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Counseling Approaches To Promote Recovery From Problematic Substance Use and Related Issues [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2023. (Treatment Improvement Protocol (TIP) Series, No. 65.)
Recovery-oriented counseling calls for counselors to possess certain competencies to work with clients effectively and empathetically.
Counselors need to take into account a range of sociocultural considerations when assessing and working with clients in or seeking recovery, which requires cultural responsiveness and an awareness of treatment barriers and inequities stemming from sociocultural factors.
A strengths-based approach is fundamental to recovery-oriented counseling, beginning with client intake and continuing throughout the duration of care.
Recurrence of substance use happens, but recovery-oriented counseling can help clients avoid it or confidently return to recovery when it does occur.
Counselor participation in recovery-oriented systems of care can benefit clients by promoting holistic, coordinated, and nonepisodic services.
Depending on the setting, counselors providing or thinking of providing recovery-oriented counseling may need to consider the ways that payment systems can affect delivery of care.
Regardless of setting and training, counselors working with clients who are in or considering recovery can provide support by helping them build their strengths, resiliencies, and resources. This approach emphasizes what is “right” or already working for clients regarding the strategies they use for coping and improving health and well-being. It emphasizes client resilience and functioning instead of client weakness and pathology.
This chapter lays the groundwork for Chapters 3 and 4 by discussing how counselors can work with clients to identify their natural supports, coping skills, talents, abilities, hopes, and dreams for the future. It provides a framework for recovery-oriented counseling by:
Setting out competencies for counselors working with people in or considering recovery.
Highlighting sociocultural considerations in recovery-oriented counseling.
Discussing the elements of strengths-based counseling.
Covering skills that are important for clients to develop in early recovery.
Describing recovery management checkups and check-ins.
Introducing an approach to promoting a healthy life for clients who are beyond early recovery.
Discussing counselor responses to warning signs of a possible recurrence of use.
Outlining some of the benefits that clients receive when counselors participate in recovery-oriented systems of care.
The chapter also looks at ways that payment systems can affect the delivery of care for counselors in healthcare and behavioral health service systems.
Exhibit ES.1 in the Executive Summary contains definitions of key terms that appear in this and other chapters.
As Chapter 1 noted, counselors can provide recovery-oriented counseling in a wide range of settings. This diversity is a strength, given the need for supports for people seeking or in recovery. But to provide such clients with consistent, high-quality care, counselors need a common foundation of knowledge and skills.450 The consensus panel identified the following competencies for working with individuals who have problematic substance use or who are in recovery.
Possess an understanding of substances, problematic substance use, and addiction treatment and recovery. Counselors should:
Based on data, understand the substances most prevalent in clients' communities.
Understand concepts of problematic substance use and recovery, including factors that influence problematic substance use, who may work with individuals with problematic substance use, and recovery and recovery pathways. (Chapter 1 discusses these topics.)
Understand specific substance use disorders (SUDs), such as alcohol use disorder (AUD) and opioid use disorder (OUD).
Understand common measurements of substance use, such as standard drink sizes.
Know commonly used drugs and the street names for them.
Understand the symptoms of intoxication and withdrawal.
Recognize warning signs for recurrence.
Be familiar with common screening instruments for problematic substance use and mental health–related conditions that may co-occur with problematic substance use (e.g., Columbia Suicide Severity Rating Scale, AUDIT, PHQ, GAD, S2BI, CRAFFT, PCPTSD).
Understand the levels of care available for treating problematic substance use.
Have knowledge of Food and Drug Administration–approved medications used to treat problematic substance use.
Understand the principles of harm reduction and the tools used to minimize harm, such as opioid education and naloxone, fentanyl and xylazine test strip distribution, and syringe services programs.
Understand the impact of genetics and epigenetics on substance use.
Be familiar with problematic behavioral issues other than substance use, such as problematic gambling and sexual behaviors.
Selected supporting resources:
Substance Abuse and Mental Health Services Administration (SAMHSA), Welcome to the Center for Behavioral Health Statistics and Quality (CBHSQ): https://www
SAMHSA, Alcohol Use: Facts & Resources:
https://www
SAMHSA, Harm Reduction: https://www
SAMHSA, Treatment Improvement Protocol (TIP) 42, Substance Use Disorder Treatment for People With Co-Occurring Disorders,
Chapter 3 and Appendix B: https://store
SAMHSA, TIP 63, Medications for Opioid Use Disorder:
https://store
State of Oklahoma, ASAM Quick Reference:
https://oklahoma
American Association for Community Psychiatry, Level of Care Utilization System (LOCUS) Guide for Patients, Families, and Providers:
https://drive
Possess an understanding of mental health–related conditions. Counselors should:
Be familiar with common co-occurring mental disorders.
Understand how problematic substance use may influence mental issues and suicidality.
Know the procedures for providing or accessing crisis services.
Know the procedures for the mandatory psychiatric evaluation process.
Have knowledge of local therapeutic resources available to clients.
Selected supporting resources:
SAMHSA, TIP 42, Substance Use Disorder Treatment for People With Co-Occurring Disorders:
https://store
SAMHSA, National Guidelines for Behavioral Health Crisis Care: Best Practice Toolkit:
https://www
Have a general understanding of common co-occurring medical conditions, including:
HIV.
Sexually transmitted infections.
Hepatitis A, B, and C viruses.
Bacterial and fungal infections, including infective endocarditis.
Alcohol-related liver disease.
Oral diseases, including tooth decay, gum disease, and dry mouth.
Skin manifestations of substance use (e.g., rashes, scars, dry skin, dental decay).451
Substance use–associated dementia.
Substance-induced mental disorders and psychoses (e.g., bipolar disorder, anxiety disorder).
Selected supporting resource:
National Institute on Drug Abuse, Common Comorbidities with Substance Use Disorders Research Report:
https://nida
Provide trauma-informed care. Counselors should:
Ensure patients' emotional and physical safety.
Know the signs and symptoms of trauma.
Understand how chronic stress, adverse childhood experiences, and discrimination can contribute to trauma.
Understand the widespread impact of trauma and its relationship to substance use.
Understand reporting mechanisms for suspected violence or abuse.
Selected supporting resource:
SAMHSA, TIP 57, Trauma-Informed Care in Behavioral Health Services:
https://store
Understand how to establish a therapeutic alliance. Counselors should:
Know how to use motivational interviewing (MI) and motivational enhancement to promote engagement in recovery services.
Understand the importance of empathy, authenticity, warmth, and unconditional positive regard.
Use inclusive, nonstigmatizing language.
Maintain compassionate, consistent, respectful, and open communication.
Use reflection techniques to facilitate emotional awareness and insight.
Selected supporting resource:
SAMHSA, TIP 35, Enhancing Motivation for Change in Substance Use Disorder Treatment:
https://store
Identify and address health disparities. Counselors should:
Understand structural competency and inequities that contribute to and perpetuate health disparities.
Understand race, gender, ethnicity, class, sexual orientation, gender identity, physical and mental disabilities, and other dimensions of individual and group identity.
Recognize and manage one's own bias, including implicit biases.
Present information in a culturally responsive way.
Understand bystander interventions for discrimination.
Selected supporting resources:
Centers for Disease Control and Prevention (CDC), Social Determinants of Health at CDC: https://www
SAMHSA, TIP 59, Improving Cultural Competence:
https://store
SAMHSA's Addiction Technology Transfer Center (ATTC) Network Southeast, Improving African-American Retention In Substance Abuse Treatment: Implicit Racial Bias and Microaggression:
https://attcnetwork
STRUCTURAL COMPETENCY.
Understand how to assess social determinants of health (SDOH) with individual clients. Counselors should:
Understand the conditions where people in the area live, learn, work, worship, and play.
Be familiar with relevant data available about the community served.
Assess clients for the impact of SDOH on their lives (The “Resource Alert: Tools for Assessing SDOH” lists helpful tools).
RESOURCE ALERT: TOOLS FOR ASSESSING SDOH.
Use a strengths-based, person-centered approach. Counselors should:
Provide services based on the client's most urgent needs (e.g., housing, food, child care).
Understand and work with the client's recovery capital (defined in the “Recovery Capital Assessment” section).
Provide individualized, age-appropriate services.
Understand individual preferences, needs, and values.
Engage in shared decision making.
Selected supporting resources:
SAMHSA, Shared Decision-Making Tools: https://www
SAMHSA, TIP 26, Treating Substance Use Disorder in Older Adults:
https://store
SAMHSA, TIP 35, Enhancing Motivation for Change in Substance Use Disorder Treatment:
https://store
SAMHSA, TIP 51, Substance Abuse Treatment: Addressing the Specific Needs of Women:
https://store
SAMHSA, TIP 56, Addressing the Specific Behavioral Health Needs of Men:
https://store
Know how to link clients to treatment and community recovery resources and actively do so. Counselors should:
Know the landscape of available recovery communities and services as well as mutual-help groups.
Know how to use 12-Step facilitation techniques to link clients to 12-Step groups as appropriate.
Understand when a client would benefit from a referral to another healthcare provider.
Be familiar with the required protocols of providers, facilities, and services.
Understand core principles of case management.
Help ensure continuity of care and integrated services.
Make warm handoffs when transferring clients to other providers or recovery communities.
Maintain communication with recovery resource partners (e.g., if a counselor links a client to peer support services, the counselor should be available to the peer provider for consultation and feedback on how the client is doing).
Selected supporting resource:
SAMHSA, Advisory, Comprehensive Case Management for Substance Use Disorder Treatment: https://store
Adhere to professional and ethical standards. Counselors should:
Ensure client safety.
Understand and adhere to client confidentiality requirements.
Know how to establish and maintain appropriate boundaries.
Selected supporting resources:
SAMHSA, Substance Abuse Confidentiality Regulations: https://www
SAMHSA, TIP 57, Trauma-Informed Care in Behavioral Health Services:
https://store
Engage in recovery advocacy. Counselors should:
Become familiar with and advocate for needed recovery services and social services not available in the community.
Understand available state advocacy services.
Selected supporting resource:
Faces & Voices of Recovery, Recovery Advocacy Movement: https:
Each person embraces culture in a unique way, and considerable diversity exists within and across races, ethnicities, and cultural heritages.459 Counselors should recognize these differences and incorporate culturally appropriate knowledge, understanding, and attitudes into culturally responsive communication and services to support clients.460
With culturally responsive approaches, clients are more likely to feel heard, empowered, and safe, which can translate into stronger engagement in treatment and recovery services. Research suggests that SUD treatment programs with a higher degree of cultural responsiveness are associated with improved access and longer retention among certain underrepresented populations. These practices may also improve minority client treatment engagement.461 Cultural responsiveness decreases disparities in treatment and recovery services among people with problematic substance use.462
Culturally responsive services require counselors to develop an understanding of the cultures of the specific clients with whom they are working, including how these cultures tend to view problematic substance use and its treatment.463 Becoming culturally responsive begins with a self-evaluation of personal biases, including how they may affect one's own ability to provide services. Counselors should then use this self-awareness to address their biases and provide inclusive care. This is an ongoing process that requires constant monitoring and learning.
RESOURCE ALERT: NATIONAL CLAS STANDARDS.
Research indicates that such factors as race and ethnicity, gender and sexual orientation, disability, and community can affect the ability of someone to receive appropriate SUD treatment and other services.464 Counselors should be sensitive to the needs of the special populations they are working with on recovery, and the plan of care may need to be adapted based on these needs. SAMHSA's publication Adapting Evidence-Based Practices for Under-Resourced Populations (https://www.samhsa.gov/resource/ebp/adapting-evidence-based-practices-under-resourced-populations) contains useful adaptation strategies; that publication's “Resources on Treating Particular Populations” section contains information on working with specific special populations—including individuals with co-occurring disorders and women—which is beyond the scope of this TIP. The following table lists some other relevant SAMHSA publications on special populations.
Links to SAMHSA's Practitioner Training and Centers of Excellence for special populations can be found at https://www.samhsa.gov/practitioner-training.
The prevalence of problematic substance use and SUDs varies by race and ethnicity. Research has shown that although Black individuals have lower levels of SUDs during adolescence compared with Hispanic people and White people, after age 25, Black individuals have a higher prevalence of substance use and SUDs than other populations. After age 35, Black men have a higher prevalence of overall substance use. Black women over 35 also report a higher prevalence of heavy drinking compared with Hispanic or White individuals.465 SAMHSA's 2021 National Survey on Drug Use and Health found that the percentage of individuals ages 12 or older with a past-year SUD was higher among American Indian and Alaska Native or multiracial individuals than among Black, White, Hispanic, or Asian individuals.466
Researchers have noted the relationship between historical trauma, discrimination, and problematic substance use among minorities, suggesting that systemic effects of racial and ethnic discrimination may result in increased rates of SUDs later in life for these populations.467,468 In addition, minority populations are more affected by the consequences of SUDs “in terms of incarceration, health problems, stigma, and violence.”469
The SUD treatment gap is significantly greater for Black and Hispanic adults than for White adults.470 Minority populations also face more barriers to SUD treatment completion and satisfaction than White populations do.471,472
For example, in a small 2022 cross-sectional study of Black individuals seeking SUD treatment, more past experiences of racial discrimination in healthcare settings were connected to self-reported delay in seeking SUD care and anticipation of discrimination during SUD treatment.473 A small qualitative 2018 study of Hispanic individuals meeting diagnostic criteria for a recent SUD found that major reasons for avoiding specialty SUD treatment included474:
A lack of interest in abstinence as a recovery goal.
Concerns that providers wouldn't treat problematic substance use effectively or in a culturally responsive way.
Findings indicate that bias is an ongoing concern for other minority groups as well, including Asian Americans and Native Americans, who report along with Black and Hispanic individuals that they still experience everyday forms of discrimination.475
Research also indicates that prescriptions for buprenorphine to treat OUD are concentrated among White individuals and people who self-pay or use private insurance for buprenorphine treatment. This disparity represents a significant inequity and barrier, given that buprenorphine treatment is effective and, unlike methadone, doesn't require regular in-person dispensing at a special clinic (opioid treatment program)476,477,478 that may require greater travel than other dispensing sites.479
Like race and ethnicity, gender and sexual orientation affect SUD treatment engagement. Research finds that women have less access to SUD treatment than men do.480 Barriers thought to contribute to this disparity include childcare obligations, pregnancy, and greater financial limitations.481,482 Women are also more likely than men to report concern about the effect of being in treatment on their reputation or job.483
Gender disparities in SUD treatment participation have long been noted in treatment for AUD, the most prevalent SUD, with a lower percentage of women receiving needed AUD care.484 Findings from a study of patients at a large community health center in the Northeast suggest that one factor in this disparity in treatment participation may be that women who screen positive for AUD are less likely to receive a diagnosis of AUD compared with men who screen positive.485
Sexual and gender minorities are at elevated risk of problematic substance use compared with their heterosexual peers.486 Research indicates that sexual minority adults have between 1.6 and 3.1 times the odds of lifetime SUDs compared with their heterosexual counterparts.487
Although sexual and gender minorities overall are more likely to seek out SUD treatment than their heterosexual peers, they face barriers in accessing quality treatment. These barriers include stigma and bias as well as lack of provider knowledge about specific needs.488,489
Only a limited number of programs are designed to serve LGBTQI+ populations. A 2020 national study looking at the availability of LGBT-specific services in mental health service and SUD treatment facilities found that fewer than one in five SUD treatment facilities reported programs specific to LGBT people.490
People living in rural communities face distinct challenges related to problematic substance use and SUD treatment. Rural residents have fewer treatment options, including a relative lack of access to opioid treatment programs and buprenorphine treatment.491 Compounding this issue, rural providers report feeling underprepared to deliver SUD treatment because of a lack of necessary supports and resources.492 And rural residents are less likely than urban residents to be administered naloxone during an opioid overdose in the emergency department.493 The decision by the Drug Enforcement Administration in June 2021 to allow opioid treatment programs to operate mobile units may help to create increased access to care in rural areas where distance and transportation may have otherwise been significant obstacles for someone seeking treatment.494
Rural residents can also face social and cultural barriers to receiving SUD treatment, including stigma around drug use and treatment seeking in general, concerns about treatment anonymity in small communities, a lack of treatment coordination and integration in rural settings,495 and mistrust among some treatment seekers about the use of medications for SUDs.496 Many people living in rural areas also face economic barriers and have health insurance gaps that affect their ability to afford SUD treatment. Lack of broadband Internet has also been cited as a barrier to telehealth treatment options in rural areas,497 although recent data suggest that significant progress has been made in increasing rural Internet access.498
The Health Resources & Services Administration's (HRSA) Federal Office of Rural Health Policy webpage (https://www.hrsa.gov/rural-health) provides and links to more information on problematic substance use in rural areas and federal and state responses to it. HRSA's Opioid Response webpage at https://www.hrsa.gov/rural-health/opioid-response contains substance use–related topics, as does the Rural Health Information Hub (https://www.ruralhealthinfo.org/topics).
A lower socioeconomic status increases a person's risk of SUDs and can affect treatment options. Socioeconomic disparities affect access and utilization of behavioral health services as well as substance use prevalence and patterns.499 An analysis of national survey data showed that among people who reported ever using illicit substances, those with a lower income (family income less than $20,000) were 34 percent more likely to report having substance use–related problems compared with people in the highest income category.500 Also, insurance coverage, specifically lack of insurance among men of color and low socioeconomic status, creates barriers to accessing treatment.501
People with disabilities are more likely to have problematic substance use than people without disabilities.502,503 Yet people with disabilities are less likely to receive treatment,504 in part because they can face a range of barriers to participating, including505,506:
Lack of accessible programs.
Lack of specialized programs for people with co-occurring conditions, including individualized treatment plans that account for diverse literacy or cognitive capabilities.
Transportation issues.
Difficulty accessing treatment locations.
Stigma and stereotypes.
Insufficient clinician training on providing services to clients with disabilities.
Lack of access to affordable quality care.507
People living with certain medical conditions, including HIV, hepatitis C virus (HCV), or chronic pain are more likely to have difficulties in accessing and receiving SUD treatment. Provider stigma may be a contributor to these barriers to SUD treatment.508,509, A study of people with HCV who inject drugs indicated that stigma negatively affected their ability to navigate and receive treatment.510 Patients with chronic pain and SUDs also face barriers to treatment, including OUD medication, because of stigma.511
Lack of knowledge of appropriate referrals was another type of barrier to SUD treatment found by a qualitative study of HIV and SUD treatment providers' perspectives on treatment barriers to people living with both HIV and SUDs.512 Some of the HIV treatment providers interviewed were unfamiliar with the different levels of SUD care and reported that they had never referred a patient to SUD treatment.
Limited research has looked at the effects of intersecting identities on SUD treatment.513 More is known about the associations between intersecting identities and substance use, information that is useful for counselors.
For example, a study of the links between intersectional stigma and specific behavioral health outcomes among Black, Hispanic, and multiracial gay and bisexual men found a significant combined effect of gay rejection sensitivity (anxious expectation of rejection for being gay) and racial discrimination on heavy drinking, through emotional regulation difficulties and internalizing symptoms of depression and anxiety.514 In another example, the authors of a study on disparities in heavy episodic drinking, cannabis use, and smoking found greater prevalence of such substance use among Black and Hispanic LGB women compared with White LGB women.515
Stigma, bias, and discrimination on the part of providers may play a key role in perpetuating healthcare disparities, including in the treatment of problematic substance use.516 Healthcare providers may have biases against people with problematic substance use, which may affect the quality of care provided.517
Research on hospitalized patients who have SUDs has found that these individuals experience stigma and discrimination from clinicians and other hospital staff.518 In a study of emergency department physicians' attitudes toward patients with SUDs, physicians reported a lower regard for patients with SUDs than patients with other conditions. In fact, 54 percent of physicians who participated in the study said they at least “somewhat agree” that they “prefer not to work with patients with substance use who have pain.”519
Individuals who use illicit drugs while in a hospital can face an inconsistent and informal range of non-person-centered responses from individual providers, including use of security staff as responders to first instances of illicit use, increased monitoring, and administrative discharge. These responses do not take into account survey findings that some patients with illicit in-hospital use report that it stems from experiencing stigma and inadequately treated pain or withdrawal.520,521,522 These findings highlight a need for more patient-centered, appropriate, and formalized institutional policies related to in-hospital patient drug use.523,524,525
Implicit bias is a prejudice or bias outside one's conscious awareness that can lead to a negative evaluation of a person based on such characteristics as race or gender. Counselors need to identify any implicit biases they may have against people with problematic substance use or in recovery, as these biases can have a negative effect on care and client rapport.526 If medication-assisted recovery is not part of the counselor's practice or their personal orientation regarding treatment, then the counselor should be conscious of any biases they may have toward individuals seeking or currently using medication for the treatment of SUD.
As one step in addressing any implicit bias they might have, counselors should take care with the language they use with and about clients who have problematic substance use. For example, counselors should527:
Use person-first language. Someone actively using substances in a problematic way should not be referred to as a “substance abuser” or “addict,” which can suggest that they, the person, are the problem. Instead, they can be referred to as a “person with problematic substance use,” which indicates that they have a problem that can be addressed.
Not confuse substance use with SUD. Counselors should refer to someone as having SUD only if they have received a clinical diagnosis.
Use neutral technical terms, rather than stigmatizing slang terms. The classic example of this guidance is to refer to drug test results as “negative” or “positive,” rather than “clean” or “dirty.”
BYSTANDER INTERVENTIONS.
Strengths-based, person-centered counseling at its core involves530,531:
Focusing on clients' resources, rather than their deficits.
Working with clients on enhancing their lives, rather than simply helping them manage problems or illness.
Respecting clients' perspectives on their goals and needs, rather than determining these priorities for clients.
No single, agreed-upon set of principles for strengths-based counseling exists. Several leading theorists of the strengths-based model have articulated principles relevant for counseling people recovering from problematic substance use. Two somewhat overlapping examples appear below.
Two prominent theorists, Charles A. Rapp and Richard J. Goscha, developed six basic principles for using the model in mental health services532:
Principle #1: People can recover, reclaim, and transform their lives.
Principle #2: The focus is on an individual's strengths, rather than deficits.
Principle #3: The community is viewed as an oasis of resources.
Principle #4: The client is the director of the helping process.
Principle #5: The worker–client relationship is primary and essential.
Principle #6: The primary setting for our work is in the community.
Rapp and Goscha noted that the principle of viewing the community as an oasis of resources (Principle #3) entails looking for the opportunities and strengths that exist in all communities, even those that lack resources or whose resources may not be obvious. By “primary and essential” in Principle #5, Rapp and Goscha meant that a strong and trusting relationship with the practitioner is needed to create the right environment for mobilizing a client's resources and goals for recovery.533
Dennis Saleebey, another prominent theorist of the strengths-based model, set out these six principles in 2012 for social work practice534:
Principle #1: Every individual, group, family, and community has strengths.
Principle #2: Trauma and abuse, illness and struggle may be injurious, but they may also be sources of challenge and opportunity.
Principle #3: Assume that you do not know the upper limits of the capacity to grow and change and take individual, group, and community aspirations seriously.
Principle #4: We best serve clients by collaborating with them.
Principle #5: Every environment is full of resources.
Principle #6: Caring, caretaking, and context.
Principle #6 underscores the importance of caring relationships as strengths, including the therapeutic relationship.535
Strengths-based counseling doesn't call for counselors or their clients in recovery to ignore reality. This approach is NOT about536:
Assuming that clients already have all the resources they need to change.
Focusing only on clients' strengths.537
Encouraging clients in recovery to “just think positive.”
A strengths-based, person-centered approach acknowledges and addresses clients' problems, but doesn't let these problems drive clients' or counselors' expectations for what clients can ultimately achieve in recovery.
A collaborative strengths-based, person-centered assessment identifies clients' current coping skills and abilities; family, social, and recovery supports; motivation; and other sources of recovery capital (discussed in “Recovery Capital Assessment” below). Counselors should view strengths broadly to include people's values; interpersonal skills; talents; knowledge and resilience gained from previous efforts to overcome problematic substance use, stressful life events, or adversity (including trauma); spirituality and faith; personal hopes, dreams, and goals; family, friend, and community connections; cultural and family narratives of resilience; and general skills in daily living.
A strengths-based, person-centered approach to counseling recognizes that even the questions asked at intake, whether on a form or in person, can influence clients' perceptions of their situation and their interest in engaging with a counselor. For example, a 2014 randomized study found that marriage and family therapy clients completing a strengths-based intake form listed significantly fewer problems and proposed significantly more solutions than did clients completing a problem-focused form.538
Examples of strengths-based, person-centered intake questions include539,540:
What do you do well?
Tell me about a time when you felt like most things were going well. What were you doing to make them go well?
How can I best help you?
The last question above reflects the fact that some clients will not regard addressing past or present problematic substance use as their top priority. Psychologist Abraham Maslow's Hierarchy of Needs, originally published in 1943 and now a staple of motivational theory, is based on his observation that people are motivated by unsatisfied needs and tend to want to fulfill basic needs—such as food, water, and shelter—before moving on to higher level needs. The five levels of Maslow's Hierarchy, often displayed as a pyramid, are, from basic to most complex541,542:
Physiological needs, such as food, water, and air.
Security and safety needs, such as financial security, housing, and health care.
Social needs, such as love and healthy social relationships.
Esteem needs, such as appreciation and respect.
Self-actualization needs, or the process of fulfilling personal potential.
Although the process of recovery does not always reflect this kind of linear order,543 the Hierarchy does effectively communicate that clients with substance use–related problems who have basic, pressing needs may be more focused on meeting those needs than on changing their substance use.544 A strengths-based, person-centered approach should include consideration of a client's hierarchy of needs, while acknowledging that there is a complex relationship between the levels.545 Clients may identify needs in various areas throughout their recovery, from managing withdrawal to establishing healthy social connections. Counselors should identify what needs matter most to clients by asking open-ended questions such as546:
What are your most important needs right now?
What areas of your life do you want to focus on to address these needs?
Chapter 4 contains an indepth discussion of resources that are available to individuals in recovery to help them meet their personal needs in areas such as health care, affordable housing (e.g., Housing First), nutrition, employment, and social connection.
Counselors can also ask clients to explore their hopes and dreams. Envisioning the future can help people look ahead in a positive way and identify their core values. This exploration can also help clients identify their recovery goals and recognize how risk behaviors may get in the way of reaching these goals. Some questions include:
What are your hopes for the future?
What would you like your life to look like in 5 years?
What recovery goals fit with your vision of the future?
As part of a strengths-based, person-centered counseling approach, the consensus panel recommends conducting a values exercise with a client seeking or in recovery. Values can be thought of as the principles, qualities, and beliefs that are most important to an individual and that the individual most wants their life to reflect. The exercise of identifying values can help a client build motivation to enter or maintain recovery by making them more aware of how substance use conflicts with their values.547,548 This sort of values work is a key part of Acceptance and Commitment Therapy (discussed in Chapter 3),549 but also fits with other counseling approaches.550
One widely used instrument is the Bull's Eye Exercise,551,552 available at https://webster.uaa.washington.edu/asp/website/site/assets/files/2367/values_exercise_bulls_eye.pdf. Another tool is the My Personal Values Worksheet (Exhibits 2.1 and 2.2). Having a client use values sort cards offers another way of conducting a values exercise.
EXHIBIT 2.1. My Personal Values (Worksheet Part 1).
EXHIBIT 2.2. My Personal Values (Worksheet Part 2).
PRIORITY OUTCOMES FOR RECIPIENTS OF SUD TREATMENT AND RECOVERY SUPPORT SERVICES.
Motivation is a critical element of behavior change556 that can predict recovery from problematic substance use.557,558 As part of strengths-based, person-centered counseling, counselors can use a strategy from MI called decisional balancing to learn what clients with active problematic substance use think they are getting out of such use and to help them find reasons to address it. MI is an evidence-based, person-centered counseling approach for helping people resolve ambivalence about changing behaviors. When clients observe that the costs of substance use outweigh the benefits, they may be motivated to reduce or stop it.559
Decisional balancing must be used carefully, as it may instead increase ambivalence among clients who are contemplating change. It is generally preferable to explore with clients what they get out of substance use before exploring possible reasons for change, as this allows the discussion to conclude with the arguments for change.560,561 More on decisional balancing and related MI strategies can be found in Chapter 3 and SAMHSA's TIP 35, Enhancing Motivation for Change in Substance Use Disorder Treatment, at https://store.samhsa.gov/product/TIP-35-Enhancing-Motivation-for-Change-in-Substance-Use-Disorder-Treatment/PEP19-02-01-003.
“Recovery capital” refers to the quantity and quality of resources available to individuals to begin and maintain long-term recovery from problematic substance use. These resources may be internal (e.g., physical health, values, hope) or external (e.g., community and cultural support, employment), and they can increase.562,563 The concept of recovery capital reflects the belief that everyone has strengths and resilience and that building on them is central to the recovery process. Having greater recovery capital is associated with positive outcomes, such as SUD treatment completion, attendance at follow-up appointments, and meeting one's recovery plan goals.564,565
As part of providing recovery-oriented counseling, counselors need to understand the concept of recovery capital and incorporate it into their practice by working with clients seeking recovery to help them identify, access, and build their own recovery capital. Recovery capital is usually divided into four categories.
Personal recovery capital includes “physical recovery capital,” such as food, access to transportation, and safe housing as well as “human recovery capital,” such as values, knowledge, educational/job skills, problem-solving skills, internal motivation or commitment to recovery, and self-awareness.566
Family/social recovery capital includes intimate relationships; biological family; family of choice; friends; and relationships at school, work, faith-based institutions, and community organizations that support individuals' recovery efforts.567
Community recovery capital includes attitudes, policies, and resources in clients' communities that promote recovery from substance use–related problems through multiple pathways.
Cultural recovery capital includes the availability of traditional and other culturally based pathways of recovery that help support clients from that culture. Cultural recovery capital also includes the values and beliefs associated with a culture that support recovery.568
Clients who have worked with peer specialists are likely to have already completed a recovery capital assessment at least once as part of receiving peer support services. Because recovery capital can change over time and no one universally accepted measure of it exists, including a recovery capital assessment as part of the overall assessment of clients with present or past problematic substance use can give counselors a better understanding of their recovery resources.
Some clients may find it challenging to identify their strengths or may say that they don't have any. Counselors can ask these clients how they have overcome adversity in the past, and how they have previously managed problematic substance use. Counselors can also reframe as potential strengths what these clients—and the counselors themselves—may think of as deficits. Some examples are in the following table.
The consensus panel recommends asking clients to look at the skills they used to obtain substances and reframing those as strengths.
Several tools are available for assessing recovery capital. Clients can often complete assessments themselves. Some tools may be more appropriate for use in certain settings or with specific populations. Below is a description of several of these tools, including information about how to access them and limitations.
Substance Use Recovery Evaluator (SURE). SURE is a brief, easy-to-complete, validated assessment that can help clients monitor and reflect on their recovery journey or their treatment outcomes. SURE collects information on 21 items within these categories: substance use, material resources, outlook on life, self-care, and relationships.569 A strength of the measure is that only 6 of the 21 items refer directly to the use of substances, highlighting how it is possible to be in recovery without focusing on abstinence.570
The SURE measure is not for use in settings such as residential rehabilitation or prisons. And because the tool was developed in Britain, the developers recommend substituting culturally appropriate terms as needed when it is used in other countries.571
More information about SURE can be found at https://www.kcl.ac.uk/research/sure-substance-use-recovery-evaluator.
Assessment of Recovery Capital (ARC). ARC is a 50-item self-report measure validated for predicting recovery. ARC assesses recovery strengths using 10 domains:572
Substance use
Psychological health
Physical health
Community involvement
Social support
Meaningful activities
Housing and safety
Risk taking
Coping and life functioning
Recovery experience
Counselors can use ARC to identify SUD treatment barriers or interventions to increase recovery capital. Rehabilitation professionals in SUD treatment programs also can use ARC to assess recovery capital, informing the development of treatment plans with a focus on recovery capital.573
Brief Assessment of Recovery Capital-10 (BARC-10). BARC-10 is a brief measure of recovery capital based on the ARC. The measure examines client responses to 10 items across all the original domains of ARC.574
This validated measure takes about a minute to complete and provides a single unified dimension of recovery capital. It is appropriate for use in diverse settings, such as recovery support service settings or health clinics.575 More information is available in the BARC-10 information sheet developed for the Virginia Department of Behavioral Health & Developmental Services at https://static1.squarespace.com/static/5cd33914797f74080d793b95/t/60678b620d8b4e517e4ca0b8/1617398627765/BARC-10+Information+Sheet.pdf.
Strengths and Barriers Recovery Scale (SABRS). SABRS is an index of recovery capital based on the Life in Recovery survey. SABRS assesses five domains—work, finances, legal status, family and social relations, and citizenship—and includes retrospective information about strengths and barriers in active addiction and in recovery.576
More information on SABRS is available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7298842/.
Although widely used, the ARC and BARC-10 tools assume abstinence is the recovery goal, which doesn't align with current recovery approaches recognizing multiple pathways, and these instruments may not be generalizable to diverse populations.577,578
Work is underway on a new assessment tool, the Multidimensional Inventory of Recovery Capital (MIRC). The items in the pilot measure were developed with feedback from service providers and people in recovery from problematic alcohol use, with significant participation by people identifying as LGBTQ+ and by people in recovery who are of color or low income. The participants in recovery also collectively reported using a variety of recovery pathways, and many reported having problems with other substances besides alcohol. The inventory can capture information about the effect on recovery outcomes of poverty, discrimination, and other disadvantages.579 The inventory covers these domains:
Human
Financial
Social
Community and cultural
More information about MIRC is available at https://www.recoveryanswers.org/research-post/reflections-from-asking-recovering-individuals-about-how-best-measure-recovery-capital/.
Chapter 4 has recommendations on practices to help build recovery capital.
Providing clients with unconditional positive regard from the outset of counseling work with them is a key aspect of strengths-based, person-centered counseling, regardless of the therapeutic approach used. (Unconditional positive regard refers to caring about, accepting, and valuing someone regardless of what they do or say.580) A 2018 meta-analysis found a small but positive association between the provision of positive regard and improved clinical outcomes that support positive regard's status as a central element of the therapeutic relationship for clients generally.581
The authors of a 2019 study of emotional intelligence among addiction counselors noted that clients with substance use–related problems can face (and may pick up on) counselor frustration with the high rate of recurrence in the SUD treatment population. The authors emphasized the importance of providing clients in SUD treatment “with a nonjudgmental environment and an attitude of unconditional positive regard,” saying, “This corrective experience can be especially therapeutic for these clients.”582
The authors of the 2018 meta-analysis offered several reasons and recommendations for incorporating positive regard into clinical practice, including the following:583
Consider that affirming clients can have many useful impacts, such as strengthening clients' engagement in therapy and sense of agency.
Don't just feel good about clients, but express positive feelings toward them (within clinical boundaries) to support their sense of worth.
Express regard in different ways, such as offering reassurance, creating positive narratives, and using positive body language.
Be open, receptive, curious, and valuing of the client.584
Let the client know that they are understood, known, and seen, which can help to release their potential for growth and reconfiguration.585
Traditional approaches to recovery have focused on identifying and reducing the impact of cues that can trigger substance use, and have suggested that individuals may return to such use when reintroduced to environments full of substance-related cues. More recent research suggests that another important element of recovery is identifying client-specific cues for healthy behaviors and positive thoughts. Such personalized “recovery cues” include images, objects, and sensory experiences that a client associates with recovery commitment and that produce positive cognitive–affective states.586
A recovery cue can be as simple as a pair of running shoes left by the door as a reminder to run. Other examples of visual recovery cues are:587,588
An image of a nature scene that the client associates with serenity.
Photos of loved ones.
A photo of a sponsor.
Supportive text messages that the counselor has sent to the client.
Examples of audio recovery cues are:589
Meditations.
Nature sounds.
Music recordings.
An audio clip of the client reading a gratitude list.
Counselors can help clients identify a collection of such cues.
During early recovery, clients need to develop coping and avoidance skills to reduce risk of recurrence to use.590 Clients should determine which coping and avoidance skills work best for them.
Coping skills are helpful ways of thinking and acting that can manage impulses and cravings, reduce stress, and support problem-solving in early recovery.591 Common strategies include:592
Learning and practicing stress reduction techniques.
Scheduling time for relaxation.
Getting more sleep.
Learning and applying problem-solving techniques.
Identifying recreational activities.593
Engaging in positive reframing.594 Positive reframing occurs when a client considers an alternative positive meaning of or perspective on a situation.595
Using urge surfing techniques, or an approach to manage urges by observing the craving without overreacting to it.598 (Chapter 3 has a description and guided exercises.)
Clients in early recovery will also want to avoid high-risk situations through avoidance strategies or skills, which can help them divert their attention from urges and identify alternative activities to engage in.599 Common avoidance coping strategies include:
Trying not to think about a problem.
Distracting oneself with other activities.
Avoiding people associated with past substance use.
Altering travel routes to avoid triggering places.
Removing drug paraphernalia from the home.600
Clients in early recovery may also need to be aware of coping mechanisms that can potentially become unhealthy, such as high or significantly increased caffeine or nicotine intake or binge eating. Chapter 3 provides more details about how counselors can help clients identify and develop positive coping and avoidance skills that fit into their treatment plan.
Self-efficacy is commonly understood as a person's belief in their ability to take action to achieve a desired outcome.601 In the context of substance use, a person with high self-efficacy has confidence in their ability to abstain or reduce such use in high-risk situations. An individual with low self-efficacy, on the other hand, is unsure of their ability to do so.602 Research indicates that people in recovery with higher levels of self-efficacy have a greater likelihood of achieving their recovery goals.603
Enhancing a client's self-efficacy may be critical to fostering long-lasting behavior change and may help to sustain their recovery.604 A first step can be using validated instruments to assess the client's self-efficacy. Several examples follow:
The Alcohol Abstinence Self-Efficacy Scale measures self-efficacy related to problematic alcohol use. The scale assesses both temptation to drink as well as confidence to abstain from alcohol use in 20 situations, using a 5-point Likert-type scale.605 The scale can be found in Appendix B of SAMHSA's TIP 35, Enhancing Motivation for Change in Substance Use Disorder Treatment, at https://store
The Drug-Taking Confidence Questionnaire assesses self-efficacy related to use of a particular substance. The 50-item, fee-based questionnaire measures how likely people are to resist urges in specific situations, using a 6-point Likert-type scale.606,607
The Drug Avoidance Self-Efficacy Scale (DASE) measures self-efficacy for multiple substances. The scale includes 16 questions rated from 1 to 7 from “certainly yes” to “certainly no” in relation to how likely people are to avoid or resist the urge to use substances.608 The DASE instrument can be found at https://adai
Chapter 3 discusses another useful tool: the Confidence Ruler.
After evaluating a client's self-efficacy, the counselor can help them improve their self-efficacy by identifying their natural coping skills, teaching them new ones, and helping them practice the use of these skills. These assessments can also help the counselor identify the unique and personally relevant high-risk situations in which the client feels a greater sense of confidence or lacks confidence.609 Comparing situations in which a client has low and high confidence can help them recognize and apply helpful coping skills to low-confidence situations.
Helping clients access low-cost, substance-free activities will support them on their recovery journey, in part by helping satisfy the needs that substance use filled. Research has highlighted the importance of engaging in substance-free activities as an alternative to use.610,611,612,613 Substance use increases in the absence of substance-free alternatives.614 Looking specifically at harmful alcohol use, research indicates that it's less likely to occur in conditions where substance-free alternatives are low cost and readily available.615,616 As one study notes, people recover from problematic substance use when the availability of substance-free rewarding activities increases.617
Counselors should help clients in recovery discover new ways (or rediscover past ways) to engage in rewarding substance-free activities that are safe, enjoyable, accessible, affordable, and personally meaningful for them.618 Care should be taken to avoid activities that the client associates with their substance use. Examples of substance-free activities include:619,620
Praying or meditating.
Attending religious services.
Taking relaxing outdoor walks.
Exercising.
Doing low-cost home improvement activities.
Crafting.
Cleaning or decluttering one's personal space.
Playing a musical instrument.
Writing.
Socializing with friends and family members may also be a good option, as long as they do not have their own problematic substance use.621 A client's ability to socialize can be affected by a variety of factors (e.g., a global pandemic that calls for social distancing, a client's physical limitations or lack of transportation), so flexibility in terms of what constitutes “social interaction” may be needed (e.g., interactive and digital socializing as opposed to in-person socializing).622
Counselors can also help clients structure their days to incorporate enjoyable activities and encourage healthy choices during a period when they would normally engage in problematic substance use623. For example, counselors could encourage clients to go for an outdoor walk or attend an exercise class in the evenings, if this is a time when problematic substance use would normally occur. Even small changes in the timing of activities may help deter problematic substance use and promote wellness.
This TIP takes the perspective that recovery extends beyond resolving problematic substance use to encompass living a healthy life. Counselors should help clients gain or further develop the resources, skills, and confidence to advance and even thrive in the four dimensions outlined below:624,625
Health. Maintaining good health by overcoming or managing one's disease(s) as well as living in a physically and emotionally healthy way
Home. Building a stable and safe place to live
Purpose. Identifying meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors
Community. Developing relationships and social networks that provide support, friendship, love, and hope
Chapter 4 discusses ways to encourage clients to work on these four domains so they can become more independent, build on their strengths, and enter into the life they want.626
Telephone check-ins and recovery management checkups (RMCs) are effective, proactive strategies for counselors to stay apprised of clients' recovery status and intervene early in actual recurrence of use.
Telephone check-ins involve regular telephone calls with clients in recovery to ask how things are going. Such check-ins typically take place frequently during early recovery or at other times when need for frequent contact is high; they become less frequent as an individual's recovery strengthens.627,628 To be recovery-oriented, such check-ins should include a focus on clients' development and application of their strengths and avoid being overly directive.629,630 Peer specialists often use telephone or text check-ins as part of their work with individuals in recovery.631
RMCs are modeled after methods for providing long-term management of chronic medical conditions like diabetes and heart disease. RMCs involve post–SUD treatment in person or with telephone interviews to determine whether individuals need to reengage in treatment. The intervention provides the individual with tailored feedback on their recovery and, if return to treatment is needed, incorporates MI, problem-solving techniques, and assertive linkage. Major studies on implementing this intervention used quarterly checkups.632
Counselors should be supportive of clients, regardless of whether they experience recurrence.633 Shaming clients or withholding counseling after a recurrence will only limit clients' progress toward their long-term goals. Instead, counselors have an opportunity to help clients put a recurrence in perspective and reinforce that a recurrence does not mean they can't achieve recovery. Nor does it mean that the client is back at square one. Many people who have experienced recurrence one or more times go on to maintain long-term recovery.634
Using a person-centered, strengths-based approach and unconditional positive regard, counselors should affirm clients' efforts to continue in recovery and encourage them to reflect on their goals and how the recurrence could be an opportunity to gain greater insight and adjust their action plan. Clients who have a recurrence should hear from their counselors that they are not alone, because the counselors can offer continuous support while they navigate a path back to recovery.
When clients who take medication to support their recovery have a recurrence, a recovery-oriented approach views this event not as a reason for automatic discharge, but as a sign that dosage and other aspects of the treatment plan may need adjusting.635,636 Individuals taking medication for OUD are at especially high risk for overdose and death should their medication be discontinued. Counselors should refer to their facility policies for guidance in these situations.
As discussed in Chapter 1, recurrence, like recovery, is not an event but a process.637 Counselors and their clients can look out for warning signs that a recurrence may occur within months or weeks and take steps to avert it.638 Stressful life events such as divorce and legal troubles are also associated with recurrence.639
THE ABSTINENCE VIOLATION EFFECT.
Awareness of common triggers and warning signs of a recurrence will help counselors proactively address them with a client if they arise. To respond to warning signs, counselors should:
Talk to the client about outcome expectancies and urges.
Identify triggers for recurrence to use.
Assess the client's confidence in high-risk situations.
Evaluate the client's motivation to continue with a treatment or recovery plan.
Consider working with the client and any providers involved in developing the client's treatment or recovery plan (such as a peer specialist) to incorporate approaches for avoiding a recurrence, or provide additional services, as needed.
Outcome expectancies are anticipated consequences, positive or negative, that result from engaging in substance use.643,644 Research indicates that a recurrence to problematic substance use can result when outcome expectancies are too positive or are not addressed.645 Higher levels of positive outcome expectancies combined with higher levels of negative urgency (behaving impulsively when in a negative mood646) may increase the risk of a recurrence to use.647
Counselors can work with clients to identify the outcome expectancies (both positive and negative) for substance use. Counselors can also help clients identify goals and objectives that will help them avoid a recurrence.
Suggested steps to support a client in recognizing and addressing outcome expectancies include:648
Listing the outcome expectancies for the substance use and resolved behavior (e.g., reduced use of substances).
Discussing the reality of each expectation.
Asking about the benefits of changing behavior (e.g., better quality of life).
Asking the client to identify reasons to stop the behavior.
Working with the client to develop specific goals and objectives.
Clients are more likely to adhere to a treatment or recovery plan if they think it will bring desirable outcomes that outweigh the benefits of engaging or reengaging in problematic substance use.649
RESOURCE ALERT: ADVANCE WARNING OF RELAPSE QUESTIONNAIRE.
Counselors should also help clients identify their triggers for problematic substance use based on what they experienced in the past. Help them identify the following:653
High-risk situations (i.e., who, where, when)
External triggers (e.g., smells, sounds)
Internal triggers (e.g., thoughts, feelings, physical cravings)
Once a client identifies these triggers, the counselor's role is to help them develop coping strategies that worked in the past and that might work again.654 To do this, the counselor should:
Ask the client about strategies they could use now to avoid high-risk situations or external triggers as well as ways to manage internal triggers without engaging in problematic substance use.
Ask the client to describe additional coping strategies.
Evaluate the client's confidence in applying these coping strategies.
HUNGRY, ANGRY, LONELY, TIRED.
The Brief Situational Confidence Questionnaire (BSCQ) is a tool that can help assess clients' level of confidence in how well they would cope in common high-risk situations. The BSCQ is an eight-question measure that asks people to rate how confident they are in their ability at that moment to resist the urge to drink heavily or use drugs in eight situations. The questionnaire's scale ranges from 0 percent to 100 percent, with 0 percent indicating not at all confident and 100 percent indicating totally confident.657
The BSCQ form is available at https://www.nova.edu/gsc/forms/appendix_d_brief_situational_confidence_questionnaire.pdf. The instructions are available at https://www.nova.edu/gsc/forms/BSCQ%20Instructions.pdf.
Using a tool like the BSCQ can help clients better understand their confidence level in high-risk situations, which can be useful in setting realistic goals and developing individualized coping strategies.658
Motivation is fluid, changing over time and by situation. As discussed above, motivation to change can increase when reasons for change and specific goals become clear.659 Motivation can decrease when a person feels doubt or ambivalence about change.
Motivation to change includes another construct: “commitment to change.” A commitment to change implies the presence of a stronger desire that may help someone maintain recovery in the face of adverse circumstances. By assessing a client's commitment to change, a counselor can evaluate the client's motivation to continue with treatment or recovery.660
Several tools exist to assess commitment to change, including the following:
Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES): SOCRATES measures readiness to change and motivation to continue with treatment or recovery. The SOCRATES 8A is for alcohol use, and the SOCRATES 8D is for other substance use. The SOCRATES uses a 5-point scale ranging from 5 (strongly agree) to 1 (strongly disagree) and can assess recognition of the problem, ambivalence, and efforts to take steps. Changes in scores over time can help clients understand the impact of an intervention on problem recognition, ambivalence, and progress toward goals.661
Commitment to Sobriety Scale: This 5-item measure assesses level of commitment to recovery from problematic substance use. The scale rates agreement with statements concerning substance use (e.g., “I will do whatever it takes to recover from my addiction” and “I never want to return to alcohol/drug use again”). It includes a 6-point scale ranging from strongly disagree (1) to strongly agree (6).662 Use this tool with clients who have abstinence as their recovery goal.
Addiction Treatment Attitudes Questionnaire: This measure assesses attitudes toward treatment and recovery. The questionnaire includes questions about commitment to lifelong abstinence (e.g., “I should never have another drink/drug” or “I believe I should never use alcohol or any mood-altering chemicals again”). Respondents rate their agreement with each statement, from 1 (strongly disagree) to 5 (strongly agree). Higher scores indicate more positive attitudes toward treatment.663 This tool is appropriate for use with clients who have abstinence as their recovery goal.
Through these tools, a counselor can explore a client's internal and external reasons for entering and staying in treatment and recovery.
When a client experiences a recurrence, it may be time to bolster or update their treatment or recovery plan and goals and reevaluate their need for other support services. Through an examination of triggers, coping strategies, warning signs, and motivation, the counselor and the client can explore revising the plan. Updates may include additional strategies for managing thoughts, urges, and impulses related to problematic use.664 Other revisions may include starting or increasing attendance at mutual-help meetings, participating in more recreational activities, and initiating or expanding delivery of peer support services.
A recurrence can lower a client's motivation and confidence about continuing their recovery journey. The client may also need support and guidance about ways to manage the negative thoughts and feelings caused by the recurrence itself. The counselor's role is to remind the client of their previous progress and to support them in moving forward through a recommitment to their recovery.665
SAMHSA recognizes that counselors in healthcare and behavioral health services must work within the realities and constraints of the payment systems that reimburse or fund their services. Variations in insurance plans and reimbursement rates and limitations on certain services can potentially act as barriers to receiving payment or make the payment process labor intensive and difficult, affecting the delivery of care. Being aware of these potential roadblocks can help providers who want to implement or increase recovery-oriented services plan and deliver care that not only meets the needs of the client but also can be reliably funded or paid for.
The literature on SUDs and payment processes identifies a variety of issues that providers should consider when planning services. These include:
Types of treatment covered. Significant variation exists from one state to another and even within states regarding which services are covered by private insurance or such federal resources as Medicaid and Medicare, and which services are partially or entirely out-of-pocket costs for the client. For example, such core services as medically supervised withdrawal and residential or intensive outpatient treatment as well as some types of medication, may not be eligible for coverage.666
“Medical necessity.” Certain states will not cover services that are not considered to be a “medical necessity.” For example, some states do not consider opioid withdrawal to be life threatening; therefore, treatment for opioid withdrawal is not covered under Medicaid in those states.667 Providers need to be aware of “medical necessity” criteria in their state or locality, or under the terms of the client's insurance provider.
Reimbursement rates and limits. Services may be reimbursed at varying rates, even within the same state. In addition, some insurance providers limit the number of certain kinds of treatment sessions or screenings a client can receive,668 potentially denying that client the duration of treatment they truly need. This issue can be further complicated by insurance providers that reimburse services based on the number of “events” (e.g., face-to-face meetings), rather than on a value-based approach that rewards sustained positive outcomes.669
Service silos. SUD treatment has historically been delivered separately from medical and psychiatric services, which can potentially disincentivize the collaborative approach and effective case management that are necessary to meet all the needs of individuals in recovery.670,671
Fee schedules. Certain fee schedules make it difficult or impossible to be reimbursed for needed services. For instance, if an individual sees a primary care provider and an addiction specialist on the same day, both providers may not be able to obtain reimbursement.672 This may discourage, or even disincentivize, the use of integrated and multisystem care, which is fundamental to effective recovery-oriented services.
Prior authorization. Some insurance providers and health plans require patients to obtain approval for certain types of care or medications prior to receiving them. Services and medications for the treatment of SUD have been subject to this requirement more frequently than other kinds of services, although some states are passing laws to change this.673 If a client's insurance plan requires prior authorization, it may delay their ability to begin taking medication needed to treat OUD or AUD.
Lack of insurance. Individuals seeking treatment for problematic substance use—particularly those who are also involved with the criminal justice system—are more likely than other populations to be uninsured.674,675
To ensure adequate and appropriate delivery of care, providers need to be willing to work with their colleagues, supervisors, and resources in the community to find creative solutions to these issues. These may include:
Accessing federal grant funding. Although the process of securing and implementing these resources can be lengthy, and the finite funding periods may limit the ability to plan long term,676 federal dollars remain a significant source of support for substance use treatment and recovery services. Funding opportunities can be located through the federal grants portal (https://www
Collecting program-level data to support funding applications. A 2021 article in a National Academy of Medicine periodical identified the importance of formalized and thorough data collection at the program level, as this can be key to securing funding on an ongoing basis.677
Educating criminal justice–involved clients about Medicaid requirements. Data from 2017 indicates that one in three referrals to SUD treatment come from the criminal justice system.678 Individuals who are incarcerated are not eligible for Medicaid reimbursements for addiction services during incarceration; however, they can apply for restored eligibility while still incarcerated. This may speed up their ability to receive services after release.679
Increasing collaboration between, and the integration of, systems of care. Providers can consistently advocate for systemic change that increases collaboration, improves coordination of care, and facilitates fuller case management. The Surgeon General's report on addiction notes that closer integration of SUD treatment services with mainstream healthcare systems can help address health disparities, reduce healthcare costs, and improve general health outcomes.680
Promoting awareness of the Paul Wellstone and Peter Domenici Mental Health Parity and Addiction Equity Act (MHPAEA). This legislation,681 signed into law in 2008, mandates that mental and substance use disorder treatment benefits under group and individual health insurance plans be comparable to medical benefits in terms of financial requirements and treatment limitations. The 2010 Patient Protection and Affordable Care Act expanded the reach of MHPAEA. Counselors and administrators can look for ways that this legislation can support enhanced program services.
Ideally, counseling for people in recovery takes place in the context of a recovery-oriented system of care (ROSC). The consensus panel emphasizes that the ROSC concept applies across settings (e.g., behavioral health, primary care, criminal justice, social services) and across the recovery continuum. The benefits of participating in a ROSC can include:682,683,684,685
Opportunities to have better coordination with clients' other providers, thereby promoting continuing, holistic care.
Collaboration with other providers from multiple disciplines who have a recovery-oriented approach to care.
Connections to other services and supports for clients in recovery, such as housing resources and child care.
Although no centralized listing of ROSCs exists, member centers of SAMHSA's ATTC Network share information on ROSCs and, in some cases, provide technical assistance with establishing them. (ATTC contact information is at https://attcnetwork.org/centers/selection.) If no ROSC exists in a given area, a counselor can partner with like-minded providers and organizations to work toward developing one. Chapter 5 provides more information.
The competencies, strategies, and resources discussed in this chapter apply to recovery-oriented counseling, regardless of the setting or the particular counseling approach used in work with individuals considering or in recovery. Chapters 3 and 4 further discuss how to incorporate the concepts in this chapter into practice. Ideally, counseling is provided in the context of a ROSC that supports people before, during, and after SUD treatment, and, in some cases, even instead of treatment.
This is an open-access report distributed under the terms of the Creative Commons Public Domain License. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.
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