Question

Paul, a 32-year-old man, seeks counseling at a community mental health center. He has recently returned from his third deployment to a combat zone. He reports drinking frequently and feeling anxious. Paul's wife has tried to reassure him that everything is fine, but he is reluctant to leave the house and has missed more than a week of work.

For this part, apply what you have learned about counseling and how professionals can work together to explain how you might collaborate with a professional in Addictions Counseling to serve the client you chose.

In this part, complete the following:

1) Assess how to ensure good collaboration and communication between the Mental Health Counselor and Addictions Counselor.

                a) Identify the type of outside agency that could assist this client to promote optimal wellness, providing two examples.

                b) Explain the standards or criteria that you would use to evaluate the collaboration.

***************Cite at least one resources from the professional literature that you use as the basis of your ideas

Answer 1

Research suggests that a therapeutic alliance is “one of the most robust predictors of treatment outcome” in psychotherapy. Some studies in the substance abuse treatment field also have found associations between the strength of the therapeutic alliance and counseling effectiveness.

One research team found that both clinician and client ratings of the alliance were strong predictors of alcoholic outpatients' treatment participation in treatment, drinking behavior during treatment, and drinking behavior at a 12-month follow-up, even after controlling for a variety of other sources of variance. Similarly, Luborsky and colleagues (1985) found that the development of a “helping alliance” was correlated with positive outcomes.

A number of researchers have verified that clients are more responsive when the therapist acts consistently as a nurturing and nonjudgmental ally (Frank and Gunderson 1990; Luborsky et al. 1997; Siris and Docherty 1990; Ziedonis and D'Avanzo 1998). For example, in a study of clients with opioid dependence and psychopathology, Petry and Bickel (1999) found that among clients with moderate to severe psychiatric problems, fewer than 25 percent of those with weak therapeutic alliances completed treatment, while more than 75 percent of those with strong therapeutic alliances completed treatment. In this study, they did not find the strength of the therapeutic alliance to be related to treatment completion among clients with few psychiatric symptoms.

Challenges for the clinician

General. The clinician's ease in working toward a therapeutic alliance also is affected by his or her comfort level in working with the client. Substance abuse counselors may find some clients with significant mental illnesses or severe substance use disorders to be threatening or unsettling. It is therefore important to recognize certain patterns that invite these feelings and not to let them interfere with the client's treatment. This discomfort may be due to a lack of experience, training, or mentoring. Likewise, some mental health clinicians may feel uncomfortable or intimidated by clients with substance use disorders.

Clinicians who experience difficulty forming a therapeutic alliance with clients with COD are advised to consider whether this is related to the client's difficulties; to a limitation in the clinician's own experience and skills; to demographic differences between the clinician and the client in areas such as age, gender, education, race, or ethnicity; or to issues involving countertransference. A consultation with a supervisor or peer to discuss this issue is important. Often these reactions can be overcome with further experience, training, supervision, and mentoring.

Individuals with COD often experience demoralization and despair because of the complexity of having two problems and the difficulty of achieving treatment success. Inspiring hope often is a necessary precursor for the client to give up short-term relief in exchange for long-term work with some uncertainty as to timeframe and benefit.

Challenges in working with clients with serious mental and substance use disorders. Achieving a therapeutic alliance with clients with serious mental illness and substance use disorders can be challenging. According to Ziedonis and D'Avanzo (1998), many people who abuse substances also may have some antisocial traits.

Such individuals are “less amenable to psychological and pharmacological interventions and avoid contact with the mental health treatment staff.” Therefore, it is reasonable to conclude that “the dually diagnosed are less likely to develop a positive therapeutic alliance than non-substance-abusing patients with schizophrenia…”

Individuals with both schizophrenia and a substance use disorder may be particularly challenging to treat. These individuals “present and maintain a less involved and more distant stance in relation to the therapist than do non-substance-abusing individuals with schizophrenia”.

The presence or level of these deficits may vary widely for people living with schizophrenia, and also may vary significantly for that individual within the course of his illness and the course of his lifetime. While “this configuration of interpersonal style suggests that developing a therapeutic alliance can be difficult,” Ziedonis and D'Avanzo insist, “working with the dually diagnosed requires a primary focus on the therapeutic alliance”.

For all clients with co-occurring disorders, the therapeutic relationship must build on the capacity that does exist. These clients often need the therapeutic alliance to foster not only their engagement in treatment but as the cornerstone of the entire recovery process. Once established, the therapeutic alliance is rewarding for both client and clinician and facilitates their participation in a full range of therapeutic activities; documentation of these types of interactions provides an advantage in risk management.

Advice to the Counselor: Forming a Therapeutic Alliance

The consensus panel recommends the following approaches for forming a therapeutic alliance with clients with COD:

• Demonstrate an understanding and acceptance of the client.

• Help the client clarify the nature of his difficulty.

• Indicate that you and the client will be working together.

• Communicate to the client that you will be helping her to help herself.

• Express empathy and a willingness to listen to the client's formulation of the problem.

• Assist the client to solve some external problems directly and immediately.

• Foster hope for positive change.