and the biochemistry of intoxication for older adults.
Alcoholism and Aging: An Annotated Bibliography and Review (Osgood et al. 1995) —
This volume surveys 30 years of research on older adults who use alcohol, providing
abstracts of articles, books and book chapters, and research studies on the prevalence,
effects, diagnosis, and treatment of alcohol use in older adults.
The stages of change can be visualized as a wheel with four to six parts,
depending on how specifically the process is broken down (Prochaska and
DiClemente, 1984). Here, the wheel (Figure 1) has five parts, with a final exit to
enduring recovery (the sixth part is recurrence or relapse). It is important to note
that the change process is cyclical, and individuals typically move back and forth
between the stages and cycle through the stages at different rates. In one
individual, this movement through the stages can vary in relation to different
behaviors or objectives. Individuals can move through stages quickly.
Sometimes, they move so rapidly that it is difficult to pinpoint where they are
because change is a dynamic process. It is not uncommon, however, for
individuals to linger in the early stages.
For most substance-using individuals, progress through the stages of
change is circular or spiral in nature, not linear. In this model, recurrence is a
normal event because many clients cycle through the different stages several
times before achieving stable change. The five stages and the issue of
recurrence are described below.
32
Clients need and use different kinds of motivational support according to
which stage of change they are in and into what stage they are moving. If you try
to use strategies appropriate to a stage other than the one the client is in, the
result could be treatment resistance or noncompliance. For example, if your
client is at the contemplation stage, weighing the pros and cons of change versus
continued substance use, and you pursue change strategies appropriate to the
action stage, your client will predictably resist. The simple reason for this reaction
is that you have taken the positive (change) side of the argument, leaving the
client to argue the other (no change) side; this results in a standoff.
34
The clinician can engage an SO by asking the client to invite the SO to a
treatment session. Explain that the SO will not be asked to monitor the client's
substance use but that the SO can perform a valuable role by providing
emotional support, identifying problems that might interfere with treatment goals,
and participating in activities with the client that do not involve substance use. To
strengthen the SO's belief in his capacity to help the client, the clinician can use
the following strategies:
! Positively describe the steps used by the SO that have been successful
(define "successful" generously). (2)
! Reinforce positive comments made by the SO about the client's current
change efforts. (2)
! Discuss future ways in which the client might benefit from the SO's efforts
to facilitate change. (2)
Clinicians should use caution when involving an SO in motivational
counseling. Although a strong relationship between the SO and the client is
necessary, it is not wholly sufficient. The SO must also support a client's
substance-free life, and the client must value that support. (1) An SO who is
experiencing hardships or emotional problems stemming from the client's
substance use may not be a suitable candidate. (1) Such problems can preclude
the SO from constructively participating in the counseling sessions, and it may be
better to wait until the problems have subsided before including an SO in the
client's treatment. (1)
In general, the SO can play a vital role in influencing the client's
willingness to change; however, the client must be reminded that the
responsibility to change substance use behavior is hers. (2)
36
During the preparation stage, the clinician's tasks broaden from using
motivational strategies to increase readiness--the goals of precontemplation and
contemplation stages--to using these strategies to strengthen a client's
commitment and help her make a firm decision to change. At this stage, helping
the client develop self-efficacy is important. (2) Self-efficacy is not a global
measure, like self-esteem; rather, it is behavior specific. In this case, it is the
client's optimism that she can take action to change substance-use behaviors.
When working with clients in the preparation stage, clinicians should try to
! Clarify the client's own goals and strategies for change. (2)
! Discuss the range of different treatment options and community resources
available to meet the client's multiple needs. (2)
! With permission, offer expertise and advice. (2)
! Negotiate a change--or treatment--plan and a behavior contract (2); take
into consideration
o Intensity and amount of help needed
o Timeframe
o Available social support, identifying who, where, and when
o The sequence of smaller goals or steps needed for a successful
plan
o Multiple problems, such as legal, financial, or health concerns
! Consider and lower barriers to change by anticipating possible family,
health, system, and other problems. (2)
! Help the client enlist social support (e.g., mentoring groups, churches,
recreational centers). (2)
! Explore treatment expectancies and client role. (2)
! Have clients publicly announce their change plans to significant others in
their lives. (2)
38
return to problem behaviors. (2) Second, many clients remain ambivalent in the
action stage of change or vacillate between some level of contemplation--with
associated ambivalence--and continuing action. (2) Moreover, clients who do
take action are suddenly faced with the reality of stopping or reducing substance
use. This is more difficult than just contemplating action. The first stages of
recovery require only thinking about change, which is not as threatening as
actually implementing it.
Clients' involvement or participation in treatment can be increased when
clinicians
! Develop a nurturing rapport with clients. (2)
! Induct clients into their role in the treatment process. (2)
! Explore what clients expect from treatment and determine discrepancies.
(2)
! Prepare clients so that they know there may be some embarrassing,
emotionally awkward, and uncomfortable moments but that such moments
are a normal part of the recovery process. (2)
! Investigate and resolve barriers to treatment. (2)
! Increase congruence between intrinsic and extrinsic motivation. (2)
! Examine and interpret noncompliant behavior in the context of
ambivalence. (2)
! Reach out to demonstrate continuing personal concern and interest to
encourage clients to remain in the program. (2)
Clients who are in the action stage can be most effectively helped when
clinicians
! Engage clients in treatment and reinforce the importance of remaining in
recovery. (2)
! Support a realistic view of change through small steps. (2)
! Acknowledge difficulties for clients in early stages of change. (2)
! Help the client identify high-risk situations through a functional analysis
and develop appropriate coping strategies to overcome these. (2)
! Assist the client in finding new reinforcers of positive change. (2)
! Assess whether the client has strong family and social support. (2)
The next challenge that clients and clinicians face is maintaining change.
With clients in the maintenance stage, clinicians will be most successful if they
can
! Help the client identify and sample substance-free sources of pleasure--
i.e., new reinforcers. (1)
! Support lifestyle changes. (2)
! Affirm the client's resolve and self-efficacy. (2)
! Help the client practice and use new coping strategies to avoid a return to
substance use. (2)
! Maintain supportive contact. (2)
After clients have planned for stabilization by identifying risky situations,
practicing new coping strategies, and finding their sources of support, they still
have to build a new lifestyle that will provide sufficient satisfaction and can
compete successfully against the lure of substance use. A wide range of life
changes ultimately needs to be made if clients are to maintain lasting abstinence.
Clinicians can help this change process by using competing reinforcers. (1) A
competing reinforcer is anything that clients enjoy that is or can become a
healthy alternative to drugs or alcohol as a source of satisfaction.
The essential principle in establishing new sources of positive
reinforcement is to get clients involved in generating their own ideas. Clinicians
should explore all areas of clients' lives for new reinforcers. Reinforcers should
not come from a single source or be of the same type. That way, a setback in
one area can be counterbalanced by the availability of positive reinforcement
from another area. Since clients have competing motivations, clinicians can help
them select reinforcers that will win out over substances over time.
Following are a number of potential competing reinforcers that can help
clients:
! Doing volunteer work, thus filling time, connecting with socially acceptable
friends, and improving their self-efficacy (2)
! Becoming involved in 12-Step-based activities and other self-help groups
(2)
! Setting goals to improve their work, education, exercise, and nutrition (2)
! Spending more time with their families and significant others (2)
40
! Participating in spiritual or cultural activities (2)
! Socializing with nonsubstance-using friends (2)
! Learning new skills or improving in such areas as sports, art, music, and
other hobbies (2)
Contingency reinforcement systems, such as voucher programs, have
proven to be effective when community support and resources are available. (1)
Research has shown that these kinds of reinforcement systems can help to
sustain abstinence in drug abusers. The rationale for this type of incentive
program is that an appealing external motivator can be used as an immediate
and powerful reinforcer to compete with substance use reinforcers. Not all
contingent incentives have to have a monetary value. In many cultures, money is
not the most powerful reinforcer.
Recurrence
Most people do not immediately sustain the new changes they are attempting to
make, and a return to substance use after a period of abstinence is the rule
rather than the exception (Brownell et al., 1986; Prochaska and DiClemente,
1992). These experiences contribute information that can facilitate or hinder
subsequent progression through the stages of change. Recurrence, often
referred to as relapse, is the event that triggers the individual's return to earlier
stages of change and recycling through the process. Individuals may learn that
certain goals are unrealistic, certain strategies are ineffective, or certain
environments are not conducive to successful change. Most substance users will
require several revolutions through the stages of change to achieve successful
recovery (DiClemente and Scott, 1997). After a return to substance use, clients
usually revert to an earlier change stage--not always to maintenance or action,
but more often to some level of contemplation. They may even become
precontemplators again, temporarily unwilling or unable to try to change soon.
Resuming substance use and returning to a previous stage of change should not
be considered a failure and need not become a disastrous or prolonged
recurrence. A recurrence of symptoms does not necessarily mean that a client
has abandoned a commitment to change.
Triggers to Change
The multidimensional nature of motivation is captured, in part, in the popular
phrase that a person is ready, willing, and able to change. This expression
highlights three critical elements of motivation--but in reverse order from that in
which motivation typically evolves. Ability refers to the extent to which the person
has the necessary skills, resources, and confidence (self-efficacy) to carry out a
change. One can be able to change, but not willing. The willing component
involves the importance a person places on changing--how much a change is
wanted or desired. (Note that it is possible to feel willing yet unable to change.)
However, even willingness and ability are not always enough. You probably can
think of examples of people who are willing and able to change, but not yet ready
to change. The ready component represents a final step in which the person
finally decides to change a particular behavior. Being willing and able but not
ready can often be explained by the relative importance of this change compared
with other priorities in the person's life. To instill motivation for change is to help
the client become ready, willing, and able.
Figure 2 provides examples of appropriate motivational strategies you can use at
each stage of change. Of course, these are not the only ways to enhance
motivation for beneficial change.
42
Figure 2: Appropriate Motivational Strategies for Each Stage of Change
Client's Stage of Change Appropriate Motivational Strategies for
the Clinician
Precontemplation ! Establish rapport, ask permission, and
build trust.
The client is not yet considering
change or is unwilling or unable ! Raise doubts or concerns in the client
to change. about substance-using patterns by
o Exploring the meaning of events
that brought the client to
treatment or the results of
previous treatments
o Eliciting the client's perceptions of
the problem
o Offering factual information about
the risks of substance use
o Providing personalized feedback
about assessment findings
o Exploring the pros and cons of
substance use
o Helping a significant other
intervene
o Examining discrepancies
between the client's and others'
perceptions of the problem
behavior
! Express concern and keep the door
open.
44
Preparation ! Clarify the client's own goals and
strategies for change.
The client is committed to and planning
to make a change in the near future ! Offer a menu of options for
but is still considering what to do. change or treatment.
! With permission, offer expertise
and advice.
! Negotiate a change--or treatment-
-plan and behavior contract.
! Consider and lower barriers to
change.
! Help the client enlist social
support.
! Explore treatment expectancies
and the client's role.
! Elicit from the client what has
worked in the past either for him
or others whom he knows.
! Assist the client to negotiate
finances, child care, work,
transportation, or other potential
barriers.
! Have the client publicly announce
plans to change.
46
Recurrence ! Help the client reenter the
change cycle and commend
The client has experienced a recurrence any willingness to reconsider
of symptoms and must now cope with positive change.
consequences and decide what to do
next. ! Explore the meaning and reality
of the recurrence as a learning
opportunity.
! Assist the client in finding
alternative coping strategies.
! Maintain supportive contact.
Bean, F.D.; Trejo, S.J.; Crapps, R.; and Tyler, M. The Latino Middle Class: Myth, Reality, and Potential. Los Angeles, CA:
Tomás Rivera Policy Institute, 2001.
Brisbane, F.L. Introduction: Diversity among African Americans. In: Center for Substance Abuse Prevention (CSAP).
Cultural Competence for Health Care Professionals Working With African-American Communities: Theory and Practice.
CSAP Cultural Competence Series 7. DHHS Publication No. (SMA) 98–3238. Rockville, MD: Substance Abuse and
Mental Health Services Administration, 1998, pp. 1–8.
Center for Substance Abuse Prevention. Substance Abuse Resource Guide: Asian and Pacific Islander Americans.
Rockville, MD: Substance Abuse and Mental Health Services Administration, 1996a. ncadi.samhsa/gov/govpubs/MS408
[accessed March 4, 2004].
Center for Substance Abuse Prevention. Substance Abuse Resource Guide: Hispanic/Latino Americans. Rockville, MD:
Substance Abuse and Mental Health Services Administration, 1996b. www.ncadi.samhsa.gov/govpubs/MS441 [accessed
March 4, 2004].
Centers for Disease Control and PreventionHIV/AIDS Surveillance Report 16:1–46, 2004.
Cross, TL.; Bazron, B.J.; Dennis, K.R.; and Isaacs, M.R. Towards a Culturally Competent System of Care, Vol. 1.
Washington, DC: Georgetown University Child Development Center, National Technical Assistance Center for Children's
Mental Health, 1989.
CSAT (Center for Substance Abuse Treatment). A Provider's Introduction to Substance Abuse Treatment for Lesbian,
Gay, Bisexual, and Transgender Individuals. DHHS Publication No. (SMA) 01–3498. Rockville, MD: Substance Abuse and
Mental Health Services Administration, 2001.
Fears, D. A Diverse — and Divided — Black Community. Washington Post, February 24, 2002, pp. A1, A8.
Gfroerer J, Penne M, Pemberton M, Folsom R. Substance abuse treatment need among older adults in 2020: The impact
of the aging baby-boom cohort. Drug and Alcohol Dependence. 69((2)):127-135; 2003. (PubMed)
Greenwood G.L, White E.W, Page-Shafer K, Bein E, Osmond D.H, Paul J, Stall R.D. Correlates of heavy substance use
among young gay and bisexual men: The San Francisco Young Men's Health Study. Drug and Alcohol Dependence.
61((2)):105-112; 2001. (PubMed)
Hubbard J.R, Everett A.S, Khan M.A. Alcohol and drug abuse in patients with physical disabilities. American Journal of
Drug Abuse. 22((2)):215-231; 1996.
Jezewski, M.A., and Sotnik, P. Culture Brokering: Providing Culturally Competent Rehabilitation Services to Foreign-Born
Persons. Buffalo, NY: Center for International Rehabilitation Research Information and Exchange,
2001.www.cirrie.buffalo.edu/cbrokering.html [accessed February 11, 2004].
Joyner L.M, Wright J.D, Devine J.A. Reliabilit and validity of the Addiction Severity Index among homeless substance
misusers. Substance Use & Misuse. 31((6)):729-751; 1996. (PubMed)
Korper, S.P., and Council, C.L., eds. Substance Use by Older Adults: Estimates of Future Impact on the Treatment
System. Analytic Series A-21. DHHS Publication No. (SMA) 03–3763. Rockville, MD: Office of Applied Studies, Substance
Abuse and Mental Health Services Administration, 2002.
LaPlante, M.P.; Kennedy, J.; Kaye, H.S.; and Wenger, B.L. Disability and employment. Disability Statistics Abstract.
Number 11. San Francisco: Disability Statistics Center, 1996.www.dsc.ucsf.edu/pdf/abstract11.pdf [accessed February
11, 2004].
La Veist, T.A.; Diala, C.; and Jarrett, N.C. Social status and perceived discrimination: Who experiences discrimination in
the health care system, how, and why? In: Hogue, C.J.R.; Hargraves, M.A.; and Collins, K.S., eds. Minority Health in
America. Baltimore: Johns Hopkins University Press, 2000, pp. 194–208.
Magura S, Nwakeze P.C, Rosenblum A, Joseph H. Substance misuse and related infectious diseases in a soup kitchen
population. Substance Use & Misuse. 35((4)):551-583; 2000. (PubMed)
McKinnon, J. The Black population in the United States: March 2002. Current Population Reports. P20–541. Washington,
DC: U.S. Census Bureau, 2003.
Metsch L.R, McCoy C.B. Drug treatment experiences: Rural and urban comparisons. Substance Use & Misuse.
34((4&5)):763-784; 1999. (PubMed)
Milby J.B, Schumacher J.E, Raczynski J.M, Caldwell E, Engle M, Michael M, Carr J. Sufficient conditions for effective
treatment of substance abusing homeless persons. Drug and Alcohol Dependence. 43:39-47; 1996. (PubMed)
Moore D, Li L. Prevalence and risk factors of illicit drug use by people with disabilities. American Journal on Addictions.
7((2)):93-102; 1998. (PubMed)
Mulvey KP, Hubbard S, Hayashi S. A National Study of the Substance Abuse Treatment Workforce. Journal of Substance
Abuse Treatment. 24:51-57; 2003. (PubMed)
Office of Applied Studies. Summary of Findings From the 2000 National Household Survey on Drug Abuse. NHSDA
Series H–13. DHHS Publication No. (SMA) 01–3549. Rockville, MD: Substance Abuse and Mental Health Services
Administration, 2001.http://oas.samhsa.gov/NHSDA/2kNHSDA/2kNHSDA.htm [accessed February 11, 2004].
Office of Applied Studies. Treatment Episode Data Set (TEDS): 1992–2000, National Admissions to Substance Abuse
Treatment Services. DASIS Series: S-17, DHHS Publication No. (SMA) 02–3727. Rockville, MD: Substance Abuse and
Mental Health Services Administration, 2002.wwwdasis.samhsa.gov/teds00/TEDS_2k_index.htm [accessed February 11,
2004].
Office of Applied Studies, Substance Abuse and Mental Health Services Administration (SAMHSA). Treatment Episode
Data Set (TEDS): 1992–2001. National Admissions to Substance Abuse Treatment Services. DASIS Series S-12. DHHS
Publication No. (SMA) 02-3778. Rockville, MD: SAMHSA, 2003b. wwwdasis.samhsa.gov/teds01/TEDS2K1Index.htm
[accessed March 19, 2004].
Office of Applied Studies. The DASIS Report: Characteristics of Homeless Admissions to Substance Abuse Treatment,
2000. Rockville, MD: Substance Abuse and Mental Health Services Administration, August 8,
2003b.http://www.oas.samhsa.gov/2k3/homelessTX/homelessTX.htm [accessed February 11, 2004].
Ogunwole, S.U. The American Indian and Alaska Native population: 2000. Census 2000 Brief. C2KBR/01–15.
Washington, DC: U.S. Census Bureau, 2002.
Oslin D.W, Pettinati H, Volpicelli J.R. Older age predicts better adherence and drinking outcomes. American Journal of
Geriatric Psychiatry. 10:740-747; 2002. (PubMed)
Perry, M.J., and Mackun, P.J. Population change and distribution: 1990 to 2000. Census 2000 Brief. C2KBR/01-2.
Washington, DC: U.S. Census Bureau, 2001.
Ramirez, R.R., and de la Cruz, G.P. The Hispanic population in the United States: March 2002. Current Population
Reports, P20–545. Washington, DC: U.S. Census Bureau, 2003.
Schmidley, D. The foreign-born population in the United States: March 2002. Current Population Reports, P20–539.
Washington, DC: U.S. Census Bureau, 2003.
Schumacher J.E, Milby J.B, Caldwell E, Raczynski J, Engle M, Michael M, Carr J. Treatment outcome as a function of
treatment attendance with homeless persons abusing cocaine. Journal of Addictive Diseases. 14((4)):73-85; 1995.
(PubMed)
50
Spicer P, Beals J, Croy C.D, Mitchell C.M, Novins D.K, Moore L, Manson S.M, the American Indian Service Utilization,
Psychiatric Epidemiology, Risk and Protective Factors Project Team.. The prevalence of DSM-III-R alcohol dependence in
two American Indian populations. Alcoholism, Clinical and Experimental Research. 27((11)):1785-1797; 2003.
Tonigan J.S. Project MATCH treatment participation and outcome by self-reported ethnicity. Alcoholism, Clinical and
Experimental Research. 27((8)):1340-1344; 2003.
Urban Institute; Burt, M.R.; Aron, L.Y.; Douglas, T.; Valente, J.; Lee, E.; and Iwen, B. Homelessness: Programs and the
People They Serve — Findings of the National Survey of Homeless Assistance Providers and Clients, Technical Report.
Washington, DC: Interagency Council on the Homeless, 1999.
www.huduser.org/publications/homeless/homeless_tech.html [accessed February 11, 2004].
U.S. Department of Health and Human Services. Mental Health: Culture, Race, and Ethnicity — A Supplement to Mental
Health: A Report of the Surgeon General. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental
Health Services Administration, 2001.www.mentalhealth.org/cre/default.asp [accessed February 11, 2004].
Wells K, Klap R, Koike A, Sherbourne C. Ethnic disparities in unmet need for alcoholism drug abuse and mental health
care. American Journal of Psychiatry. 158:2027-2032; 2001. (PubMed)
Woody G.E, Donnell D, Seage G.R, Metzger D, Marmor M, Koblin B.A, Buchbinder S, Gross M, Stone B, Judson F.N.
Non-injection substance use correlates with risky sex among men having sex with men: Data from HIVNET. Drug and
Alcohol Dependence. 53((3)):197-205; 1999. (PubMed)
Section 3, Chapter 8
Bandura, A. Self-Efficacy: The Exercise of Control. New York: W.H. Freeman, 1997.
Blomqvist, J. Paths to recovery from substance misuse: Change of lifestyle and the role of treatment. Substance Use and
Misuse. 31(13):1807-1852, 1996.
Brecht, M.L., and Anglin, M.D. Conditional factors of maturing out: Legal supervision and treatment. International Journal
of the Addictions. 25:395-407, 1990.
Brownell, K.D.; Marlatt, G.A.; Lichtenstein, E.; and Wilson, G.T. Understanding and preventing relapse. American
Psychologist. 41:765-782, 1986.
Chen, K., and Kandel, D.B. The natural history of drug use from adolescence to mid-thirties in a general population
sample. American Journal of Public Health. 85(1):41-47, 1995.
DiClemente, C.C. Motivational interviewing and the stages of change. In: Miller, W.R., and Rollnick, S., eds. Motivational
Interviewing: Preparing People To Change Addictive Behavior. New York: Guilford Press, 1991. pp. 191-202.
DiClemente, C.C.; Carbonari, J.P.; Montgomery, R.P.G.; and Hughes, S.O. The Alcohol Abstinence Self-Efficacy Scale.
Journal of Studies on Alcohol. 55(2):141-148, 1994.
DiClemente, C.C., and Prochaska, J.O. Processes and stages of self-change: Coping and competence in smoking
behavior change. In: Shiffman, S., and Wills, T.A., eds. Coping and Substance Abuse. New York: Academic Press, 1985.
pp. 319-343.
DiClemente, C.C., and Prochaska, J.O. Toward a comprehensive transtheoretical model of change: Stages of change and
addictive behaviors. In: Miller, W.R., and Heather, N., eds. Treating Addictive Behaviors, 2nd ed. New York: Plenum
Press, 1998.
DiClemente, C.C., and Scott, C.W. Stages of change: Interactions with treatment compliance and involvement. In: Onken,
L.S.; Blaine, J.D.; and Boren, J.J., eds. Beyond the Therapeutic Alliance: Keeping the Drug-Dependent Individual in
Treatment. NIDA Research Monograph Series, Number 165. DHHS Pub. No. (ADM) 97-4142. Rockville, MD: National
Institute on Drug Abuse, 1997. pp. 131-156.
Institute of Medicine. . Treating Drug Problems. Washington, DC: National Academy Press, 1990b.
Marlatt, G.A., and Gordon, J.R., eds. Relapse Prevention: Maintenance Strategies in the Treatment of Addictive
Behaviors. New York: Guilford Press, 1985.
Miller, W.R., and Heather, N., eds. Treating Addictive Behaviors, 2nd ed. New York: Plenum Press, 1998.
Orleans, C.T.; Schoenbach, V.J.; Wagner, E.H.; Quade, D.; Salmon, M.A.; Pearson, D.C.; Fiedler, J.; Porter, C.Q.; and
Kaplan, B.H. . Self-help quit smoking interventions: Effects of self-help materials, social support instructions, and
telephone counseling. Journal of Consulting and Clinical Psychology. 59:439-448, 1991.
Prochaska, J.O., and DiClemente, C.C. Stages and processes of self-change of smoking: Toward an integrated model of
change. Journal of Consulting and Clinical Psychology. 51:390-395, 1983.
Prochaska, J.O., and DiClemente, C.C. The Transtheoretical Approach: Crossing Traditional Boundaries of Therapy.
Homewood, IL: Dow Jones-Irwin, 1984.
Prochaska, J.O., and DiClemente, C.C. Stages of change in the modification of problem behaviors. In: Hersen, M.; Eisler,
R.M.; and Miller, P.M., eds. Progress in Behavior Modification. Sycamore, IL: Sycamore Publishing Company, 1992. pp.
184-214.
Prochaska, J.O; DiClemente, C.C.; and Norcross, J.C. Changing: Process approaches to initiation and maintenance of
changes. In: Klar, Y.; Fisher, J.D.; Chinsky, J.M.; and Nadler, A., eds. Self-Change: Social, Psychological, and Clinical
Perspectives. New York: Springer-Verlag, 1992a. pp. 87-114.
Prochaska, J.O.; DiClemente, C.C.; and Norcross, J.C. In search of how people change: Applications to addictive
behaviors. American Psychologist. 47:1102-1114, 1992.
Prochaska, J.O., and Goldstein, M.G. Process of smoking cessation: Implications for clinicians. Clinical Chest Medicine.
12:727-735, 1991.
Prochaska, J.O.; Velicer, W.F.; Rossi, J.S.; Goldstein, M.G.; Marcus, B.H.; Rakowski, W.; Fiore, C.; Harlow, L.L.; Redding,
C.A., Rosenbloom, D.; and Rossi, S.R. . Stages of change and decisional balance for 12 problem behaviors. Health
Psychology. 13(1):39-46, 1994.
Robins, L.N.; Davis, D.H.; and Goodwin, D.W. Drug use by U.S. Army enlisted men in Vietnam: A follow-up on their return
home. American Journal of Epidemiology. 99:235-249, 1974.
Sobell, L.C.; Sobell, M.B.; Toneatto, T.; and Leo, G.I. What triggers the resolution of alcohol problems without treatment?
Alcoholism: Clinical and Experimental Research. 17:217-224. 1993.
Sobell, M.B., and Sobell, L.C. Guiding self-change. In: Miller, W.R., and Heather, N., eds. Treating Addictive Behaviors,
2nd ed. New York: Plenum, 1998. pp. 189-202.
Sutton, S. Can stages of change provide guidelines in the treatment of addictions? In: Edwards, G., and Dare, C., eds.
Psychotherapy, Psychological Treatments and the Addictions. New York: Cambridge University Press, 1996.
Tucker, J.A.; Vuchinich, R.E.; and Gladsjo, J.A. Environmental events surrounding natural recovery from alcohol-related
problems. Journal of Studies on Alcohol. 55:401-411, 1994.
Strang, J.; Bacchus, L.; Howes, S.; and Watson, P. Turned away from treatment: Maintenance-seeking opiate addicts at
two-year follow-up. Addiction Research. 6:71-81, 1997.
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Section 4, Chapter 1:
Preparing for the
Written Examination
The focus of this information is the written examination process. At the
present time, two national certification and/or licensure examinations are used
across the nation. They are as follows:
1. The International Certification and Reciprocity Consortium/Alcohol and
Other Drug Abuse (IC&RC/AODA) National Exam, and
2. The National Association of Alcoholism and Drug Abuse Counselors
(NAADAC) National Exam.
III. Referral 10 7%
V. Counseling 33 22%
II. Counseling
Practice 40% 25%
III. Theoretical
Bases 15% 25%
IV. Professional
Issues 15% 25%
54
At this time, the majority of states use the IC&RC examination as its initial
licensure or certification examination. Once you are credentialed, if you wish to
pursue one of the national credentials from NAADAC, you will be required to take
their examination as well (unless you are credentialed in a NAADAC testing
state).
Each test question on the written examination will contain the same three
key components: the question (or stem) you read in order to find an
answer; the key (or correct answer); and either three (3) or four (4)
distractors (or incorrect answers). The following sample question
identities the three components.
This question is a “fill in the blank” question that rewards mental “recall” of
information. In other words, you have to be able to reach inside your
memory and come up with the correct answer all by yourself “without any
prompting.”
a. Al Gore
b. Ross Perot
c. Ralph Nader
d. Pat Buchannan
56
Now you are asked to identify the correct answer through “recognition” not
recall. In other words, you are asked only to “recognize” the correct
answer when it is given you, not recall it exclusively from memory. Most
individuals find it’s much easier to come up with the correct answer if you
are given alternatives from which to choose.
Why is this important in your preparation for this exam? Because rather
than spending study time just “memorizing” information to be “recalled”
later, it is better to “input” the information into your memory in such a way
that it will be available later when given a clue or prompted by a statement
or phrase (the distractors and key). Try to focus your learning on
identifying facts, terms, basic concepts and answers. Read and review
materials with the idea of organizing, comparing, translating, interpreting,
giving descriptions or definitions, and stating main ideas. Think about how
you would use your new knowledge to solve problems by applying
acquired knowledge, facts, techniques and rules in a different way.
Keep in mind, too, that the exam is asking you to answer the test
questions with the BEST response. This is different than simply asking
you to choose the CORRECT response. What this means is that you will
see two very different types of questions on the exam. One type will be
questions which do have only one CORRECT answer. For the purpose of
illustration, let’s call these questions Type One questions. The second
types of questions are those which may have more than one CORRECT
answer, of which you are expected to select the BEST answer to the
question. We will call these questions Type Two questions.
Each time you start to answer a question, stop and ask yourself, “Does
this question have only one CORRECT answer, or can there be more than
one CORRECT answer and my task is to pick the BEST answer.” It is
very important that you ask yourself this for each question.
a. absorption.
b. distribution.
c. detoxification.
d. oxidation.
If you know your basic addiction pharmacology, you will recognize that
only answer, “c” is correct – detoxification. To do well on this type of
question, first decide “there is only one possible CORRECT answer.”
Then choose the CORRECT answer after reading ALL of the alternatives.
Type One questions are easier to answer than the following Type Two
question.
a. confusion.
b. cerebral atrophy and cardiovascular damage.
c. depressed reflexes.
d. ataxia.
This is a Type Two question because two or more of the answers to this
question are CORRECT. In fact, ALL of the answers to this question are
CORRECT. Your task is to choose the BEST correct answer if you want
to get this question right.
This is a more difficult question to answer correctly than the previous Type
One question. It involves more skillful thinking and analysis.
So, which answer is the BEST answer to this question? The BEST
answer is “b” – cerebral atrophy and cardiovascular damage. Why?
Answer “b” is the BEST answer because it “covers” all of the other
answers. Another way of putting it is that cerebral atrophy and
cardiovascular damage cause the other symptoms listed. Answer “b” is
primary to the other three choices.
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In other types of questions like these, it may be that you must do one thing
first before you could do any of the others. Or, as a result of doing certain
things, the final outcome is your BEST response. It simply means that
you must carefully look at all responses (distractors) before you select
your correct response (key).
As with the first 137 questions, the final thirteen questions will also be set
up with a BEST answer (key) and three other answers (distractors) to
choose from. You will again find both Type One questions and Type Two
questions like we have explained above.
To do well on these questions, you will need to be very familiar with the
Twelve Core Functions and their related forty-six (46) Global Criteria. We
have provided this information for you in Appendix B at the back of the
manual.
Let’s look at two practical examples of this new style of questions for the
exam using the following incomplete and abbreviated short case history.
(You will be provided an opportunity to review a full sample case history
with five sample questions later in this manual.)
Mary was admitted to the hospital detox unit and then admitted to the
treatment programs twelve day intensive residential treatment program
sixty-two hours later with a diagnosis of DSM-IV Axis 1 “Alcohol
Dependence.”
Now see if you can answer each of the following questions before
checking the correct answer and explanation that follow.
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Question 1.
Question 2.
Of the four possible choices, investigating the likelihood that Mary could
be self-medicating with alcohol to deal with depression seems the most
clinically relevant additional screening process needed. All three of the
other options presented would be useful, especially a detailed history of
her alcohol/drug use, and would have followed her admission to care. But
the identification of any coexisting conditions – especially depression –
would certainly have made an immediate impact on any decision for
additional professional assessments and/or services during her short stay
and aftercare. Even if she were to deny any past diagnosis of depression,
asking about depression and documenting her response would raise a red
flag in her case that could warrant further investigation during the course
of care.
Perhaps this question was easier for you. When you read the question,
the key words in the question itself are “most likely.” In order for you to
have done well on this question, you would have to be familiar with
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NAADAC’s Code of Ethics for Addiction Professionals, Principle 3:
Competence (Item a) states “The NAADAC member shall recognize
boundaries and limitations of the member’s competencies and not offer
services or use techniques outside of these professional competencies.”
Even though the counselor may have had hypnosis training, the practice
of hypnosis, especially by a male counselor with a female client, is
considered to be outside the scope of acceptable practice for an addiction
counselor. The boundary issue alone makes this unethical behavior.
More importantly, of the four choices, none of the other three introduce
any ethical dilemmas.
5. Avoid Procrastination
Avoid the "escape syndrome". If you find yourself fretting or talking about
other things rather than studying, relax for a few minutes and rethink what
you are doing - reappraise your priorities and if necessary rethink your
study plan to address your worries and then START WORKING.
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6. Develop Good Study Skills
Deal with unread materials - succinctly. Approach your unread materials
keeping in mind all of your study plans, how much time you have to catch
up on your reading, and what it is you need to pull out of the reading.
Preview the material, dividing it up into parts looking for the organizational
scheme of the work. Decide what parts in the reading you can omit, what
parts you can skim, and what parts you want to read. Set time limits for
each part, and keep to the limits. Use the following techniques to help
move through the reading:
! Skim all the reading material first (except the parts you have
decided to omit) so you will have at least looked at everything
before the test. Take notes on what you skim.
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4. Check Your Test
Preview the whole test before beginning to answer any questions. Make
sure your copy has no missing or duplicate pages. Ask the instructor or
proctor to clarify any ambiguities. Read the directions carefully.
This still allows you more than 30 minutes at the very end of the test to
review any questions you still have not answered (and guess if all else
fails), and then transfer your answers to the answer sheet. We encourage
this to help you avoid any erasure marks on the answer sheet, which can
be problematic as the answer sheet is computer scored.
You’ll notice that your body begins to tingle, and you’ll feel refreshed and
calm. Deep breathing improves the flow of oxygen to the brain and
removes the excess carbon dioxide that builds up during periods of
intense brain activity – this is a critical item for good thought
processing and memory recall.
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9. Read All the Answers
Never select a response until you have read all of the choices. Keep in
mind that the instructions will be for you to answer “the BEST possible
response” – this could mean that there is more than one CORRECT
response, but only one is the BEST.
If all else fails, guess. An answer left blank is automatically wrong, but
guessing will give you the potential of collecting the point if you guess
right.
The success/failure rates do vary from state to state, though the national average
for passing either exam seems to be in the neighborhood of 50%, +/- a few points
each test cycle.
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How to Use Section 4
The test questions in this manual are representative of the knowledge
required in the field of chemical dependency counseling (content knowledge).
They are NOT actual test questions from either the IC&RC or NAADAC
exams. They are intended to assist you in assessing your own knowledge and
understanding of information regarding the chemical dependency profession.
Because most states use the IC&RC exam, this format (150 questions) is used in
the sample examination.
Find time to sit down and take the entire examination in one sitting. Note
your starting and ending times so you can begin to judge the speed and
efficiency that you will need to answer questions when you actually sit for your
credentialing exam. Once you have completed all the questions, go to Section 4,
Chapter 3 of the manual and check your responses. Then check your score -
your goal is to obtain a score of 105 out of the possible 150 exam questions. If
you don’t obtain this score, note the areas of greatest weakness by looking at the
content areas of the questions, and concentrate your study and review prior to
actual examination to these areas.
A Final Word
After many hours of educational and “in field” training, have faith in the
knowledge you have obtained in working towards your credentials. Many test
candidates tend to forget the time and effort they have given to reach the point of
testing. Instead of believing in themselves and calling upon the knowledge and
skills learned in their training, they focus only on the exam itself. Many panic and
think, “I don’t know if I can pass this test!” Trust your skills. Don’t try to cram
many years of training into a few short weeks of review. Instead, use review
materials like those found in this manual (and especially the sample exam) to
help pinpoint your areas of strength and weakness. Then use your time to
review what you need help in - not what you already know.
We wish you the best of luck when sitting for your exam, and let us be the
first to congratulate you on reaching this point in your professional development.
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Section 4, Chapter 2:
Sample Written Examination
Read each of the following questions. Then choose the BEST response to each
question. Place you answer on a separate piece of paper. Be sure each
response is numbered. Once completed, turn to Chapter 3 of this section and
score your examination. A score of 105 is considered to be a passing score.
a. Screening
b. Assessment
c. Intake
d. Orientation
2. A client tells a counselor that she is unhappy with the way her treatment is
progressing. The counselor should:
4. A female client reports that she has some concerns about the relationship
between her husband and her 14-year-old daughter from a previous
marriage. She reports that her husband and daughter frequently argue,
that her daughter refuses to take direction from her stepfather, mid that
her daughter regularly complains about her stepfather’s “faults” and
describes how her biological father is better. The MOST relevant
professional to whom a referral should be made is a:
a. Social worker.
b. Clinical psychologist.
c. Licensed professional counselor.
d. Marriage and family therapist.
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7. According to Marlatt’s model of the relapse process, which of the following
statements is NOT true?
a. Clients should be taught skills for anticipating, avoiding, and coping with
their personal high-risk situations.
b. Clients should be taught constructive responses to cope with lapses when
they do occur.
c. Clients should be helped to recognize that one or more temporary lapses
are likely to occur and are permitted.
d. Any positive expectations that clients have about drug use should be
countered with reminders about the lows that follow the highs and about
the long-term negative consequences of substance abuse.
8. According to the DSM-IV, all of the following are criteria for psychoactive
substance dependence EXCEPT:
a. teaching clients to formulate and carry out plans to change their behavior.
b. focusing on the person instead of the presenting problem.
c. assisting clients in enhancing their coping skills.
d. individualizing the treatment plan.
12. During the screening process, a critical task that the counselor has is to:
13. During the assessment process, your alcohol and tranquilizer abusing
client reveals a history of self-destructiveness when frustrated and an
inability to delay impulses. The MOST appropriate assessment battery in
this case is:
a. the Beck Depression Scale , the MAST test , and the MMPI.
b. the Beck Depression Scale , the MAST test, and the Stanford-Binet.
c. the MAST test, the Strong-Campbell, and the Stanford-Binet.
d. the MMPI, the Strong-Campbell, and the Stanford-Binet.
14. During the screening process, a critical task that the counselor has is to:
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16. In determining whether a chemically dependent patient should be treated
in an inpatient or outpatient program, all of the following should be
considered EXCEPT:
a. whether the patient has a history of sobriety during the last several years.
b. whether the patient’s job and family are likely to give him another chance if
this treatment fails.
c. whether the patient has family support for sobriety.
d. whether the patient has a history of failed treatment on an outpatient or
inpatient basis.
18. It is crucial for the case manager to be aware of what may inhibit
minorities' participation in the substance abuse treatment continuum.
Suppose that you are a case manager, working in an outpatient program
with a Somali client. AA is an integral part of your program, yet you are
aware of the fact that while "accepting one's powerlessness" is a central
tenet of 12-Step self-help programs, members of oppressed groups may
not accept it, given their own societal powerlessness. What would be the
best thing to do in such a case?
a. Ask the client to participate, never-the-less, and suggest he simply “do his
best” when dealing with the issue of powerlessness.
b. Let the client know that participation in AA is mandatory, and that if he
doesn’t participate, he could be discharged for “noncompliance.”
c. Be sensitive to such cultural differences and seek out other recovery
resources that are relevant to the individual's values.
d. Seek out another Somali who is in a local AA group and ask the he or she
sponsor your client.
20. Joe is a 27-year old addict who has begun counseling, but has not yet
been able to give up using drugs. During one session, he tells his
counselor that he is beginning to feel that "it is useless to try to stop," and
that "sometimes life is not worth living." The counselor is concerned that
Joe could be suicidal. The counselor should:
a. assess Joe's potential for suicide without directly asking him about suicide
plans, but assess his high-risk factors.
b. assess Joe's potential for suicide by asking him about his intent, and
evaluating high risk factors.
c. determine if Joe has a gun or other weapon.
d. initiate involuntary hospitalization procedures.
a. Advocacy
b. Cooperation
c. Stabilization
d. Flexibility
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23. When language is a barrier to treatment planning, this situation can be
overcome by:
a. employing an interpreter.
b. training the counselor in cultural sensitivity.
c. requiring the client to utilize a family member as an interpreter.
d. getting the client a language tutor.
24. The first contact that a potential client would have with an agency would
likely be for the purpose of:
a. family therapy.
b. education.
c. psychosocial assessment.
d. screening.
25. The MOST SIGNIFICANT barrier to effective treatment for alcohol and
other drug abuse for single parents is lack of:
a. job skills.
b. child care services.
c. educational training.
d. primary health care.
a. Sarah can expect her unresolved conflicts to rise to the surface because
of her work in the treatment center.
b. Sarah can resolve her personal pain by working professionally with
addicted family units in a treatment center.
c. Sarah may be more comfortable with her clients because she is familiar
with their behavior.
d. Sarah may have unfinished business with her parents.
27. You are asked to see a client in the emergency room for a consultation.
The nursing notes read: pupils dilated; gooseflesh; lacrimation; muscle
jerks; flu syndrome; vomiting; diarrhea; nervousness; yawning; and severe
anxiety. You conclude that the client is withdrawing from:
a. Hallucinogens.
b. CNS depressants.
c. Opioids.
d. Dextro-amphetamines.
a. Rational Recovery.
b. Secular Organization for Sobriety.
c. Men and Women for Sobriety.
d. Codependents Anonymous.
30. A single mother with three young children enters your clinic and begins to
discuss her current drug use. She tells you that she hasn’t been home for
several days and has left the 8 year old in charge. What do you do?
31. One of the counselor’s tasks is to guide the client in relating and
communicating in specific terms, rather than in general or abstract terms.
That characteristic or ability is called:
a. Confrontation.
b. Immediacy.
c. Potency.
d. Concreteness.
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32. One of the earliest models for case management services in the criminal
justice system was created in 1972, when the White House launched a
demonstration program known as:
a. Although Ralph did have a relapse, recovery should be easier the second
time around.
b. This constitutes a relapse, and Ralph may need to begin the recovery
process all over again.
c. Ralph should be reassured that this behavior is permissible as long as he
did not lose control and become drunk.
d. The counselor should talk to Ralph about the implications of dangerous
situations like this, but assure him that it is possible to continue his
recovery process.
a. increasing self-control.
b. increasing coping skills.
c. decreasing anxious responding.
d. decreasing negative thought patterns.
36. Providing the client with information regarding program rules, and
infractions that can lead to discharge, normally occurs during the:
a. screening.
b. orientation.
c. assessment.
d. group therapy sessions.
37. Which of the following is NOT a commonly used technique for crisis
intervention:
a. cutting down on drinking, feeling annoyed and guilty, and dealing with
hangovers.
b. making a distinction between problem drinkers and alcoholics.
c. craving a drink, drinking alone, feeling guilty, and employment difficulties.
d. client perceptions, guilt, and “eye-openers."
39. The focus of intervention in the criminal justice system is first to:
a. rehabilitate offenders.
b. use the threat of incarceration as a motivator to change.
c. protect the health, safety, and welfare of the public.
d. keep the chronic, chemically dependent person off the streets.
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40. The goal of Al-Anon is:
a. Male to male
b. Male to female
c. Female to female
d. Female to male
43. The description of the client’s rights typically occurs during the:
a. assessment.
b. intake.
c. orientation.
d. referral.
44. During the intake, a counselor can expect to address all of the following
issues EXCEPT:
a. self-disclosure.
b. releasing information.
c. protecting confidentiality.
d. obtaining informed consent to treatment.
48. Which statement BEST describes how a counselor can avoid professional
burnout?
84
49. A cocaine-dependent client admits being fired from his job for
absenteeism, losing his home and car by defaulting on his loans, and
associating only with peers who use cocaine. He states that he does not
require residential treatment because his problem is not serious enough.
He further states that he has lost his house and car because his wife didn't
work enough hours. Which defense mechanisms is this client displaying?
50. A client says to you, "I am getting to like you very much and I’d like us to
get a lot closer.” You should first:
55. The tendency of the family to try and maintain balance is called:
a. equilibrium.
b. stability.
c. homeostasis.
d. accommodation.
86
57. Your client, Eric, discloses to the group that he is homosexual. Another
member of the group shifts in his seat and changes the subject, talking
about a superficial incident that happened earlier in the day. The
facilitator’s MOST appropriate response would be to:
a. interrupt the second speaker and remind him of the group rules.
b. remind Eric that you are here to treat addiction and ask how this relates to
his addiction.
c. tell Eric that this disclosure is more appropriate for an individual session
and you will meet with him later.
d. ask questions which facilitate a group response to Eric’s disclosure and
elicit more feeling content from Eric.
a. Valium.
b. Halcion.
c. Tranzadone.
d. Xanax.
a. educational level.
b. appearance.
c. speech.
d. thought processes.
61. The provision of information concerning alcohol and other drug abuse and
the available services and resources, is termed:
a. consultation.
b. client education.
c. counseling.
d. case management.
62. When making a referral you should do all of the following EXCEPT:
a. share what you know about the referral agency with your client.
b. follow through with the referral agency to ensure you get your referral fee.
c. offer to make the initial contact in order to ensure that the client sees the
right person.
d. Have the client sign a release of confidentiality form before following
through with the referral.
88
67. According to Rational-Emotive Behavior Therapy, we develop emotional
disturbances because of our:
68. Because addiction affects so many facets of the addicted person's life,
____________________ promotes recovery and enables the substance
abuse client to fully integrate into society as a healthy, substance-free
individual.
70. When a client discloses suicidal thoughts, the counselor’s first step is to:
71. When assessing the signs and symptoms of alcohol withdrawal, all of the
following may be noted EXCEPT:
74. In a crisis interview with a client, you are MOST concerned with:
a. Guilt and anger are painful emotions that are part of grieving
b. Symptoms of grief typically disappear within six months
c. The grieving process should be hurried so the client can resume his life
d. Grief is only a responses to situations involving death
76. Your client has been advised by his sponsor to discontinue a needed
antidepressant medication. You believe this advice to be premature and
possibly harmful. What action should you take as a first step?
a. Obtain your client’s authorization and contact the sponsor to discuss the
situation further
b. Have the client discontinue involvement in AA until antidepressant
medication is no longer needed
c. Encourage your client to ignore the sponsor’s advice and continue the
medication
d. Encourage your client to look for another, more understanding sponsor
90
77. You are having difficulty with a client early on in the case. The BEST
thing for you to do is:
78. While taking an alcohol drug history, which of the following is a good clue
to alcohol dependency?
79. You have assessed your client and determined that he is a problem
drinker. He insists that the reason he drinks is because of his wife’s
behavior. Your initial objective should be to help him:
a. compulsion.
b. delusion.
c. hallucination.
d. obsession.
82. All of the following statements about the effects of alcohol abuse on the
body are true EXCEPT:
83. The interpersonal style in which a member of a minority group has made a
conscious or subconscious decision to reject the general attitudes,
behaviors, customs, rituals, and stereotypic behaviors associated with
his/her own minority group to assimilate into the mainstream white culture
is known as:
84. Brian is a 15-year old boy who has been admitted to a program for
chemical dependency. He has a history of running away from home,
erratic performance in school, and has been arrested twice for petty theft.
In assessing Brian, the counselor should first consider which of the
following before making a treatment recommendation?
92
86. The therapeutic reasoning for self-disclosure in group counseling is to:
a. provide the group members with insight into the counselor’s background.
b. convince group members that the counselor has more life experiences
than they do.
c. demonstrate how to react when other group members disclose personal
information.
d. facilitate the growth of the group by relating to client or group issues.
a. natural narcotic.
b. semi-synthetic narcotic.
c. synthetic narcotic.
d. quasi-narcotic.
a. Women more often than men will cite a traumatic event that precipitated
their drinking.
b. Female alcoholics are more likely to be sociopathic and male alcoholics
are more likely to have affective problems.
c. Female alcoholics are less frequently characterized as feeling depressed
and guilty than male alcoholics.
d. Women move more slowly from the early stages to the later stages of
abusive drinking than men.
92. Which of the following is MOST helpful for counselors in defining their
professional roles for counseling clients?
94
94. A treatment professional utilizing case management will do all of the
following EXCEPT:
a. assist the client with needs generally thought to be outside the realm of
substance abuse treatment.
b. provide the client a single point of contact for multiple health and social
services systems.
c. advocate for the treatment center's approach to care.
d. be flexible, community-based, and client-oriented.
97. The branch of pharmacology that deals with the biological, biochemical,
and physical characteristics of natural drugs is:
a. Pharmacokinetics.
b. Pharmacognosy.
c. Pharmacotherapeutics.
d. Pharmacodynamics.
100. Some populations suffer greater rates of addiction than others. The
Native American population, for example, have addiction rates of:
a. 20%.
b. 30%.
c. 40%.
d. > 50%.
101. The BEST way of dealing with individual needs in a group is to:
96
104. In order to provide clients with updated information concerning addiction
and recovery, the counselor must:
a. assessment.
b. referral.
c. counseling.
d. consultation.
a. The family cannot get well until the dependent person seeks help.
b. The children in a dysfunctional family can be protected from the problems
cause by chemical dependency.
c. The divorce rate in dysfunctional families is highest after recovery has
been initiated.
d. Family problems development in the later phases of the addiction process.
108. The quality of counseling is directly related to the counselor’s ability to:
109. A client says that his wife has vowed to leave him if he resumes drinking.
The best response by the counselor would be:
110. Which self help group would be most appropriate for a mother whose drug
and alcohol-abusing son is causing her distress?
a. Alateen
b. ACOA
c. Al-Anon
d. A.A.
a. screening.
b. orientation.
c. the assessment.
d. intake.
112. You begin working with a drinking alcoholic who recently had eight months
of sobriety. He asks how he can stay sober. You respond by:
113. Which term refers to a client’s projecting past emotional feelings and/or
attitudes onto the counselor?
a. Transference
b. Countertransference
c. Reaction formation
d. Sublimation
98
114. Which of the following responses would be helpful in establishing a
therapeutic relationship with a client?
a. “What’s the matter with you? Why didn’t you just take care of the problem
yourself?”
b. “Let’s get right to the point. You’ve got a drinking problem”
c. “Let’s talk about each of our expectations for counseling”
d. “Let me tell you what you need to stay sober”
117. A 42-year-old male has just completed intake admission forms and is
considered appropriate and eligible for treatment. Which step should occur
next?
a. reactions to stress.
b. episodic in nature.
c. intrapsychic disturbances.
d. maladaptive ways of perceiving, thinking, and relating.
119. While the overall national suicide rate has increased slightly but
consistently in recent years, disproportionate increases have occurred
among:
120. If Seconal is taken in combination with one of the following drugs, it leads
to a “potentiation” of effect. Which drug will cause this effect?
a. Alcohol
b. Amphetamines
c. Opiates
d. Cocaine
a. counter-transference.
b. investigation.
c. self-disclosure.
d. role-playing.
100
123. Which of the following is a TRUE statement?
a. Alcohol accounts for one-half of the ten leading causes of death in the
Native American population.
b. Cultural issues no longer play a role in alcoholism rates with the Native
American population.
c. Past efforts to treat the Native American alcoholic have proven highly
successful.
d. Revia has proven to be a popular intervention in the effective treatment of
Native American populations.
124. During a session you notice that the client is getting progressively more
agitated. You suspect a potential for violence unless something is done
immediately. Your BEST course of action would be to:
125. After a counselor has made a summary statement, the most important
thing the counselor should do is:
a. remain quite for a time to allow the client to consider the summarized
material.
b. document the summary as soon as possible as part of the treatment plan.
c. recommend that the client discuss the session with his/her sponsor.
d. terminate the session immediately.
127. In a dysfunctional family system, the traditional role which the spouse
plays is referred to as:
a. the Hero.
b. the Scapegoat.
c. the Primary Enabler.
d. the Mascot.
128. A frequent client reaction during the termination phase of counseling is:
a. defensiveness.
b. acting out behavior.
c. apathy.
d. lack of trust.
a. intake.
b. orientation.
c. case review.
d. psychosocial assessment.
130. Which of the following is the BEST example of a counselor setting limits
with a client?
a. “We’re here to discuss your alcohol problem – I don’t want to talk about
your marriage”
b. “Counseling is a very unstructured process - anything goes”
c. “Our meetings will consist of four 50 minute sessions at 10 a.m. each
Wednesday”
d. “What’s important is that I help you. I’ll counsel you no matter what”
a. Early intervention
b. Detoxification services
c. Intensive outpatient or partial hospitalization
d. Residential or inpatient services
102
133. Regarding a “seropositive” result, which of the following is NOT a meaning
of HIV antibody test results?
a. the client.
b. all staff of the facility.
c. the agency board of directors.
d. only those persons directly involved in providing clinical services.
135. Which of the following issues must always be considered when consulting
with out-of-agency professionals?
a. Confidentiality
b. Documentation of client problems
c. The client’s aftercare plan
d. The level of commitment of the client to follow through
a. when the client appears to have gained all that he or she can from
therapy.
b. at the point specified in the therapeutic contract.
c. at the onset of therapy.
d. when the client brings it up.
137. All of the following are symptoms of the manic phase of bipolar mood
disorder EXCEPT:
a. deflated self-esteem.
b. euphoria.
c. high levels of verbal output.
d. pressured speech.
Bill is a 28 year old male who has been divorced for about a year. He has two
children, both girls, ages 5 and 3.
At the time of his initial interview he was dressed neatly and displayed no visible
signs of intoxication with no shakes or tremors. He arrived on time for his
appointment and displayed appropriate speech.
Bill stated he started using alcohol and smoking marijuana at age 15, but denied
excessive use of marijuana except for recreational purposes at most twice a
week.
His drinking was initially confined to drinking four to six 12 ounce cans of beer at
a time a couple of weekends per month. He states he didn’t drink at all during
the week. However, now he says it takes at least two to four cans of beer plus
several mixed drinks for him to feel good. He also reports occasional losses of
memory and admitted over the last 18 months prior to the initial interview that he
has started drinking during the week, but only at night after his work is over.
When questioned about his use of other drugs, he would neither confirm nor
deny use of other substances, although he did deny any use of prescription
medications.
Bill was oriented to time, place, and person, fully alert and his memory appeared
intact. He did not admit to any suicidal or homicidal thoughts or ideations. From
his vocabulary and speech he appeared to be of above average intelligence
although he states that he dropped out of school before completing the eleventh
grade. He did earn his GED as a requirement for his first full time employment
and he expressed a desire to continue his education by enrolling in college.
During the final week of Bill’s treatment, an appointment was scheduled with a
local college admissions counselor.
During the course of the interview Bill admitted that all of his difficulties with the
law were alcohol related and that he got along with his wife quite well when he
was not drinking.
104
Based upon the initial interview, Bill was given a provisional Axis I diagnosis of
“alcohol dependence” and admitted to an Intensive outpatient program. After
completion of the initial interview, Bill was given a tour of the facility, a client
handbook, and introduced to his primary counselor and scheduled an
appointment the next day to discuss what the client could expect during
treatment and what would be expected of him in return.
During his treatment Bill worked with his counselor to develop four primary
treatment goals:
1) To spend at least four hours every other weekend with his children;
2) To attend three A.A. meetings a week for the next three months;
3) To abstain from alcohol and all mind altering and mood enhancing
substances; and
4) Complete the 12 week Intensive outpatient treatment program.
Bill was quite resistant to attending A.A. meetings because of fear of being seen
by his friends at meetings. The counselor helped Bill deal with his feelings by
encouraging him to “A, B, C” his thoughts about what people might think of him if
seen at meetings and documented the client’s progress in his chart with a
process note. In addition, Bill was provided a set of videotapes which provided
information about the disease concept of addiction, family dynamics, relapse
prevention and problem solving strategies to review during his first two weeks of
treatment.
In the sixth week of counseling, Bill became quite agitated and insisted he was
going to have to stop treatment because his work schedule had been changed –
four of his employees had quit their jobs and he was going to have to fill in their
responsibilities. His counselor met with him and encouraged him to calm down
and accept a change in his daily treatment schedule.
Given his limited financial means and approximately $7,500 of debt on his Visa
card and the fact that Bill talked excessively about his enormous debt, his
counselor sought the advice of his clinical supervisor since financial problems
were outside his scope of expertise. The clinical supervisor suggested that the
counselor schedule an appointment with a non-profit credit counseling agency
near his home. After explaining the discussion with his supervisor, Bill agreed to
the appointment.
Upon completion of the 12 week program, the client was discharged with
instructions to attend 90 A.A. meetings in 90 days and twice weekly aftercare
sessions. It was noted that the counselor lived less than two blocks from the
client and so they agreed to car pool to aftercare meetings.
Based on the information found in the case history, please select the BEST
response to each of the following questions.
138. What counseling theory was applied to the client’s resistance to attending
AA Meetings?
a. Motivational Interviewing
b. Rational Emotive
c. Client Centered
d. Gestalt
a. The client was deeply in debt because of his credit card use
b. The client’s wife had left him because of his physical abuse of her
c. The client wanted to leave treatment because of his work schedule
d. The client did not want to attend AA meetings in the community
141. What are the PRIMARY factors that made the client appropriate for this
level of care?
106
142. Which of the following essential tasks was NOT completed during the
client’s intake process?
a. The counselor sought the advice of his clinical supervisor regarding the
client’s finances
b. The counselor scheduled an appointment with a credit counseling agency
c. The counselor arranged for the client to change his work schedule
d. The counselor helped the client find an AA meeting and sponsor
144. Which of the following important treatment planning activities were NOT
accomplished in working with this client?
a. The counselor formulated appropriate short term goals for the client
b. The counselor identified and ranked the client’s problems needing
resolution
c. The counselor worked with the client in establishing the client’s treatment
goals
d. The client’s treatment goals were expressed in measurable behavioral
terms
145. Which of the following client behaviors contributed the most to the
counselor’s development of the provisional diagnosis of “alcohol
dependency?”
a. The client admitting all of his legal problems were alcohol related
b. The client’s denial of use of prescription medication
c. The client’s report of increased use of alcohol and occasional memory
loss
d. The client’s conviction for his second DUI offense
146. Which of the following essential orientation functions were NOT performed
with this client?
148. The PRIMARY example of the counselor’s use of effective recording and
recordkeeping in this case was:
149. An example of the use of effective case management with this case was:
108
150. What essential component of client education is missing in this case?
a. The client was not informed of his rights and responsibilities at the start of
his treatment.
b. The client was not informed of his legal responsibilities and obligations
related to his DUI.
c. The client was not informed of community recovery resources available to
him upon discharge
d. The client was not offered the opportunity to participate in weekend family
education seminars
110
Section 4, Chapter 3:
Sample Written Examination
Test Key
1. b. Assessment 14. d. establish rapport with the client.
12. d. establish rapport with the client. 25. b. child care services.
112
61. b. client education. 77. d. seek out supervision with a
colleague or supervisor.
62. b. follow through with the referral
agency to ensure you get your referral 78. a. Increased tolerance and withdrawal
fee. symptoms when abstinence is attempted
63. d. A client reports recent child abuse 79. b. take responsibility for his behavior.
64. b. from the client’s first contact with 80. c. segregated treatment programs.
the treatment center.
81. a. compulsion.
65. d. therapeutic communities do reduce
drug use relative to untreated clients or 82. b. stimulation of the brain’s frontal
those who are simply detoxified and lobe can occur.
released.
83. a. the Acculturated Interpersonal
66. e. consult with his physician Style.
regarding nicotine/medication
interaction. 84. d. Brian’s familial relationships and
social milieu
67. b. intrinsic beliefs about certain
beliefs. 85. c. remorse, self-hatred, and shame.
69. c. The purpose of the release of 87. d. the speed of the onset and
information duration of the effects.
71. c. decreased sensitivity to sounds, 89. a. Women more often than men will
oversensitivity to tactile sensations. cite a traumatic event that precipitated
their drinking.
72. a. Identifying the client’s problems
and needs, strengths and weaknesses 90. d. A partnership between AA and the
professional community was repeatedly
73. c. The presence of withdrawal emphasized by the founders of AA.
symptoms
91. c. The inability to control the amount
74. d. focusing questions about the one drinks
present situation and the client’s means
of coping with the stress. 92. b. An ethical code of conduct
75. a. Guilt and anger are painful 93. a. assisting a client to utilize the
emotions that are part of grieving support systems and community
resources available.
76. a. Obtain your client’s authorization
and contact the sponsor to discuss the
situation further
94. c. advocate for the treatment center's 114. c. “Let’s talk about each of our
approach to care. expectations for counseling”
95. a. the “here and now.” 115. a. The counselor should coordinate
regular meetings with all professionals
96. a. “I’m not sure I understand. Let me involved in the client’s treatment.
check this out”
116. b. something specifically designed
97. b. Pharmacognosy. to increase the occurrence of a particular
behavior.
98. c. elderly people who develop
chemical dependency late in life. 117. d. The counselor should provide the
client with an overview describing the
99. a. spouse who participates in joint goal, objectives, rules, and obligations of
counseling sessions. the program.
109. d. “she’s really serious about your 127. c. the Primary Enabler.
sobriety”
128. b. acting out behavior.
110. c. Al-Anon
129. a. intake.
111. c. the assessment.
130. c. “Our meetings will consist of four
112. d. asking him what worked before. 50 minute sessions at 10 a.m. each
Wednesday”
113. a. Transference
114
131. c. to support the gains made in 143. b. The counselor scheduled an
treatment. appointment with a credit counseling
agency
132. b. Detoxification services
144. b. The counselor identified and
133. a. The person has the AIDS virus ranked the client’s problems needing
resolution
134. d. only those persons directly
involved in providing clinical services. 145. c. The client’s report of increased
use of alcohol and occasional memory
135. a. Confidentiality loss
Counseling Core Function. (Global Criteria 21, 22, 23, 24 & 25)
139. c. – The client wanted to leave treatment because of his work schedule
The client’s distress over his work schedule had to be dealt with
immediately because it posed a threat to his treatment.
141.a. – There were no physical complications and the client was motivated
116
142. d. –The client signed all required consent forms.
There is no evidence in this case history that the client signed consent
forms during intake which is a standard requirement for admission into the
program.
144. b. – The counselor identified and ranked the client’s problems needing
resolution.
Even though the counselor identified four treatment plan goals, he failed to
rank them.
145. c. – The client’s report of increased use of alcohol and occasional memory
loss.
146. a. – The client was provided an estimate of the cost of his treatment.
147. d. – Seeking the advice of his clinical supervisor about the client’s financial
problems
148. d. – The counselor completing a process note for the client’s chart.
The Case History contains evidence that the counselor documented his
counseling work with the client in helping him overcome his resistance to
attending A.A. meetings.
150. c. – The client was not informed of community recovery resources available
to him upon discharge.”
There is no evidence in this Case History that the client was provided any
information about the available alcohol and drug services and resources in
his community, other than a referral to A.A.
118
Answers by Content Area
To identify any weak areas of your professional knowledge, first score
your examination, and then mark the incorrect responses in red on the following
pages. Then note any of the content areas in which you missed more than half
of the questions. Spend your preparation time prior to taking your licensure
examination efficiently by concentrating your review in the areas needed.
PROFESSIONAL SCREENING
RESPONSIBILITIES/ETHICS 12. 14. 24. 141.
5. 19. 26. 30. 50. 53.
54. 77. 99. 140. SPECIAL POPULATIONS
25. 57. 89. 98. 100.
RECOVERY/SELF-HELP 123.
28. 40. 90. 110.
THEORY OF CHANGE
REFERRAL 9. 35. 42. 67.
4. 62. 93. 143.
TREATMENT PLANNING
RELAPSE 2. 52. 106. 111. 131.
7. 46. 136. 144.
120
APPENDIX A:
BIBLIOGRAPHY & ADDITIONAL
RESOURCES
IC&RC RECOMMENDED MATERIALS
The following references are recommended as study tools for the IC&RC/AODA
counselor certification examination. Note, however, that this is not a
comprehensive list of all references used as a basis for the examination. You
may find other references that you are comfortable with using as study tools.
8. Corey, G. and Marianne S. Corey. Groups: Process & Practice. 7th Ed.
Brooks/Cole, 2006.
11. Doweiko, Harold. Concepts in Chemical Dependency. 7th Ed. New York:
Wadsworth Publishing, 2008.
13. Herdman, John. Global Criteria: The Twelve Core Functions of the
Substance Abuse Counselor. Learning Publications, 2000.
14. Inaba, Darryl. Uppers, Downers, All-Arounders. 6th Ed. Ashland, OR: CNS
Publications, 2007.
15. Kinney, Jean. Loosening the Grip. 9th Ed. New York: McGraw-Hill, 2008.
16. Miller & Rollnick. Motivational Interviewing. 2nd Ed. Guilford Press, 2002.
17. Ray, O. and Charles Ksir. Drugs, Society and Human Behavior, 12th Ed.
New York: WCB/McGraw-Hill, 2006.
* While a majority of the questions on the exam are taken from these texts, this is
not intended to be a complete bibliography for the AODA exam. It was compiled
to give applicants a reasonable number of texts to use for exam preparation.
Even information referenced from other texts is usually found in these books.
122
APPENDIX C:
The Twelve Core Functions
and Global Criteria
1. SCREENING
Screening: the process by which a client is determined appropriate and eligible
for admission to a particular program. The eligibility criteria are generally
determined by the focus, target population and funding requirements of the
counselor's program or agency. Many of the criteria are easily ascertained.
These may include the client's age, sex, place of residence, legal status, veteran
status, income level, and the referral source.
GLOBAL CRITERIA
1. Evaluate psychological, social, and physiological signs and symptoms of
alcohol and other drug use.
2. INTAKE
Intake: the administrative and initial procedures for admission to a program.
GLOBAL CRITERIA
6. Complete required documents for admission to the program.
124
3. ORIENTATION
Orientation: describing to the client:
! the general nature and goals of the program;
! the rules governing client conduct and infractions that can lead to
disciplinary action or discharge from the program;
! in a nonresidential program, the hours during which services are available;
! treatment costs to be borne by the client, if any and;
! client's rights.
"The orientation may be provided before, during and/or after the client's
screening intake. It can be conducted in an individual, group, or family
context. Portions of the orientation may include other personnel for
certain specific parts of the treatment, such as medication."
GLOBAL CRITERIA
9. Provide an overview of the program to the client by describing program
goals and objectives.
10. Provide an overview to the client by describing program rules and client
obligations and rights.
4. ASSESSMENT
Assessment: Those procedures by which a counselor/program identifies and
evaluates an individual's strengths, weaknesses, problems, and needs for the
development of the treatment plan.
GLOBAL CRITERIA
12. Gather relevant history from the client including but not limited to alcohol
and other drug abuse using appropriate interview techniques.
15. Explain to the client the rationale for the use of assessment techniques in
order to facilitate understanding.
16. Develop a diagnostic evaluation of the client’s substance abuse and any
coexisting conditions based on the results of all assessments in order to
provide an integrated approach to treatment planning based on client’s
strengths, weaknesses, and identified problems and needs.
5. TREATMENT PLANNING
Treatment Planning: the process by which the counselor and the client:
! identify and rank problems needing resolution;
! establish agreed-upon immediate and long-term goals, and;
! decide on treatment methods and the resources to be used.
126
The following expanded definition of "treatment planning" may be used as a set
of general guidelines:
GLOBAL CRITERIA
17. Explain assessment results to the client in an understandable manner.
18. Identify and rank problems based on individual client needs in the written
treatment plan.
19. Formulate agreed upon immediate and long-term goals using behavioral
terms in the written treatment plan.
6. COUNSELING
Counseling (Individual, Group and Significant Others): the utilization of special
skills to assist individuals, families, or groups in achieving objectives through:
! explorations of a problem and its ramifications
! examination of attitudes and feelings
! consideration of alternative solutions and
! decision-making.
On the other hand, a cognitive approach may be appropriate for a client who is
depressed, yet insightful and articulate.
GLOBAL CRITERIA
21. Select the counseling theory(ies) that apply(ies).
22. Apply technique(s) to assist the client, group, and/or family in exploring
problems and ramifications.
23. Apply technique(s) to assist the client, group and/or family in examining
the client’s behavior, attitudes, and/or feelings if appropriate in the
treatment setting.
128
7. CASE MANAGEMENT
Case Management: Activities which bring services, agencies, resources, or
people together within a planned framework of action toward the achievement of
established goals. It may involve liaison activities and collateral contacts.
"The client may also be receiving other treatment services, such as family
therapy and chemotherapy, within the same agency. These activities
must be integrated into the treatment plan, and communication must be
maintained with the appropriate personnel."
GLOBAL CRITERIA
28. Coordinate services for client care.
8. CRISIS INTERVENTION
Crisis Intervention: Those services which respond to an alcohol and/or other
drug abuser's needs during acute emotional and/or physical distress.
GLOBAL CRITERIA
30. Recognize the elements of the client crisis.
9. CLIENT EDUCATION
Education: provision of information to individuals and groups, concerning alcohol
and other drug abuse and the available services and resources.
GLOBAL CRITERIA
33. Present relevant alcohol and other drug use/abuse information to the
client through formal and/or informal processes.
34. Present information about available alcohol and other drug services and
resources.
130
10. REFERRAL
Referral: identifying the needs of the client that cannot be met by the counselor
or agency and helping the client to utilize the support systems and community
resources available.
GLOBAL CRITERIA
35. Identify need(s) and/or problem(s) that the agency and/or counselor
cannot meet.
39. Assist the client in utilizing the support systems and community resources
available.
GLOBAL CRITERIA
40. Prepare reports and relevant records integrating available information to
facilitate continuum of care.
42. Utilize relevant information from written documents for client care.
132
GLOBAL CRITERIA
43. Recognize issues that are beyond the counselor’s base of knowledge
and/or skill.
45. Adhere to applicable laws, regulations and agency policies governing the
disclosure of client identifying data.
46. Explain the rationale for the consultation to the client, if appropriate.
134