assignment on substance abuse

Module 9: Health Management

Assignment: substance abuse.

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Center for Substance Abuse Treatment. A Guide to Substance Abuse Services for Primary Care Clinicians. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1997. (Treatment Improvement Protocol (TIP) Series, No. 24.)

A Guide to Substance Abuse Services for Primary Care Clinicians.

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Chapter 4—Assessment

Unlike brief intervention, in-depth substance abuse assessment requires specialized skills and consumes a substantial amount of time -- anywhere from 90 minutes to 2 hours. As a result, many primary care clinicians will refer patients suspected of having a substance abuse problem to specialists for both assessment and treatment, although clinicians in underserved areas or with expertise in substance abuse may assume partial or total responsibility for this function. However, even clinicians who will not perform substance abuse assessments should have a basic understanding of their elements and objectives so that they can

• Initiate appropriate referrals
• Participate effectively as a member of the treatment team, if required
• Better fulfill the gatekeepers' monitoring responsibility with respect to patient progress
• Carry out needed case management functions as appropriate

Throughout this chapter, assessment will refer to in-depth assessment as distinct from the postscreening brief assessment discussed in Chapter 3.

• Assessment Parameters

Substance abuse assessment is the further investigation of patients (1) whose positive screening results indicate that substance abuse is likely and (2) whose responses to the questions in a brief assessment (see Chapter 3) suggest that compulsion to use, impaired control, presence of other psychosocial problems, or absence of social support will render brief intervention ineffective (College of Family Physicians of Canada, 1994). Information gained through an assessment will clarify the type and extent of the problem and will help determine the appropriate treatment response. Assessment

• Examines problems related to use (e.g., medical, behavioral, social, and financial)
• Provides data for a formal diagnosis of a possible problem
• Establishes the severity of an identified problem (i.e., mild, moderate, intermediate, or severe stage)
• Helps to determine appropriate level of care
• Guides treatment planning (e.g., whether specialized care is needed, components of an appropriate referral, and eligibility for services)
• Defines a baseline of the patient's status to which future conditions can be compared (National Institute on Alcohol Abuse and Alcoholism, 1995a)

If one thinks of screening as triage, then assessment is acquiring the information needed to direct a patient to appropriate treatment. At a minimum, patients must be assessed for

• Acute intoxication and/or withdrawal potential
• Biomedical conditions and complications
• Emotional/behavioral conditions (e.g., psychiatric conditions, psychological or emotional/behavioral complications of known or unknown origin, poor impulse control, changes in mental status, or transient neuropsychiatric complications)
• Treatment acceptance or resistance
• Relapse potential or continued use potential
• Recovery/living environment (American Society of Addiction Medicine, 1996, p. 6)

Assessing along these dimensions helps the assessor confirm that a substance abuse problem exists and recommend an appropriate level of care (see Chapter 5 for a discussion of substance abuse treatment systems and processes). Through a combination of clinical interview, personal history-taking, and self-reports, supplemented by laboratory testing and collateral reports as appropriate, the assessment process identifies patients' health problems, interest in and readiness for treatment, and feasible treatment options. It also provides information on a patient's familial, educational, social, and vocational supports and deficits. Like screening, assessment may be a recurring event if clinical evidence indicates the need.

• Who Should Assess?

Professional position is less important than specific training for performing accurate assessments. Where possible, the Consensus Panel recommends referring patients to an experienced substance abuse specialist for intensive assessment. If referral is not possible, the Panel believes that physicians, physician assistants, and advanced practice nurses (nurse practitioners and clinical nurse specialists) with experience in empathic motivational interviewing may perform intensive assessments after receiving training in

• The signs and symptoms of substance abuse
• The biopsychosocial effects of alcohol and other drugs and likely progression of the disease
• Common comorbid conditions and medical consequences of abuse
• The terms used in the classification system of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 1994a), their interpretation, and their relationship to the findings that emerged during the assessment history
• The appropriate use, scoring, and interpretation of standardized assessment instruments

Understanding the Impact Of Culture and Gender

Clinicians performing in-depth assessments should also understand how patients' gender and cultural background bear on the characteristics and severity of the disease (Spector, 1996). For example, more males than females abuse alcohol and drugs, and older women are more likely than older men to abuse prescription drugs. Culture and gender also may influence patients' recognition of their problems (e.g., local cultural norms may condone or accept male drunkenness) and their reaction to the assessment process and recommended treatment interventions (e.g., substantial stigma may be associated with substance abuse treatment, especially for women and older patients of either sex). Assessors also should be aware of the influence of their own gender and cultural background on their response to patients with suspected substance abuse problems and on their interpretation of the information provided through the assessment process. While an understanding of "typical" patterns is useful in anticipating problem areas, experienced assessors resist the temptation to stereotype patients and subsume them within broad categories based on language, ethnicity, age, education, and appearance. An oft-repeated anecdote illustrating the dangers of stereotyping concerns a well-dressed, middle-aged woman and her disheveled teenage son seen in an emergency room following a car accident. The young man was screened for substance abuse; the mother was not. Several hours after admission, the woman went into alcohol withdrawal.

When referring patients for assessment, primary care clinicians should consider whether a particular patient will relate more readily to a male or female assessor of similar cultural background or if a patient who speaks English as a second language will respond more easily to questions posed in his native tongue (Spector, 1996).

Knowledge of Comorbid Mental Disorders

The relationship between mental disorders and substance use disorders is variable and complicated. The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that, in the general population, 4.7 to 13.7 percent of individuals between the ages of 15 and 54 may have both a mental disorder and a substance abuse or dependence problem (Substance Abuse and Mental Health Services Administration, 1995). Intoxication with a drug can produce psychiatric symptoms that subside with abstinence, but for those with a mental illness, substance use may mask, exacerbate, or be used to ameliorate psychiatric symptoms; precipitate psychological decompensation; or increase the frequency with which individuals require hospitalization. Because substance abuse disorders often manifest symptoms similar to those of mental health disorders, misdiagnosis may occur.

Inadvertent bias may affect the assessment process when performed by addiction specialists who do not recognize or accept the role of mental disorders in prompting or sustaining substance use or who have no experience with dually diagnosed patients. Conversely, some mental health practitioners dismiss substance abuse as merely symptomatic of underlying mental health disorders and do not acknowledge it as a problem requiring specific attention. While screening results, per se, do little to illuminate comorbid mental health disorders, information gleaned through a patient's history or inability to respond to brief intervention may suggest a mental health problem. If possible, primary care clinicians should refer patients to assessors who understand and are trained in mental health as well as substance abuse assessment and who are willing and able to expand the assessment process as needed to identify the multiple dimensions that may be contributing to a patient's problems (Institute of Medicine, 1990).

Whether referring for or conducting intensive assessments themselves, primary care clinicians also should be alert to the possibility of conflict of interest when assessors are linked to a program or practice providing substance abuse services. There may be financial incentives (e.g., fee-for-service arrangements) or ideological pressure to interpret assessment results in such a way as to steer patients to a particular program or treatment provider (Institute of Medicine, 1990). Aside from insisting on an independent assessment source, which may be impractical, clinicians have few options for ensuring objective assessments (Institute of Medicine, 1990). However, primary care providers who understand the purposes of assessment and are familiar with its components will be in a better position to identify and subsequently avoid biased assessors.

The Assessment Setting

Like screening, assessments must be conducted in private, and patients must be assured that the information they provide is confidential. Patients often will not reveal information about drug or alcohol use because they fear that information will be shared with their family members or employers or be used against them by law enforcement agencies or health insurance organizations. Prior to conducting an assessment, assessors should review current legal protections with the patient and discuss the limitations that apply to sharing information. (See Appendix B for a detailed discussion of confidentiality as it pertains to substance abuse.)

• Assessment Components

Assessment comprises a medical and psychological history along with family, social, sexual, and drug use histories and a physical examination. (The physical examination and the interviews to obtain histories may be split, with a primary care clinician performing the physical and a nonmedical substance abuse specialist conducting the interviews. When this occurs, close collaboration between the two providers is essential.) In its 1990 report, Broadening the Base of Treatment for Alcohol Problems, the Institute of Medicine recommended conducting "sequential" and "multidimensional" assessments for alcohol problems (Institute of Medicine, 1990). The Consensus Panel recommends the same approach when assessing for other drug-related problems. Essentially, sequential assessment entails separating "the process of assessment into a series of stages, each of which may or may not lead into the next stage" (Institute of Medicine, 1990, p. 249; Skinner, 1981) depending on the information obtained previously. In this model, a broad-based assessment is conducted first. If the information compiled suggests that other problems may be present, such as a psychiatric disorder, then a series of progressively more intense procedures would be initiated to confirm and characterize that finding. This approach not only provides information needed for treatment planning, it saves both patient and assessor time. Moreover, by ensuring that "further information is necessary [it also] justifies its increased cost" (adapted from Skinner, 1981, in Institute of Medicine, 1990, p. 250).

A multidimensional approach to assessment ensures that the variety of factors that impinge on an individual's substance abuse (level, pattern, and history of use; signs and symptoms of use; and consequences of use) are considered when evaluating individual patient problems and recommending treatment (Institute of Medicine, 1990). Detailed characterization not only helps assessors match patients to appropriate available services, it also provides information useful in anticipating relapse triggers and planning for relapse management (see Chapter 5).

A number of assessment instruments elicit similar information (see Appendix C), and specialized substance abuse treatment assessors may use one or more with patients. Administering an instrument can take from 90 minutes to 2 hours, depending on the instrument(s). Training is frequently required, and costs for purchase and required staff time can be substantial. While primary care clinicians trained or experienced in addiction medicine may use the instruments described in the appendix, many clinicians will not because they lack the time, training, and resources to do so. Based on members' clinical experience, the Consensus Panel recommends that an assessment include at least the components presented in Figure 4-1.

The figure also includes additional questions on certain sensitive topics for situations in which primary care clinicians cannot refer for specialized assessment and require additional information in order to make a reasonable decision about the need for formal substance abuse treatment. In addition to the elements listed under the Mental Health History component in Figure 4-1, primary care clinicians contemplating a possible referral for treatment should evaluate level of cognition because it is such an important measure of a patient's ability to participate in treatment. Results of a mental status examination can support diagnoses of intoxication, withdrawal, depression, and suicidal tendencies and signal the possibility of psychosis and organic states such as dementia.

Assessment Instruments

Assessment instruments assist in gathering consistent information, clarifying and elaborating on information obtained through the patient history and physical examination, and establishing a baseline against which patient progress can be monitored. Instruments are not a substitute for clinical judgment, but the uniformity they introduce to the assessment process helps to ensure that key areas are not overlooked (Institute of Medicine, 1990). Standardized tools have already been tested for reliability and validity and offer assessors ready-made and carefully sequenced questions that are easy to use in patient interviews and relatively simple to score (National Institute on Drug Abuse, 1994). Some instruments can be self-administered, are available in multiple languages, are computerized, and are in the public domain. However, many require that those administering them be trained in their use.

Although the Consensus Panel does not recommend the use of assessment instruments in the primary care setting because of the time, training, and resources required to administer them properly, clinician members of the Panel with training in addiction medicine have had experience with a number of standardized assessment tools and found them effective. Appendix C describes selected assessment instruments and provides information on ordering them. Clinicians interested in reviewing instruments for possible use with their patients should consider

• The literacy levels required to take them
• Whether instruments can be easily administered to patients with language or comprehension problems
• If the questions are both appropriate for and sensitive to the kinds of problems encountered in primary care
• Whether the time and costs involved are reasonable (National Institute on Drug Abuse, 1994)
• Supplementing Assessment Results

Collateral reports and laboratory tests are tools used to supplement and, in some cases, augment the information obtained during the intensive assessment.

Collateral Reporting

Collateral reporting (information supplied by family and friends) can help a clinician validate substance use because patients do not always reply honestly to assessment questions, especially those concerning illicit drug use. In addition, some patients cannot recall information accurately because of cognitive impairments. Collateral reports can be useful in determining or confirming

• Which substances a patient used
• Age at first use
• Frequency of use

Quantities used per occasion

• Duration of periods of abstinence
• Concurrent or sequential choice of substances
• Dysfunctional or inappropriate use of alcohol or prescription drugs (e.g., using anxiolytics or alcohol to induce sleep or sedatives to reduce anxiety)

However, before a clinician can obtain information from family members and significant others, the patient must give consent. In some cases, permission may be denied or family members will refuse to cooperate or cannot be contacted. While less than ideal, assessors in this situation may ask the patient, "Has anybody told you that you're doing this too often?" or "Has anybody complained about your behavior when you use?" Because people with substance use disorders are often "in denial," responses that provide a perspective that differs from the patient's account of his use and its consequences frequently suggest a problem. Sometimes, patients' explanations for why their interpretation conflicts with those of family and friends also can be useful in gauging a patient's understanding of his situation and readiness to change: "My wife is so rigid, drinking just loosens me up. When I'm uninhibited, she gets nervous." Or, "I just smoke pot to relax. What my Mom really doesn't like are my friends."

Supporting Laboratory Tests

Common laboratory tests for direct measures of recent alcohol use include blood alcohol content (BAC) levels, urine, Breathalyzers TM , and recheck Breathalyzers TM . These tests measure current use and are used for the most part by law enforcement and hospital emergency room personnel (National Institute on Alcohol Abuse and Alcoholism, 1993). Drug tests include analysis of urine, hair, and saliva, though the latter two are not commonly used.

Midanik reports that 71 percent of patients' self-reports matched the findings on their Breathalyzer TM tests when the patients knew the test would be given (Midanik, 1989). While studies of illicit drug use show varying reliability in patient self-reports, clinical experience with patients involved in alcohol-related motor vehicle crashes has found surprisingly high accuracy, considering the legal ramifications, in self-reports of alcohol consumption (Cherpitel, 1989; Gibb et al., 1984). Patients, however, may be more likely to provide accurate reports if they believe that disclosure may be important to their care for an illness or injury. Because of the limitations of self-reporting and of under-reporting due to the stigma associated with problem drinking, many assessors use laboratory testing to

• Confirm recent use (prior to recommending methadone, for example)
• Validate suspicions about recent use
• Support findings from the assessment pointing to chronic use
• Provide information about alcohol- and other drug-related physical problems (e.g., liver damage)

Alcohol: Blood alcohol concentration (BAC) determinations

Testing for blood alcohol concentrations (BACs) provides a short-term indicator useful in assessing current impairment caused by alcohol. Tests are typically conducted following involvement in traffic or other serious accidents or injuries where excessive drinking may be a factor. Blood alcohol concentrations are measured in milligrams (mg) of alcohol per deciliter (dl) of blood. This figure is converted to a percentage. One hundred mg/dl equals 100 mg percent or 0.1 percent. Thus, a BAC of 0.1 mg percent is equivalent to a concentration in blood of 100 mg of alcohol per deciliter of blood.

A woman weighing 150 pounds would achieve a level of 100 mg/dl if she drank approximately four drinks in an hour (six drinks in an hour for a 200-pound man), with a standard drink defined as 12 ounces of beer, 1_ ounces of liquor or distilled spirits, or 5 ounces of wine. However, individuals' alcohol metabolism varies not only according to gender and body weight, but also by food ingested, speed of alcohol consumption, age, and physical condition, among other factors.

In men, impairment from alcohol consumption has been shown to occur at the level of 50 mg/dl, though fine motor skills can be impaired at lower levels. In women and elderly persons, impairment may occur at even lower levels. The probability that an auto crash will occur begins to rise when the driver's BAC exceeds 40 mg/dl (American Medical Association, 1986), and climbs steeply as BAC moves up to 100 mg/dl. Most people demonstrate impaired driving at levels of 50 to 70 mg/dl.

Most persons metabolize alcohol at a rate of 15 to 25 mg per hour. Thus, the longer the time between imbibing and testing, the lower the BAC. Vomiting also may eliminate alcohol from the stomach before it reaches the blood.

A single elevated blood alcohol level does not provide information about the regularity and severity of alcohol abuse unless the counts are extremely high. For example, a level of 200 or higher without noticeable intoxication indicates a high degree of tolerance to alcohol, which suggests alcohol dependence.

In emergency situations or hospital-based settings, especially when responding to trauma victims, BACs contribute information important to clinicians in devising effective treatment plans. However, the Consensus Panel does not recommend their routine use in the office-based primary care setting.

Alcohol: Gamma-glutamyl transferase (GGT)

Alcohol, almost all types of liver disease, and a variety of other diseases including hepatitis, pancreatic cancer, and diabetes mellitus, can increase the activity of the enzyme gamma-glutamyl transferase (GGT) in the blood. GGT tests measure damage to liver cells; a rise in GGT levels has been correlated with an increase in alcohol intake (Persson et al., 1990). Because other conditions, as well as age, lifestyle, and gender, also affect its activity levels, GGT is an imperfect indicator of heavy alcohol use. Nevertheless, among problem drinkers and alcoholics, it can be useful in encouraging patients to provide honest answers to assessment questions, in evaluating the health impact of chronic, heavy alcohol use, and in monitoring progress in treatment (National Institute on Alcohol Abuse and Alcoholism, 1993). Based on their clinical experience, members of the Consensus Panel recommend checking the GGT as part of the assessment process. If it is elevated, lowering it can serve as a measurable goal of treatment.

Two relatively new tests, carbohydrate-deficient transferrin (CDT) and aspartate aminotransferase (AST) appear to have some value in identifying heavy alcohol consumption, and researchers are investigating a number of other measures in an effort to develop improved diagnostic tools. Until large-scale studies begin to confirm their effectiveness for screening and assessment, these tests will be used primarily by researchers (National Institute on Alcohol Abuse and Alcoholism, 1993).

Illicit drugs: Urine tests

Typically, urine tests for illicit drugs provide information on a patient's recent use of sedative-hypnotics, cocaine, opiates, and cannabis, although screening for other drugs (e.g., phencyclidine or LSD) can be specially requested. Patients who have used drugs within 72 hours prior to the test -- regardless of whether they are dependent on the drug or are using it for the first time -- will screen positive. A drug user who knows that testing is likely or who, for a variety of other reasons, has abstained from drugs (other than marijuana) within that time period will test negative. Since marijuana is fat-soluble, its metabolites can be detected in urine for 2 weeks or longer, depending on the sensitivity of the test and the patient's pattern of use.

Testing methods differ in sensitivity. Enzyme immunoassay (EIA) and radioimmunoassay (RIA) are commonly used for routine drug screening (Sullivan, 1995). Gas chromatography-mass spectrometry (GC-MS) is a separate technology that is considerably more sensitive and is used to confirm positives from EIA and RIA tests. Some laboratories automatically confirm all positive tests with GC-MS. If a laboratory does not follow this procedure and an assessor is using the results for any purpose other than clinical confirmation (e.g., when an employment- or court-mandated screen is positive and job security or legal status is threatened as a result), the positive test should always be verified by GC-MS.

Much like supplemental laboratory tests for alcohol, urine tests may be used during assessment to encourage honest responses to questions, to confirm suspicions about use when it is denied, and to verify use of heroin prior to referral or admission to a methadone program. During treatment, urine tests help to monitor progress and, in methadone programs, help ensure that patients are ingesting their methadone.

Since primary care patients frequently provide urine specimens for analysis, collecting urine for drug testing theoretically could be conducted with minimal disruption in the primary care setting if staff were willing to implement appropriate chain of custody and confidentiality procedures. However, urines cannot be collected deceptively. Prior to screening a specimen for drugs, the patient's permission must always be obtained (see Appendix B for more on confidentiality).

Some drug users tamper with specimens to avoid detection, even if they have granted permission for testing. Some may substitute another person's sample, dilute the specimen, or add epsom salts and sodium bicarbonate to it to neutralize pH. For this reason, urine samples should be checked for temperature, color, and consistency (sediment). Some specimen containers are equipped with temperature strips, and some laboratories routinely assess samples for color and other anomalies.

Although not required, a positive urine screen, together with findings from a patient's history, mental assessment, and physical examination, provides strong support for a diagnosis of substance use disorder.

• Making the Diagnosis

The categorical classification of "Substance-Related Disorders" in the DSM-IV provides the standard against which a formal diagnosis is made. Within this large category, 11 different classes of substances, including alcohol, are considered. Disorders are divided into two broad groups: "Substance Use Disorders," which includes "Substance Dependence" and "Substance Abuse," and "Substance-Induced Disorders," which includes a host of disorders ranging from "Substance Intoxication" and "Substance Withdrawal" to "Substance-Induced Anxiety Disorder." Using the DSM-IV criteria, an assessor makes a drug-specific diagnosis by disorder. DSM-IV diagnoses include alcohol abuse, alcohol dependence, cocaine intoxication, and hallucinogen abuse (American Psychiatric Association, 1994a).

Assessors use the information compiled during the personal history, interview, physical examination, and other patient-specific assessments such as the mental status examination to determine the DSM-IV diagnosis (many assessors rely on The Quick Reference to the Diagnostic Criteria from DSM-IV to facilitate diagnosis during the assessment process [American Psychiatric Association, 1994b] ). In addition to helping assessors characterize a patient's problem, another advantage of a DSM-IV diagnosis is that its standard nomenclature and classification system are generally understood by those other clinicians who may be collaborating in a patient's treatment, and such diagnoses are accepted by health insurance companies. The DSM-IV diagnostic criteria for substance dependence and substance abuse appear in Figures 4-2 and 4-3.

Once an assessor has made a diagnosis, the next critical step is to work with the patient in determining the level and type of services that the patient needs. Over the past several years, the substance abuse treatment field, led by the American Society of Addiction Medicine (ASAM), has been grappling with the concept and implementation of patient placement criteria that identify both major problem areas that should be considered in designing an individual treatment plan and the array of services most likely to address those problems. ASAM's Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition (ASAM PPC-2) offers guidelines that are consistent with the DSM-IV to help assessors and other clinicians evaluate the "severity and intensity of service required" (American Society of Addiction Medicine, 1996, p. 14). See TIP 13, The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders, for more on patient placement criteria (CSAT, 1995a).

Central to this evolving model of patient placement is that level of care and service mix may change as patient needs dictate. When selecting the level of care, the goal should be the least restrictive treatment that is effective. ASAM's criteria help focus attention on an individual's needs (American Society of Addiction Medicine, 1996). Rather than forcing a fit between a patient and a single program, those criteria provide information that frees assessors and patients to critically evaluate assessment results, investigate various options in the community, and construct a plan that incorporates needed services from a variety of resources. The realities of service availability and insurance coverage, however, ultimately affect both the level and type of service a patient receives.

• Cite this Page Center for Substance Abuse Treatment. A Guide to Substance Abuse Services for Primary Care Clinicians. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1997. (Treatment Improvement Protocol (TIP) Series, No. 24.) Chapter 4—Assessment.
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Journaling Prompts That’ll Keep You Writing for Months

No, this isn’t homework. Though you may have only heard of journal prompts in the context of teachers giving assignments, think of this more like a personal journal. It won’t be graded, and that’s a promise.

Keeping a substance use journal can be a vital tool in achieving sobriety. Knowing your triggers to usage, and emotions before and after use and getting real with yourself about the root causes of your addiction can be a game-changer. Truly knowledge is power, and empowering yourself with awareness of your own feelings and behaviors can help you to self-reflect and make important decisions when the going gets tough.

Starting an addiction recovery journal can seem daunting. If you’re looking for a place to begin, here are enough addiction treatment journal prompts to keep you reflecting for weeks, along with some tips to keep writing once you’ve gone through the prompts. 

Grab your journal and get started on one of the below prompts today!

• What does your dream life look like?
• What is an aspiration you had when you were younger?
• What is a manageable goal you want to accomplish in the next year?
• What is a manageable goal you want to accomplish within the next five years?
• Who has a life you admire, and why?
• Write about someone you know who has overcome a lot of challenges.
• Create a story with yourself as the main character. What do you achieve?
• Write a description of the celebration your friends and family throw you to toast to 5 years of sobriety.
• Write a thank you speech to all those who have helped you in your journey. Remember to thank yourself.
• If you were asked to give a motivational speech to people struggling with addiction, what advice would you give them?
• Write about the best parts of your childhood.
• Write about the hardest parts of your childhood, and what you learned from them.
• When was a time you had a vivid revelation, a time you learned something profound about yourself or the world?
• How do you determine whether someone is trustworthy?
• Write about the kindest thing someone has done for you.
• If you could come to a sense of peace about one event in your past, what would it be?
• Write about a time when addiction recovery taught you a valuable lesson.
• How would you explain addiction to someone who has never experienced it before?
• Why is generosity important?
• If you need to remove someone from your life who jeopardizes your sobriety, what would you say to that person?
• Picture yourself many years from now talking to children, grandchildren or great-grandchildren about addiction. How would you explain your experiences to a child?
• When you think of the word “shame,” what comes to mind?
• What gives you a sense of hope?
• How did your younger self-deal with worry and how has that changed?
• Write about the benefits of sharing your experience, like with your mental health professional. How does it feel to be listened to?
• What was your outlook on life when you were younger?
• What is your outlook on life currently?
• Write about your self-care routine.
• Why is self-care important for addiction recovery?
• If you were to take a month-long, all-expenses-paid vacation, describe how it would look.
• If your addiction were a character, how would it look, talk and behave?
• Can you remember the point when you first felt like you were addicted to a substance?
• Describe your body or your personality. How does it make you feel?
• When did you feel best about yourself?
• How have the relationships in your life impacted your sobriety?
• If a book was written that truly helped you in your recovery, what would that book be about?
• What would it take to feel proud of yourself?

Staying consistent with your journaling

More addiction recovery journaling prompts are easy to find. Although many of the above prompts are specifically tailored to address addiction and recovery, most journaling prompts can be geared to fit your recovery journey. As the writer, you get to decide where the topic is headed. A simple internet search can bring up hundreds more writing prompts for your journal.

If you’re still having writer’s block, try the following techniques to get the ideas flowing:

• Search for quotes. Write about whether or not you agree with the quote and why. Then, write about how the quote could be applied to addiction and recovery
• Write about a memory from before your usage. Even if the memory doesn’t involve substances, write about how it relates to the path of your life
• Write about your wildest life goals and try out “solution-based therapy.” This type of therapy focuses on getting a person to see the ideal future. Once that’s in front of your eyes it’s easier to be motivated about the steps you need to take to get there. If it’s helpful, roll with it and get more specific. Write about what your daily routine would look like in a perfect world, or how you could talk about your addiction recovery journey looking back on it
• Write about one of the prompts again. If you’re going down the list and it’s been at least a month since you last wrote about it, feel free to draft an updated journal entry. Fulfill the prompt again and see how your thoughts have changed

The addiction treatment you deserve

Keeping a recovery journal can be an important step in your journey. Whether you’ve already started one or are just beginning now, these prompts can help guide you to the freedom of sobriety through understanding your emotions, your past and your goals. As always, discuss your thoughts with your mental health professional at Real Recovery. Your therapist can give you more ideas, support and encouragement in your journaling and remind you that all the work you do is making a difference.

Addiction recovery journals go a long way toward helping you cope productively with substance use challenges. However, journaling in itself — although very successful in helping you process thoughts and feelings — should never replace clinical treatment . If you or someone you love is struggling with substance use habits, know that Real Recovery can help. Call 1 (855) 363-7325 today, or learn about our PHP, IOP and OP services offered in awe-inspiring Asheville, North Carolina when you contact us to pursue health and healing.

Get the help you or your loved one needs — today .

If you or someone you know is struggling with substance use challenges, call us at (855) 363-7325 or contact us now.

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HHS announces Maternal Mental Health Task Force's National Strategy, Report to Congress

HHS announces the release of the Report to Congress and National Strategy to Improve Maternal Mental Health Care developed by the Task Force on Maternal Mental Health.

SAMHSA announces FentAlert Challenge winners

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HHS, through SAMHSA, is announcing several grant opportunities totaling $46.8 million and cover a broad range of behavioral health priorities for the agency.

SAMHSA announces Art of Recovery project

This initiative seeks submissions that showcase how creative expression serves as a pathway to solace, healing, and empowerment in mental health and substance use recovery.

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HHS, through SAMHSA, announced the 2024 State Opioid Response (SOR) and Tribal Opioid Response (TOR) Notices of Funding Opportunity.

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Exploring Experiential Learning Through an Abstinence Assignment Within an Addictions Counseling Course

Volume 7 - Issue 4

Chad M. Yates, Alexia DeLeon, Marisa C. Rapp

Counselors-in-training may struggle in working with addictions populations for various reasons, including limited training, pre-existing stigma toward the population, and low self-efficacy treating substance use disorders. This is concerning because professional counselors have the highest proportion of clients with a primary substance abuse diagnosis. The authors explored the experiential learning approach of an abstinence project within an addictions course in an attempt to give students a genuine experience that parallels what an individual with an addiction may experience. The authors utilized generic qualitative analysis to explore the experience of 17 counseling students completing the abstinence assignment. The emergent themes of (1) concrete experiences, (2) dealing with cravings, (3) student’s self-reflection of learning, and (4) empathetic understanding and challenging attitudes are presented. Finally, future areas of research and implications for counselor educators are discussed.

Keywords: substance use disorders, abstinence assignment, generic qualitative analysis, counselors-in-training, addictions

Counselor educators face considerable challenges in providing comprehensive and effective training for counselors-in-training (CITs) serving persons with substance use disorders (SUDs). These challenges include students’ unfamiliarity with addictions or addicted populations, few opportunities to infuse addictions-related materials into the general curriculum, and no uniform national curriculum standards for addictions-related education (Chasek, Jorgensen, & Maxson, 2012; Salyers, Ritchie, Cochrane, & Roseman, 2006). This is concerning, as addiction remains a consistent issue for the general population. Approximately 21.5 million Americans meet criteria for an SUD (Substance Abuse and Mental Health Services Administration, 2015), reinforcing the need for competent addictions counselors. Professional counselors (excluding specified addictions counselors) have the highest proportion of clients with a primary substance abuse diagnosis, in comparison to social workers, psychologists, and psychiatrists (Harwood, Kowalski, & Ameen, 2004). Additionally, CITs also treat clients with addictions much more frequently during their training. Salyers et al. (2006) found that a high percentage of CITs see clients in their practicum and internship experiences who present with substance abuse concerns. Due to the frequency of addiction concerns counselors and CITs treat, it is imperative that counselor education programs continue to address training necessary to accommodate these concerns.

In response to the growing need to train effective addictions counselors, the Council for Accreditation of Counseling & Related Educational Programs (CACREP; 2016) constructed standards that counselor educators should infuse within the curriculum. The integration of the standards across all CACREP-accredited programs has been slow, but a 2013 survey of programs found that 76.7% of counseling graduates had at least one course related exclusively to substance abuse counseling (Iarussi, Perjessy, & Reed, 2013). This is a substantial increase considering Salyers et al.’s (2006) findings that only 58.2% of counseling graduates had taken at least one course related to substance abuse counseling. Starting in 2009 and continuing within the 2016 standards, CACREP specifically called for counselors to understand the theories and etiology of addictions and addictive behaviors, including strategies for prevention, intervention, and treatment (CACREP, 2016). These changes have provided steps toward greater competency in the treatment of addictions; however, most students still have only one course during their program devoted to addictions (Chasek et al., 2012). As most counseling education programs continue to only have a single course devoted to addictions education, it is critical to investigate the educational experiences of CITs and explore the educational experiences that maximize student learning.

A common concern when educating CITs about addictions is the attitudes and biases they bring with them to an addictions course (Chasek et al., 2012). The pre-existing attitudes and behaviors espoused by CITs are often derived from moralistic notions of addiction (Chasek et al., 2012). Clinicians’ negative attitudes toward persons with addictions often lead to reduced outcomes in treatment (McLellan, Lewis, O’Brien, & Kleber, 2000). Blagen (2007) suggested that negative attitudes need to be addressed during training to help CITs facilitate relationship building with persons with addictions. A common tool utilized in addictions training to foster empathy and understanding of persons with addictions is the abstinence assignment. The abstinence assignment asks students to abstain from a substance or behavior for a set period and journal about the experience. This learning approach has been explored in a pharmaceutical education program (Baldwin, 2008), allowing students to successfully meet all four of the course’s learning objectives: (1) describe feelings and experiences related to the process of withdrawal from habituating or addicting substances or activities; (2) describe the importance of abstinence in the maintenance of recovery from habituating or addicting substances or activities and discuss the implications of relapse to the recovery process; (3) discuss the importance of support systems in recovery from habituating or addicting substances; and (4) describe the process of addiction and recovery (Baldwin, 2008).

Baldwin (2008) found generally favorable opinions of the assignment and strong ties to reflective learning through class surveys conducted before and after the assignment. However, no study to date has explored students’ learning processes during an abstinence assignment. The aim of the current study was to understand the pedagogy behind the abstinence assignment and to explore the experience of students completing the project. It was hoped that the study would reveal if the abstinence assignment could foster empathetic experiences for persons with addiction and if the assignment could enhance understanding of withdrawal, craving, and relapse. Specific research questions included: (a) what, if any, were the empathetic experiences of students concerning clients with addictions; (b) how was the concept of craving experienced and made meaningful by participants; (c) what were the elements of the learning process for participants completing the abstinence assignment; and (d) how did students find ways to deal effectively with cravings and abstinence through the project? This study utilized qualitative data analysis methodology to explore the experiences of 17 CITs who completed an abstinence assignment during their addictions course. A review of pertinent literature follows.

CITs often face considerable difficulty learning addiction-specific tools and skills. These challenges typically arise due to students’ limited exposure to persons who are addicted, limited experiences of cravings and triggers, limited understanding of the lives of those with addictions, and limited self-efficacy of being effective with this population (Harwood et al., 2004). This lack of awareness, coupled with classroom material that is disconnected from the students’ experiences, may lead students to feel unprepared for treating clients with addiction concerns. The infusion of experiential learning activities is one way to counter the above concern. Kolb (1984) stated that learning new concepts involves directly encountering these concepts within real world experiences. In Kolb’s theory, “Learning is the process whereby knowledge is created through the transformation of experience” (Kolb, 1984, p. 38). Effective learning is seen when a person progresses through a cycle of four stages: (1) having a concrete experience, followed by (2) observation of and reflection on that experience, which leads to (3) the formation of abstract concepts (analysis) and generalizations (conclusions), which are then (4) used to test hypotheses in future situations, resulting in new experiences (Kolb, 1984). Experiential learning is a means of acquiring knowledge through action and feelings; it creates an emotional understanding and challenges attitudes (Warren, Hof, McGriff, & Morris, 2012).

Sias and Goodwin (2007) explored an experiential learning approach of CITs attending 12-step meetings and then journaling their experience. Students attending 12-step meetings reported growth and new awareness of the experience of persons with addictions. Students described the fear and uncertainty clients faced when beginning a support group. They also reported challenging their pre-existing stereotypes of persons with addictions, through interacting with those in recovery. Results from studies such as Sias and Goodwin (2007) can help further understanding of the barriers in learning about addictions and also help educators implement experiential learning approaches more intentionally.

Barriers to Learning

In training emerging clinicians to work with persons with addictions, research has revealed that many trainees lack empathy and emotional understanding for this population (Baldwin, 2008; Giordano, Stare, & Clarke, 2015; Sias & Goodwin, 2007). Research has shown the struggles CITs may experience in showing empathy, emotional understanding, and challenging bias toward persons with addictions. These struggles may impact the quality of care toward persons with addictions (Chasek et al., 2012; Giordano et al., 2015). Furthermore, many CITs report poor self-efficacy in being clinically effective with persons struggling with addictions (Harwood et al., 2004). Celluci and Vik (2001) found that approximately 144 mental health providers in Idaho who treated persons with an SUD rated their graduate training as inadequate preparation for treating clients with an SUD. The importance of strong educational experiences is reinforced by Carroll (2000). Carroll reported that CITs with more addictions courses were increasingly likely to treat or refer a client for an SUD and to think of an SUD as a distinct disorder, compared to CITs with less addictions training.

Another potential learning barrier for students is negative stigma toward persons with addictions. Society’s negative portrayal of those battling addictions may play a role in counselor trainees’ perceptions and attitudes regarding this population (McLellan et al., 2000). For instance, the general public is reported as viewing persons with drug addictions negatively, as blameworthy and dangerous (Corrigan, Kuwabara, & O’Shaughnessy, 2009). CITs possess similar negative attitudes, beliefs, and biases regarding addictions and addiction treatment (Chasek et al., 2012). These authors investigated CITs’ attitudes toward persons with addictions and the effectiveness of substance abuse counseling. They concluded that students who had less bias toward persons with addictions were more likely to view treatment for substance abuse as effective.

Counselor educators are charged with the responsibility to ensure that competent counseling professionals are entering the field (CACREP, 2016). As present research shows the struggles that many CITs are facing in relation to persons with addictions, it is vital that further research is conducted to examine how counselor educators can remedy this known lack of empathy and emotional understanding through pedagogical intervention. Although anecdotal evidence from past generations of counselor educators has shown the experiential assignment of abstaining from a substance as useful, to date no counseling literature exists that shows empirical evidence for this assumption. Consequently, we investigated the experience of students utilizing the abstinence assignment and built upon the limited understanding of integrating an abstinence assignment into addictions curriculum.

Qualitative Research Design

Generic qualitative analysis (GQS; Percy, Kostere, & Kostere, 2015) was employed as a qualitative methodology to examine the pedagogical implications of utilizing an abstinence assignment within an addictions course. GQS seeks to understand and discover the perspectives and worldviews of participants and is intended to explore what participants directly experienced, or what the experience was about (Percy et al., 2015). The present study utilized existing abstinence journals and reflection summaries that included descriptions and reflections of students’ experiences of participating in the abstinence assignment; it was deemed appropriate to use a qualitative methodology that would support the analysis of these data resources (Percy et al., 2015).

Participants

The participants selected for the study were master’s-level counseling students enrolled in their second and last year of study. These students were enrolled in an addictions counseling course, and a major course requirement was an abstinence assignment. Students were instructed to select a substance or behavior from which they wished to abstain for 4 weeks. There was a total of 17 participants (14 females and three males). The ages of participants ranged from 24 to 44 years with a mean age of 26. All 17 participants identified as White. Participation in the study was solicited after the participants completed their abstinence journals and reflective summaries, and received grades for the assignment. The participants were informed that participation in the study was completely voluntary and would have no impact on their grade. Data analysis was conducted once the course was completed. Of the 17 participants, the following is a list of the chosen substances or behaviors with the number of students: Soda or Carbonated Beverages (3), Sugar (4), Alcohol (3), Eating Out at Restaurants (2), Social Media or Entertainment Activities (3), Procrastination (1), and Evening Snacking (1).

Abstinence Assignment

This exercise was designed to help students experience some of the feelings/thoughts that addicted individuals experience when they quit their drug or behavior of choice. Students were told: This exercise requires that you give up a substance (e.g., nicotine, caffeine, or alcohol) or a behavior (e.g., eating sweets, playing video and computer games, watching television) for a period of 4 weeks. During this assignment, you will write a goodbye letter to your substance or behavior detailing why you are choosing to give up the substance or behavior and what the substance or behavior means to you, and you will keep an abstinence log of your experiences. This log will describe your feelings and reactions, especially focusing on times you “lapse” or experience cravings ( minimum one page log of two entries per week ). Finally, you will write a summary paper, which will serve as the conclusion to the 4-week exercise.

Data Analysis and Trustworthiness Procedures

The researchers obtained Institutional Review Board approval prior to the analysis of the data. Data analysis procedures were followed according to the guidelines set forth by Percy et al. (2015). The researchers first familiarized themselves with the study materials—which included a goodbye letter to the substance or behavior, abstinence journals, and reflection summaries—by reading through each item and making notations (highlights) about significant statements that reflected the research questions for the study. The above step was performed independently by the first and second author for all 17 transcripts. The two researchers (authors one and two) met at two different times, once halfway through the initial transcript analysis and again at the end to compare and contrast notes.

After this step was completed, the researchers compared notes to identify common theme listings from the data. The researchers created a definitional agreement for each emergent theme. The goal of this step was to isolate significant themes represented in both researchers’ notes. Each researcher had to agree that there was ample evidence to support this theme and agree on the mutual definition of this theme. To aid the researchers in coding, the work of Kolb’s Experiential Learning Model (Kolb, 1984) was incorporated into the coding procedures to link existing learning theory steps to the process that was being discovered within the transcripts. Once the coding structure was in place, the first author coded each of the 17 participant transcripts. Coding each participant was performed by highlighting significant statements that represented the theme and its definition. For example, the researcher coded a significant statement from Participant 1: I can see why this is so difficult for some people to stay sober; I’m having a hard time and only . . . giving up sugar. This significant statement was coded as empathy. Upon completion of this coding, both researchers independently reviewed the list of significant statements under each theme and noted if the statement was representative of the existing theme definition. If the significant statement was not representative, it was either discarded or represented under a more appropriate theme.

The researchers met upon completion of this step to share the results of the review of significant statements. The researchers then decided if each change to the significant statement was warranted. Following the above step, the researchers organized all themes into similar categories. After this categorization was complete, the researchers utilized an auditor outside of the study who shared a similar background and training in qualitative research to review the significant statements under each theme and identify if they were representational to the existing theme definition and if the themes fit within their designated category. The auditor made notes about significant statements to discard or to move to another theme. Upon completion of the auditor’s review, the category, theme structure, and theme definitions were emailed to each participant of the study for member checking. Each participant was asked to comment on the list of themes and the researchers’ definitions of each theme to ensure that they were credible. Participants with comments for the researchers were contacted again, and category and theme structures were reviewed and revised based on the participants’ input.

Four themes emerged during the data collection process. The first theme was “concrete experiences” of the participants completing the abstinence assignment. This theme contained several subthemes, such as withdrawal cues, cravings, relapse, justifications of relapse, shame after relapse, and triggers. The second theme that emerged was “dealing with cravings.” Within this theme were the subthemes of replacement behaviors and relapse avoidance. The third theme contained elements of “student’s self-reflection of learning.” This theme contained two subthemes: reflective observation and abstract conceptualization. The last theme consisted of statements showcasing students engaging in empathetic understanding and challenging their attitudes or perceptions of persons with addictions.

Theme One: Concrete Experiences

Theme One contained participant descriptions of completing the abstinence assignment. These concrete experiences, cravings, relapse, and shame over relapse are similar to experiences of persons beginning and sustaining recovery. The most often identified statement from participants was craving for their identified substance. Participant 3 journaled, “Sometimes I wish I could just take all of my cravings and put them in a jar and smash the jar so I don’t have to deal with them anymore.” Beginning to deny the use of a substance had begun to produce strong desires often unknown by participants. Participant 15, who abstained from soda, described hearing a soda dispenser and the physical effect she noticed in her body for the first time, “It was odd to note that I had a sensation go through my entire body as I heard it. It made me think and consider Pavlov’s dogs. Truthfully, I thought about Diet Coke the rest of the day.” Cravings were often accompanied by withdrawal in participants who had given up substances they had consumed over long periods. Participant 12 reported, “Today I was run-down and fatigued, and I developed a low-grade headache that stayed with me all day. And even though I ate more than I usually eat in a day, I felt like I was starving.”

Reading through the 17 participants’ journals, researchers found consistent patterns of subthemes often occurring in a sequential order. The subthemes order was descriptive of a trigger or cravings, followed by relapse, justification for the relapse, and finally shame and guilt over the relapse. Upon review of the participants’ transcripts, this pattern was found in 15 of the 17 participants and occurred between one and three times per participant. Participant 13, who abstained from sugar, described a cycle of trigger, craving, relapse, justification of relapse, and shame over relapsing: “Tonight was Superbowl Sunday. My aunt made a gluten free cake with dulce de leche and strawberries on top, and I ate two slices . . . I felt like I deserved it because I was doing so good on this abstinence assignment.” Participant 13 further recalled, “I feel a little bad about it now, but I honestly feel like it was justifiable and I plan on going back to the no sugar and no gluten thing again tomorrow anyway.”

Instances of complete breakdown on the students’ abstinence goals often appeared. These especially occurred with students who chose substances like grains, carbs, or sugar. The defining elements of these complete breakdowns were a sense of low self-efficacy and overwhelming guilt and shame. Participant 10, who abstained from fast food, expressed, “I have eaten at fast food restaurants three times since last Thursday . . . I literally feel disgusted at myself that I haven’t been able to control my cravings or at least have enough self-control to just be mindful about my choices.” The experience of emotional and physical symptoms related to abstaining from a behavior or substance prompted students to begin exploring effective personal strategies for dealing with their cravings.

Theme Two: Dealing With Cravings

Paralleling the experience of individuals in the early stages of recovery, participants actively dealt with cravings in various ways, including healthy and unhealthy coping mechanisms. When participants selected strategies that were unhealthy or unhelpful, the researchers labeled these as replacement behaviors. These behaviors often consisted of replacing their substances with other substances. For example, switching from sugary foods to fatty or salty foods, and avoiding a trigger or cravings by staying overly busy. These behaviors are not new to professionals working with clients with addictions. Below are examples of the participants engaging in these replacement behaviors. Participant 1, who abstained from soda, described noticing her behaviors as, “I ate a lot more . . . than I normally do. Because of how many chips I was eating I realized that I had replaced my drink [soda] with chips and salsa.” Noticing the pattern was a valuable learning experience that helped the participant to confront her substitution later in the assignment.

However, other students were unable to observe the ties connected to these behaviors and future relapse. Participant 5, who abstained from social media, reported, “I was also very busy the last couple of days because I’ve been preparing for my counseling presentation. Maybe I’ve successfully distracted myself from the temptation.” Nearly all participants reported engaging in replacement behaviors at some point in their experience. However, many of these participants discovered more successful ways to cope with triggers and cravings. When participants reported positive craving coping strategies, the researchers labeled these experiences as relapse avoidance strategies. These strategies often involved the elimination of potential triggering events or objects within the participants’ environments, relying on significant others and family members for support, talking to classmates about their cravings, and using healthy substitutions in place of their substance.

Participant 5 reported an instance of a relapse avoidance strategy: “I actually uninstalled and deactivated my Twitter. That way if I go to tweet something, I would have to download the app and activate my account. Two layers of activity would definitely put a damper on impulsivity.” Additionally, Participant 6, who had given up sugar, reported, “I got rid of all the sugar in the house.”

Relying on classmates and family was often described as essential from participants who reported they felt they had successfully abstained. Participant 3, who abstained from sugar, reported, “I talked with one of my friends about how the relapse has impacted my overall motivation and she really helped me get through and process.” Participant 5 added, “I’ve enlisted the help of my husband—(he) agreed to check my Twitter handle to make sure it is deactivated. This keeps me honest. I like the accountability piece because I can’t tweet in secret.” The healthy substitution often resembles behaviors like a step-down program or funneling energy into healthy activities and hobbies such as exercising or spending time with close friends. Participant 3, described replacing sugary sodas with a healthier alternative: “I found this type of soda . . . that is basically naturally flavored water. To say it’s curbed my sugar craving is an understatement.” Others described tending to general wellness to alleviate the stress associated with abstinence. Participant 7, who abstained from alcohol, reported, “I noticed myself going to sleep earlier yesterday . . . which I believe was a coping strategy for dealing with my irritability of trying to relax without allowing myself to have a drink.”

These strategies represent active experimentation and learning about how best to be successful at abstaining from the identified substance or behavior. Reflections on these experiences were essential to the learning goals associated with this project. The next theme explores these reflections and provides insight into the learning that was taking place throughout the assignment.

Theme Three: Student’s Self-Reflection of Learning

Theme Three explored the elements of personal learning the participants reflected upon. The researchers identified learning through Kolb’s Experiential Learning Model (Kolb, 1984). The researchers were interested in participants’ statements that evidenced reflective observations, defined as observations and reflections on what their experience was about and how it resonated with them. The researchers also were interested in participants’ statements that evidenced abstract conceptualization. We defined abstract conceptualization as the reflection upon concepts related to treating persons with addictions followed by generalizations from these reflections to future work with clients.

Examples of reflective observation can be found within Participant 2’s description of her difficulty in remaining abstinent from television for the assignment and how she discovered the difficulty of the change process within herself: “I feel like all I’ve done is replace not thinking because I watch mindless shows on television to not thinking because I play mindless games on my phone. I’ve thought about replacing it with exercise, but I feel myself rebelling against that.”

Many of the participants’ reflections facilitated greater awareness about how difficult it was to change any reinforced behavior or the difficulty of abstaining from a substance or behavior. Many reflected on discovering the difficulty of living without their substance or behavior. Participant 4, who abstained from social media, described, “It was very surprising to me when I realized how automatic my impulses were and how often I gave into them. During this time, my eyes were opened to how much this habit impacted my life.” In addition to discovering how hard it was to live without something they once enjoyed, many participants described experiencing new insight into the minds and behaviors of persons in recovery. Participant 13, who abstained from sugar, described, “It was much more difficult to abstain when I was around people who were consuming around me. I felt a greater social pressure and found myself feeling insecure (and) disconnected in social settings.” Participant 13 reported that pressure to continue was difficult to maintain: “Once I relapsed and we were nearing the end of the four weeks, it was hard for me to remain motivated to continue . . . the craving, the desire to connect with people and fit in, and the unexplainable high I get from eating sugar and gluten had to be outweighed by something else.”

Additionally, participants described the change process as something tangible and less theoretical. Participants could describe and reflect upon where they were within the stages of change and began to appreciate the difficulty of sustaining lasting change. Participant 11, who abstained from alcohol, described her awareness of the change process as, “Change doesn’t just happen overnight; it requires many things, including commitment, energy, the right motivation, and the right timing.” In addition, Participant 3, who abstained from sugar, added, “I talk in my notes at my site all the time about motivation for change and what that looks like for each of my clients, and I couldn’t even apply it to myself.”

The participants began to understand the experience of what counselors were asking clients to do by abstaining from drugs or alcohol. They also began to understand how to apply this learning to clients who were currently struggling with addictions and help with the understanding of the concepts of addiction. Participant 12, who abstained from sugar, reported, “This experience helped me understand how counterproductive it is to tell other people what they need to do to change. People don’t change until they are ready . . . to assume that a person will change just because someone tells them to is a mistake.”

Additionally, participants recalled what was most difficult about abstaining and built stronger conceptualizations about the role of triggers in relapse. Participant 17, who abstained from alcohol, reported, “I went dancing with some friends last night at a bar in town and found myself being asked several times why I wasn’t drinking.” This participant expressed the frustration about the experience as, “It began to get really annoying, and I feel (it) gave me some insight into the role that others play in the process of addiction and becoming sober, and how risky it can be in certain environments.”

The application of the experience of abstinence impacted all of the participants to some degree. Overall, they stated they felt a greater capacity of empathy for persons with addictions based upon how difficult abstinence was. Most participants reflected that the way they viewed a person in recovery was altered based on their experience of abstinence. The assignment generated new learning opportunities and understanding of the concepts of addiction and also enhanced their empathy for clients suffering from addictions. This enhancement of empathy was found within Theme Four, discussed below.

Theme Four: Empathy and Attitudes

The participants all stated that a significant learning outcome of the assignment was empathy for those with addictions. Participant 3, who abstained from sugar, reported, “I can see how people would struggle giving up drugs when their body has such a dependence on their drug of choice. I am struggling and counting down the days and I’m only giving up sugar.” This empathy was often associated with a strong protest that they were only experiencing a small proportion of the suffering that persons in recovery go through. Participant 10, who abstained from fast food, described growing his awareness of persons with addictions as, “I know one of my limitations in counseling is not being able to relate to my clients because I haven’t experienced some of the things that they have, like an addiction.” Participant 10 discussed the benefits from the abstinence assignment as, “by doing something as simple as this, I feel that I am in a much better place to help clients.”

Other participants described that empathy helped them deepen their understanding and care for those in their close family who had gone through addictions. Participant 17 reported, “I have personally observed my father going through his journey in alcohol and opiate addictions. I have felt the pain, suffering, frustration, and struggle as a family member, which makes this assignment very personal for me.” Participants reported these empathetic gains as important because they provided new perspectives on the lives of persons with addictions. Gaining empathy helped move participants closer to understanding persons with addictions as human beings who were attempting to steer themselves away from alcohol and drugs. This helped them to combat previous biased views of persons with addictions and altered previous attitudes and beliefs that are ineffective in helping this population.

This study explored the pedagogy behind an abstinence assignment and the experiences of students who participated. Specifically, the researchers wished to discover (1) What, if any, were the empathetic experiences of students concerning clients with addictions; (2) how was the concept of craving experienced and made meaningful by participants; (3) how did students find ways to deal effectively with cravings and abstinence through the project; and (4) what were the elements of the learning process for participants completing the abstinence assignment? A discussion of the research questions, including analysis of the themes, follows.

Empathetic Experiences of Students

Addressing bias and negative stigma associated with persons with addictions is a major aim of most addictions courses, as negative stigma has contributed to lower therapeutic outcomes for clients struggling with addictions (McLellan et al., 2000). This study explored the empathetic understanding of students completing the abstinence assignment and found that participants reported accessing empathy for persons struggling with addictions through experiences of craving, triggers, and relapse. Moreover, students empathized with the pain and suffering that abstaining produced and described the needed patience of treating clients with addictions. This empathy was fostered through an experiential understanding of craving, which is better explored within the second research question of how students found ways to effectively deal with cravings and abstinence via the project.

Experiences of Craving

An essential element of Kolb’s Experiential Learning Model (Kolb, 1984) is concrete experience. A concrete experience is a learning stage that involves having students experience a phenomenon physically, mentally, and psychologically. Although the experiences from the abstinence assignment are only approximations of individuals with addictions, they may still be important, as they provide students insight into withdrawal, craving, triggers, relapse, shame, and justification concerning relapse. This study’s first theme supports the learning objective that students experienced genuine addiction-related experiences. Students were cognizant that their experiences may not have perfectly compared to individuals addicted to drugs and alcohol; however, they stated often that the abstinence assignment produced suffering and uncertainty over their ability to abstain successfully from their chosen substances or behaviors. Students also reflected upon how they learned to cope through effective and ineffective ways with the experiences of craving and relapse. This was encouraging, as it provided students with strategies on how to help future clients during recovery.

Effectively Dealing With Cravings

Students often struggle with understanding where to start treatment with persons entering recovery (Carroll, 2000). This uncertainty may stem from unfamiliarity with the experiences of addictions and from lack of awareness of appropriate therapeutic goals for clients suffering from addictions. Students in this study reported understanding the concepts of triggers and cravings much more tangibly, while often discussing how they would broach these topics more readily with clients after completing the abstinence assignment. The students also reported ways they found to effectively manage their cravings that they felt could be useful to explore with clients in the future. These ways included many of the well-established treatment interventions for addictions that advocate for removal of all substances or substance use–related materials from home; restructuring daily living to replace or avoid triggering things, places, or times; the building of a supportive structure of family and peers; allowing others to hold the person responsible for future substance use; limiting exposure to cross-dependency through the use of other substances; actively discussing current cravings and triggers with family or peer support; and relying on healthy living strategies, like eating and sleeping well, to bolster defenses against triggers. We see from the list above that students were able to extrapolate strategies through abstaining from a substance or behavior to their work with clients. A closer inspection of Theme Three, students’ self-reflection of learning, found further support for the application of this project.

Elements of the Learning Process

In examining the students’ learning process, this study was interested in discovering if Kolb’s model could be an effective explanation of students’ learning during the abstinence assignment. It was discovered that the stage of concrete experiences was experienced during the period of abstaining. The assignment also required a reflection log or journal and a summarization paper. Within these portions of the assignment, the researchers found ample evidence to support that students engaged in reflective observations that helped them assign meaning to their experiences during abstaining, and also provided room for students to actively think through what these experiences meant for their work with clients (i.e., abstract conceptualization). Due to time considerations and inaccessibility to students, the researchers were unable to observe elements of Kolb’s fourth stage (i.e., active experimentation). Future research might build upon the present design to investigate the application of skills with CITs having undergone an abstinence assignment.

Implications for Counselor Education

Madson, Bethea, Daniel, and Necaise (2008) explored current training within counseling psychology and mental health counseling programs and recommended key areas educators should attend to within the realm of addictions. These areas included: (a) thoroughly assess SUD, (b) determine the appropriate level of treatment, and (c) develop treatment plans that include evidence-based substance abuse treatment (Madson et al., 2008). Madson et al. identified key areas that closely aligned with CACREP Standard II.3.D., which calls for counselors to understand the theories and etiology of addictions and addictive behaviors, including strategies for prevention, intervention, and treatment. It is the authors’ belief that the abstinence assignment helps students prepare for the above standards in a way that surpasses traditional didactic content. Speculatively, this may be why the abstinence assignment has been seen as a hallmark of addictions training. Baldwin’s (2008) investigation of abstinence assignments found that 69% of participants felt the abstinence assignment had a major positive effect, and 44% of participants agreed that they better understood the process of addictions recovery as a result of the assignment. This study aimed to build upon Baldwin’s findings; specifically, to explore if the abstinence assignment was found valuable by students; and to discover if it provided a valuable learning experience about the phenomenological experiences of persons with addictions, an understanding of the symptoms of addictions, and an understanding of preliminary treatment approaches to use with clients. The researchers found key themes within the research that supported the assignment meeting the above learning goals. With these findings, the authors believe in the continued infusion of this assignment within counselor education.

The abstinence assignment carries pedagogical considerations for an educator to take into account before including it in the curriculum. These considerations include how an instructor intends to provide feedback and assess the reflection journals. Content of feedback should be considered to help elicit further reflection for the student to deepen the learning experience. Moreover, the instructor will want to consider ethical issues that may arise from the grading of this assignment. If a student is disclosing dangerous or high-risk behaviors or demonstrating signs or behaviors of a process addiction, instructors will need to address their concerns and support the student’s developmental needs.

Future Research

There are several recommendations for future research. First, future research is needed to examine the application of skills with counselors who have completed an abstinence assignment. Qualitative and quantitative inquiry could provide insight as to whether students are translating their learning from this assignment into clinical practice. Secondly, research may expand upon this study by examining students’ prior experience with addictions or persons struggling with addictions to inquire if prior knowledge influenced their learning experience. Finally, continued empirical exploration into additional pedagogical interventions to examine effectiveness in addictions curriculum is needed.

Limitations

Several limitations exist within the current study. A primary limitation known from the beginning of the study was the utilization of a class assignment as the primary means of data collection with all White participants. While other studies have utilized class assignments as means of data collection (Baldwin, 2008; Sias & Goodwin, 2007), it is unknown if participants provided consistently accurate representations of their progress, or if different types of students would have different experiences. This limitation was partially mitigated by encouraging journaling and reflection upon success and failures during abstinence. Another limitation was the inability to monitor the application of the learning material potentially being applied with internship clients.

Researchers investigated the pedagogical advantages of utilizing an abstinence project within an addictions course, along with exploring the empathetic understanding of students completing the abstinence project. Elements of their learning process were identified and results found that students reported increased empathy for persons struggling with addictions through their experience of abstinence. The authors recommend employing the abstinence assignment in an addictions course curriculum in counselor education. Future research is needed to examine the application of skills with counselors having undergone an abstinence assignment.

Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest or funding contributions for the development of this manuscript.

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Chad M. Yates is an assistant professor at Idaho State University. Alexia DeLeon is an assistant professor at Lewis & Clark. Marisa C. Rapp is a doctoral student at Idaho State University. Correspondence can be addressed to Chad Yates, 921 South 8th Ave, Stop 8120, Pocatello, ID 83209-8120, [email protected].

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