Reference Work Entry

Handbook of Clinical Psychology Competencies

pp 901-928

Substance Use Disorders

  • David J. KavanaghAffiliated withQueensland University of Technology
  • , Jason ConnorAffiliated withUniversity of Queensland
  • , Ross YoungAffiliated withQueensland University of Technology

Abstract:

Basic competencies in assessing and treating substance use disorders should be core to the training of any clinical psychologist, because of the high frequency of risky or problematic substance use in the community, and its high co-occurrence with other problems. Skills in establishing trust and a therapeutic alliance are particularly important in addiction, given the stigma and potential for legal sanctions that surround it. The knowledge and skills of all clinical practitioners should be sufficient to allow valid screening and diagnosis of substance use disorders, accurate estimation of consumption and a basic functional analysis. Practitioners should also be able to undertake brief interventions including motivational interviews, and appropriately apply generic interventions such as problem solving or goal setting to addiction. Furthermore, clinical psychologists should have an understanding of the nature, evidence base and indications for biochemical assays, pharmacotherapies and other medical treatments, and ways these can be integrated with psychological practice.

Specialists in addiction should have more sophisticated competencies in each of these areas. They need to have a detailed understating of current addiction theories and basic and applied research, be able to undertake and report on a detailed psychological assessment, and display expert competence in addiction treatment. These skills should include an ability to assess and manage complex or co-occurring problems, to adapt interventions to the needs of different groups, and to assist people who have not responded to basic treatments. They should also be able to provide consultation to others, undertake evaluations of their practice, and monitor and evaluate emerging research data in the field.

Abstract:

Basic competencies in assessing and treating substance use disorders should be core to the training of any clinical psychologist, because of the high frequency of risky or problematic substance use in the community, and its high co-occurrence with other problems. Skills in establishing trust and a therapeutic alliance are particularly important in addiction, given the stigma and potential for legal sanctions that surround it. The knowledge and skills of all clinical practitioners should be sufficient to allow valid screening and diagnosis of substance use disorders, accurate estimation of consumption and a basic functional analysis. Practitioners should also be able to undertake brief interventions including motivational interviews, and appropriately apply generic interventions such as problem solving or goal setting to addiction. Furthermore, clinical psychologists should have an understanding of the nature, evidence base and indications for biochemical assays, pharmacotherapies and other medical treatments, and ways these can be integrated with psychological practice.

Specialists in addiction should have more sophisticated competencies in each of these areas. They need to have a detailed understating of current addiction theories and basic and applied research, be able to undertake and report on a detailed psychological assessment, and display expert competence in addiction treatment. These skills should include an ability to assess and manage complex or co-occurring problems, to adapt interventions to the needs of different groups, and to assist people who have not responded to basic treatments. They should also be able to provide consultation to others, undertake evaluations of their practice, and monitor and evaluate emerging research data in the field.

32.1 10.1 Overview

Substance use disorders (SUDs) are common, with an incidence in the general population of around 9% (excluding tobacco) – a rate similar to mood and anxiety disorders (Grant et al., 2004). Furthermore, they often have a severe impact on physical health, psychological status, and social functioning (e.g., Bush, Autry, Bush, & Autry, 2002). Together, these features highlight the importance of effective prevention and treatment responses. Clinical psychologists have contributed significantly to the development, evaluation, and implementation of interventions in this field, and assurance of their competencies has substantial potential impact on service quality.

While all psychological disorders require a multidisciplinary approach if they are to be fully understood, this is especially true for SUDs. The fact that these disorders involve ingestion of psychoactive agents requires that practitioners have a basic understanding of relevant information derived from pharmacology, neurophysiology, genetics, and general medicine. This knowledge becomes especially important for expert practitioners.

However, the need for multidisciplinary knowledge should not overshadow the importance of knowledge and skills acquired from the mainstream discipline of clinical psychology. Despite recent developments in the basic science and pharmacotherapy of addiction, assessments and frontline treatments for substances of abuse retain strong influences from psychological theory and research. In many cases, interventions have been adapted from other problem areas (e.g., anxiety, social skills). In others, specific interventions have grown within SUDs (e.g., motivational interviewing, relapse prevention), some of which are now applied in the treatment of other disorders. This chapter discusses the evidence base for psychological responses to substance misuse and the nature of related competencies and describes key areas from other disciplines as well.

32.1.1 10.1.1 Key Concepts

Psychoactive substances alter the functioning of the central nervous system, so the users experience temporary changes in consciousness (including emotions, perceptions, and other cognitions). They are broadly categorized into depressants, stimulants, and hallucinogens. Intoxication with depressants results in acute suppression of neural activation, and depending on the neural systems involved, it is typically experienced as sedating. Depressants do not necessarily trigger or worsen a depressed mood, although some may do so (e.g., dysphoria subsequent to an episode of alcohol use). Stimulants trigger neural excitation, while perceptual changes are the key hallmark of hallucinogens. These categories should be seen as shorthand descriptions that are to some extent, simplifications. For example, some substances do not easily fit into this rubric. Cannabis has subjective effects across all three categories (Green, Kavanagh, & Young, 2003), and some effects of cocaine (typically categorized as a stimulant) involve inhibition of neural transmission (Frishman, Del Vecchio, Sanal, & Ismail, 2003). Substances often have contrasting effects over time, setting, and dosage (e.g., initial increases in pulse and blood pressure at low doses of alcohol, but reductions at higher doses).

While levels of intoxication generally increase with dosage, individuals show differential sensitivity to effects, and effects of a given dose may change over time, depending on their physiological state and history of use. Psychoactive substances can be seen as poisons, since overdoses can have deleterious effects (e.g., sedatives suppress respiration or heartbeat and stimulants can increase heart rate and blood pressure to the point where cardiac fibrillation or brain hemorrhage may occur). Metabolism of the substance protects the body to same extent from toxic accumulation, although this protection is limited by enzyme kinetics. Some metabolites can also have aversive and potentially dangerous effects. An example is acetaldehyde, the initial metabolite of alcohol (Jelski & Szmitkowski, 2008), which can produce symptoms of nausea and sympathetic nervous system arousal.

Withdrawal refers to effects of stopping or substantially reducing consumption. In general, withdrawal effects approximate the opposite of intoxication (e.g., sedation/excitation), although the full story is more complex. Repeated use triggers structural and functional neural changes: some involve sensitization to the presence of the substance (e.g., increased motivational salience; Robinson & Berridge, 1993); others comprise neural adaptation. The latter effects are experienced as increased tolerance when more of the drug is needed to have the same effect. Over time, adaptational responses become faster and stronger, and pleasure from intoxication becomes less intense and shorter in duration (Koob & Le Moal, 2008; Solomon, 1980). Use becomes more strongly associated with relief of withdrawal (“needing”) rather than hedonic “wanting” (Robinson & Berridge). Increased incentive salience and tolerance are important contributors to progressive increases in consumption that are commonly seen with psychoactive substance use, and the progressive neural adaptation underpins development of a full withdrawal syndrome after a history of heavy use. There is a significant classical conditioning effect, with withdrawal being more pronounced in the presence of environmental cues associated with drug administration.

Substances with a high potential for misuse have extremely pleasurable net effects of intoxication or are particularly prone to tolerance and an aversive impact from cessation. Route of administration is an important contributor to rate of uptake and distribution through the body, with injection and inhalation typically resulting in a steeper trajectory of effects than gastrointestinal use.

The rate of metabolism is also important. Substances which are rapidly metabolized into inactive metabolites and are rapidly excreted (e.g., nicotine) are associated with frequent consumption, not only because more frequent use is required to maintain the acute substance effects, but also because the salience and aversive nature of a rapidly developing withdrawal is a powerful trigger for immediate use. On the other hand, substances with a longer half life (e.g., methadone and some benzodiazepines) produce challenges for the ongoing maintenance of abstinence in the presence of a withdrawal that may extend over several weeks.

32.2 10.2 Developmental Symptoms and Their Assessment

32.2.1 10.2.1 Problem Features

For many people, some substance use (e.g., caffeine or alcohol) is pleasurable and nonproblematic. For others, substance use can have a severe impact on health, quality of life, and economic and social functioning (Connor, Saunders, & Feeney, 2006). High-risk use refers to consumption that conveys a significant risk of later problems. Some substances (e.g., cigarette smoking) have no level of consumption that is physically “safe.” In other cases (e.g., alcohol), there may be benefits of low-level use, so that net health effects may be positive (Li, 2008; cf. Fillmore, Kerr, Stock-well, & Bostrom, 2006). Recommended maximum limits for alcohol vary across countries and over time: the current level in the USA is less than or equal to two drinks (28 g ethanol) a day for men and less than or equal to one drink (14 g ethanol) a day for women (United States Department of Agriculture and United States Department of Health and Human Services, 2005).

Two key substance-related disorders in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) (American Psychiatric Association, 1994) are abuse and dependence. Substance abuse refers to repeated substance use, despite impairments in functioning across important interpersonal, social, and occupational domains, or recurrent use in situations that are physically hazardous. It is positioned in the context of social norms and culture. For this reason, it does not appear in International Classification of Diseases – 10th Revision (ICD-10) (World Health Organization, 2004), which, instead, has a diagnosis of harmful use (i.e., a pattern of use that is producing mental or physical harm).

Substance dependence additionally involves a pervasive, chronic cluster of psychological, behavioral, and physiological drives that maintain the condition typically associated with excessive administration. The current conceptualization of dependence relies extensively on the seminal description of the alcohol dependence syndrome by Edwards and Gross (1976). The features include withdrawal (or use to avoid it), tolerance, inability to control use (i.e., often used more than intended or over a longer period; a persistent desire or unsuccessful attempts to stop or reduce), high priority for use (i.e., substantial time obtaining, using, or recovering; other important activities stopped or reduced), and continued use despite physical or psychological harm (a feature similar to ICD-10 Harmful Use). DSM-IV requires three of the seven features to be present in a 12-month period and the presence of clinically significant impairment or distress.

While abuse was thought to be a milder form of substance use problem in DSM-IV (Feingold & Rounsaville, 1995), more recent research has cast doubt on whether most abuse criteria involve milder symptoms (Li, 2008). Substance-related problems are better described along a continuum of severity (Gillespie, Neale, Prescott, Aggen, & Kendler, 2007; Kahler & Strong, 2006), with particular features occurring at different levels of frequency of use or severity of dependence in different substances (Gillespie et al., 2007).

Key clinical psychology competencies in the addictions field should not only encompass the basic concepts summarized above, but reflect the emerging sophistication in our understanding of substance-related disorders and the potential for significant changes in diagnostic criteria over time. In the remainder of this chapter, we use the term substance use disorder (SUD) to embrace abuse, harmful use or dependence, and substance misuse, to include both SUDs and high-risk use.

Substance misuse contributes disproportionately to human morbidity and mortality, with the high prevalence and risks from tobacco and alcohol use offering a particularly heavy burden (World Health Organization, 2008). The impact of a specific substance on an individual is augmented by heightened risks of co-occurring substance misuse (Substance Abuse and Mental Health Services Administration, 2008) and other mental disorders. Approximately half of the people with an alcohol use disorder and three quarters with another drug use disorder also meet criteria for at least one other mental disorder (Kessler, McGonagle, Zhao, & Nelson, 1994). Because of their high population prevalence, depression and anxiety disorders are the most commonly co-occurring mental disorders, even though the greatest relative risk occurs in bipolar disorder and schizophrenia (Regier et al., 1990). So, one in four people with alcohol dependence carry a lifetime history of mood disorder and one in three have had an anxiety disorder (Merikangas et al., 1998). High rates of comorbidity mean that competencies for practice in SUDs should not be seen in isolation: a competent practitioner in this field should also have competence in assessment and treatment of other mental disorders and should be able to tailor assessment and treatment for people with co-occurring substance misuse (Kavanagh & Connolly, 2009a, b).

32.2.2 10.2.2 Assessment

Assessment should always be integrated into the therapeutic process, and this is especially important in addictive disorders. Rather than being an information-gathering exercise, assessment provides valuable lead into brief opportunistic interventions that develop awareness and build motivation. As discussed further below, there is strong evidence supporting the efficacy of brief interventions delivered in this manner.

32.2.2.1 10.2.2.1 Establishment of Trust

Substance use problems often attract negative social responses, and the use of many substances is illegal. It is therefore not surprising that many substance users reject labels they perceive as value-laden (e.g., “alcoholic”) and minimize substance-related problems, particularly when reporting them to others. Use and abstinence of specific substances can be confirmed by biochemical assays, but self-report remains the only practical way to obtain the level of detailed information that allows development of a detailed functional analysis. Before someone is willing to freely discuss their substance use and its effects, they must be assured that disclosure will not have negative consequences. Development of a nonjudgmental and warm relationship and clarity about confidentiality and use of information are particularly important when trust is initially low.

32.2.2.2 10.2.2.2 Assessment of Consumption

Intoxication and cognitive impairment can make it difficult for users to encode and recall substance use, but inaccuracy in consumption can also arise from the way in which questions are asked. Such inaccuracy may be interpreted as a consequence of “alcoholic denial,” but there is little evidence to support this. Omitting questions about specific substance groups is a frequent cause of underreporting, and reports of “usual” consumption are prone to recall biases and error, particularly if there are substantial variations in usage over time. If there are stable weekly or monthly patterns, accuracy can be increased by asking about specific substances that are used each day of the week or month, and further improvements can be made by triangulation from multiple estimates (recent frequency and typical amount; weekly purchases, cost). Tracking usage often requires detailed knowledge of quantities that are actually used (e.g., drink sizes): this may entail both education and home tasks.

Use of event-cued recall of consumption on a calendar-based Timeline Followback (Sobell & Sobell, 1993) can provide detailed information about consumption over the previous 1–3 months. If the person is highly motivated, daily self-monitoring may be used over short periods. Cues and time-stamped records can be offered by using e-mails, electronic diaries, or mobile telephones, and errors due to intoxication may be reduced by tracking products (e.g., number of bottles, amount of the substance or money remaining). Self-monitoring may underestimate usual consumption by cueing self-control. While potentially problematic for assessment, this feature may be used to assist early stages of treatment (Kavanagh, Sitharthan, Spilsbury, & Vignaendra, 1999).

Where an underestimated consumption is suspected, a “bogus pipeline” effect may be used (Roese & Jamieson, 1993), where the person is informed that confirmatory evidence, such as physiological measures, can be used to check reports. While this strategy may be unavoidable when there are contingencies for reduction or abstinence, care is needed to maintain trust and rapport when it is used. It also raises broader ethical issues, and collateral reports may be used as a more pragmatic and honest means to validate self-reports. However, collateral reports also raise ethical and pragmatic problems. Substance use may be hidden from others, and collaterals are subject to the same recall errors and biases as the client.

It is tempting to see biochemical analyses as the gold standard, although considerations of cost, limited sensitivity to small amounts or longer periods, and ambiguity of interpretation can be issues. For example, breath analyses for smoking or alcohol have practical application only to consumption over the previous few hours. Plasma thiocyanate can detect smoking over the previous 14 days, but is relatively insensitive to light smoking (Pre & Vassy, 1992). Current biomarkers of heavy alcohol use vary in sensitivity and specificity, and some are also inflated by other conditions, but a combination of markers increases accuracy (Miller & Anton, 2004). In general, assays have greater utility for outpatient assessment where the focus is on detection of abstinence versus use (rather than changes in quantity and frequency), and where the substance or a metabolite is present for a longer period (e.g., cannabis; Musshoff & Madea, 2006), or where it is captured (e.g., in hair). However, even when all of these are present, sensitivity can still sometimes be an issue (e.g., plasma provides greater sensitivity to cannabis use than hair; Musshoff & Madea). A general clinical psychologist may be expected to understand basic assays and reports (e.g., blood alcohol level, carbon monoxide, substances detected by a laboratory), but a specialist in alcohol and other drugs should be able to administer a breath test and be aware of limitations of other specific biochemical assays.

32.2.2.3 10.2.2.3 Functional Analysis

A functional analysis of substance misuse has the same elements as other problems (Wilson, Spence, & Kavanagh, 1989; chapter 9), embracing both deficits and strengths (e.g., periods of abstinence or moderation; effective coping, unaffected aspects of the person’s life), examining historical and current antecedents and consequences or incentives, and covering cognitive, affective, behavioral, physiological, and social domains. Since ambivalence about consumption or engagement in treatment is often present, careful analysis of positive and negative incentives for current use and behavior change (and the accuracy of these expectancies) is particularly important.

32.2.2.4 10.2.2.4 Psychometric Measures

There are many robust psychometric instruments for screening and assessment of SUDs. It is beyond the scope of this chapter to review each of these measures. Sound summaries are provided by Dawe, Loxton, Hides, Kavanagh, and Mattick (2002) and Allen and Wilson (2003).

32.3 10.3 Maintenance Factors of Substance Misuse

While psychological, biological, cultural, and social factors contribute to the development of problematic use, there is no simple explanation for some becoming dependent, while others do not. The predominant theories for etiology of problem drinking up to the early 1960s were grounded in a disease model. On the basis of anthropological (MacAndrew & Edgerton, 1969) and experimental (Marlatt & Rohsenow, 1980) studies, the idea that problematic substance use and anticipated effects of substances draw heavily on learned behavior has gained acceptance. While the genesis of substance use problems clearly involves genetic risk (Wong, Schumann, Wong, & Schumann, 2008), this needs to be complemented with a broader understanding of the psychological and socio-cultural processes involved in problem drinking.

In common with other problem domains, social-cognitive theory (Bandura, 1982) continues to make a significant impact on our understanding of the initiation and maintenance of addictive disorders. Bandura (1997) identified two types of expectations that have particular relevance to addictions: outcome and self-efficacy expectancies. Positive outcome expectancies of substance use develop from an early age, often vicariously, and are associated with increased risk of substance-related problems (Goldman, 1987; Young & Oei, 1993). Low self-efficacy expectancies for control of substance use are associated with increased substance use (Skutle, 1999) and relapse following treatment (Maisto, Connors, & Zywiak, 2000). Outcome and self-efficacy beliefs are typically more powerful predictors together than individually (Baldwin, Oei, & Young, 1993; Bandura, 1999).

Other psychological theories that have informed our conceptualization of substance misuse include Social Control Theory (based on family and affiliative group beliefs and supervision), Behavioral Choice Theory (based on the relative access to drug and nondrug rewards), and Stress and Coping Theory (where coping skills to face challenges without substance use are suboptimal or absent; Moos, 2008).

Identified risk factors for substance misuse support the premises of all four theories. These include: (1) social environmental adversity, such as high crime, alienation, and high population density, (2) family pathology such as parental substance misuse, family disruption, poor attachment and low parental monitoring, and (3) peer influence, such as a heavy or precocious peer substance use and delinquency and individual risks, including the presence of childhood traumatic events, conduct disorder symptoms, impulsivity, low self-esteem and mood or anxiety disorder. Risk factors are comprehensively reviewed in Armstrong and Costello (2002) and Weinberg, Rahdert, Colliver, and Glantz (1998).

32.4 10.4 Evidence-Based Treatment Approaches

There is substantial evidence on effectiveness of interventions for alcohol (Miller & Wilbourne, 2002) and tobacco use (The Clinical Practice Guideline Treating Tobacco Use and Dependence Update Panel Liaisons and Staff, 2008). Evidence to support intervention choices for many other substances is less advanced. For example, psychological intervention for benzodiazepine dependence provides incremental improvements in outcomes above gradual dose reduction alone, but there is insufficient evidence to identify effective treatment components (Parr, Kavanagh, Cahill, Mitchell, & Young, 2009).

32.4.1 10.4.1 Motivational and Brief Interventions

Motivational interviewing (MI) was developed by Miller (1983) for treatment of problem drinkers and further refined by Miller and Rollnick (1991) and Rollnick and Miller (1995). MI has been defined as “a client centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (Miller & Rollnick, 2002). Ambivalence is a common feature of clients considering making a change to problematic substance use. Key goals of MI are to avoid labeling, support self-efficacy, recognize and accept ambivalence as normal, and encourage the client’s own reflection and dialog for change.

Several reviews and meta-analyses support the efficacy of MI in the treatment of most SUDs (e.g., Kaner et al., 2007; Rubak, Sandback, Lauritzen, & Christensen, 2005; Vasilaki, Hosier, & Cox, 2006), although studies on nicotine dependence show high heterogeneity and low effect sizes (Burke, Arkowitz, & Menchola, 2003; Dunn, Deroo, & Rivara, 2001). Confrontation, which is antithetical to MI, is an ineffective treatment (Miller & Wilbourne, 2002).

In the Miller and Wilbourne (2002) meta-analytic review of 361 controlled alcohol treatment trials, MI and other brief interventions had greater cumulative support than a wide range of other psychological and pharmacological treatments. Two landmark trials have compared a multi-session version of MI, motivation enhancement therapy (MET), with comparison treatments (Project MATCH Research Group, 1998; UKATT Research Team, 2005). These trials demonstrated that MET had equivalent efficacy to Cognitive-Behavioral Therapy (CBT), Twelve-Step Facilitation (TSF; Project MATCH Research Group), and Social Behavior and Network Therapy, a CBT-based treatment (UKATT Research Team, 2005, 2008), and that it achieved this benefit in substantially fewer sessions. Consistent with the model underpinning MI, outpatients who commenced at lower levels of baseline motivation and reported higher anger levels had better outcomes from MET in Project MATCH, although the former effect was restricted to the first year of follow-up (Project MATCH Research Group, 1997, 1998).

32.4.2 10.4.2 Twelve-Step Facilitation (TSF)

The most widely recognized TSF approach is Alcoholics Anonymous (AA). It involves self-help groups that offer ongoing mutual peer support, and promote an abstinence goal (Anonymous, 2007; Vaillant, 2005). While health practitioners do not participate in AA activities, both approaches may co-occur. Central to TSF is that participants accept that they are powerless over their substance use. Other steps involve taking greater responsibility, including restitution for past harm to others, while letting go of inner struggle. Although the core theme is to surrender to a higher power to assist with change, TSF does not support any specific religion. Other features in some countries include use of a buddy system (a “sponsor”) to provide support between group meetings.

There are significant methodological challenges in assessing the efficacy of AA, since most groups do not register participants, attendance, or outcomes. Few controlled studies of self-help groups exist (Kelly, 2003), and almost exclusively these examine alcohol dependence. While there is support for the hypothesis that more AA attendance is associated with better outcomes (Emrick, 2001), this result confounds commitment to change with group exposure. While two meta-analytic studies found little support for AA in treatment of alcohol use disorders (Ferri, Amato, & Davoli, 2006; Kownacki & Shadish, 1999), trials often lack a placebo, no-treatment, or wait-list control.

To provide more rigorous tests of the relative efficacy of TSF, some studies have used an intervention that applies a TSF philosophy, without actually being an AA group. Outcomes of such trials are mixed at best (Miller & Wilbourne, 2002). Identification of patient characteristics associated with a greater impact from TSF has also had little success. In Project MATCH, participants with a social network of heavy drinkers did better from TSF than MI, but only at the 3-year follow-up (Project MATCH Research Group, 1997, 1998).

32.4.3 10.4.3 Cognitive-Behavioral Therapies (CBTs)

In SUDs, cognitive therapy (Beck, 1993) is particularly applied to excessively positive substance expectancies, low self-efficacy and negative beliefs about abstinence, as well as to depressogenic or anxiety-related cognitions that may trigger dysfunctional substance use. Other common elements in CBTs for substance misuse include development of skills in predicting high-risk situations for substance use, and applying problem solving and response planning. Skills in refusing social pressure to use substances and stress management may be developed, and there is often a focus on increasing pleasurable activities and social roles that are inconsistent with substance use.

Efficacy of CBT for alcohol dependence is well established (e.g., Assanangkornchai & Srisurapanont, 2007; Berglund et al., 2003), although it appears to have similar impact to several other “active” treatments. As already discussed, Project MATCH found similar treatment outcomes betwen CBT, MI, and TSF (Project MATCH Research Group, 1997, 1998). The efficacy of CBT for cannabis (Denis, Lavie, Fatseas, & Auriacombe, 2006), cocaine (Knapp, Soares, Farrell, & Silva de Lima, 2007), and amphetamine misuse (Denis et al., 2006; Knapp et al., 2007; Lee & Rawson, 2008) is also receiving growing support.

32.4.4 10.4.4 Behavioral Therapies Based on Operant or Classical Conditioning

While behavioral approaches based on operant or classical conditioning are often employed within multicomponent CBTs, their effects can also be considered separately. The most widely studied behavioral therapies are cue exposure and contingency management.

Cue Exposure. Repeated pairing of substance use with both positive effects and environmental cues elicits conditioned responses that increase the probability of use. Cravings (or urges to use substances) are often elicited by exposure to conditioned stimuli (Carter & Tiffany, 1999). Repeated exposure to conditioned stimuli can induce habituation of craving (e.g., Kavanagh et al., 2006). Exposure to cues may be combined with cognitive therapy or skills training in resisting substance use (Monti et al., 1993), an approach that blurs distinctions between habituation-based treatment and other CBTs.

Most controlled trials have focused on alcohol. Cue exposure (CE) is typically more effective than control conditions such as relaxation training (Drummond & Glautier, 1994), but has similar efficacy to CBT (Dawe, Rees, Mattick, Sitharthan, & Heather, 2002; cf. Sitharthan, Sitharthan, Hough, & Kavanagh, 1997), and its addition to CBT may not add to efficacy (Kavanagh et al., 2006).

Contingency Management (CM). CM introduces a tangible reinforcer (e.g., money or vouchers for inpatient privileges) to increase desired behaviors such as session attendance or abstinence. Adding CM to treatment of cocaine abuse has had promising results (Stitzer & Petry, 2006), and there is a growing support with cannabis and amphetamine dependence (Carroll et al., 2006; Denis et al., 2006; Lee & Rawson, 2008).

Provision of external reinforcement creates a vulnerability to extinction of the behavior once reinforcers are withdrawn. This may be particularly problematic when there is intrinsic motivation to participate in treatment and control consumption, since the person may reattribute their behavior to the external reinforcer (Deci, Koestner, & Ryan, 1999). If external reinforcers are used, they should be presented as an adjunct to other incentives rather than a replacement, and the primary emphasis (particularly in latter treatment sessions) needs to be on internal motivation and naturalistic rewards that are likely to continue after formal treatment ceases. Aversive therapies were popular in the 1960s and 1970s, but for ethical reasons, they are no longer in common use.

32.4.5 10.4.5 Couples and Family Therapy

In the past, substance misuse has often been treated as an individual problem. Recognizing social factors in substance misuse and recovery has resulted in a greater emphasis on inclusion of family members in interventions. Couples and family therapies have been found to be effective in treatment of both alcohol (O’Farrell & Fals-Stewart, 2002) and other substance misuse (Powers, Vedel, & Emmelkamp, 2008).

32.4.6 10.4.6 Community Reinforcement Therapy (CRT)

Although originally conceptualized as an operant approach, CRT incorporates many elements from CBTs and other case-management interventions (Azrin, 1976; Hunt & Azrin, 1973), including referral to other professionals (e.g., for legal or financial issues), TSF, pharmacotherapy, behavioral marital therapy, and development of social roles (e.g., employment) and recreational activities that are inconsistent with substance use. Later versions incorporate written contracts, tracking of high-risk situations, rehearsal of skills in resisting substance use, peer support, and sometimes CM (Secades-Villa, Garcia-Rodriguez, Higgins, Fernandez-Hermida, & Carballo, 2008). CRT has empirical support across several substances, although numbers of trials remain limited (Roozen et al., 2004; Smith, Meyers, & Miller, 2001).

One version of CRT, Community Reinforcement and Family Training (CRAFT; Meyers, Miller, Hill, & Tonigan, 1998), attempts to induce behavioral change in people who refuse treatment, by encouraging concerned family members or friends to reward instances of substance control or treatment, and withdraw reinforcement for substance misuse. While there are few trials of CRAFT, available evidence is supportive, and suggests that systematic reinforcement produces superior results to Al-Anon, which are AA-related groups for family members, with some similar aims and strategies to CRAFT (Smith et al., 2001).

32.4.7 10.4.7 Pharmacological Approaches

For alcohol, heroin, and nicotine dependence in particular, there are strong data to support a combined pharmacological and psychological treatment. Support for pharmacotherapy of cannabis, stimulant, and hallucinogen misuse is more limited.

Alcohol. The pharmacotherapy for alcohol dependence that has the longest history is disulfiram or antabuse, which stops the metabolism of acetaldehyde, producing sympathetic nervous system activation, nausea, vomiting, and headaches. The knowledge that this aversive response will occur after ingestion of alcohol can assist users to maintain total abstinence. While there is some evidence that consistent, supervised use of disulfiram can improve alcohol outcomes (Fuller & Gordis, 2004; Hardt, 1992), poor adherence (Fuller & Gordis) means that it has little demonstrated effectiveness (Helig & Egli, 2006). In addition, potential physical complications from disulfiram (e.g., to a compromised cardiovascular system) have restricted its utility (Chick, 1999; Malcolm, Olive, & Lechner, 2008), and a medical assessment is required before its prescription.

More recently, naltrexone and acamprosate have been used. There is evidence of efficacy for both medications, and in particular, each may add to the effects of psychological treatment (Bouza, 2004; Feeney, Connor, Young, Tucker, & McPherson, 2006; Kranzler, 2001). Clients with severe alcohol dependence, high current consumption, a history of unsuccessful treatment and significant craving may particularly benefit from adjunctive pharmacotherapy. While often characterized as an anticraving medication, naltrexone may have its main impact on craving by reducing rewards from drinking, rather than affecting craving more directly. Consistent with this, its differential benefits are more typically seen with occasions of heavy drinking than abstinence (Pettinati et al., 2006). Both agents may also allow an indirect effect via the opportunity to benefit more from psychosocial interventions.

Nicotine. Nicotine replacement therapy doubles the chances of successfully quitting (Stead, Perera, Bullen, Mant, & Lancaster, 2008), as does bupropion (an antidepressant; Hughes, 2007). A new agent, varenicline triples the chances of quitting, compared with placebo (Cahill, 2008). Best practice for nicotine dependence currently includes one of these pharmacotherapies.

Opiates. Methadone (an opiate agonist) remains the frontline replacement therapy for opiate dependence. Typically treatment involves daily oral doses. Methadone retains the clients in treatment longer, improves functional outcomes, and reduces opiate use compared with control treatments (Mattick, Breen, Kimber, Davoli, & Breen, 2003). Buprenorphine (a partial opiate agonist) offers an alternative to methadone with similar efficacy (Mattick et al., 2003). Advantages over methadone include lower potential for abuse and reduced physical dependence. Naltrexone (an opiate antagonist) has been relatively ineffective in treating opiate dependence, primarily due to poor treatment retention (Minozzi et al., 2006). There is some empirical support for stand-alone psychological interventions for opiate dependence (Mayet, Farrell, Ferri, Amato, & Davoli, 2004), and evidence that psychological and pharmacological treatments are synergistic (Stein et al., 2004).

32.4.8 10.4.8 Preventive Intervention

Community-based universal prevention approaches that increase purchase cost and legal age of access to (licit) substances have been among the more effective strategies to reduce substance-related harm, particularly in young people (Stockwell, Gruenewald, Toumbourou, & Loxley, 2005). Media and social marketing campaigns have been successful in reducing tobacco use at a population level (Bala & Lesniak, 2007), but there is less evidence for other substances. The most widely studied universal prevention programs are school-based interventions. Many programs show improvements in substance use in the short term (<12 months), but data on long-term maintenance of improvements are weak (Foxcroft, Ireland, Lowe, & Breen, 2002; White & Pitts, 1998), unless the intervention has a broad skills base and is delivered over several years. Screening “at risk” populations and providing brief, opportunistic treatment does appear to reduce consumption and decrease numbers progressing to problematic substance use (Babor & Kadden, 2005; Kaner et al., 2007). Key aspects of successful programs appear to be engagement in prosocial goals and activities, rather than education about substances and their effects.

32.5 10.5 Mechanisms of Change Underlying the Intervention

Historically, substance misuse treatment research has been more focused on “what works” than on “why it works.” Identifying the mechanisms responsible for effectiveness is a tall order (Kazdin, 2006), and meeting those criteria has remained elusive in virtually all psychotherapies, including those for addictions (Longabaugh, 2007). Despite the lack of advancement of our knowledge to date, potential contributors to effects of addiction treatments have been identified. Attendance and participation in AA or other treatments frequently emerge as a predictor (Forys, McKellar, & Moos, 2007) but as noted above, they are confounded with motivation.

32.5.1 10.5.1 Potential Client–Therapist Mechanisms

Stage of Change. While it is not an explanatory theory, the Stages of Change (or Transtheoretical) model of Prochaska and DiClemente (1983) has been an influential summary of client preparedness in SUD treatment. There is some evidence that participants with lower motivation to change respond more effectively to MI, although the meditational effect of readiness to change has received only inconsistent support (Morgenstern & McKay, 2007).

Therapeutic Alliance. The UKATT trial (UKATT Research Team, 2005) identified therapist–client alliance as the strongest predictor of outcome. Patients who perceive therapists as less understanding are more likely to drop out of therapy for substance misuse (Cournoyer, Brochu, Landry, & Bergeron, 2007). However, therapeutic alliance has not consistently been predictive of outcome (Long, Williams, Midgley, & Hollin, 2000).

32.5.2 10.5.2 Potential Social or Contextual Mechanisms

Relationship Functioning. There is evidence of marital satisfaction increasing after behavioral couple therapy for alcohol misuse, and for better alcohol outcomes after improvements in marital interaction, but as yet there is no full test of mediation (Morgenstern & McKay, 2007).

Group Membership. It is difficult to untangle effects of AA, but commitment to AA practices is positively associated with outcome (Longabaugh et al., 2005). Social network support for abstinence has been proposed as a critical contributor to positive outcomes from AA (Longabaugh, Wirtz, Zweben, & Stout, 1998) and social support may be important across treatments, particularly for males (Moos, 2007).

32.5.3 10.5.3 Potential Psychological Mechanisms

Learning. While there is intuitive appeal that therapy involves learning (e.g., of new skills), there are little data on its potential mediational role. Morgenstern and Longabaugh (2000) could find no evidence of skills mediation in CBT. When coping skills have been associated with outcome, changes in those skills have not been specific to CBT (Morgenstern & McKay, 2007). Approach-related coping is generally associated with better outcomes than avoidance coping (Moos, 2007), but both can be effective (Litt, Kadden, Cooney, & Kabela, 2003; Maisto et al., 2000). Most research on meditational effects of coping skills has examined effects of perceived coping, rather than directly observing behaviors (e.g., Litt et al., 2003). Indirect evidence that skills practice is important is provided by observations that homework completion is related to better outcomes from CBT (Carroll, Nich, & Ball, 2005), although these require replication, and as with session attendance, this factor confounds with motivation. Reinforcement expectancies have also shown promise as predictors of outcome, but further tests of their role as a treatment mechanism remain to be undertaken (Young & Oei, 1993).

Self-Efficacy. Prospective treatment-based studies have predominately examined situational confidence in the form of self-efficacy beliefs. Self-efficacy predicts relapse to heavy drinking for up to 2 years (Kavanagh, Sitharthan, & Sayer, 1996; Walton, Blow, Bingham, & Chermack, 2003). When both alcohol expectancy and self-efficacy are examined together, self-efficacy beliefs are typically stronger predictors of alcohol consumption post treatment than alcohol expectancy (Solomon & Annis, 1990). However, some studies have failed to find evidence of a predictive role of self-efficacy (McKay, Maisto, & O’Farrell, 1993; McKellar, Harris, & Moos, 2006). An incremental contribution from self-efficacy above performance achievements is most often seen in contexts where the person has information about future challenges to their coping skills, which enables them to predict their behavior control (Bandura, 1982). If they have little experience in controlling substance use, respondents may not yet know which situations will be most difficult, and if there is little change in situational challenge over time, there is less opportunity for self-efficacy to improve on predictions from past performance.

Self-efficacy is a summative subjective estimate of coping potential, and questions can also be raised about factors that maximize it. McKellar, Ilgen, Moos and Moos (2008) found the best predictor of self-efficacy to be AA attendance in the 12 months following treatment, with lesser contributions from diminished depression, avoidance coping, and social support.

32.5.4 10.5.4 Potential Macro- and Microenvironmental Mechanisms

Availability of Contingent Reinforcement. Alternative, nonsubstance related sources of reinforcement predict more positive outcomes (Moos, 2007), and many people with substance use problems live in environments with relatively impoverished availability and variety of reinforcers. As discussed above, both CM and CRT systematically manipulate access to a range of reinforcers, contingent on abstinence and other functional behaviors (Petry et al., 2005). Development of social roles such as employment or relationships with nonusers results in complex and sustainable “natural” reinforcers being put in place (along with other potential benefits, such as reduced exposure to temptation and acquisition of control skills).

Craving. In CE, repeated exposure to interoceptive and exteroceptive cues without ingesting the substance allows habituation of craving, in part because of the absence of pairing with pleasure or relief that is associated with substance use. As already noted, it can also be seen within an operant or skills-training paradigm, in which resistance of substance use is socially reinforced. Limitations to effectiveness of CE may in part stem from limited generalizability from clinical to natural settings, and the fact that any effective treatment involves repeated trials of resisting substance use in the natural environment (Kavanagh et al., 2006). Modification of cognitive responses such as craving may further improve effects of exposure (Kavanagh, Andrade, & May, 2004).

32.5.4.1 10.5.4.1 Changes in CNS Receptor Density and Activity

There are profound homeostatic changes that occur over prolonged exposure to addictive substances and alter the internal environment. For example, significant reductions in D2 dopamine receptors in key reward structures, including the Nucleus Accumbens, may influence mood, craving, and associative memory, as well as having downstream effects on gamma-aminobutyric acid (GABA) and endogenous opiates (Young, Lawford, Nutting, & Noble, 2004). Indirect sensitization of dopamine neurons may also occur via changes in stress-induced glucocorticoid release (Uhart & Wand, 2009) that mirror changes in the macro-environment, and emphasize the potential importance of effective stress management. Treatment of secondary depression or dysthymia may also affect neurotransmitter activity, as may environmental selection, social functioning, and confidence. Limitations to neural recovery may occur directly (e.g., from neurotoxic effects of substances) or indirectly (e.g., via nutritional deficits or brain trauma).

32.6 10.6 Basic Competencies of the Clinician

All clinical psychologists should have a basic understanding of substance use and misuse, and be able to assess consumption, screen for SUDs, conduct a functional analysis of a SUD and offer a basic evidence-based intervention. They should be particularly adept at dealing with substance-related problems of high population prevalence (e.g., nicotine, alcohol) and low physical dependence. Given high frequencies of other co-occurring disorders in people with substance misuse, practitioners should be able to adjust assessment and intervention techniques from other problem domains to people with co-occurring disorders with high population prevalence (e.g., anxiety and depression), and to clients that are most commonly seen in their clinical practice.

32.6.1 10.6.1 Generalized Competencies

Formation of a Trusting Relationship. While development of rapport and trust, listening and reflective skills, empathy, warmth, and acceptance are general competencies across problem domains, the counter-normative nature of substance use problems and the suspicion or hostility towards addiction services that is often seen in clients make it critical that these generalized competencies are highly developed in addiction practitioners. These attributes must be genuinely expressed – that is, psychologists cannot have negative attitudes toward people with addictive disorders if they are to be effective change agents.

Generalized Skills in Assessment and Intervention. Discussion of specific competencies for substance misuse below will assume that practitioners have well-developed competencies across areas covered in Volume I, encompassing the nature, conduct, and reporting of the following together with skills in referral and liaison with other health agents, giving and receiving effective supervision and consultation, and skills in searching and evaluating research evidence:
  • Interview-based assessments, including standard diagnostic interviews, mental status examinations, risk assessments, and detailed functional analyses,

  • Common psychometric measures, including tests of depression, anxiety, quality of life, and cognitive functioning, and

  • Cognitive and behavioral interventions (e.g., cognitive therapy, problem solving, social skills training, cognitive-behavioral marital interventions, contingency management) for individuals, families, and groups.

The focus below is on application of this knowledge and skills to substance misuse.

32.6.2 10.6.2 Basic Knowledge

To demonstrate competency, a clinical psychologist should have a broad, basic understanding of addictions and their assessment and management, including:
  • Key concepts of substance use and misuse (as outlined above).

  • Primary psychoactive drugs in current use and sources of information about population consumption patterns. While the range of abused substances is large and consumption patterns are subject to rapid change, psychologists should know drug classes, basic mechanisms, and the names (including common street names) of frequently misused substances. Ready access to information to community survey data on substance use is also needed. These data can provide normative information to challenge overestimations of the frequency of heavy consumption, and alert the practitioner to emerging consumption patterns.

  • Ethanol content of common alcoholic drinks, standard drink sizes, and recommended maximum consumption limits. Both standard drink sizes (Devos-Comby & Lange, 2008) and recommended maxima vary across different countries: clinical psychologists should be aware of local practices, and be able to calculate daily or weekly consumption of standard vendor serves of beer, wine, or spirits (excluding cocktails) in grams of ethanol.

  • Intoxication and withdrawal effects, including their duration. This should cover commonly used substances (caffeine, alcohol, nicotine, cannabis, and in some countries, cocaine) and substance groups (meth/amphetamines/3,4-methylenedioxymethamphetamine (MDMA), opiates, hallucinogens, inhalants). It should include an understanding of the stages and primary features of discontinuation syndromes, particularly alcohol or benzodiazepine withdrawal, which carry significant risks of adverse outcomes, including death (e.g., from seizures). In contrast, heroin withdrawal, which is typically viewed as more dangerous than withdrawal from alcohol, is rarely life-threatening and resembles a severe dose of influenza.

  • Common short- and long-term risks from frequently used substances and substance groups. These should not only involve pharmacological effects (e.g., alcoholic liver cirrhosis), but also risks from adulterated content (e.g., insoluble substances), mode of administration (e.g., infection via injection), loss of consciousness (e.g., inhalation of vomit), and associated risk behaviors (e.g., injuries, sexually transmitted diseases, nutritional deficiencies, hypothermia). It should also involve an awareness of common social, economic, occupational and legal consequences, and related deficits in functional behavior and quality of life.

  • Features of key substance-related disorders. In DSM-IV, this involves an understanding of criteria for substance dependence, abuse, intoxication and withdrawal, and an awareness of substance-induced disorders. Categories or criteria may significantly change in subsequent editions of DSM, and the clinical psychologist should be aware of any changes as they occur.

  • Factors associated with substance uptake and misuse. This includes an appreciation of subgroups associated with higher rates of substance misuse, and variables correlated with uptake and maintenance of use and misuse. A basic appreciation is needed of potential determinants within the ethnic, linguistic, or subcultural groups that are most likely to be encountered by the practitioner.

  • Factors associated with positive outcomes and relapse. Practitioners should understand factors and coping strategies associated with natural recovery. They should have a general appreciation of the following, including differences across substances (e.g., alcohol, nicotine) and client subgroups (e.g., low/high dependence, physical disorder, cognitive deficit):
    • Nature and treatment implications of harm reduction, moderation, and abstinence goals

    • Relative frequency of moderation and abstinence

    • Associations of moderation and abstinence with physical, functional, and neuropsychological outcomes

They should appreciate the distinctions between lapses and relapses, and common risk situations for lapses.
  • Cognitions, emotions, and behaviors commonly associated with risks of misuse and relapse. These cognitions should include low self-efficacy for substance control, permissive thoughts, overly positive substance expectancies, craving, and goal violation effects. Primary affective foci are depression, anxiety, anger, while key behaviors include deficits in substance refusal and alleviation of dysphoria.

  • Theoretical models of substance misuse, relapse, and recovery. Clinicians should appreciate the nature and evidence status of key theoretical approaches and exemplars, and their application to practice. Awareness of the Stages of Change model, its descriptive nature, and utility, are needed.

  • Strategies to assess consumption. This include quantity–frequency measures, Timeline Followback (Sobell & Sobell, 1992), and self-monitoring.

  • Psychometric instruments in common use. Knowledge of psychometric characteristics for measures of common addictive disorders, in the areas of screening (e.g., the Alcohol Use Disorders Identification Test; Saunders, Aasland, Babor, de la Fuente, & Grant, 1993) and degree of dependence or functional impact (e.g., Severity of Alcohol Dependence Questionnaire; Stockwell, Hodgson, Edwards, Taylor, & Rankin, 1979; Fagerstrom Tolerance Questionnaire; Tate & Schmitz, 1993).

  • Medical management. Practitioners should have a basic awareness of withdrawal and medically supported detoxification regimes and pharmacotherapies for substance dependence.

  • Psychological interventions and their relative evidence base. Appreciation is needed for strategies with a strong evidence base and for the lack of evidentiary support for confrontational methods. The knowledge should be sufficient to make an informed referral and know contexts where a basic generalized competency (e.g., social skills training, meditation, relaxation training) can usefully be applied. A more detailed knowledge of brief interventions including MI and of relapse prevention (including identification of high-risk situations and related problem solving) is required.

  • Common ethical issues in addiction practice. Substance misuse can present significant legal and ethical challenges for practitioners, especially where there are negative potential consequences of full disclosure (e.g., forensic, employment, housing), and where the clinical psychologist is an agent of the court, employer, or other authority. Awareness of common ethical issues and their resolution is required.

32.6.3 10.6.3 Basic Skills

32.6.3.1 10.6.3.1 Assessment

  • Accurate estimation of usual and current consumption across all psychoactive substances. This includes self-report data on usual quantity and frequency of consumption, assessment of current consumption using a Timeline Followback, and application of self-monitoring.

  • Reliable use and valid interpretation of relevant screening instruments.

  • Family history of substance misuse. Clinicians should be able to identify the presence and nature of substance misuse by members of the client’s immediate and extended family.

  • Personal history of substance use and misuse, and associated factors. Clinicians should be able to construct a timeline of substance use and misuse and periods of abstinence or moderation, identifying situational contexts for changes over time, together with physical, cognitive-affective, and functional outcomes. The nature and perceived effect of past treatments or self-help involvement should be noted. They should also be able to gather a history of any co-occurring disorders, and relate episodes of those disorders to the substance use history.

  • Situational triggers and consequences of recent substance use and abstention or control. Both perceptions or expectations and the actual nature and degree of association of triggers and consequences should be assessed. Current risk to the client and others should be covered.

  • Reliable diagnosis of SUDs, using a written standardized protocol.

  • Preparation of appropriate reports on the above issues and communication of the results to clients, family members, and health care agents.

32.6.3.2 10.6.3.2 Intervention

  • Effective conduct of a brief intervention. This involves feedback of assessment information (including population data), provision of informed advice, assistance in developing a behavior change plan, and follow-up of progress.

  • Basic competence in conducting a motivational interview. This includes the six principles of a mnemonic such as FRAMES (feedback, responsibility, advice, menu, empathy, and self-efficacy; Miller & Rollnick, 2002), and key strategies to elicit change talk (e.g., decisional balance, values exploration).

  • Application of clinical psychology interventions from other domains. These techniques should include effective education (e.g., about standard drinks), contingency management (e.g., for abstinence), problem solving (e.g., for high-risk situations), social skills training (e.g., for substance refusal), including effective use of modeling, cognitive therapy (e.g., for overly positive substance expectancies), CBTs for couples and families (e.g., to elicit nonintrusive social support for change, address social triggers for substance use, or reduce carer distress), and development of pleasurable or achievement-related activities and roles that are inconsistent with substance use.

32.7 10.7 Expert Competencies of the Clinician

Expert or specialist clinicians should have a higher level of knowledge, skills, and self-efficacy in all basic competencies, and be able to deal with more complex presentations or assist people who have not responded to basic interventions. They should be able to adapt their assessment and treatment approach to people of different ages, genders, or ethnic or cultural backgrounds. In addition, treatment needs to be responsive to different levels and types of substance use problems, or different maintaining factors, and to those with co-occurring physical or mental health issues. The specialist clinician should maintain a sound, current grasp of developments in addiction practice, emerging data on epidemiology, assessment and treatment, and a high level of skills in evaluating published evidence. The specialist should show creativity in the development of innovative interventions that are tailored to the needs of individuals and subgroups, while retaining consistency with existing research data and with results of a comprehensive functional assessment.

32.7.1 10.7.1 Specialist Knowledge

Addiction specialists should have a detailed and current understanding of:
  • Key substance-related concepts and related mechanisms (e.g., tolerance, reinstatement).

  • The full range of psychoactive drugs in current use, and recent trends in consumption. This knowledge should include current street names for these substances, their cost, usual dosage, and the likely nature of their active constituents.

  • Nature of intoxication and withdrawal effects of psychoactive substances in current use. While the nonspecialist was expected to have a basic understanding of effects from very common substances and primary substance groups, specialists should have a more detailed knowledge of specific substances, appreciate key neural mechanisms in intoxication, and have a broad understanding of metabolism of commonly used drugs (e.g., alcohol) and of drug interactions.

  • Short- and long-term risks from the use of specific substances. Particularly detailed knowledge is required about risks from substances in common use (e.g., nicotine, alcohol).

  • Features of substance-related disorders. This knowledge should include a detailed understanding of the nature of specific symptoms of SUDs, and be sufficient to allow reliable differential diagnosis in contexts of significant cognitive impairment or comorbidity. It should cover an appreciation of the features, frequency, causation, management, and prognosis of commonly associated physical disorders (e.g., human immunodefi-ciency virus/acquired immune deficiency syndrome (HIV/AIDS), Wernicke–Korsakoff syndrome).

  • Factors associated with substance uptake, and with onset and maintenance of misuse. An understanding is needed of the current status of variables associated with the onset and maintenance of substance misuse, and with relapse and recovery. This includes an understanding of the heritability of alcohol and other substance misuse, and a basic appreciation of specific genetic or other physiological hypotheses and their evidence base. A sophisticated understanding of ethnic, linguistic, or subcultural factors should be present, especially in relation to groups that are most likely to be encountered by the practitioner.

  • Factors associated with positive outcomes and relapse. Specialists should have a detailed appreciation of processes underpinning lapses and relapses, maintained recovery, relative merits, and applications of harm reduction, moderation, and abstinence goals.

  • Cognitions, emotions and behaviors commonly associated with risk of misuse and relapse.

  • Theories of substance misuse, relapse, and recovery. The specialist needs a detailed knowledge of the current evidence on specific models, and their relative utility.

  • Evidence status of strategies to assess consumption, and ways to maximize accuracy.

  • Psychometric instruments for screening, degree of dependence and functional impact of substance use, and their relative reliability, validity, and utility.

  • Medical management. Specialists should have a detailed appreciation of the nature, evidence base and indications for: (a) medical treatments for withdrawal and detoxification, and (b) pharmacotherapies for substance dependence. Knowledge of these interventions should include a basic appreciation of common complications or side effects and their management, and be sufficient to allow informed referral and collaboration, but not primary responsibility for their application.

  • Psychological interventions and their relative evidence base. This knowledge should be sufficient to underpin an evidence-based application of a wide range of preventive and treatment strategies, including interventions for people with high levels of dependence or complex co-occurring problems. A particularly sophisticated knowledge of brief interventions including MI and relapse prevention is required. Specialists should also have a detailed appreciation of TSF and other self-help approaches in common use, and of potential synergies with other interventions.

  • Ethical and legal issues in addiction practice. A sophisticated awareness of a wide range of ethical dilemmas and an ability to critically analyze alterative resolutions is required.

32.7.2 10.7.2 Specialist Skills

32.7.2.1 10.7.2.1 Assessment

  • Effective engagement of reluctant or suspicious clients in assessment.

  • Conduct of assessments in challenging contexts (e.g., other ethnic settings, or in the presence of cognitive dysfunction or other comorbidity).

  • Accurate estimation of usual and current consumption across all psychoactive substances. This includes the use of multiple imputation methods (e.g., amount and frequency, cost, usual purchase amount), resolution of conflicting information from multiple sources, sensitive application of a bogus pipeline technique, reliable and valid administration of a breath analysis for carbon monoxide or alcohol, and knowledge of biological assays.

  • Appropriate selection, reliable use and valid interpretation of psychometric instruments to screen for SUDs, and assess variables such as degree of dependence, functional impact, coping strategies, self-efficacy, substance expectancies, and social support.

  • Conduct and reporting of a detailed functional analysis, incorporating historical and current aspects. This should include an ability to undertake assessment in the style of a motivational interview, assess the degree of contingency, disentangle aspects relating to each of multiple substances, and assess the degree of interrelationship between co-occurring disorders or other problems. An expert, evidence-based assessment of specific risks to clients and others can be given.

  • Reliable diagnosis of SUDs. This should include a high level of reliability in the use of a standardized diagnostic interview, including the assessment of the independence of potentially comorbid disorders.

  • Preparation of reports on the above issues, and communication of the results. This should include the ability to prepare and defend an expert forensic report and identify appropriate multidisciplinary management strategies or referrals where indicated.

32.7.2.2 10.7.2.2 Intervention

  • Expert competence in conducting a motivational interview, including its application to subgroups in different affective states, or with varying cognitive abilities and personalities.

  • Application of clinical psychology interventions from other domains. A high level of skills is expected, in modifying these techniques to people with SUDs, including those with severe substance dependence or co-occurring disorders, and in developing individually tailored, integrated, and multicomponent treatments, based on needs, capacities, and goals of the client, as identified in a functional analysis.

  • Expert competence in specific strategies such as cue exposure and relapse prevention and in the integration of psychological intervention with medical or self-help approaches is needed.

32.7.2.3 10.7.2.3 Consultation and Supervision

The expert clinician is not only expected to have specialist skills in case management; but also to maintain a leadership role. In both consultation-liaison and supervision, the addiction specialist should be able to clearly communicate with practitioners from different disciplines or domains of practice and with varying levels of existing knowledge.

The nature of consultation-liaison and supervision or mentoring skills do not significantly differ from their application in other practice domains: The primary distinction here is the content that is being discussed. Consultants provide an authoritative and timely opinion on assessment and management, which is based on a sound assessment and detailed understanding of the current literature, and acknowledges its limitations (e.g., expertise, opportunity to assess the client, state of the field). Management recommendations should provide sufficient information for the other practitioner to implement them effectively, or recognize the necessity for additional training or client referral.

At times, consultation will merge into informal supervision. However, formal supervision typically involves a negotiated agreement for regular contact and a focus on practice-related work based on supervisees’ needs and negotiated goals (Kavanagh, Spence, Wilson, & Crow, 2002). While supervision frequently incorporates reflection on practice and related problem solving, common deficits are in the observation of practice, modelling of skills by the supervisor, and skills practice within sessions (Kavanagh et al., 2003).

32.7.2.4 10.7.2.4 Research Skills

Most addiction specialists will not publish research throughout their career, but day-to-day clinical practice will require a sophisticated and current understanding of research methodology and the abililty to evaluate and appropriately critique research reports.

32.8 10.8 Transition from Basic Competence to Expert

Basic competence is expected to be attained by the end of clinical psychology training programs, based on required units and clinical placement experience. Core units of generic clinical programs are unlikely to contain sufficient learning and experience to prepare addiction specialists, although elective coursework and placements could offer a sound foundation.

It may be possible to progress from a basic level of clinical competencies to a specialist or expert level by a combination of extensive supervised practice within an addiction setting, self-directed reading, participation in workshops, and conference or colloquium attendance. Feasibility of this route would be heightened if the practitioner had undertaken elective addiction units in their clinical program. However, a systematic and comprehensive coverage of expert competencies is best assured by the development of specialist tertiary programs and assessment procedures to ensure that competencies have been acquired.

A multidisciplinary postgraduate program on addiction or a postgraduate program for addiction counselors offers some benefits above self-directed learning, although its benefits would fall short of those from specialist psychology programs. Depending on their content, some multidisciplinary programs can offer training toward selected specialist competencies. However, it is difficult for multidisciplinary addiction programs to develop specialist skills to levels that would qualify a practitioner as an expert clinical psychologist in addiction, unless it had coursework and placement streams for specific professions to such an extent that it became indistinguishable from programs specifically for clinical psychologists.

We propose that clinical psychologists who wish to specialize in addiction should have already completed an accredited clinical psychology program, rather than going directly into a specialist program from an undergraduate degree. We take this position because the high occurrence of other comorbidities and their close association with substance misuse require that assessment and management of addictions take account of the full range of clients’ problems, rather than exclusively focusing on substance use. Development of addiction as a subspecialty of clinical psychology provides a practitioner with greater breadth and flexibility of skills and with greater occupational choices and utility to services than would be offered by addiction psychology as a totally separate type of psychology practice.

We argue that a post-clinical program in addiction should be of at least a year’s duration, in order to cover the expert competencies mentioned above in sufficient breadth and depth. It should include substantial structured clinical experience in the management of substance misuse under close supervision of clinical psychologists with an addiction specialty. A substantial part of specialist placements should be in a specialist addiction facility, in order to obtain an understanding of multidisciplinary addiction teams.

While basic competency in addiction practice requires a general appreciation of research and technological developments, there is a much greater requirement on specialists to maintain currency of their expert knowledge and skills. A specialist license or other recognition would require satisfaction of ongoing professional development, which ideally should include assessments to demonstrate the acquisition of knowledge and skills rather than just attendance.

32.9 10.9 Summary

Much of the knowledge and skills that are required for clinical psychologists to practice in substance misuse can be mapped from elements of sound clinical practice (e.g., development of rapport and engagement, conduct of a functional analysis, application, and interpretation of psychometric assessments, report writing, contingency management, ability to work in a multidisciplinary team). Other competencies can be mapped from those in other problem domains such as anxiety (e.g., exposure and response prevention), depression (e.g., cognitive therapy), or social skills. The primary task in these generic competencies is to appreciate their relevance to substance misuse (e.g., the social skill of substance refusal), and learn how to modify them for people with substance misuse.

A second set of competencies is also familiar, since although they originated in substance misuse, they now have wider application. Examples are motivational interviewing and relapse prevention based on prediction of high-risk situations. If these competencies are not already in the standard preparation of clinical psychologists, they should be.

Other aspects, such as an understanding of the nature and effects of substances, mechanisms underlying their effects, risk factors for substance misuse, processes of recovery or relapse, and relevant pharmacotherapies, are more specific to substance misuse domain. Because of the high frequency of substance misuse and its importance for outcomes from other disorders, clinical psychologists should be able to deal with low-severity and commonly occurring substance misuse, if they are to be effective as generalist practitioners.

Specialists of course require a more sophisticated understanding. Since the field is still evolving rapidly, the knowledge of both needs to remain current.

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