Introduction

Considering that this book is written specifically for psychotherapists, we begin by discussing why we think all mental health practitioners should be able to address alcohol and drug problems competently and routinely in their patients. We then discuss the unique advantages and limitations of office-based treatment and for which patients it may be best suited. The final section of this chapter addresses logistical considerations in treating patients with substance use disorders (SUDs) in office practice.

Before delving into these issues we feel it is important to address a long-standing problem that has contributed in many ways to our motivations for writing this book. Namely, why practitioners from all of the various mental health disciplines have long overlooked or avoided dealing with the problems of SUDs, and why have so few have developed special expertise or chosen to specialize in this area. Although this situation has been improved somewhat in recent years, lack of adequate clinical attention to such pervasive and potentially destructive disorders, though perplexing at first, can be understood in light of certain barriers that have existed over the course of many decades. These barriers, as discussed later, include gaps in professional education and training on SUDs and their treatment, a stereotyped view of individuals with alcohol and drug problems that discourages therapists from engaging them, and conflicts between certain aspects of traditional psychotherapy and the basic principles of addiction treatment.

The various mental health disciplines that educate and train clinicians need to overcome these barriers because failure to identify, treat, and/or properly refer patients with significant alcohol and drug problems can lead to poor clinical outcomes and may also result in legal liabilities for therapists who misdiagnose or overlook these problems (Zweben & Clark, 1991). Those of us who specialize in treating SUDs frequently see patients who were in therapy for years with well-intentioned psychotherapists who apparently did not assess the nature and extent of a patient's involvement with alcohol and drugs, or knew of the problem but did not recognize the need to intervene until the patient's substance use caused a severe crisis. Regrettably, some therapists find out about a patient's alcohol and drug problems only after the patient ends up in a hospital emergency room for treatment of an overdose or suddenly drops out of therapy to seek specialized help from an addiction treatment program or practitioner.

We recognize, however, that responsibility for poor outcomes with these patients often does not lie with the therapist. Many addicted patients actively withhold information from therapists about their substance use out of fear of rejection or just not being ready to address this issue. Because such patients rarely show detectable signs of intoxication when they appear for therapy sessions, even a seasoned addiction specialist may be unable to accurately identify the problem when the patient is deliberately trying to hide it. We can recall numerous cases in our own clinical experiences when we concluded, based on the available information, that no alcohol or drug problem was present, only to find out at a later time that the patient was arrested, fired from a job, or admitted to an inpatient facility for an untreated addiction. Regrettably, incidents like this sometimes cannot be prevented, despite a clinician's best efforts and intentions.

WHY PSYCHOTHERAPISTS HAVE AVOIDED DEALING WITH SUDS

Education and Training Gaps

The most obvious reason why psychotherapists have avoided dealing with SUDs is that most mental health professionals (we ourselves included) received little if any formal training in the diagnosis and treatment of SUDs during graduate school, internship, or beyond. Despite the extraordinary prevalence of SUDs among people who seek mental health services, astonishingly few training programs in the mental health professions (e.g., psychology, psychiatry, social work, mental health counseling) offer specific course work or clinical supervision in this area and most offer none at all. There is a core knowledge base and skill set for treating SUDs that is glaringly absent from most professional training programs. This deficiency fosters professional disinterest, a sense of clinical impotence, and negative stereotyping of patients with alcohol and drug problems. One consequence is that many therapists assume as a matter of course that patients with SUDs can and should be treated only by specialists or in addiction treatment programs. These therapists are quick to refer patients with alcohol and drug problems, especially those with more severe problems, to other caregivers and/or discharge them from their own practices. This is unfortunate, considering that many substance-abusing patients respond well to intervention by therapists with whom they have established a good therapeutic relationship. The fact is that therapists are often in an excellent position to help patients recognize an alcohol or drug problem and develop the motivation to address it. Even in cases in which the patient's substance abuse problem is more severe than the therapist feels prepared to deal with, cultivating the patient's readiness to accept referral for further assessment and/or specialized treatment, when indicated, is critically important.

The failure of most graduate training programs to address SUDs has led to a continuing dearth of competent practitioners in this area. Although some therapists seek extra training, it may be difficult to assess true proficiency. This situation is beginning to change, however, now that certain professional organizations have developed credentialing mechanisms for practitioners who demonstrate at least basic knowledge and clinical expertise in diagnosing and treating SUDs. For example, the American Psychological Association now offers a certificate of proficiency for psychologists who meet...