Module 2

Counselling Techniques

Compiled by Caleb Atmore CADC, CCS

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TABLE OF CONTENTS

Holistic Tools
Acupuncture
Spirituality Enhancement
Meditation
Nutritional Counselling

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Learning Objectives
• Introduction to Addiction Counselling
• Importance of Personal and Professional Growth
• Types of Counselling Overview
• Counselling Tools and Concepts
• Therapeutic Approaches Overview
• Understanding of Ethics in Counselling

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M2 Counselling Techniques
Section 1: Introduction
INTRODUCTION TO ADDICTION COUNSELLING
This module covers counselling techniques and skills used specifically in the addiction counselling field. As
addiction professionals we need to understand that in many ways, addiction counselling is different to the
ordinary counselling approach. Addicts generally have characteristics and behaviours that make ordinary
approaches in counselling very difficult. Being in most cases extremely dishonest and manipulative, not to
mention usually in denial about their problem, treating addicts can be very problematic.

The most effective addiction counsellor will be well rounded, with an ability to shift between key skills. Having
a feel for when and how to use skills in counselling is what makes the difference between average counsellor,
and a good counsellor. Sometimes a counsellor can be too assertive and directive, where they will seem to talk
at a client, rather than to them. This creates barriers in the kind of relationship you need to create with a client.
Then on the other hand, counsellors may be too empathetic and passive to the point that they can get sucked
into focusing too much on the problem rather than the solution. Being able to set boundaries and confront an
addict’s denial are essential to addiction counselling.

Remember that addiction counselling is an intervention. When you provide guidance or assist a client in making
a decision, you intervene in order to help that person to achieve a desired outcome.

Aim of counselling:

Helps clients take charge of their lives by:

• developing their ability to make wise and realistic decisions

• assisting them to alter their own behaviour to produce desirable results
• providing information for informed decision making

Addiction Counselling

What is addiction counselling?

An intervention which gives the client an opportunity to explore his or her substance use and consequences
confidentially, and to discuss available treatment options most appropriate to his/her circumstances

Why is addiction counselling needed?

• to encourage and motivate clients to reduce their drug use-related risks

• to support clients in seeking care and support
• Addicts who wish to stop using substances often benefit from counselling in combination with treatment
options

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What attributes make an ideal counsellor:

• Creative and imaginative

• Practical Shows
• Respect for client
• Action-oriented
• Doesn’t impose own views or concerns

Things to avoid when providing addiction counselling:

• Moralizing. Remember, the goal of your work is to help clients solve their problems. Never moralize
their experience.

• Ordering. You are their counsellor, not their supervisor or employer. You have no right to tell your clients
what to do.

• Threatening. Try to avoid attitudes or language that make your clients feel that they are threatened.
You should provide a supportive environment for your clients to share their problems.

• Arguing. Clients may not heed your advice and may use words that hurt you. Stay calm and help them
understand that they have the right to make their own decisions and that you will respect those decisions.

• Disagreeing. Your task is not to determine what is wrong and what is right. This may lead to
disagreement between you and your client, which can stall the counselling process.

• Over-interpreting. A counsellor's job is to understand his/her clients and to link their thoughts and goals
with a coherent plan. Counsellors must avoid over-interpreting what clients are telling them. Over-
interpreting may lead to misunderstandings of, or inappropriate focus on, some of the factors that are
critical in influencing behaviour change.

• Sympathizing. We will discuss empathy and sympathy later. A professional counsellor should not
become emotionally involved during the counselling session.

• Judging. Counselling assists clients to identify what puts them at risk. Judging your client may lead to
mistrust and denial of problems. You should listen without judging, criticizing or blaming, and try to gain
a better understanding of your client from his/ her viewpoint.

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Empathy versus Sympathy

Empathize

- Listen to and understand client's experience from his/her perspective

- Not always in agreement

- Summarize and provide feedback

- Help client find own solutions

- Client's suffering is not your burden

Sympathize

- Always side with client

- Emotionally involved

- Experience as if burden is shared

A counsellor successfully expresses empathy toward clients by listening and understanding what they are going
through. Counsellors are not obligated to agree with their clients, but they must not be judgmental in
disagreeing. The counsellor provides feedback and helps clients find their own solutions. Counsellors should
avoid sympathizing, should not take sides, and should not get emotionally involved as that will undermine the
potential benefits of counselling and can cause counsellor burnout.

Empathizing means understanding the circumstances, the situation, and what is happening to the client. It does
not mean sharing emotions. In empathizing, one is objective and compassionate without being overly emotionally
involved. Sympathizing is agreeing with the person, feeling their emotions, and being on their side.

When you sympathize, your clients no longer have you as a counsellor; they might do just as well talking to
themselves in a mirror. You stop being objective and reflective; you are just the same as your clients.

In empathizing, you understand what the person has gone through: their suffering, pain, and hurt. But when you
become sympathetic, you carry their pain and agree wholeheartedly with them, and you lose the ability to be
an effective counsellor.

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Counselling Principles for Quality Service

The success of drug addiction services in the community relies very much on the number of clients who utilize the
service. Bearing that in mind, there are certain principles that drug addiction counselling needs to adhere to so
as to promote quality services.

These are:

• Voluntary
• Confidential
• Reliable
• Non-judgmental
• Respectful
• Safe
• Linked with other services

Voluntary

Support clients to make decisions on their own

• Clients make decisions by themselves

• Clients do not feel forced to do anything
• Any breach will damage whatever trust has been built

When something is voluntary, it means that the person does it of their own free will. Counsellors help clients to
identify sound solutions, but they have no right to force clients to do anything. "Voluntary" is a critical principle
in counselling.

Let's take an example of a male client who comes talk to a counsellor. The counsellor explains the purpose of
counselling and asks questions to assess the severity of his drug use and talks about drug addiction treatment
options. Let's say the client does not want to commit to any plans. The counsellor has to respect this decision. The
counsellor can encourage, but not force the client to enter the treatment program.

Confidentiality

Confidentiality must be assured:

• Client personal information kept confidential

• Prevents reference to, or discussion about a client, except as professionally appropriate, and then
only with client’s consent
• Any breach of confidence will damage any trust that was built

Confidentiality is critical when working with drug-using clients. It is important that confidentiality is assured at
all times. Counsellors need to remember that a client's personal information must be kept confidential and they
cannot share it with anyone else outside of the professional relationship. Confidentiality prevents reference to,
or discussion about a client, except in situations where professionally appropriate. Then it must be done with
the knowledge and consent of the client.

In some cases, confidentiality will need to be breached if the counsellor finds that the client is knowingly placing
him/herself or others at risk. One such example might be if the client informs the counsellor that he/she is
considering suicide. In such circumstances, counsellors should advise their supervisors of the risk and determine
what course of action should be undertaken.

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Reliable

• Express sincere empathy

• Make clients feel they are being listened to and cared for
• Provide accurate information and clear explanations
• Demonstrate confidentiality

Clients will view counsellors who are reliable as sincere. Reliable counsellors are also punctual, predictable and
caring. Clients of reliable counsellors feel they are being listened to and cared for by their counsellors.
Counsellors who provide accurate information, clear explanations and appropriate referrals will be viewed as
more reliable than those who do not.

A reliable counsellor will also keep clients' personal information confidential.

Non-Judgmental

• Always stay neutral, without reaction to clients' issues

• Counsel only after learning from clients’ experience
• Obtain and maintain an understanding of clients’ perception of norms
• Always stay neutral; try not to judge or react strongly to your clients' issues. This lets you keep in
control and the client remain open to change.
• Counsellors will be able to counsel successfully when they learn from their clients’ experiences. Use
the information to guide the discussion.
• Having a good understanding of your clients’ perception of norms is very important. It helps you
relate their beliefs to the range of possible options you will help them consider.

Respectful

• Treat every client the same

• Respect clients as you expect others to respect you
• Mutual respect ensures effective communication and exchange

No principle of good counselling can stand alone. Each supports the other. We have discussed the need for
services to be voluntary, confidential, and non-judgmental. Services must also be respectful, safe, and link to
other services.

Having respect for your clients means that you treat every client the same. Your attitude towards them should
be consistent, regardless of their age, gender, appearance, social position, or financial status. Respect your
clients as you would expect others to respect you.

Mutual respect ensures effective communication and counsellor-client exchange. With mutual respect, clients will
become more cooperative, open and comfortable to share with you their “real problems”, which enables you
and your clients to identify sound solutions.

Safe

• Safety is crucial for both counsellors and clients

• Includes the safety of the client, his/her information, site property and physical environment
▪ the clients and their information
▪ clinic property
▪ the broader physical environment

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 Linked with other services

• Effective counselling is not limited to addressing drug use-related needs alone

• Linkage with other services is key, especially HIV services

Participation in drug addiction counselling brings stability to many clients. This stability allows them to deal with
a variety of other related issues that may be beyond the skills and expertise of the drug addiction counselling
service. In particular, problems such as housing, employment, health-related issues such as HIV and legal
problems are more likely to be managed in an effective way when the person is in drug addiction counselling.
Linking counselling services to those other services is an important component of effective drug addiction
counselling.

Personal Characteristics of Effective Counsellors

Particular personal qualities and characteristics of counsellors are significant in creating a therapeutic alliance
with clients. My views regarding these personal characteristics are supported by research on this topic (Norcross,
2011; Skovholt & Jennings, 2004). Nobody expects any counsellor to fully exemplify all the traits described
in the list that follows. Rather, the willingness to struggle to become a more therapeutic person is the crucial
variable. This list is intended to stimulate you to examine your own ideas about what kind of person can make
a significant difference in the lives of others.

 Effective counsellors have an identity. They know who they are, what they are capable of becoming,
what they want out of life, and what is essential.
 Effective counsellors respect and appreciate themselves. They can give and receive help and love out
of their own sense of self-worth and strength. They feel adequate with others and allow others to feel
powerful with them.
 Effective counsellors are open to change. They exhibit a willingness and courage to leave the security
of the known if they are not satisfied with the way they are. They make decisions about how they would
like to change, and they work toward becoming the person they want to become.
 Effective counsellors make choices that are life oriented. They are aware of early decisions they made
about themselves, others, and the world. They are not the victims of these early decisions, and they are
willing to revise them if necessary. They are committed to living fully rather than settling for mere
existence.
 Effective counsellors are authentic, sincere, and honest. They do not hide behind rigid roles or facades.
Who they are in their personal life and in their professional work is congruent. Effective counsellors
have a sense of humour. They are able to put the events of life in perspective. They have not forgotten
how to laugh, especially at their own foibles and contradictions.
 Effective counsellors make mistakes and are willing to admit them. They do not dismiss their errors lightly,
yet they do not choose to dwell on them, either.
 Effective counsellors generally live in the present. They are not riveted to the past, nor are they fixated
on the future. They are able to experience and be present with others in the “now.”
 Effective counsellors appreciate the influence of culture. They are aware of the ways in which their own
culture affects them, and they respect the diversity of values espoused by other cultures. They are
sensitive to the unique differences arising out of social class, race, sexual orientation, and gender.
 Effective counsellors have a sincere interest in the welfare of others. This concern is based on respect,
care, trust, and a real valuing of others.
 Effective counsellors possess effective interpersonal skills. They are capable of entering the world of
others without getting lost in this world, and they strive to create collaborative relationships with others.
They readily entertain another person’s perspective and can work together toward consensual goals.

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  Effective counsellors become deeply involved in their work and derive meaning from it. They can accept
the rewards flowing from their work, yet they are not slaves to their work.
 Effective counsellors are passionate. They have the courage to pursue their dreams and passions, and
they radiate a sense of energy. Effective counsellors are able to maintain healthy boundaries. Although
they strive to be fully present for their clients, they don’t carry the problems of their clients around with
them during leisure hours. They know how to say no, which enables them to maintain balance in their
lives (Corey, 2013).

Dealing with Your Anxieties

Most beginning counsellors have ambivalent feelings when meeting their first clients. A certain level of anxiety
demonstrates that you are aware of the uncertainties of the future with your clients and of your abilities to
really be there for them. A willingness to recognize and deal with these anxieties, as opposed to denying them,
is a positive sign. That we have self-doubts is normal; it is how we deal with them that matters. One way is to
openly discuss our self-doubts with a supervisor and peers. The possibilities are rich for meaningful exchanges
and for gaining support from fellow counsellors who probably have many of the same concerns and anxieties.
(Corey, 2013).
Being Yourself and Self-Disclosure

Because you may be self-conscious and anxious when you begin counselling, you may have a tendency to be
overly concerned with what the books say and with the mechanics of how to proceed. Inexperienced counsellors
too often fail to appreciate the values inherent in simply being themselves. If we are able to be ourselves in
our therapeutic work and appropriately disclose our reactions in counselling sessions, we increase the chances
of being authentic. It is this level of genuineness and presence that enables us to connect with our clients and to
establish an effective therapeutic relationship with them. It is possible to err by going to extremes in two
different directions. At one end are counsellors who lose themselves in their fixed role and hide behind a
professional facade. These counsellors are so caught up in maintaining stereotyped role expectations that little
of their personal selves shows through. Counsellors who adopt this behaviour will likely remain anonymous to
clients, and clients may perceive them as hiding behind a professional role.
At the other end of the spectrum is engaging in too much self-disclosure. Some counsellors make the mistake of
inappropriately burdening their clients with their spontaneous impressions about their clients. Judging the
appropriate amount of self-disclosure can be a problem even for seasoned counsellors, and it is often especially
worrisome for new counsellors. In determining the appropriateness of self-disclosure, consider what to reveal,
when to reveal, and how much to reveal. It may be useful to mention something about ourselves from time to
time, but we must be aware of our motivations for making ourselves known in this way. Assess the readiness of
a client to hear these disclosures as well as the impact doing so might have on the client. Remain observant
during any self-disclosure to get a sense of how the client is being affected by it.
The most productive form of self-disclosure is related to what is going on between the counsellor and the client
within the counselling session. The skill of immediacy involves revealing what we are thinking or feeling in the
here and now with the client, but be careful to avoid pronouncing judgments about the client. When done in a
timely way, sharing persistent reactions can facilitate therapeutic progress and improve the quality of our
relationship with the client. Even when we are talking about reactions based on the therapeutic relationship,
caution is necessary, and discretion and sensitivity are required in deciding what reactions we might share.
(Corey, 2013).

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Avoiding Perfectionism

Perhaps one of the most common self-defeating beliefs with which we burden ourselves is that we must never
make a mistake. Although we may well know intellectually that humans are not perfect, emotionally we often
feel that there is little room for error. To be sure, you will make mistakes, whether you are a beginning or a
seasoned therapist. If our energies are tied up presenting an image of perfection, this will affect our ability to
be present for our clients. I tell students to question the notion that they should know everything and be perfectly
skilled. I encourage them to share their mistakes or what they perceive as errors during their supervision
meetings. (Corey, 2013).
Being Honest About Your Limitations

You cannot realistically expect to succeed with every client. It takes honesty to admit that you cannot work
successfully with every client. It is important to learn when and how to make a referral for clients when your
limitations prevent you from helping them. However, there is a delicate balance between learning your realistic
limits and challenging what you sometimes think of as being “limits.” Before deciding that you do not have the
life experiences or the personal qualities to work with a given population, try working in a setting with a
population you do not intend to specialize in. This can be done through diversified field placements or visits to
agencies. (Corey, 2013).
Understanding Silence

Silent moments during a therapeutic session may seem like silent hours to a beginning therapist, yet this silence
can have many meanings. The client may be quietly thinking about some things that were discussed earlier or
evaluating some insight just acquired. The client may be waiting for the therapist to take the lead and decide
what to say next, or the therapist may be waiting for the client to do this. Either the client or the therapist may
be distracted or preoccupied, or neither may have anything to say for the moment. The client and the therapist
may be communicating without words. The silence may be refreshing, or the silence may be overwhelming.
Perhaps the interaction has been on a surface level, and both persons have some fear or hesitancy about
getting to a deeper level. When silence occurs, acknowledge and explore with your client the meaning of the
silence. (Corey, 2013).
Dealing with Demands from Clients

A major issue that puzzles many beginning counsellors is how to deal with clients who seem to make constant
demands. Because counsellors feel they should extend themselves in being helpful, they often burden themselves
with the unrealistic idea that they should give unselfishly, regardless of how great clients’ demands may be.
These demands may manifest themselves in a variety of ways. Clients may want to see you more often or for
a longer period than you can provide. They may want to see you socially. Some clients may expect you to
continually demonstrate how much you care or demand that you tell them what to do and how to solve a
problem. One way of heading off these demands is to make your expectations and boundaries clear during
the initial counselling sessions or in the disclosure statement. (Corey, 2013).

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Dealing with Clients Who Lack Commitment

Involuntary clients may be required by a court order to obtain therapy, and you may be challenged in your
attempt to establish a working relationship with them. It is possible to do effective work with mandated clients,
but practitioners must begin by openly discussing the nature of the relationship. Counsellors who omit
preparation and do not address clients’ thoughts and feelings about coming to counselling are likely to
encounter resistance. It is critical that counsellors not promise what they cannot or will not deliver. It is good
practice to make clear the limits of confidentiality as well as any other factors that may affect the course of
therapy. In working with involuntary clients, it is especially important to prepare them for the process; doing so
can go a long way toward lessening resistance. (Corey, 2013).
Tolerating Ambiguity

Many beginning counsellors experience the anxiety of not seeing immediate results. They ask themselves: “Am
I really doing my client any good? Is the client perhaps getting worse?” I hope you will learn to tolerate the
ambiguity of not knowing for sure whether your client is improving, at least during the initial sessions. Realize
that oftentimes clients may seemingly “get worse” before they show therapeutic gains. Also, realize that the
fruitful effects of the joint efforts of the therapist and the client may manifest themselves after the conclusion of
therapy. (Corey, 2013).
Becoming Aware of Your Countertransference

Working with clients can affect you in personal ways, and your own vulnerabilities and countertransference
are bound to surface. If you are unaware of your personal dynamics, you are in danger of being overwhelmed
by a client’s emotional experiences. Beginning counsellors need to learn how to “let clients go” and not carry
around their problems until we see them again. The most therapeutic thing is to be as fully present as we are
able to be during the therapy hour, but to let clients assume the responsibility of their living and choosing
outside of the session. If we become lost in clients’ struggles and confusion, we cease being effective agents in
helping them find solutions to their problems. If we accept responsibility for our clients’ decisions, we are
blocking rather than fostering their growth.
Countertransference, defined broadly, includes any of our projections that influence the way we perceive and
react to a client. This phenomenon occurs when we are triggered into emotional reactivity, when we respond
defensively, or when we lose our ability to be present in a relationship because our own issues become involved.
Recognizing the manifestations of our countertransference reactions is an essential step in becoming competent
counsellors. Unless we are aware of our own conflicts, needs, assets, and liabilities, we can use the therapy hour
more for our own purposes than for being available for our clients. Because it is not appropriate for us to use
clients’ time to work through our reactions to them, it is all the more important that we be willing to work on
ourselves in our own sessions with another therapist, supervisor, or colleague.
If we do not engage in this kind of self-exploration, we increase the danger of losing ourselves in our clients
and using them to meet our unfulfilled needs. The emotionally intense relationships we develop with clients can
be expected to tap into our own unresolved problem areas. Our clients’ stories and pain are bound to affect
us; we will be touched by their stories and can express compassion and empathy. However, we have to realize
that it is their pain and not carry it for them lest we become overwhelmed by their life stories and thus render
ourselves ineffective in working with them. Although we cannot completely free ourselves from any traces of
countertransference or ever fully resolve all personal conflicts from the past, we can become aware of ways
these realities influence our professional work. Our personal therapy can be instrumental in enabling us to
recognize and manage our countertransference reactions. (Corey, 2013).
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Developing a Sense of Humour

Therapy is a responsible endeavour, but it need not be deadly serious. Both clients and counsellors can enrich
a relationship through humour. What a welcome relief when we can admit that pain is not our exclusive domain.
It is important to recognize that laughter or humour does not mean that clients are not respected, or work is not
being accomplished. There are times, of course, when laughter is used to cover up anxiety or to escape from
the experience of facing threatening material. The therapist needs to distinguish between humour that distracts
and humour that enhances the situation. (Corey, 2013).
Sharing Responsibility with the Client

You might struggle with finding the optimum balance in sharing responsibility with your clients. One mistake is
to assume full responsibility for the direction and outcomes of therapy. This will lead to taking from your clients
their rightful responsibility of making their own decisions. It could also increase the likelihood of your early
burnout. Another mistake is for you to refuse to accept the responsibility for making accurate assessments and
designing appropriate treatment plans for your clients. How responsibility will be shared should be addressed
early in the course of counselling. It is your responsibility to discuss specific matters such as length and overall
duration of the sessions, confidentiality, general goals, and methods used to achieve goals.
It is important to be alert to your clients’ efforts to get you to assume responsibility for directing their lives.
Many clients seek a “magic answer” as a way of escaping the anxiety of making their own decisions. It is not
your role to assume responsibility for directing your clients’ lives. Collaboratively designing contracts and
homework assignments with your clients can be instrumental in your clients’ increasingly finding direction within
themselves. Perhaps the best measure of our effectiveness as counsellors is the degree to which clients are able
to say to us, “I appreciate what you have been to me, and because of your faith in me, and what you have
taught me, I am confident that I can go it alone.” Eventually, if we are effective, we will be out of business!
Declining to Give Advice

Quite often clients who are suffering come to a therapy session seeking and even demanding advice. They
want more than direction; they want a wise counsellor to make a decision or resolve a problem for them.
However, counselling should not be confused with dispensing information. Counsellors help clients discover their
own solutions and recognize their own freedom to act. Even if we, as counsellors, were able to resolve clients’
struggles for them, we would be fostering their dependence on us. They would continually need to seek our
counsel for every new twist in their difficulties. Our task is to help clients make independent choices and accept
the consequences of their choices. The habitual practice of giving advice does not work toward this end. (Corey,
2013).

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Learning to Use Techniques Appropriately

When you are at an impasse with a client, you may have a tendency to look for a technique to get the sessions
moving. Relying on techniques too much can lead to mechanical counselling. Ideally, therapeutic techniques
should evolve from the therapeutic relationship and the material presented, and they should enhance the client’s
awareness or suggest possibilities for experimenting with new behaviour. Know the theoretical rationale for
each technique you use, and be sure the techniques are appropriate for the goals of therapy. This does not
mean that you need to restrict yourself to drawing on procedures within a single model; quite the contrary.
However, it is important to avoid using techniques in a hit-or-miss fashion, to fill time, to meet your own needs,
or to get things moving. Your methods need to be thoughtfully chosen as a way to help clients make therapeutic
progress. (Corey, 2013).
Developing Your Own Counselling Style

Be aware of the tendency to copy the style of a supervisor, therapist, or some other model. There is no one
way to conduct therapy, and wide variations in approach can be effective. You will inhibit your potential
effectiveness in reaching others if you attempt to imitate another therapist’s style or if you fit most of your
behaviour during the session into the procrustean bed of some expert’s theory. Your counselling style will be
influenced by your teachers, counsellors, and supervisors, but don’t blur your potential uniqueness by trying to
imitate them. I advocate borrowing from others, yet at the same time, doing it in a way that is distinctive to
you. (Corey, 2013).
Maintaining Your Vitality as a Person and as a Professional

Ultimately, your single most important instrument is the person you are, and your most powerful technique is
your ability to model aliveness and realness. It is of paramount importance that we take care of ourselves, for
how can we take care of others if we are not taking care of ourselves? We need to work at dealing with those
factors that threaten to drain life from us and render us helpless. I encourage you to consider how you can
apply the theories you will be studying to enhance your life from both a personal and a professional standpoint.
Learn to look within yourself to determine what choices you are making (and not making) to keep yourself vital.
If you are aware of the factors that sap your vitality as a person, you are in a better position to prevent the
condition known as professional burnout. You have considerable control over whether you become burned out
or not. You cannot always control stressful events, but you do have a great deal of control over how you
interpret and react to these events. It is important to realize that you cannot continue to give and give while
getting little in return. There is a price to pay for always being available and for assuming responsibility over
the lives and destinies of others. Become attuned to the subtle signs of burnout rather than waiting for a full-
blown condition of emotional and physical exhaustion to set in. You would be wise to develop your own strategy
for keeping yourself alive personally and professionally.
Self-monitoring is a crucial first step in self-care. If you make an honest inventory of how well you are taking
care of yourself in specific domains, you will have a framework for deciding what you may want to change.
By making periodic assessments of the direction of your own life, you can determine whether you are living the
way you want to live. If not, decide what you are willing to actually do to make changes occur. By being in
tune with yourself, by having the experience of centeredness and solidness, and by feeling a sense of personal
power, you have the foundation for integrating your life experiences with your professional experiences.
Such an awareness can provide the basis for retaining your physical and psychological vitality and for being
an effective professional. Counselling professionals tend to be caring people who are good at taking care of
others, but often we do not treat ourselves with the same level of care. Self-care is not a luxury but an ethical
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mandate. If we neglect to care for ourselves, our clients will not be getting the best of us. If we are physically
drained and psychologically depleted, we will not have much to give to those with whom we work. It is not
possible to provide nourishment to our clients if we are not nourishing ourselves.
Mental health professionals often comment that they do not have time to take care of themselves. My question
to them is, “Can you afford not to take care of yourself?” To successfully meet the demands of our professional
work, we must take care of ourselves physically, psychologically, intellectually, socially, and spiritually. Ideally,
our self-care should mirror the care we provide for others. If we hope to have the vitality and stamina required
to stay focused on our professional goals, we need to incorporate a wellness perspective into our daily living.

Personal and Professional Growth

• Counsellor burnout: Signs and Symptoms: early warning signs; unique needs of the recovering counsellor; prevention
techniques.

Symptoms of Burnout

o Feeling tired or drained most of the time

o Lowered immunity, getting sick a lot
o Frequent headaches, back pain, muscle aches
o Sense of failure, self-doubt
o Feeling helpless, trapped and defeated
o Loss of motivation
o Increased negative outlook
o Decreases Satisfaction, sense of accomplishment
o Withdrawing from responsibilities
o Isolating yourself from others
o Procrastinating

Burnout prevention tips

o Start the day with a relaxing ritual. Rather than jumping out of bed as soon as you wake up, spend at least
fifteen minutes meditating, writing in your journal, doing gentle stretches, or reading something that inspires
you.
o Adopt healthy eating, exercising, and sleeping habits. When you eat right, engage in regular physical activity,
and get plenty of rest, you have the energy and resilience to deal with life’s hassles and demands.
o Set boundaries. Don’t overextend yourself. Learn how to say “no” to requests on your time. If you find this
difficult, remind yourself that saying “no” allows you to say “yes” to the things that you truly want to do.
o Take a daily break from technology. Set a time each day when you completely disconnect. Put away your laptop,
turn off your phone, and stop checking email.
o Nourish your creative side. Creativity is a powerful antidote to burnout. Try something new, start a fun project,
or resume a favourite hobby. Choose activities that have nothing to do with work.
o Learn how to manage stress. When you’re on the road to burnout, you may feel helpless. But you have a lot
more control over stress than you may think. Find someone to talk to about your own personal stress and
problems.

• Personal growth: Recognizing personal strengths and limitations and using that knowledge to promote personal and
professional growth.

o the importance of stress management

o relaxation techniques; leisure time skills
o physical exercise; proper nutrition
o the importance of discussing personal feelings with other professionals, AA sponsor, friends, and significant
others
o “practicing what we preach.”

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 • The recovering counsellor: Attending self-help meetings; personal programs for sobriety—the job will not keep you
sober.

• Professional growth: Ethical and professional standards, the relationship of consultation to counsellor support and
performance.

o the skills of a successful helper (empathy, self-disclosure, concreteness)

o resources for personal and professional growth (training, education, time management, consultation)
o the value of periodic self-assessment to professional growth (career planning)
o sources for secure information on current trends and developments in alcoholism and related fields
(professional associations, related groups, trade journals).

TYPES OF COUNSELLING
Individual, Group, and Family Counselling

• Objectives of counselling: Exploration of a problem and its ramifications; examination of attitude and
feelings; consideration of alternative solutions; decision making; therapeutic approaches (e.g., reality
therapy, rational emotive therapy, behaviour therapy, systematic therapy, transactional analysis).

• Family counselling: Theories of family co-dependency; techniques for motivating family involvement in
the treatment process; techniques of multifamily group counselling; limitations of the chemical
dependency counsellor; working with the family therapist; selecting an appropriate family therapist for
on-going family work; role-playing.

• Group counselling: Purpose and function of different types of counselling groups (open versus closed;
members with similar characteristics versus members who are different); models of groups, counsellor
intervention (specific variables to observe, considerations in timing an intervention, and types of
intervention); therapeutic factors in group counselling (getting feedback from others, having permission
to express strong feelings, feelings of belonging to a group); client behaviours that may affect group
participation outcome (minimum length of participation in the group, regular and timely attendance,
commitment to sobriety, commitment to participate); process group versus didactic/training group;
theories about the stags of group development; the role of the group counsellor at various stages of
group development; the difference between individual-oriented and group-oriented behaviour; group
techniques and exercises (their purposes, and possible consequences); group orientation process (group
ground rules, expectations of group members, and purposes of the group).

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Section 2: Individual Counselling

COUNSELLING TECHNIQUES AND CONCEPTS

Technique

A technique is a way of efficiently accomplishing a task in a manner that is not immediately obvious or
straightforward. An example of technique might be the way you cook fried rice. While many people can cook
fried rice, each of the steps necessary to accomplish making superior fried rice is not immediately obvious.

This section provides an overview of counselling techniques that may be useful with addicted clients.
Arranged in alphabetical order, each technique is identified with a clinical model, as described in the Clinical
Models section.

We classify these techniques on a three-point scale: (1) directive, (2) moderately directive, and (3)
nondirective. At one end of the scale, directive techniques openly confront and challenge the client to take
specific action (e.g., complete homework). At the opposite end, nondirective techniques, the counsellor
empathically supports the client. When using moderately directive techniques, the counsellor focuses both
on giving support and assisting the client in taking action (e.g., active scheduling):

• Acting as if (individual psychology—directive): In a role-play situation, clients act out the way they would
like to be in various life scenarios and explore alternatives. The underlying premise is that with practice
these behaviours feel more natural (G. Corey, 2000).

• Active listening (person-centred—nondirective): The counsellor uses a cluster of skills to increase accurate
understanding about what is being said. Good listening requires that the counsellor interact with the
client, offering affirming comments about what has been said, rephrasing the client’s comments to
encourage further commentary, and other appropriate expressions (see “Clinical Microskills” later in
this part; Egan, 1994).

• Activity scheduling (behaviour therapy—moderately directive): The counsellor works with the client to
initiate activities that move the client from inactivity to a more productive and vital state. Aside from
these activities, scheduling— itemizing choices and strategies—may immediately impact the client
positively (Corsini & Wedding, 2001).

• Analogies or images to illustrate problems (REBT—moderately directive): Analogies or images are used
to see a problem from a different viewpoint (G. Corey, 2000).

• Assertion training (behaviour therapy—moderately directive): Assertiveness, the ability to express one’s
needs and thoughts confidently without being either passive (hiding or muting) or aggressive (forcing
and badgering), is useful for clients who cannot express anger or frustration, who have difficulty saying
no, who allow others to take advantage of them, who have difficulty expressing affection, or who feel
they do not have the right to express thoughts and feelings. This training is a collection of techniques—
behaviour rehearsal, exposure, modelling, and reinforcement (Meichenbaum, 1977). Elaboration of
each is listed separately.

• Attending and listening (individual psychology—nondirective): The counsellor learns the core of a client’s
thoughts and feelings by being psychologically involved, engaging the client with eye contact, and
paying close attention to both verbal and nonverbal communication (Howatt, 2005).
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• Behaviour modelling (behaviour therapy—moderately directive): Also called vicarious learning
(developed by Bandura), the client learns by first observing the counsellor (or someone else) perform a
specific action, then imitates the modelled behaviour (Corsini & Wedding, 2001).

• Bibliotherapy (behaviour therapy—moderately directive): Reading assignments stimulate discussion,

convey new values and attitudes, help reframe the problem, and provide possible solutions (G. Corey,
2000).

• Brainstorming (individual psychology—moderately directive): This is an uncritical discussion of all

responses to open-ended, thought-provoking questions and problems, each designed to stimulate a list
of ideas pertinent to various choices and options (Egan, 1994).

• Catching oneself (individual psychology—directive): This technique is useful with clients who
catastrophize, are perfectionists, have eating disorders, and demonstrate obsessive-compulsive
behaviour. It raises awareness of self-destructive behaviour or irrational thought without self-
condemnation. Clients learn to anticipate events and change their behaviour patterns (G. Corey, 2000).

• Challenging (choice theory—directive): This is an invitation to recognize thoughts and/or behaviour that
is self-defeating, harmful to others (or both), and to change that behaviour (Howatt, 2000).

• Cognitive modelling (behaviour therapy—moderately directive): The counsellor performs tasks while
engaging in self-encouragement to demonstrate how clients may talk themselves successfully through a
task (Howatt, 2005).

• Cognitive restructuring (behaviour therapy—nondirective): The counsellor teaches clients to identify and
evaluate their thoughts and to replace negative ones with more realistic and appropriate thoughts
(James & Gilliland, 2001).

• Congruence (person-centred therapy—nondirective): The counsellor is honest and consistent in word and
behaviour (G. Corey, 2000).

• Contingency contracts (behaviour therapy—directive): The client and counsellor develop a contract
together designating behaviour to be performed or changed. Rewards are based on the achievement
of stated goals, the conditions under which they will be received, and the specific time frames for
completion (Howatt, 2000).

• Continuum line (REBT—directive): Clients rate their feelings about their addiction on a scale of 1 to 100
with 1 being the worst (they hate it) and 100 being the best (they love it). This provides an understanding
of where the client is in the treatment process and generates middle-ground options for clients
manifesting black or white thinking (Howatt, 1995).

• Contracting for change (transactional analysis—directive): Clients work with the counsellor to develop a
contract that specifically states what they plan to change in order to reach self-designated goals. The
counsellor is a witness and a facilitator (Howatt, 2000).

• Counter-conditioning (behaviour therapy—moderately directive): Also known as reciprocal inhibition

(Wolpe, 1982), the client practices being able to calmly respond to a stressful situation. The client learns
to lower anxiety levels by breathing deeply, stretching, and relaxing shoulder and neck muscles.

• Decatastrophize (cognitive—directive): Using “what if” questions, clients discover that their problems
may have grown out of proportion in their mind. This reduces anxiety so that positive collaboration and
cooperation can take place between client and counsellor (Howatt, 2000).

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• Description (existential—nondirective): Clients vividly describe to the counsellor what they are feeling or
experiencing, thus facilitating a better understanding between them (Howatt, 1995).

• Disputing perfectionism (REBT—nondirective): The counsellor shows clients (who thinks they must always
be good at everything) that perfectionism is self-defeating (Corsini & Wedding, 2001).

• Diversion (cognitive—directive): The counsellor distracts a sad or anxious client’s attention away from
the present concern, breaking an emotionally laden thought pattern, so that the client can return to the
appropriate treatment track (G. Corey, 2000).

• Empathy (person-centred therapy—nondirective): The counsellor sees and feels the client’s world as
though immersed in that world. By assuming the internal frame of reference of the other, the counsellor
understands the client’s private pain (James & Gilliland, 2001).

• Encouragement (individual psychology—directive): The counsellor praises clients’ strengths and progress,
recognizing, labelling, and accepting their positive qualities. This increases clients’ self-confidence,
counters discouragement, and helps them set realistic goals (G. Corey, 2000).

• Exaggeration (Gestalt—directive): The counsellor asks the client to exaggerate a certain thought,
emotion, or body movement that has just been expressed, allowing the client to become more aware of
hidden feelings and defence mechanisms (Howatt, 2000).

• Extinction (behaviour therapy—moderately directive): Undesirable behaviours are discouraged and

eventually eliminated by removing rewards that stimulate the behaviour (Corsini & Wedding, 2001).

• Feedback (behaviour therapy—moderately directive): Praise, encouragement, and specific constructive

suggestions for modifying errors help clients learn new behaviours (James & Gilliland, 2001).

• Fruit basket technique (REBT—directive): The counsellor shows a fruit basket with good and bad fruit to
demonstrate that although the client may have some flaws and done some bad things, the client also
has virtues and is basically a good person (Howatt, 2000).

• Goal setting (interpersonal—directive): Brainstorming specific objectives and strategies and then
arranging emerging plans in the best sequence for a positive outcome mobilizes the client to
appropriate action (Corsini & Wedding, 2001).

• Graduated exposure (behaviour therapy—directive): Step-by-step exposure to real-life situations enable

clients to practice skills or preferred behaviour in anxiety-provoking situations (Howatt, 2000).

• Graduated task assignment (behaviour therapy—directive): Clients learn to reduce anxiety while
developing new skills by taking an assigned task (often given as homework) that begins simply and
then gradually becomes more difficult and complex (Howatt, 1995).

• Helper self-disclosure (individual psychology—moderately directive): The counsellor appropriately shares

selected and focused experiences, behaviours, and feelings with clients. This builds the client-counsellor
relationship and encourages the client to disclose hidden feelings and thoughts (Howatt, 2005a).

• Humour and jolting language (sarcasm; REBT—moderately directive): Appropriate humour by the
counsellor can relax clients and encourage them to open up. Sarcasm may help clients identify their
irrational beliefs and laugh at their behaviour (Howatt, 2000).

• Imagery (cognitive—directive): Metaphors and/or visual pictures developed by counsellor and client
may help clients develop insight about their thinking and provide the counsellor with a clearer impression
of clients’ automatic thoughts (G. Corey, 2000).
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• Immediacy (individual psychology—directive): Addressing what is going on in the present counselling
session may help the client see that what is occurring is a sample of everyday life (G. Corey, 2000).

• Language exercises (Gestalt—directive): An examination of speech patterns that helps clients increase
self-awareness and personal responsibility by acknowledging their thoughts, feelings, and actions
(Howatt, 1995).

• Magic wand (individual psychology—directive): Clients pretend they have a magic wand and can wish
for anything to allow them to look beyond present circumstances and define their real wants in life
(Howatt, 2000).

• Offering options (individual psychology—directive): The counsellor offers clients a choice among several
options (Corsini & Wedding, 2001).

• Paradoxical intention (reality therapy—moderately directive): Clients are instructed to consciously

exaggerate debilitating thoughts and behaviours, creating an awareness of how out of proportion their
response is to the situation. Also called prescribing the symptoms and anti-suggestion (Wubbolding,
1988).

• Paradoxical intervention (logo therapy—directive): The counsellor places clients in a double bind to cut
through their resistance by asking them to exaggerate or even perfect a problematic behaviour (G.
Corey, 2000).

• Paradoxical technique (REBT—directive): Clients are asked to perform the presenting irrational
behaviour at a certain time every day, thus removing the gratification received from performing the
irrational behaviour (Howatt, 2000).

• Playing the projection (Gestalt—directive): Clients pretend to be the recipient of the statements that they
make about others. These statements, often projections of attributes that clients possess, bring awareness
of inner conflicts (G. Corey, 2000).

• Push-button technique (individual psychology—directive): Clients close their eyes and alternately picture
a pleasant and an unpleasant experience while paying attention to the feelings accompanying each
experience. This teaches clients that they can create whatever feelings they wish by relying on their
thoughts (Corsini & Wedding, 2001).

• Reframing (cognitive—directive): Reframing provides a different interpretation of a particular situation,

allowing a client to understand an original complaint from different angles (G. Corey, 2000).

• Reinforcement (behaviour therapy—directive): A pleasant stimulus increases a desired behaviour (James

& Gilliland, 2001).

• REBT self-help form (REBT—directive): The client completes this form and the counsellor uses it to
determine the nature and extent of a client’s faulty beliefs. (These REBT forms can be obtained from
the Institute for Rational Emotive Therapy, 45 East 65th Street, New York, 10021, 212-535-0822;
Howatt, 2005.)

• Role play (behaviour therapy—moderately directive): Playing different roles enhances clients’ ability to
interact effectively with others in differing situations. Clients begin by acting out a designated situation
and then develop their own scenario. They then keep track of difficult situations that occur outside
therapy. One of these situations is chosen for role-playing, with either coaching or modelling by the
counsellor. After each role-play, feedback is given pertaining to the client’s strengths and weaknesses
(Corsini & Wedding, 2001).

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 • Self-monitoring (cognitive—directive): Clients monitor and record their thoughts just prior to, or during,
problem behaviour. During counselling sessions, the client discloses these thoughts, providing clues to the
behaviour and its treatment (James & Gilliland, 2001).

• Sharing hunches (Gestalt—directive): The counsellor or group members share feelings and perceptions
of other members in a tentative manner or in the form of an intuition or hunch. This provides clients with
insight into how others see them (should only be done with clients’ permission; G. Corey, 2000).

• Spitting in the client’s soup (individual psychology—directive): When counsellors determine that clients
are getting a reward from maladaptive behaviour, they may spoil the reward for clients by making
them aware of the nature and consequences of this behaviour (Howatt, 2000).

• Staying with the feeling (Gestalt—directive): When clients experience unpleasant feelings, the counsellor
encourages them to stay with these feelings. By experiencing and confronting negative emotions,
courage develops, as does growth through experiencing pain (G. Corey, 2000).

• Systematic desensitization (behaviour therapy—directive): Clients imagine various scenes so they

gradually overcome fearful responses to anxiety-producing events. Clients are first helped to relax
physically, then asked to imagine a low-anxiety item from a prepared list and maintain focus on that
item while remaining calm until no more anxiety is felt. The counsellor then has the client move on to
imagine a more stressful scene, repeating the procedure step by step until the client can respond to the
worst item on the list with calmness instead of fear (James & Gilliland, 2001).

• Teaching the ABC model (REBT—directive): This teaching tool is based on the idea that irrational beliefs
are the core of an individual’s problems: A—activating event; B—belief about that event; C—the
consequence(s) of the belief. It teaches clients that their belief about an event, and not the event itself,
leads to the subsequent feelings or behaviours (Corsini & Wedding, 2001).

• Two-chair technique (Gestalt—moderately directive): Chairs, set up across from each other, allow clients
to dialogue with themselves and play all the roles. Clients change chairs when they change roles
(Howatt, 2000).

Additional Resources

Gilliland, B. E., & James, R. K. (1998). Theories and strategies in counselling and psychocounselling (4th ed.). New York: Allyn & Bacon,
is a well-written and detailed review of the most commonly used counselling theories useful in addiction counselling. Howatt, W. A.
(2000). The human services counselling toolbox. Pacific Grove, CA: Brooks/Cole, is a reference tool containing information on theory,
techniques, and strategies for working with persons with addictive disorders. This book was developed with students who were
learning how to become addiction counsellors. Corsini, R. J., & Wedding, D. (Eds.). (2001). Current psychotherapist (6th ed). Belmont,
CA: Brooks/Cole; one of the most complete and detailed books on counselling theory in print today. Sommers-Flanagan, J., &
Sommers-Flanagan, R. (2004). Counselling and psychotherapy theories in context and practice: Skills, strategies, and techniques.
Hoboken, NJ: Wiley.

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CLINICAL MICROSKILLS
The following Microskills work well with clients (Howatt, 2002):

• Active listening: Be actively engaged, totally focused, and show empathy for the client.

• Body gestures: Be mindful of your and your client’s body language and remember that kinetics (body
language) can influence up to 80% of all communication.

• Chronemics: Be accurate regarding time, locations, and recall.

• Clarification statements: State what you think the client is saying to determine if you are tracking the
conversation properly.

• Conflict avoidance: While it is not necessary to always agree with a client, avoid debate.

• Congruence: Stay in tune with your intentions and motivations as you talk. Is your body language in
sync with your verbal message?

• Consequence questions: Ask clients about the likely consequences of their actions. Are they aware of the
cost of their choices?

• Contextual listening: Listen for content and details, and how the events impact the client, cognitively
and emotionally.

• Emotional filter: Be aware of your own emotions when a client is talking and do not let clients override
your rationality.

• Empathy: Be genuinely concerned about clients, their feelings, problems, and well-being.

• Encouraging gestures: Supportive statements by the counsellor encourage the client to continue
exploring a stressful topic.

• Eye contact: Maintain direct eye contact when it is comfortable and safe for a client, but be aware
that clients from some cultures may initially regard direct eye contact as confrontational and threatening.

• Favourite phrases: Note the client’s favourite words and expressions and use them when appropriate.

• Frame of reference: Ascertain clients’ point of view—and “internal mental filters”—that shape their
perceptions of events.

• Gender and cultural differences: Seek to understand and respect individual differences. If you don’t
know, ask.

• Generalizing: Help clients address specific issues and problems instead of masking them with general
statements.

• “I” language: Help clients take responsibility for their feelings. It might be useful for the client to say,
“When I say/hear/experience, I feel . . .”

• Inferences: Evaluate clients by their actions, not by their words.

• Innocent probes: Use expressions such as “Hmmm,” “I understand,” “yes,” and so on, to keep the
conversation going and to demonstrate that you are listening and engaged.

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• Justifying question: Ask questions in a non-judgmental manner if you need to point out inconsistencies
in what is being said. This shows you are listening and tracking the conversation.

• Mirroring: Use similar body language—hand gestures, body position, and movement—as clients to
make them feel more relaxed and comfortable.

• Nonattention: Ignore attacking or offensive comments and behaviours by looking away; do not reinforce
the inappropriate behaviour.

• Nonthreatening communication: Be aware of the inherent power of your position. Assist clients; don’t try
to control them.

• Observe proximities: Since the typical client prefers to communicate at a range of 4 to 6 feet, arrange
the two counselling chairs at a 45-degree angle to each other, so that client and counsellor each have
an open field and free space in front. Since space preferences vary, ask if you’re not sure.

• Open-ended questions: Ask questions that encourage clients to explore and elaborate, not just reply with
a yes or no.

• Overcoming deflection: Help clients address the issues instead of shying away from painful subjects (by
changing the topic, generalizing, asking questions, or extensive joking).

• Positive assets statement: Frankly and honestly point out clients’ positive qualities.

• Positive regard: Maintain consistent non-judgmental caring no matter what actions clients choose.

• Reality congruence: Note if clients’ views of their situation are consistent with reality. Do clients say one
thing but their voice and body posture suggest something else?

• Reflecting: Repeating key concepts presented by clients encourages disclosure of further information.

• Reframing: Provide clients with another, more optimistic way to look at a problem.

• Selective attention: Ask a question to get the client back on task with focus on the present situation and
needs.

• Shadowing: Repeat what the client said, using the client’s own words.

• Summarizing: Review what the client has said to ensure that you have properly heard and understood
the client’s story.

• Silence: Be calm and patient and allow spaces, when appropriate, to reflect.

• Validating: Make a clear statement that you understand the situation and acknowledge the client’s
views.

• Voice tone: Match the client’s speech in terms of speed, volume, tone, timbre, and pitch when
appropriate.

• Values invasion: Go with the client’s personal values as to what is important and meaningful, do not
impose your own.

• Vocabulary: Speak at the client’s level and be aware of regionalisms and colloquialisms.

• Warm regard: Genuinely show non-judgmental, accepting, positive regard for the client through

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thought and deed. Additional Resources Howatt, W. A. (2002). Discipline of communication. Kentville,
Nova Scotia, Canada: A Way with Words. This, user-friendly tool, helps addiction counsellors improve
communication skills. Find an excellent resource for to obtain additional information about microskill
training at the web site of Microtraining and Multicultural Development:
www.emicrotraining.com/microskills.html.

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COMMON DEFENCE MECHANISMS
Primitive Defence Mechanisms

Denial

Denial is the refusal to accept reality or fact, acting as if a painful event, thought or feeling did not exist. It is
considered one of the most primitive of the defence mechanisms because it is characteristic of early childhood
development. Many people use denial in their everyday lives to avoid dealing with painful feelings or areas
of their life they don’t wish to admit. For instance, a person who is a functioning alcoholic will often simply deny
they have a drinking problem, pointing to how well they function in their job and relationships.

Regression

Regression is the reversion to an earlier stage of development in the face of unacceptable thoughts or impulses.
For an example an adolescent who is overwhelmed with fear, anger and growing sexual impulses might become
clingy and start exhibiting earlier childhood behaviours he has long since overcome, such as bedwetting. An
adult may regress when under a great deal of stress, refusing to leave their bed and engage in normal,
everyday activities.

Acting Out

Acting Out is performing an extreme behaviour in order to express thoughts or feelings the person feels
incapable of otherwise expressing. Instead of saying, “I’m angry with you,” a person who acts out may instead
throw a book at the person, or punch a hole through a wall. When a person acts out, it can act as a pressure
release, and often helps the individual feel calmer and peaceful once again. For instance, a child’s temper
tantrum is a form of acting out when he or she doesn’t get his or her way with a parent. Self-injury may also
be a form of acting-out, expressing in physical pain what one cannot stand to feel emotionally.

Dissociation

Dissociation is when a person loses track of time and/or person, and instead finds another representation of
their self in order to continue in the moment. A person who dissociates often loses track of time or themselves
and their usual thought processes and memories. People who have a history of any kind of childhood abuse
often suffer from some form of dissociation. In extreme cases, dissociation can lead to a person believing they
have multiple selves (“multiple personality disorder”). People who use dissociation often have a disconnected
view of themselves in their world. Time and their own self-image may not flow continuously, as it does for most
people. In this manner, a person who dissociates can “disconnect” from the real world for a time, and live in a
different world that is not cluttered with thoughts, feelings or memories that are unbearable.

Compartmentalization

Compartmentalization is a lesser form of dissociation, wherein parts of oneself are separated from awareness
of other parts and behaving as if one had separate sets of values. An example might be an honest person who
cheats on their income tax return and keeps their two value systems distinct and un-integrated while remaining
unconscious of the cognitive dissonance.

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Projection

Projection is the misattribution of a person’s undesired thoughts, feelings or impulses onto another person who
does not have those thoughts, feelings or impulses. Projection is used especially when the thoughts are
considered unacceptable for the person to express, or they feel completely ill at ease with having them. For
example, a spouse may be angry at their significant other for not listening, when in fact it is the angry spouse
who does not listen. Projection is often the result of a lack of insight and acknowledgement of one’s own
motivations and feelings.

Reaction Formation

Reaction Formation is the converting of unwanted or dangerous thoughts, feelings or impulses into their
opposites. For instance, a woman who is very angry with her boss and would like to quit her job may instead
be overly kind and generous toward her boss and express a desire to keep working there forever. She is
incapable of expressing the negative emotions of anger and unhappiness with her job, and instead becomes
overly kind to publicly demonstrate her lack of anger and unhappiness.

Less Primitive, More Mature Defence Mechanisms

Less primitive defence mechanisms are a step up from the primitive defence mechanisms in the previous section.
Many people employ these defences as adults, and while they work okay for many, they are not ideal ways
of dealing with our feelings, stress and anxiety. If you recognize yourself using a few of these, don’t feel bad
– everybody does.

Repression

Repression is the unconscious blocking of unacceptable thoughts, feelings and impulses. The key to repression is
that people do it unconsciously, so they often have very little control over it. “Repressed memories” are memories
that have been unconsciously blocked from access or view. But because memory is very malleable and ever-
changing, it is not like playing back a DVD of your life. The DVD has been filtered and even altered by your
life experiences, even by what you’ve read or viewed.

Displacement

Displacement is the redirecting of thoughts feelings and impulses directed at one person or object, but taken
out upon another person or object. People often use displacement when they cannot express their feelings in a
safe manner to the person they are directed at. The classic example is the man who gets angry at his boss, but
can’t express his anger to his boss for fear of being fired. He instead comes home and kicks the dog or starts
an argument with his wife. The man is redirecting his anger from his boss to his dog or wife. Naturally, this is a
pretty ineffective defence mechanism, because while the anger finds a route for expression, it’s misapplication
to other harmless people or objects will cause additional problems for most people.

Intellectualization

Intellectualization is the overemphasis on thinking when confronted with an unacceptable impulse, situation or
behaviour without employing any emotions whatsoever to help mediate and place the thoughts into an
emotional, human context. Rather than deal with the painful associated emotions, a person might employ
intellectualization to distance themselves from the impulse, event or behaviour. For instance, a person who has
just been given a terminal medical diagnosis, instead of expressing their sadness and grief, focuses instead on
the details of all possible fruitless medical procedures.

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Rationalization

Rationalization is putting something into a different light or offering a different explanation for one’s
perceptions or behaviours in the face of a changing reality. For instance, a woman who starts dating a man she
really, really likes and thinks the world of is suddenly dumped by the man for no reason. She reframes the
situation in her mind with, “I suspected he was a loser all along.”

Undoing

Undoing is the attempt to take back an unconscious behaviour or thought that is unacceptable or hurtful. For
instance, after realizing you just insulted your significant other unintentionally, you might spend the next hour
praising their beauty, charm and intellect. By “undoing” the previous action, the person is attempting to
counteract the damage done by the original comment, hoping the two will balance one another out.

Mature Defence Mechanisms

Mature defence mechanisms are often the most constructive and helpful to most adults, but may require practice
and effort to put into daily use. While primitive defence mechanisms do little to try and resolve underlying
issues or problems, mature defences are more focused on helping a person be a more constructive component
of their environment. People with more mature defences tend to be more at peace with themselves and those
around them.

Sublimation

Sublimation is simply the channelling of unacceptable impulses, thoughts and emotions into more acceptable
ones. For instance, when a person has sexual impulses they would like not to act upon, they may instead focus
on rigorous exercise. Refocusing such unacceptable or harmful impulses into productive use helps a person
channel energy that otherwise would be lost or used in a manner that might cause the person more anxiety.
Sublimation can also be done with humour or fantasy. Humour, when used as a defence mechanism, is the
channelling of unacceptable impulses or thoughts into a light-hearted story or joke. Humour reduces the intensity
of a situation, and places a cushion of laughter between the person and the impulses. Fantasy, when used as a
defence mechanism, is the channelling of unacceptable or unattainable desires into imagination. For example,
imagining one’s ultimate career goals can be helpful when one experiences temporary setbacks in academic
achievement. Both can help a person look at a situation in a different way, or focus on aspects of the situation
not previously explored.

Compensation

Compensation is a process of psychologically counterbalancing perceived weaknesses by emphasizing strength

in other arenas. By emphasizing and focusing on one’s strengths, a person is recognizing they cannot be strong
at all things and in all areas in their lives. For instance, when a person says, “I may not know how to cook, but I
can sure do the dishes!,” they’re trying to compensate for their lack of cooking skills by emphasizing their
cleaning skills instead. When done appropriately and not in an attempt to over-compensate, compensation is
defence mechanism that helps reinforce a person’s self-esteem and self-image.

Assertiveness

Assertiveness is the emphasis of a person’s needs or thoughts in a manner that is respectful, direct and firm.
Communication styles exist on a continuum, ranging from passive to aggressive, with assertiveness falling neatly
in-between. People who are passive and communicate in a passive manner tend to be good listeners, but rarely
speak up for themselves or their own needs in a relationship. People who are aggressive and communicate in
an aggressive manner tend to be good leaders, but often at the expense of being able to listen empathetically
to others and their ideas and needs. People who are assertive strike a balance where they speak up for
themselves, express their opinions or needs in a respectful yet firm manner, and listen when they are being
spoken to. Becoming more assertive is one of the most desired communication skills and helpful defence
mechanisms most people want to learn, and would benefit in doing so.
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COMMON STYLES OF NEGATIVE SELF-TALK
Self-talk is an ever-present part of life. You continually appraise or assess stressors as to their nature and likely
effects on your experience. In short, you think about them. As noted, the content of this thinking affects the
emotional, physical, and behavioural responses that follow.

Life is challenging, hard, sometimes downright difficult. Yet people’s thinking often makes events worse than
they truly need be. Several common styles of negative self-talk can be identified through which individuals
sometimes make themselves miserable—or miserable to be around:

• Negativizing: Filtering out positive aspects of a situation, while focusing only on negatives
• Awfulizing: Turning a difficult or unsatisfactory situation into something awful, terrible, and intolerable
• Catastrophizing: Expecting that the worse almost certainly will happen
• Overgeneralizing: Generalizing from a single event or piece of information to all or most such things
• Minimizing: Diminishing the value or importance of something to less than it actually is
• Blaming: Attributing responsibility for events, especially negative ones, to someone else, even when
such responsibility rightfully belongs to self
• Perfectionism: Setting impossible standards toward self, others, or both in many situations
• Musterbation: Demanding that events must turn out as I want them to—otherwise, it inevitably will be
very upsetting to me.
• Personalizing: Believing that others’ behaviour or feelings are entirely caused by self
• Judging human worth: Evaluating total worth of self or others on the basis of traits or behaviour
• Control fallacy: The belief that happiness depends on cajoling or coercing others to do what I think they
should
• Polarized thinking: Things are black and white, right or wrong, good or bad. There is no middle ground
• Being right: I am continually on trial to prove that my opinions and actions are correct. Being wrong is
unthinkable. Therefore, I must go to any length to demonstrate my rightness
• Fallacy of fairness: Feeling resentful because the world does not conform to my sense of what is fair
• Shoulding: Constant imposition of shoulds and should haves on self, others or both

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REWRITING OLD BELIEFS

The following are 20 common unreasonable or irrational beliefs that often lead to negative situational self-
talk. Read them and then do the exercise, “Rewriting Irrational Beliefs.”

Irrational Beliefs

• Other people and outside events upset me.

• I am think-skinned by genetic nature—I was born that way.
• I cannot control my thoughts and feelings.
• I cannot change. I am too old, too set in my ways, beyond hope.
• It is imperative that I be accepted by others, especially by those who are important to me.
• Most people are bad and wicked and cannot be trusted.
• If things do not go my way, it will be awful, terrible, or catastrophic.
• The only way to improve my stress is to shape up others around me who do such dumb things.
• It is easier to avoid responsibilities and difficulties than to face them.
• My early childhood experiences determine my emotions and behaviour, and there is little I can do
about it.
• I deserve to be upset or depressed over my shortcomings.
• I am fully justified in being aggravated over others’ shortcomings, deficiencies, and blunders.
• I should be thoroughly competent, adequate, and achieving in all respects.
• The world should always be fair, justice should always triumph, and I am fully justified in feeling angry
when these do not occur.
• I feel like I should do perfectly in nearly anything I attempt.
• There usually is one solution to a problem. It is pretty intolerable when this solution is not found or
followed.
• I have a clear idea how other people should be and what they should do most of the time.
• Others should treat me kindly and considerately at all times.
• I have a right to expect a relatively pain-free and trouble-free life.
• When people around me are upset, it is usually because of something I have said or done.

From Stress Management for Wellness (2nd ed., pp. 235–237), by W. Schafer, 1992, Fort Worth, TX: Harcourt Brace
Jovanovich College Publishers. Reprinted with permission.

REWRITING IRRATIONAL BELIEFS

• Circle the irrational beliefs you recognize as more present in yourself than you would like.
• List those you would like to change in a separate list, leaving several lines between each one.
• Below each one, write a more rational or reasonable version, keeping in mind the three criteria of rational beliefs:
factual, moderate, helpful.
• After rewriting each one, ask: What concrete difference would it make in my life to act on these new reasonable
beliefs?

Additional Resources To find an excellent online resource for life management tips, see the Willamette Learning Enhancement
Resources at www.willamette.edu/cla/ler /managinglife.htm. Mind Tools has a section on stress management that will assist clients
learn how to cope with stress. For a host of effective stress management tips go to www.mindtools.com. The National Institute on
Drug Abuse has a useful report on the connection between stress and addictions: www.nida.nih.gov/StressAlert/StressAlert.html.

29
Section 3: Therapeutic Approaches

CLINICAL MODELS OF THERAPY

Most counselling or therapeutic approaches originate from one or more of the following Clinical Models of
Therapy. This manual will give you a brief overview of the origins and concepts, but each of these approaches
are broad, and can be studied individually in much detail. This manual focuses more on the techniques derived
from each of these approaches.

SIGMUND FREUD’S PSYCHOANALYTIC THERAPY

Psychoanalytic Therapy (also called psychodynamic and psychoanalysis) is based on the assumption that
behaviour results from the conflict between the conscious and unconscious minds, and biological and social forces
(H. S. Friedman & Schustack, 2003).

Every personality has three parts: id, the source of psychic energy that drives the instincts for survival and
pleasure; superego, the conscience that promotes personal ideals and acts as moral judge of right and wrong;
and the ego, the executive part that mediates between id and the superego, between inner strivings and
reality, and tries to maintain mastery over the id’s drives (Corsini & Wedding, 2001). Freud (1961) postulated
that all human motivation derives from a biological drive to obtain pleasure and avoid pain—a dynamic he
called “the pleasure principle” (Freud, 1958). According to Freud, a client’s adult pathology can be traced to
early sexual development, particularly a lack of sexual gratification during one of five psychosexual
developmental stages that Freud labels oral, anal, phallic, latency, and genital.

THERAPEUTIC APPROACH

The client comes into the therapist’s office, reclines comfortably on a couch, and free associates (there is no
predetermined agenda) about thoughts that come spontaneously to mind. The counsellor helps the client uncover
unconscious dynamics by going with the flow of these unplanned expressions.

The therapist helps the client understand how unconscious ego states and defence mechanisms can negatively
impact personal development. Although the following ego defence mechanisms may help a client manage
unwanted emotions, they can also impede emotional growth: Repression (pushing a memory out of conscious
memory), Regression (returning to an earlier stage of development), and Reaction Formation (reacting in the
opposite way to an unacceptable impulse) (Corey, 2000).

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CARL G. JUNG’S ANALYTIC PSYCHOANALYSIS

Fascinated with the importance of spiritual development for an individual’s mental health, Jung also assumed
that people can find their place in the world by understanding their unconscious mind. He believed that each
person has a personal unconscious made up of repressed events, wishes, feelings, and conflicts and also shares
a “collective unconscious”—memories of their ancestral and racial heritage. These latter memories are
organized around images called archetypes (Howatt, 2000).

THERAPEUTIC APPROACH

The unconscious mind, once explored, opens the door for healing mental illness (Jung, 1954a). Dream Analysis,
Jung’s method for communicating with the unconscious mind, reveals archetypes that the therapist interprets for
the client (Jung, 1954b).

Although addiction counsellors may not be trained in Dream Analysis (which takes years), they can use two
counselling applications—personality and spirituality. Exploring personality traits such as introversion and
extroversion assists clients in understanding how they interact with others. Jung’s seminal work on extroversion
and introversion led to the development of the Myers-Briggs Type Indicator (Howatt, 2005). Clients may
complete this scale and use the results to develop awareness and determine core competencies needed to
support their recovery.

As the history of Alcoholics Anonymous shows, addressing and strengthening spirituality in daily living can be
vital in helping clients recover from their addictive disorders and develop healthier personalities.

ALFRED ADLER’S INDIVIDUAL PSYCHOLOGY

Adler taught that each client pursues fictional goals in an unhealthy quest for superiority. Unrealistic goals may
be overwhelming and lead to discouragement and such self-destructive behaviours as crime, addiction, and
psychosis (Adler, 1929, 1958).

THERAPEUTIC APPROACH

The first step—assessment—is to learn about the client’s family of origin, birth order, early recollections,
dreams, and current life tasks. Next is helping the client develop insight about the cost of trying to fulfil
unrealistic goals. With these insights, the client makes new, healthier goals. To move the client away from
feelings of discouragement and inferiority, the therapist helps the client make a realistic action plan and
develop the necessary skills to achieve his new goals (Howatt, 2005). Other Adlerian techniques, such as the
Magic Wand and Confrontation, can also be used (see “Counselling Techniques” later in Part IV).

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CARL ROGERS’S PERSON-CENTERED THERAPY

Rogers’s client-centred philosophy assumes that each person is, by nature, good, worthy, and valuable (1951).
This person-centred therapy trusts that clients have within themselves resources to improve their life situation. If
this inner potential and ability emerges, the client needs only support, not direction.

THERAPEUTIC APPROACH

This nondirective and non-confrontational counselling method assumes clients possess innate ability to evaluate
and wisely choose their behaviours. The effective counsellor adheres to what Rogers (1959) calls three core
conditions of counselling: (1) empathy—responding to the client with intense interest, valuing the client’s
perception of the world and the meaning they attach to it; (2) congruence—being honest and consistent in
behaviour and thought; and (3) warm regard—showing non-judgmental, accepting, positive regard for the
client through word and deed. These three core conditions may appear simple, but their mastery takes a strong
commitment of time and effort by the counsellor.

FRITZ PERLS’S GESTALT THERAPY

Awareness, the principal goal of Gestalt Therapy (Perls, 1969), comes by focusing on clients’ present situations
and current behaviours, how they perceive their behaviours and how they interpret their experiences (Corey,
2000). The therapist observes only the client’s behaviour and does not attempt to determine the causes of the
behaviour.

THERAPEUTIC APPROACH

Awareness, the therapist’s principal tool, is achieved by exploring current behaviours, feelings, and thoughts.
The therapist assigns homework and assists the client in creating life experiments that demonstrate and reinforce
how maladaptive behaviours have a negative impact on health and wellness. Experiments may include role-
play to stress dysfunctional interaction patterns and to experiment with healthier ways (Perls, 1969, 1973).

Getting to the core of personality, Perls states, is much the same as peeling off the layers of an onion. These
are the five layers of awareness (metaphoric onion): (1) phony—responding to others in an inauthentic and
stereotypical manner; (2) phobic—avoiding the pain of realistic self-examination and taking responsibility for
one’s own actions; (3) impasse—stalling in the present level of maturity; (4) implosive—starting to get in touch
with true self by questioning defence mechanisms; (5) explosive—a great release of energy when one finally
lets go of all phony roles and pretences (Howatt, 2000).

Because impasse in therapy is caused by the client’s defence mechanisms (e.g., introjections—accepting others’
beliefs without testing them), the therapist designs experiments to teach the client about these layers of
awareness and how defence mechanisms underlie faulty perceptions of reality.

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IRVIN YALOM’S EXISTENTIAL PSYCHOTHERAPY

Existential means pertaining to existence. Working with the conscious rather than the unconscious mind,
existential counselling seeks to ask and answer fundamental questions about being a human being (e.g., finding
meaning in life) and the struggles inherent in this existence.

Yalom (1981) postulates that many psychological problems are directly rooted in one of four ultimate concerns:
death (there is no escape), freedom (each client is free to define his or her own world), isolation (there is a gulf
between self and others and self and the world), and meaninglessness (how one defines the meaning of life and
its purpose).

THERAPEUTIC APPROACH

The therapist assists the client in exploring each of the four ultimate concerns and provides examples of how
addressing them can improve life. As active participants, therapists share their personal views and ask questions
related to the paraphrasing, see Counselling Techniques and Clinical Microskills, later in Part IV.

VIKTOR FRANKL’S LOGOTHERAPY

Viktor Frankl, observing how he and his fellow prisoners coped with extraordinarily stressful circumstances in
Nazi concentration camps, concluded that circumstances and events in the outer world (things outside the inner
self) do not matter as much as the ultimate freedom of people to determine the meaning of their situation. In
his classic book Man’s Search for Meaning, Frankl (1963) explains that, although brutal guards may have
inflicted suffering and pain on his body, they could not control his mind. Logotherapy, the idea that clients have
the ability and responsibility to make their own choices regardless of their environment, assumes that a client
always has a choice; and no-choice is still a choice.

THERAPEUTIC APPROACH

The therapist teaches clients how to avoid the victim role by mentally separating from their external environment
and taking responsibility for their own lives. Two of Frankl’s techniques are dereflection (turning clients’ attention
from their problematic situation to the creative ways they are coping or could cope) and paradoxical intentions
(encouraging an exaggerated form of the undesired behaviour).

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ALBERT ELLIS’S RATIONAL-EMOTIVE BEHAVIOUR THERAPY

Ellis postulates that most, if not all, of a client’s emotional problems result from irrational thinking, and moreover,
everyone can learn how to think effectively (Ellis, 1962). Directive and didactic, this cognitive-behavioural
approach works with clients at a conscious level, teaching new insights and skills in the therapist’s office to be
practiced at home. Ellis’s Rational-Emotive Behaviour Therapy (REBT) shares a common thread with Glaser’s
Reality Therapy and Beck’s Cognitive Behavioural Therapy, all of which use problem-solving and learning by
employing new behavioural skills (discussed in the paragraphs that follow).

THERAPEUTIC APPROACH REBT addresses the client’s irrational thinking with an ABC model: (1) Activating
Event—an external event that upsets the client; (2) Belief—client’s irrational belief about A; and (3)
Consequences—what clients do and feel in response to their irrational belief about the activating event (Ellis,
1994).

Next the counsellor focuses on the DEF part of the ABC model: (4) Disputing— the counsellor challenges the
client’s irrational thinking and conclusions about A and B. Using techniques such as REBT homework sheets, the
counsellor teaches the client to recognize irrational thinking and to think realistically; (5) Effect— cognitive
change in the client, rational thinking; and (6) Feeling—instead of anxiety or depression, client’s feelings are
appropriate to the situation.

WILLIAM GLASSER’S CHOICE THEORY AND REALITY THERAPY

Choice Theory assumes that individuals choose most of their behaviour and that it is internally motivated by the
need to meet one or more of the following basic needs: love and belonging (the most important), power, fun,
freedom, and survival. All behaviour is total, meaning that clients’ actions will affect their thinking, which in turn
will control feelings and physiology. Using a car as a metaphor, Glasser (1998) teaches that what the front
wheels (behaviour and thinking) the rear wheels (feeling and physiology) will follow. For example, a depressed,
lethargic client who is sitting around the house can change his or her emotional state by doing something
different.

THERAPEUTIC APPROACH

Based on choice theory, reality therapy seeks to help clients build their love and belonging relationships.
Glasser (1998) names Seven Caring Habits: supporting, encouraging, listening, accepting, trusting, respecting,
and negotiating differences. He also identifies Seven Deadly Habits: criticizing, blaming, complaining, nagging,
threatening, punishing, and bribing or rewarding to control.

Promoting the concept of an internal locus of control (self-responsibility), reality therapy offers a frame of
reference to help clients see why they do what they do and how changing any element (e.g., spending time
around the house) will change other aspects of the whole (e.g., feeling depressed and having low physical
energy). Therapists ask strategic questions—What do you have now that meets your needs? What do you
want? What are you doing to get what you want? Is what you are doing working? Reality therapy helps clients
learn to meet their own needs.

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AARON BECK’S COGNITIVE BEHAVIOURAL THERAPY

Based on the premise that most of a client’s negative thinking derives from automatic faulty thinking, Beck
(1976) suggests that the client’s present difficulties (e.g., depression) result from thinking errors and negative
thinking. The therapist’s goal is to help the client become aware of negative thought patterns and change them.
Beck authored four popular clinical scales: Beck Depression, Beck Anxiety, Beck Hopelessness, and Beck Suicide
(see Part III).

THERAPEUTIC APPROACH

The therapist first reduces the client’s present level of anxiety by using empathy and reframing, then uncovers
and monitors the client’s faulty processing and negative schema. Using Socratic dialogue (thoughtful questioning
of client), the client is taught how to think more accurately and effectively. After this, therapist and client design
a behavioural experiment to test the client’s beliefs and assumptions. Finally, behavioural strategies are
implemented (e.g., journaling) to reinforce the new skills designed to prevent further faulty processing. Cognitive
Behavioural Therapy (CBT) works best, Beck (1970) explains, with clients who have acceptable reality levels
(no delusions).

ERIC BERNE’S TRANSACTIONAL ANALYSIS

Berne taught that everyone interacts from three ego states—each with its own feelings, thoughts, and ways of
behaving—that make up the human personality: Parent, Adult, and Child (Berne, 1972).

THERAPEUTIC APPROACH

Helping clients develop a healthy life script — “I’m OK – You’re OK.” — is the clinical objective (Berne, 1961).
All clients have the potential to make change and have a part in them that is acceptable to others. The actual
work of Transactional Analysis (TA) revolves around four constructs: (1) exploration of transactions— what
people say and do to and with each other; (2) games and cons—the games people play to get what they
want; (3) scripts—how feedback from early transactions in childhood affect adulthood; (4) structures—the
analysis of the different ego states a client communicates from in different transactions. “Strokes” (i.e., positive
feedback) is one of the biggest motivators for behaviour (Berne, 1961).

OTHER BEHAVIOURAL APPROACHES

Several other key behavioural approaches are available, such as Pavlov’s classical conditioning, Skinner’s
operant conditioning, and Bandura’s social learning theory. Although each stand alone as an independent
therapeutic model, they all emphasize the environment’s impact on behaviour. Pavlov (1960) taught that
behaviour is the result of conditioned reflexes whereas B. F. Skinner (1971) states that behaviour is the result
of rewards (positive or negative). Bandura (1977) emphasizes that a person can learn by simply observing the
environment.

THERAPEUTIC APPROACH

The counsellor designs activities in five stages to help the client modify unwanted behaviours: (1) study the
client’s present behaviours; (2) define the primary problems; (3) determine client’s goals; (4) select interventions
and make an action plan; (5) start action plan, monitor, and follow up (Wilson, 2001).

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COGNITIVE BEHAVIOURAL TOOLS
Active, directive, time-limited, and structured, these therapeutic modalities assume that clients’ behaviours are
largely determined by the ways in which they think.

Contingency Management

Based in the theoretical underpinning of Skinner’s operant conditioning, Contingency Management (CM)
enforces desired behaviours that strengthen recovery. Positive reinforcement means delivering a reward.
Negative reinforcement, not to be confused with punishment or a negative outcome, means removing an
undesirable restriction or situation. Positive punishment means delivering an undesirable consequence, whereas
negative punishment means removing a desirable one.

In CM, reinforcements are generally considered more effective than punishments. CM gives the recovery more
firepower by competing with the rewards of the addict’s drug or behavioural habit. This is especially important
for the many users who resent authority figures and regulations (Coombs, 2001).

In designing CM plans, first determine the desired target outcome and criteria for success (e.g., weekly urine
test). Incentive programs can use voucher systems where clients can earn points and then select a reward
purchased or provided through the treatment practitioner. The list of incentives should be long enough to please
a variety of clients, and its focus should be recreational (e.g., going to a movie). Although CM can be used with
goals such as attendance at therapy sessions, Budney, Sigmon, and Higgins (2001) encourage treatment
professionals to use this strategy first and foremost to reward clients for staying free from addictive behaviours.

Additional Resources

Higgins, S. T., Wong, C. J., Badger, G. J., Ogden, D., & Dantona, R. L. (2000). Contingent reinforcement increases cocaine abstinence
during outpatient treatment and 1 year of follow up. Journal of Consulting and Clinical Psychology, 68, 64–72.

Cue Exposure

Recognizing drug use as a habit, with addicts responding to accustomed cues and contexts by ingesting their
substance of choice, Cue Exposure (CE) treatment trains clients to stop responding habitually to their traditional
triggers. Called “extinction,” it is the unconditioning of conditioned triggers and responses (e.g., local bars
linked with drinking) by repeatedly exposing a client, in a controlled environment, to these potential triggers.
Repeated exposures erase reaction to the cue (Coombs, 2001).

When administering cues, the counsellor will need to track clients’ responses, usually by asking them to self-
report cravings, negative mood, and physiological responses on a scale of 1 to 10 (Conklin & Tiffany, 2001).
Treatment for a particular cue is ended when a client no longer responds to the cue though an occasional review
to ensure continued extinction is helpful. Properly administered, cue exposure treatment can strengthen the
client’s resistance to relapse.

Additional Resources

Bouton, M. E. (2000). A learning-theory perspective on lapse, relapse, and the maintenance of behaviour change. Health Psychology,
19, 57–63.

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Affect Regulation Coping Skills Training

Coping skills training acknowledges that addicts generally use addictive substances or behaviours to regulate
their own moods; they self-medicate to avoid uncomfortable feelings (Scott et al., 2001). This technique focuses
on helping clients learn positive coping skills for addressing challenges and the unpleasant emotions they invoke.

The objective of coping skills training is to enhance and develop clients’ internal locus of control. When clients
achieve this control, they will possess the requisite skills to take charge of the emotions that influence positive
behavioural choices. Clients learn that they can alter their unwanted moods and increase their self-confidence
more by taking constructive actions than by using psychoactive drugs (Kern & Lenon, 1994).

Clinicians use the following five-step model: (1) Assessment; (2) Establishing commitment (to stay clean and
away from unwanted emotions); (3) Identifying feelings (to learn how to identify emotions); (4) Homework (e.g.,
daily journaling); and (5) Setting goals that meet client needs and measuring progress (Scott et al., 2001).

Additional Resources

For a detailed review of this recovery tool, see Scott, R. L., Kern, M. F., & Coombs, R. H. (2001). In R. H. Coombs (Ed.), Addiction
recovery tools. Thousand Oaks, CA: Sage.

Recovery Contracts

Behavioural contracts reinforce positive behaviours and monitor supportive recovery. Talbott and Crosby
(2001) explain, “The chemically dependent patient requires psychological, physiological, and spiritual
frameworks to guide him or her through the recovery process. Contracts are an essential part of this external
structure” (p. 127). These contracts provide the client with a detailed road map of the daily actions needed to
deal with life stress and to reduce distractions.

An effective recovery contract has seven key components: (1) Presentation of the contract in a serious and
compassionate manner, preferably with the significant other and any program representatives in attendance;
(2) Releases of information—the patient must sign off on privacy releases for family members, co-workers, and
others to be involved in contract reporting; (3) Leverage through clearly understood consequences when
expectations are not met (behaviours should be highly specific); (4) Organization of a client’s support system;
(5) Statement of short treatment time frame so that the client feels capable of compliance. Most contracts are
designed to cover a 5-year span, but they are renewed annually, biannually, or even quarterly; (6) Contract
review, which should take place formally at least every 6 months and informally on an ongoing basis; and (7)
A “slip” relapse clause. Clients should be educated regarding warning signs so they can seek help before they
head into a full-blown relapse (Talbott & Crosby, 2001).

Additional Resources

For a detailed chapter on this topic, see Talbott, G. D., & Crosby, L. R. (2001). Recovery contracts: Seven key elements. In R. H.
Coombs (Ed.), Addiction recovery tools: A practice handbook. Thousand Oaks, CA: Sage.

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PSYCHOSOCIAL TOOLS
These treatment modalities focus on strengthening and reinforcing the network of a client’s social support
network.

Family Strengthening

Family members typically enable the client’s addictive behaviours. This co-dependency, an adaptation
paralleling addiction, needs to be identified and treated. Brown and her colleagues (S. Brown, Lewis, & Liotta,
2000; Schmid & Brown, 2001) use a developmental model that consists of four addictive stages:

1. Active addiction: In this stabilizing phase, all family members are screened and treated for their own
addictions or dual diagnosis issues.

2. Transition: Family members accept there is an addicted person in the family and come to terms with the need
to take action.

3. Early recovery: Family members start to act differently and no longer act on impulse. The focus is on education
and the development of new behaviour that supports the family; the addictive family member no longer controls
the family.

4. Ongoing recovery: The family is out of denial and is no longer emotionally, cognitively, and behaviourally
trapped. This is a crucial stage for each family member in healing from the trauma of living with an addict.

Additional Resources

For more on this subject, see Schmid, J., & Brown, S. (2001). Family treatment: Stage-appropriate psychotherapy for the addicted
family. In R. H. Coombs (Ed.), Addiction recovery tools: A practical handbook. Thousand Oaks, CA: Sage.

Group Therapy

Group therapy is an effective tool for two basic reasons: (1) Group interaction helps penetrate “the addict’s
massive wall of denial,” (Washton, 2001, p. 240) and (2) recovering addicts need a strong social support
system (Coombs, 2001). When you group several addicts together in a therapeutic atmosphere, they call each
other’s bluffs even as they provide an encouraging recovery environment.

Washton (2001) suggests arranging different types of groups for progressive stages of recovery: (1) Self-
evaluation groups for clients who are not yet ready to commit to abstinence and need motivational
enhancement; (2) Early recovery groups, lasting from several months to a year, where members work on
acknowledging their addiction, achieve abstinence, and stabilize their lives; and (3) Relapse prevention groups
for those in advanced recovery who have maintained abstinence for some time and are ready to focus
specifically on those issues that make them more vulnerable to relapse.

Additional Resources

For an effective resource on group treatment planning, see Jongsma, A. E., Jr., & K. M. Paleg. (1999). Group therapy treatment planner.
New York: Wiley.

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Peer Support

Peer groups provide hope and give recovering addicts a much-needed social support system in lieu of their
network of drug-using friends. Social support groups, common in 12-step programs, help break down denial
and encourage participants to change and take personal responsibility for their actions. For high impact, Alcohol
Anonymous (AA) suggests that newcomers attend 90 meetings in 90 days (Kurtz, 2001).

At these meetings—whether 12-step oriented or a 12-step alternative—members share their recovery stories,
discuss insights and concerns, or study pertinent literature. Recovery is greatly enhanced when a group member
working the program can call a sponsor—a senior member of the group who is assigned to assist addicted
individuals outside meetings any time of day or night for help in resisting the urge to relapse.

Lifestyle Planning and Monitoring

The two key features in the big-picture approach to addiction recovery are getting off drugs and creating a
healthy, drug-free way of life (Zackon, McAuliffe, & Chien, 1993). Zackon (2001) identifies three common
barriers to success: (1) the people problem (building a satisfying new social network); (2) the work problem
(finding rewarding employment); and (3) the pleasure problem (acquiring new means of entertainment and
excitement). He points out that the drug lifestyle, with its immediate gratification and highs, is not easily
replaced by a straight life, which may seem inherently dull and unsatisfying to drug users.

Howatt (1999) explains that clients who wish to gain a healthy lifestyle must balance five elements: money,
career, relationships, self, and health. Zackon (2001), suggests that a recovery lifestyle needs eight vital
elements: (1) Participation in a community that supports abstinence and nourishes moral or spiritual values; (2)
productive work (or appropriate training or education) that yields sustenance and social approval; (3) social
activities with friends who offer drug-free recreation and support; (4) a home setting that is comforting and
relatively free of strong “triggers” (incitements to use); (5) personal growth activities in any or all of the
preceding; (6) standard practices for avoiding high-risk (trigger-laden) situations; (7) standard practices for
coping with unavoidable high-risk situations, and (8) regularity in personal routines and schedules.

Additional Resources

For resources on how to implement life management skills, see Kern, M., & Lenon, L. (1994). Take control now! Life management. Los
Angeles: Management Skills. A user-friendly book on life coaching is provided by Curly, M. (2001). The life coaching handbook.
London: Crown House. For more information on coaching training, visit Coach U at www.coachinc.com.

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HOLISTIC TOOLS
Traditionally used by nonmedical specialists, these treatment modalities address the health of the entire body,
not just a specific body part or malady. Clinicians trained in Western medicine philosophy and techniques have
been incorporating these elements of Eastern medicine into their treatment arsenals.

Acupuncture

Some 1,000 treatment programs use acupuncture in treating addictions, both to ease withdrawal symptoms
and to prepare clients for psychosocial recovery (M. O. Smith & White, 2001). Acupuncture has a calming
effect and improves treatment retention; in addition, it is safe and cost-efficient (Brewington, Smith, & Lipton,
1994).

During treatment, needles are inserted smoothly and shallowly and other than a brief pinching sensation, pain
or bleeding are rarely experienced. The technique generally produces an immediate sense of relaxation.
Clients may also feel warmth, tingling, electrical movement, or heaviness either in the application area (usually
the ears) or some other part of the body (M. O. Smith & White, 2001). Touch, movement, heat, and electricity
can also stimulate the points. Related acupuncture procedures include acupressure, shiatsu, reiki, and tai ji chaun.

In addition to treating the obvious needs for relaxation and relief of withdrawal symptoms, acupuncture
addresses the addict’s general state of physiological imbalance and ill health. Holistic treatment can also
support treatment of coexisting psychiatric disorders ranging from depression to paranoia. The Lincoln Recovery
Centre has found a group setting to be most successful, and has trained clinicians to administer this treatment.
The National Acupuncture Detoxification Association (NADA) assists programs interested in applying this
treatment modality (www.acudetox.com).

Additional Resources

For information on certified and licensed clinicians, visit the American Association of Oriental Medicine (www.aaom.org) and the
National Certification Commission for Acupuncture and Oriental Medicine (www.nccaom.org). Also, see Knaster (1996). Discovering
the body’s wisdom. New York: Bantam Books.

Spirituality Enhancement

Though spirituality has long been a central focus of 12-step programs, only recently has Western medicine
acknowledged its importance. Spirituality cannot be measured scientifically, but its consequences can. Research
has documented that praying for strength has health-enhancing benefits (Dossey, 1997). Even atheist nations
like the former USSR, turned to spirituality-based programs to deal with rampant alcoholism in their society.

Efforts to develop spiritually can open doors of opportunity for clients who are willing to experiment. A large
literature is developing on the relationship between spirituality and health.

Additional Resources

To learn more about the application of spirituality and addiction counselling, visit the Centre for Spiritual Awareness (www.csa-
davis.org) and read Kus, R. J. (Ed.). (1995). Spirituality and chemical dependency. New York: Harrington. This excellent resource
provides a strategy for implementing spirituality into recovery. See also Carl Jung’s classical writings described in Part IV of this
book.

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Meditation

Meditation, “a specific state of attending to a particular focus while withdrawing one’s attention from the
outside world,” (Snarr, Norris, & Fahrion, 2001, p. 307), is used effectively to support recovery. An alternative
to the addictive state, meditation slows the mind and body to achieve a restful state normally achieved by
addicts only through their addictive elixir. By slowing down the central nervous system, the client calms the mind
and reduces stress. When the brain rhythms are slowed, the brain produces mind-altering and brain-healing
substances, such as neuropeptides, enkephalins, and endogenous opiates that reduce craving and promote
abstinence (Blum & Payne, 1991). Through mastering a meditative state, clients are better able to connect their
conscious and unconscious mind for the purpose of healing (Benson & Stark, 1997).

Breathing and hand temperature training are two basic meditation techniques. Regulating breathing is the first
skill learned by beginning students of meditation. The goal is to replace shallow thoracic breathing with deeper
diaphragmatic breathing, a calming practice. Hand temperature training, in which clients learn to adjust the
warmth and blood flow in their hands, is an example of biofeedback which also integrates the mind/body
connection.

Additional Resources

For tools to learn more about meditation and its application to addiction, see Schaub, B., & Schaub, R. (1997). Healing addiction. New
York: Delmar; Davis, M., Eshelman, E. R., & McKay, M. (1995). The relation and stress reduction workbook (4th ed.). Oakland, CA: New
Harbinger; and Lohman, R. (1999). Yoga techniques applicable within drug and alcohol rehabilitation programmes. Therapeutic
Communities: International Journal for Therapeutic and Supportive Organizations, 20(1), 61–72. This Internet resource provides a user-
friendly application for how to meditate: www.how-to-meditate.org.

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Nutritional Counselling

Many addicts become malnourished and have a severe imbalance in their body’s biochemistry. Adding
nutritional counselling to your repertoire will close what tends to be a glaring gap in the addict’s treatment
needs (Gordis, 1993).

Early animal studies showed that well-nourished subjects demonstrated “wisdom of the body” by rejecting
alcohol in favour of water, while malnourished subjects were more likely to consume alcohol (Williams et al.,
1955, cited in Beasley, 2001). In another study, even bacterial cultures were better able to resist the toxic
effects of alcohol when they were better nourished (Ravel et al., 1955, cited in Beasley, 2001). Three decades
later, Guenther (1983) treated two groups of addicts, differentiating in her approach only by incorporating a
nutritional component into one program. A follow-up at 6 months found that 81% of the nutrition groups were
not drinking, as opposed to 38% of the control group (Guenther, 1983). Patients in the nutrition group also
claimed to experience fewer cravings.

Building on Guenther’s (1983) work in their program for 111 patients in New York, Beasley (2001, p. 294)
found, “[All] had severe and chronic alcoholism. All had long and difficult histories of alcohol and drug abuse,
with many failed treatment attempts. All their diets were deficient; 80% were overtly clinically malnourished,
almost two thirds had liver disease, and almost half were also addicted to other drugs.” After 12 months in his
treatment program that included a strong nutritional component, 91 patients were still participating, and 74%
of these patients were sober (Beasley, 2001, p. 294).

Addiction counsellors should develop core competencies in nutritional counselling. Simple basics such as eating
regular healthy meals and drinking lots of bottled water (2 litres a day) are only two examples.

Additional Resources

To support your client’s nutritional needs while in recovery, an excellent guide is Beasley, J. D., & Knightly, S. (2001). Food for
recovery: The complete nutrition companion for recovering from alcoholism, drug addiction, and eating disorders (2nd ed.). New York:
Crown Books. Centre for Food Safety and Applied Nutrition, 5100 Paint Branch Parkway, College Park, MD 20740-3835,
http://vm.cfsan.fda.gov/list.html. Clemens Library, Internet Resources for Nutrition: www.csbsju.edu/library /internet/nutrition.html.
Coombs, Robert H. (Ed.). (2001). Addiction recovery tools: A practical handbook. Thousand Oaks, CA: Sage. This edited book offers
more extensive elaboration on each of the recovery tools briefly reviewed in this chapter. It also discusses ways to match clients with
recovery tools.

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Section 4: Group Counselling

GROUP COUNSELLING
Types of Groups

• Psychoeducational groups, which teach about substance abuse.

• Skills development groups, which hone the skills necessary to break free of addictions.
• Cognitive–behavioural groups, which rearrange patterns of thinking and action that lead to addiction.
• Support groups, which comprise a forum where members can debunk each other’s excuses and support
constructive change.
• Interpersonal process group (referred to hereafter as “interpersonal process groups” or “therapy
groups”), which enable clients to recreate their pasts in the here-and-now of group and rethink the
relational and other life problems that they have previously fled by means of addictive substances.

Therapeutic Strategies in Early Treatment

In 1975, Irvin Yalom elaborated on earlier work and distinguished 11 therapeutic factors that contribute to
healing as group therapy unfolds:

• Instilling hope—some group members exemplify progress toward recovery and support others in their
efforts, thereby helping to retain clients in therapy.
• Universality—groups enable clients to see that they are not alone, that others have similar problems.
• Imparting information—leaders shed light on the nature of addiction via direct instruction.
• Altruism—group members gain greater self-esteem by helping each other.
• Corrective recapitulation of the primary family group—groups provide a family-like context in which
long-standing unresolved conflicts can be revisited and constructively resolved.
• Developing socializing techniques—groups give feedback; others’ impressions reveal how a client’s
ineffective social habits might undermine relationships.
• Imitative behaviour—groups permit clients to try out new behaviour of others.
• Interpersonal learning—groups correct the distorted perceptions of others.
• Group cohesiveness—groups provide a safe holding environment within which people feel free to be
honest and open with each other.
• Catharsis—groups liberate clients as they learn how to express feelings and reveal what is bothering
them.
• Existential factors—groups aid clients in coming to terms with hard truths, such as (1) life can be unfair;
(2) life can be painful and death is inevitable; (3) no matter how close one is to others, life is faced
alone; (4) it is important to live honestly and not get caught up in trivial matters; (5) each of us is
responsible for the ways in which we live.

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GROUP LEADERSHIP
Group Leadership, Concepts, and Techniques

Effective group leadership requires a constellation of specific personal qualities and professional practices. The
personal qualities necessary are constancy, active listening, firm identity, confidence, spontaneity, integrity,
trust, humour, and empathy.

Leaders should be able to

• Adjust their professional styles to the particular needs of different groups

• Model group-appropriate behaviours
• Resolve issues within ethical dimensions
• Manage emotional contagion
• Work only within modalities for which they are trained
• Prevent the development of rigid roles in the group
• Avoid acting in different roles inside and outside the group
• Motivate clients in substance abuse treatment
• Ensure emotional safety in the group
• Maintain a safe therapeutic setting (which involves deflecting defensive behaviour without shaming the
offender, recognizing and countering the resumption of substance use, and protecting physical
boundaries according to group agreements)
• Curtail emotion when it becomes too intense for group members to tolerate
• Stimulate communication among group members

Essential Qualities of the Group Leader

Constancy

An environment with small, infrequent changes is helpful to clients living in the emotionally turbulent world of
recovery. Group facilitators can emphasize the reality of constancy and security through a variety of specific
behaviours. For example, group leaders always should sit in the same place in the group. Leaders also need
to respond consistently to particular behaviours. They should maintain clear and consistent boundaries, such as
specific start and end times, standards for comportment, and ground rules for speaking. Even dress matters.
The setting and type of group will help determine appropriate dress, but whatever the group leader chooses
to wear, some predictability is desirable throughout the group experience. The group leader should not come
dressed in a suit and tie one day and in blue jeans the next.

Active listening

Excellent listening skills are the keystone of any effective therapy. Therapeutic interventions require the clinician
to perceive and to understand both verbal and nonverbal cues to meaning and metaphorical levels of meaning.
In addition, leaders need to pay attention to the context from which meanings come. Does it pertain to the here-
and-now of what is occurring in the group or the then-and-there history of the specific client?

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Firm identity

A firm sense of their own identities, together with clear reflection on experiences in group, enables leaders to
understand and manage their own emotional lives. For example, therapists who are aware of their own
capacities and tendencies can recognize their own defences as they come into play in the group. They might
need to ask questions such as: “Am I cutting off discussions that could lead to verbal expression of anger because
I am uncomfortable with anger? Have I blamed clients for the group’s failure to make progress?”

Group work can be extremely intense emotionally. Leaders who are not in control of their own emotional
reactions can do significant harm—particularly if they are unable to admit a mistake and apologize for it. The
leader also should monitor the process and avoid being seduced by content issues that arouse anger and could
result in a loss of the required professional stance or distance. A group leader also should be emotionally
healthy and keenly aware of personal emotional problems, lest they become confused with the urgent issues
faced by the group as a whole. The leader should be aware of the boundary between personal and group
issues (Pollack and Slan 1995).

Confidence

Effective group leaders operate between the certain and the uncertain. In that zone, they cannot rely on
formulas or supply easy answers to clients’ complex problems. Instead, leaders have to model the consistency
that comes from self-knowledge and clarity of intent, while remaining attentive to each client’s experience and
the unpredictable unfolding of each session’s work. This secure grounding enables the leader to model stability
for the group.

Integrity

Largely due to the nature of the material group members are sharing in process groups, it is all but inevitable
that ethical issues will arise. Leaders should be familiar with their institution’s policies and with pertinent laws
and regulations. Leaders also need to be anchored by clear internalized standards of conduct and able to
maintain the ethical parameters of their profession.

Trust

Group leaders should be able to trust others. Without this capacity, it is difficult to accomplish a key aim of the
group: restoration of group members’ faith and trust in themselves and their fellow human beings (Flores 1997).

Humour

The therapist needs to be able to use humour appropriately, which means that it is used only in support of
therapeutic goals and never is used to disguise hostility or wound anyone.

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Empathy

Empathy, one of the cornerstones of successful group treatment for substance abuse, is the ability to identify
someone else’s feelings while remaining aware that the feelings of others are distinct from one’s own. Through
these “transient identifications” we make with others, we feel less alone. “Identification is the antidote to
loneliness, to the feeling of estrangement that seems inherent in the human condition” (Ormont 1992, p. 147).
For the counsellor, the ability to project empathy is an essential skill. Without it, little can be accomplished.
Empathic listening requires close attention to everything a client says and the formation of hypotheses about
the underlying meaning of statements (Miller and Rollnick 1991). An empathic substance abuse counsellor

• Communicates respect for and acceptance of clients and their feelings

• Encourages a non-judgmental, collaborative relationship
• Is supportive and knowledgeable
• Sincerely compliments rather than denigrates or diminishes another person
• Tells less and listens more
• Gently persuades, while understanding that the decision to change is the client’s
• Provides support throughout the recovery process (Centre for Substance Abuse Treatment [CSAT]
1999b, p. 41)

One of the great benefits of group therapy is that as clients interact, they learn from one another. For
interpersonal interaction to be beneficial, it should be guided, for the most part, by empathy. The group leader
should be able to model empathic interaction for group members, especially since people with substance use
disorders often cannot identify and communicate their feelings, let alone appreciate the emotive world of
others. The group leader teaches group members to understand one another’s subjective world, enabling clients
to develop empathy for each other (Shapiro 1991). The therapist promotes growth in this area simply by asking
group members to say what they think someone else is feeling and by pointing out cues that indicate what
another person may be feeling.

One of the feelings that the group leader needs to be able to empathize with is shame, which is common among
people with substance abuse histories. Shame is so powerful that it should be addressed whenever it becomes
an issue. When shame is felt, the group leader should look for it and recognize it (Gans and Weber 2000).
The leader also should be able to empathize with it, avoid arousing more shame, and help group members
identify and process this painful feeling. Figure 4-1 discusses shame and group therapy.

Spontaneity

Good leaders are creative and flexible. For instance, they know when and how to admit a mistake, instead of
trying to preserve an image of perfection. When a leader admits error appropriately, group members learn
that no one has to be perfect, that they––and others––can make and admit mistakes, yet retain positive
relationships with others.

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Figure 4-1. Shame

Often failed attachments in childhood and failed relationships thereafter result in shame, an internalized
sense of being inferior, not good enough, or worthless. Shame flares whenever clients encounter the
discrepancy between their drug‐affected behaviour and personal or social values. In group therapy,
feelings of shame may be intensified because feelings of self‐consciousness are elevated and other group
members are present. The presence of other group members “often stimulates regressive longings” (Gans
and Weber 2000, p. 385). Furthermore, group members have a marked tendency to compare themselves
with one another (Gans and Weber 2000). In the past, when group facilitators used highly confrontational
efforts to break through denial and resistance, an undesirable side effect was intensified shame, which
increased the likelihood that group members would relapse or leave treatment. Shame interferes
dramatically with attempts to heighten a client’s self‐esteem, which in turn is important to recovery (Alonso
and Rutan 1988).

Clients with addictions often are exquisitely sensitive and prone to project their shame onto relationships
within the group. Often, at an unconscious level, they anticipate disapproval or hostility when none was
intended. In this way, clients may demote themselves to the role of secondary player in the group.
One way to neutralize unintentionally shame‐provoking comments is to reframe member‐to‐member
communications. For example, if a group member asks, “Sally, where were you last week? You didn’t come
to group.” Sally may interpret the question as a criticism or even an implication that she has returned to
active use. The group facilitator may choose to reframe this member‐to‐member communication by
speaking to the concern that the questioner really has for Sally’s well‐being.

This reframing would begin with the group leader asking why the group member wanted to know where
Sally had been, adding something like, “I suspect your question reflects the feeling that you missed Sally
last week and find group more enjoyable when she is here.” By focusing on positive interactions that reveal
competency, the group facilitator helps move clients from shame to an affirmative image of themselves. The
group leader should pay attention to member‐to‐member interaction, looking for instances of relational
competence and support. The leader’s supportive interactions eventually develop into group norms that
combat the shame attached to addictive illness.

Source: Consensus Panel.

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Section 5: Ethics in Counselling

ETHICS
Counsellors are accountable for knowing local and federal laws as well as professional ethical codes. Ethical
principles codified by the Association of Addiction Professionals (NAADAC, 1994) include these areas:

• Non-discrimination
• Responsibility (for objectivity and integrity)
• Competence
• Legal and moral standards
• Public statements
• Publication credit
• Client welfare
• Confidentiality
• Client relationships
• Interprofessional relationships
• Remuneration
• Societal obligations

Ethical codes of conduct for addiction counsellors, are specified by these three professional organizations: (1)
the International Certification and Reciprocity Consortium/Alcohol and Other Drug Abuse, Inc. (ICRC;
www.icrcaoda.org), (2) The Association for Addiction Professionals’ ethical standards for counsellors
(www.naadac.org), and (3) the Canadian Addiction Counsellor Certification Board (CCCB; www.caccb.ca).

Universal Professional Values

The following professional values need to be honoured in the treatment of clients (White & Popovits, 2001, p.
28):

• Autonomy: Freedom over one’s destiny.

• Obedience: Obey legal and ethically permissible directives.

• Conscientious refusal: Disobey illegal or unethical directives.

• Beneficence: Do good; help others.

• Gratitude: Pass good along to others.

• Competence: Be knowledgeable and skilled.

• Justice: Be fair; distribute by merit.

• Stewardship: Use resources wisely.

• Honesty and candour: Tell the truth.

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 • Fidelity: Keep your promises.

• Loyalty: Do not abandon the client.

• Diligence: Work hard.

• Discretion: Respect confidence and privacy.

• Self-improvement: Be the best that you can be.

• Nonmalfeasance: Do not hurt anyone.

• Restitution: Make amends to persons injured.

• Self-interest: Protect yourself.

• Other culture: Specific values.

Here are some concrete ways to protect yourself from ethical and legal problems (Popovits, 2005):

• Take care of yourself: Effective self-care, an essential precursor to ethical conduct, prevents counsellors
from using a client to meet their physical, emotional, and spiritual needs (White & Popovits, 2001, p.
28).
• Get ethically educated: Ethical decision making involves learned skills as well as good character. Seek
training workshops and self-instructional reading to help you maintain an ethically safe environment for
practicing your basic ethical decision-making skills.
• Utilize mentors: Develop a small group of consultants or peers who will provide a sounding board and
objective advice on how to deal with difficult choices.
• Know thyself: Practice rigorous self-analysis to avoid breaches in ethical conduct when you are
personally vulnerable in your relationship with one or more clients.
• Ask for help: Seek formal consultation when you feel vulnerable and when there appears to be an
exception to the normal ethical prescriptions.
• Protect yourself: Don’t be alone. Create a paper trail (e.g., a journal) that documents your ethical
decision-making processes and decisions.
• Respect your clients, your co-workers, your craft, and yourself: Adhere to the ultimate ethical mandate,
“First, do no harm.”

Ethical Decision Making

Making ethical decisions is a critical skill for all addiction counsellors. To help navigate through the quagmire
of policies, ethical codes, and laws, here are some helpful pointers (White & Popovits, 2001):

• Analyse the situation in terms of who will potentially benefit and who could potentially be harmed. This
requires detailing both the probability and degree of benefit and harm. In this first step, you also
examine whose interests in the situation might be in conflict (e.g., what is best for the client in a particular
situation may not be what is best for you, the counsellor, or your agency).
• Examine whether universal or culturally relevant values dictate the best direction to take (e.g., an action
that could be beneficial in one cultural context might do harm or injury in another context).
• Explore how existing ethical codes, laws, regulations, organizational policies, or historical practices
apply to the situation in question.

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Confidentiality

Client confidentiality, an imperative for counsellors, is commonly breached in three ways (White, 2005):

• Internal confidentiality: Discussing information with peers who are not involved in the case and really do
not need to know;
• Casual interagency encounters: Sharing information with other agencies that are working with the same
client and family; and
• Casual encounters with clients in public: Talking to clients about their personal issues outside the treatment
environment.

Since few addiction counsellors are trained about legal issues related to their profession, it is important to
become familiar with the ethical codes that govern counselling organizations, as well as federal regulations for
confidentiality and privacy. Any time a counsellor is faced with an unfamiliar situation, it is of paramount
importance to seek supervision and consultation (Popovits, 2005).

Additional Resources

Federal regulations established to protect client privacy and confidentiality can be reviewed online. To read the entire legislation of
42 CFR Part 2 (confidentiality of Alcohol and Drug Abuse Patient Records), see www.access.gpo.gov/nara
/cfr/waisidx_00/42cfr2_00.htm.
Also access the Health Insurance Portability and Accountability Act of 1996 (HIPAA) at www.cms.hhs.gov/hipaa.

Informed Consent
Client consent must be obtained before offering any kind of service. This involves informing the client of:

• The nature and purpose of the procedure/treatment.

• The risks and consequences.
• The alternatives.
• The risks of no treatment. This is the most common source of legal liability (Popovits, 2005).

Most agencies have standardized forms and policies outlining the procedures to follow and requirements to
gain consent.

Ethical Dilemmas
A national survey identified these ethical dilemmas in clinical practice (Kenneth S. Pope & Valerie Vetter, Ethical
Dilemmas Encountered by Members of the American Psychological Association: A National Survey,
http://kspope.com/ethics /ethics2.php):

• Confidentiality concerning child abuse reporting, treating clients with human immunodeficiency virus (HIV)
or suffering from acquired immunodeficiency syndrome (AIDS), clients who threaten to commit or have
committed a violent act, and elder abuse;
• Dual relationships: dealing with boundary issues around roles;
• Payment sources: the challenge of working with clients who do not have the resources to pay and are in
great need for help;
• Conduct of colleagues: addressing peers who are not acting professionally;
• Sexual involvement: setting a standard and not becoming sexually involved with a client under any
circumstances.

Since any of these factors can be career ending if not handled correctly, immediately seek guidance from a
supervisor or peer if confronted with one of these dilemmas.

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Additional Resources

For a wealth of information on ethics and malpractice, visit Ken Pope’s web site at http://kspope.com/ethics/ethical.php. Also see,
Hedges, L., Hilton, R., Hilton, V., & Caudill, O. B. (1996). Therapists at risk. Northvale, NJ: Aronson, addresses how counsellors can
avoid ethic violations. To view NAADAC 12 core principles, the pillars for NAADAC Ethical Standards, go to http:/naadac.org. For
an excellent overview about confidentiality issues, see Popovits (2005). “Disclosure dilemmas: Legal compliance for counsellors.” In R.
H. Coombs (Ed.), Addiction counselling review: Preparing for comprehensive, certification of licensing exams. Mahwah, NJ: Erlbaum. For
an excellent overview of professional ethics, see White (2005) in the same volume.

Guidelines for Clinicians on Evaluating Bias and Prejudice

• The processes of gaining knowledge about the workings of discrimination and oppression and for
guarding against bias should be ongoing and lifelong.
• Clinicians should learn about their own culturally shaped assumptions so as to refrain from unconsciously
imposing them on others and should exhibit a professional’s values, standards, and actions.
• Clinicians should work harder to recognize institutionalized racism than they do to perceive individual
prejudice; that is, they should recognize how bias is structured into policies, practices, and norms in
program relations.
• Clinicians should question the knowledge base and theories that underlie their practice in order to
eliminate prejudice and bias in that practice.
• Clinicians should look at their own feelings and reactions and listen to the feedback of others to
recognize how their own ideas have been unconsciously shaped by discriminatory social dynamics.
• Clinicians can use their knowledge of how their personal characteristics are likely to affect a range of
others to reduce communication problems and disputes between group members.

Transference and Counter-Transference

Transference is a phenomenon characterized by unconscious redirection of feelings from one person to another.
One definition of transference is "the inappropriate repetition in the present of a relationship that was important
in a person's childhood." Another definition is "the redirection of feelings and desires and especially of those
unconsciously retained from childhood toward a new object." Still another definition is "a reproduction of
emotions relating to repressed experiences, especially of childhood, and the substitution of another person ...
for the original object of the repressed impulses." Transference was first described by Sigmund Freud
acknowledged its importance for psychoanalysis for better understanding of the patient's feelings. The inclusion
of "inappropriate" in the first definition notwithstanding, transference is normal and does not constitute
underlying pathology in itself; it is only inappropriate when patterns of transference lead to maladaptive
thoughts, feelings or behaviours.

Counter-Transference occurs when the therapist begins to project his or her own unresolved conflicts onto the
client. While transference of the client’s conflicts onto the therapist is considered a healthy and normal part of
psychodynamic therapy, the therapist’s job is to remain neutral. At one time, counter-transference was widely
believed to contaminate the therapeutic relationship. Current thinking is more complex. Although many now
believe it to be inevitable, counter-transference can be damaging if not properly managed. With proper
monitoring, however, some sources show that counter-transference can play an important role. Therapists are
encouraged to pay close attention to their feelings of counter-transference, and to seek peer review and
supervisory guidance as needed. Rather than eliminating counter-transference altogether, the goal is to use
those feelings productively rather than harmfully.

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NAADAC CODE OF ETHICS
The NAADAC (Association for Addiction Professionals) Code of Ethics are one of the most widely known sets of
guidelines for addiction counsellors and can be found on the NAADAC website at www.naadac.org

Principle 1: Non-Discrimination

The counsellor shall not discriminate against clients or professionals based on race, religion, age, gender,
disability, national ancestry, sexual orientation or economic condition.

The counsellor shall avoid bringing personal or professional issues into the counselling relationship. Through an
awareness of the impact of stereotyping and discrimination, the counsellor guards the individual rights and
personal dignity of clients.

The counsellor shall be knowledgeable about disabling conditions, demonstrate empathy and personal
emotional comfort in interactions with clients with disabilities, and make available physical, sensory and
cognitive accommodations that allow clients with disabilities to receive services.

Principle 2: Responsibility

The counsellor shall espouse objectivity and integrity, and maintain the highest standards in the services the
counsellor offers.

The counsellor shall maintain respect for institutional policies and management functions of the agencies and
institutions within which the services are being performed, but will take initiative toward improving such policies
when it will better serve the interest of the client.

The counsellor, as educator, has a primary obligation to help others acquire knowledge and skills in dealing
with the disease of alcoholism and drug abuse.

The counsellor, who supervises others, accepts the obligation to facilitate further professional development of
these individuals by providing accurate and current information, timely evaluations and constructive consultation.

The counsellor, who is aware of unethical conduct or of unprofessional modes of practice, shall report such
inappropriate behaviour to the appropriate authority.

Principle 3: Competence

The counsellor shall recognize that the profession is founded on national standards of competency which
promote the best interests of society, of the client, of the counsellor and of the profession as a whole. The
counsellor shall recognize the need for ongoing education as a component of professional competency.

The counsellor shall recognize boundaries and limitation of the counsellor’s competencies and not offer services
or use techniques outside of these professional competencies.

The counsellor shall recognize the effect of impairment on professional performance and shall be willing to
seek appropriate treatment for oneself or for a colleague. The counsellor shall support peer assistance
programs in this respect.

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Principle 4: Legal and Moral Standards

The counsellor shall uphold the legal and accepted moral codes which pertain to professional conduct.

The counsellor shall be fully cognizant of all federal laws and laws of the counsellor’s respective state governing
the practice of alcoholism and drug abuse counselling.

The counsellor shall not claim either directly or by implication, professional qualifications/affiliations that the
counsellor does not possess.

The counsellor shall ensure that products or services associated with or provided by the counsellor by means of
teaching, demonstration, publications or other types of media meet the ethical standards of this code.

Principle 5: Public Statements

The counsellor shall honestly respect the limits of present knowledge in public statements concerning alcoholism
and drug abuse.

The counsellor, in making statements to clients, other professionals, and the general public, shall state as fact
only those matters, which have been empirically validated as fact. All other opinions, speculations and
conjecture concerning the nature of alcoholism and drug abuse, its natural history, its treatment or any other
matters, which touch on the subject of alcoholism and drug abuse shall be represented as less than scientifically
validated.

The counsellor shall acknowledge and accurately report the substantiation and support for statements made
concerning the nature of alcoholism and drug abuse, its natural history, and its treatment. Such acknowledgments
should extend to the source of the information and reliability of the method by which it was derived.

Principle 6: Publication Credit

The counsellor shall assign credit to all who have contributed to the published material and for the work upon
which the publication is based.
The counsellor shall recognize joint authorship and major contributions of a professional nature made by one
or more persons to a common project. The author who has made the principal contribution to a publication must
be identified as first author.

The counsellor shall acknowledge in footnotes, or in an introductory statement, minor contributions of a

professional nature, extensive clerical or similar assistance and other minor contributions.

The counsellor shall in no way violate the copyright of anyone by reproducing material in any form whatsoever,
except in those ways which are allowed under the copyright laws. This involves direct violation of copyright as
well as the passive assent to the violation of copyright by others.

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Principle 7: Client Welfare

The counsellor shall promote the protection of the public health, safety and welfare and the best interest of the
client as a primary guide in determining the conduct of all counsellors.

The counsellor shall disclose the counsellor’s code of ethics, professional loyalties and responsibilities of all
clients.

The counsellor shall terminate a counselling or consulting relationship when it is reasonably clear to the counsellor
that the client is not benefiting from the relationship.

The counsellor shall hold the welfare of the client paramount when making any decisions or recommendations
concerning referral, treatment procedures or termination of treatment.

The counsellor shall not use or encourage a client’s participation in any demonstration, research or other non-
treatment activities when such participation would have potential harmful consequences for the client or when
the client is not fully informed. (Principle 9)

The counsellor shall take care to provide services in an environment which will ensure the privacy and safety of
the client at all times and ensure the appropriateness of service delivery.

Principle 8: Confidentiality

The counsellor working in the best interest of the client shall embrace, as a primary obligation, the duty of
protecting client’s rights under confidentiality and shall not disclose confidential information acquired in
teaching, practice or investigation without appropriately executed consent.

The counsellor shall provide the client his/her rights regarding confidentiality, in writing, as part of informing
the client in any areas likely to affect the client’s confidentiality. This includes the recording of the clinical
interview, the use of material for insurance purposes, the use of material for training or observation by another
party.

The counsellor shall make appropriate provisions for the maintenance of confidentiality and the ultimate
disposition of confidential records. The counsellor shall ensure that data obtained, including any form of
electronic communication, are secured by the available security methodology. Data shall be limited to
information that is necessary and appropriate to the services being provided and be accessible only to
appropriate personnel.

The counsellor shall adhere to all federal and state laws regarding confidentiality and the counsellor’s
responsibility to report clinical information in specific circumstances to the appropriate authorities.

The counsellor shall discuss the information obtained in clinical, consulting or observational relationships only in
the appropriate settings for professional purposes that are in the client’s best interest. Written and oral reports
must present only data germane and pursuant to the purpose of evaluation, diagnosis, progress, and
compliance. Every effort shall be made to avoid undue invasion of privacy.

The counsellor shall use clinical and other material in teaching and/or writing only when there is no identifying
information used about the parties involved.

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Principle 9: Client Relationships

It is the responsibility of the counsellor to safeguard the integrity of the counselling relationship and to ensure
that the client has reasonable access to effective treatment. The counsellor shall provide the client and/or
guardian with accurate and complete information regarding the extent the potential professional relationship.

The counsellor shall inform the client and obtain the client’s agreement in areas likely to affect the client’s
participation including the recording of an interview, the use of interview material for training purposes, and/or
observation of an interview by another person.

The counsellor shall not engage in professional relationships or commitments that conflict with family members,
friends, close associates, or others whose welfare might be jeopardized by such a dual relationship.

The counsellor shall not exploit relationships with current or former clients for personal gain, including social or
business relationships.

The counsellor shall not under any circumstances engage in sexual behaviour with current or former clients.

The counsellor shall not accept as clients anyone with whom they have engaged in sexual behaviour.

Principle 10: Inter-professional Relationships

The counsellor shall treat colleagues with respect, courtesy, fairness and good faith and shall afford the same
to other professionals.

The counsellor shall refrain from offering professional services to a client in counselling with another professional
except with the knowledge of the other professional or after the termination of the client’s relationship with the
other professional.

The counsellor shall cooperate with duly constituted professional ethics committees and promptly supply
necessary information unless constrained by the demands of confidentiality.

The counsellor shall not in any way exploit a relationship with a supervisor, employee, student, research
participant or volunteer.

Principle 11: Remuneration

The counsellor shall establish financial arrangements in professional practice in accord with the professional
standards that safeguard the best interests of the client first, and then of the counsellor, the agency, and the
profession.

The counsellor shall inform the client of all financial policies. In circumstances where an agency dictates explicitly
provisions with its staff for private consultations, clients shall be made fully aware of these policies.

The counsellor shall consider the ability of a client to meet the financial cost in establishing rates for professional
services.

The counsellor shall not engage in fee splitting. The counsellor shall not send or receive any commission or rebate
or any other form of remuneration for referral of clients for professional services.

The counsellor, in the practice of counselling, shall not at any time use one’s relationship with clients for personal
gain or for the profit of an agency or any commercial enterprise of any kind.

The counsellor shall not accept a private fee for professional work with a person who is entitled to such services
through an institution or agency unless the client is informed of such services and still requests private services.

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Principle 12: Societal Obligations

The counsellor shall to the best of his/her ability actively engage the public policy and legislative processes,
educational institutions, and the general public to change public policy and legislation to make possible
opportunities and choice of service for all human beings of any ethnic or social background whose lives are
impaired by alcoholism and drug abuse.

We hope you enjoyed this course module

ACCSA – Addiction Counsellor Certifications South Africa Pty (Ltd)

www.accsa.co.za
[email protected]

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