VISTAS 2007 Online


A Researched-based, Experiential Model for Teaching a Required Addictive Behaviors Course to Clinical Counseling Students


Mark T. Blagen
Regent University

Blagen, Mark, T., Ph.D., CAC, is an Assistant Professor of Counseling and Psychology in the School of Psychology and Counseling at Regent University. Dr. Blagen has been a Certified Addictions Counselor since 1990 and has taught addictions courses since 1992. His primary research interests include defining the spiritual dimensions of addiction recovery, understanding the therapeutic factors of 12-step recovery, understanding the nature of natural recovery, and investigating the relationship of purpose in life and the use of alcohol and other drugs.


Introduction

In the last year, an article published in both Counselor Education and Supervision (Salyers, Ritchie, Luellen & Roseman, 2005) and Journal of Addictions & Offender Counseling (Salyers, et al., 2006), highlighted the important issue of including an addictive behaviors course as a CACREP requirement. As many counseling programs consider moving to 60 semester hours and as state licensing requirements and other factors influence CACREP and non-CACREP programs to require an addictive behaviors course, several important factors must be considered. This article discusses one of these important factors and describes a researched-based model that has been effective in addressing this factor.

The Problem

Teaching an addictive behaviors course is different from teaching most other counseling courses. The primary reason for this difference is that most counseling students come into an addictive behaviors course with strongly held opinions as to what addictive behaviors are. Unfortunately most of these opinions are based on incomplete or inaccurate information. As a result, an important objective of an addictive behaviors course is to facilitate the deconstruction of these strongly held beliefs that are based on incomplete or inaccurate information and offer students an opportunity to replace them with more accurate information, and skills and attitudes that are facilitative in forming a counseling relationship win an addicted individual.

Solving this problem is nothing new for counselor educators in that most students who commence a multicultural counseling course do so with biases that are based on faulty or incomplete information. There is a substantial body of literature that guides counselor educators in how best to address these biases in the framework of an academic course (Sue & Sue, 2003; Diller, 1999; Lee & Richardson, 1991).    

A Possible Solution

Within the context of a three semester-hour addictive behaviors course, two goals must be met. The first goal is to ensure that the basic competencies of understanding what addiction is, how it manifests, how to intervene, and what are the best ways of delivering services, is presented. The second more important goal is to remove any existing cognitive and affective blocks that would prevent assimilation or more preferably accommodation of new information from occurring. These two goals must be addressed simultaneously. By analogy, it is similar to treating an addicted individual who has a second diagnosis of bi-polar disorder. If only one disorder is treated, failure is assured, but if you address these co-occurring disorders as though they are indeed co-occurring, then improvement or progress is assured. So, teaching the basic competencies and addressing the inaccurate and incomplete information problem must be done concurrently.

How is this done? What follows is a framework that was developed by one CACREP program that has been teaching a required addictive behaviors course for over five years.

The basic premise of this framework is that all content must be facilitated in a maximally experiential method. Experiential learning has a long history of use in counselor education (McAulife, 2002) and is an effective learning strategy in general (Proudman, 1992) and specifically in the teaching of addictive behaviors courses (Osborn & Lewis, 2004).

The Method

Since most CACREP programs offer addictive behaviors as an elective course (Osborn & Lewis, 2004) and since there are no specific CACREP standards (currently) for an addictive behaviors course, instructors of these courses must think deeply as to what should be the content objectives for such a course. The program described here generalized the content objectives to the following: how is addiction defined, what are the theoretical etiologies of addiction, what does addiction look like, how are addictions assessed, what are process addictions and how are they similar and different from substance addictions, how is client engagement and the change process initiated, what are the goals of treatment, and how is the change process maintained. Other important objectives include understanding the unique ethical and legal issues related to addiction, and the importance of understanding the client's cultural worldview including cultural genocide implications, collective versus individualistic cultural issues, spiritual orientation, disability considerations and other multicultural and power differentials. And finally, the issues of co-occurring disorders, and affected family issues are objectives that are discussed throughout the course. Most students who have taken this course indicate that this is one of the most relevant courses they have experienced, but they also name it as being one of the most difficult. Students are required to read 18 chapters out of two different textbooks, 16 journal articles and watch four videos in preparation for class. Currently the textbooks in use are Substance abuse: Information for school counselors, social workers, therapists, and counselors (3 rd ed.), (Fisher & Harrison, 2005), and Addiction and grace (May, 1991). Both texts are well received by the students. The 14 journal articles are designed to supplement the text readings and assist the students in understanding the complex nature of addiction and the change process. These articles include, include Rediscovering fire: Small interventions, large effects, (Miller, 2000), Science-based views of drug addiction and its treatment, (Leshner, 1999), Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcome evaluation, (McLellan, Lewis, O’Brien, & Kleber, 2000), Treating the sexually addicted client: Establishing a need for increased counselor awareness, (Hagedorn, & Juhnke, 2005), and Recovery: Its history and renaissance as an organizing construct concerning alcohol and other drug problems, (White, 2005).

With the exception of a “traditional” term paper, each class session and each outside project is experiential in nature. Each class begins with the students getting in small groups and sharing their required critical thinking questions with each other. These critical thinking questions were written prior to class based on the assignment for that class. The small group discussion provokes learning from each other and helps the small group to formulate a critical thinking question they would like to present to the class as a whole. Although instructor direction is sometimes required, most of the discussion is lead by the students. Toward the end of the discussion, the instructor will briefly summarize the discussion and emphasize key points of the assigned material. This activity will often take half of the three-hour class period.

The last half of class is devoted to various experiential exercises. Since much of the focus of the course relates to understanding and using Motivational Interviewing (MI), students work in dyads or small groups practicing various skills related to MI. Other experiential activities include mock therapy groups, role plays and student skills demonstration. Students also learn how to use the Alcohol Use Disorders Identification Test (AUDIT) and the Substance Abuse Subtle Screening Inventory -3 (SASSI-3) through case example, group work.      

Outside projects include attending four Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings and writing a reaction paper about these meetings. Part of this paper includes comparing what they wrote on the first night of class on what addiction is, and who becomes addicted. The comparison reveals an enormous amount of personal growth and learning that is often painfully obvious to the student as they compare their thoughts on the first night and their thoughts after having attended four AA or NA meetings. There are several purposes for attending AA/NA meetings. The first purpose is to experience, in an extremely personal way, the struggle and beauty of the recovery process. A second purpose is for the student to clearly see any stigma they have toward those who are addicted. A third purpose is for the student to understand the need for advocacy for persons who are addicted.

The following are several quotes from the end of project paper. Obviously, some of what is stated in these papers is designed for the instructor’s consumption and to influence grading, but as will be shown later in this paper, even anonymous comments in the post-course evaluations reveal similar sentiments concerning this project.  

  • Attendance of the 12 step meetings has enriched my life…I came to understand, appreciate, and value the utility of this program. As a result, I will never be the same.
  • Attending these meetings was a life changing experience for me.
  • Going to these meetings helped me to challenge my stereotypes.
  • This experience changed my mind entirely about the effectiveness of these meetings and I got to experience the raw beauty of the people who attend them.
  • In summary, my attendance at these AA meetings was a powerful experience. I was blessed to watch the power of the human spirit in action and it was, indeed, an awesome sight.
  • To be able to attend these meetings put a human face on a devastating addiction, and opened my eyes to a broader experience that I would not have been able to obtain through merely words within a text.
  • I have found myself at times wishing I was an alcoholic so that I could really take part in the incredible process that happens at these meetings. I was, at very least, challenged to be more honest, vulnerable and accepting in my daily encounters with friends, family and strangers. I feel drawn to find that space of brokenness in each person where God can dwell. It is the essence of being human, so small and weak, and yet touching the infinite and unbreakable.
  • Through these meetings I know that I have reached my goal that I set at the outset of the class in gaining compassion and understanding for those struggling with addiction.
  • From these experiences and meetings, I have developed a compassion and a deeper understanding for those who deal addiction in their everyday lives…I have a greater respect for those who are taking these steps and a greater understanding of why it is so hard to take these steps each day.

Another outside project the students must do that provides enormous learning and growth is the personal change project. By the second week, each student must turn-in the introduction to their personal change paper. The introduction includes the substance, behavior or activity that they want to change during the course of the semester; their rationale for the change, expected obstacles and how they plan on overcoming these obstacles. In general, the students are very excited about this project. This lasts about three to four weeks until they realize how difficult change is. Stages of Change and MI are used in small group and in dyads to assist the student in becoming more motivated to successfully make the change and assisting in understanding what defense mechanizations the student is using to prevent the change from occurring. The primary purpose of this project is for the student to learn the difficult nature of change and to increase their empathy toward those who are dealing with the change related to alcohol or other drugs. The following is a sample of end of project comments.

  • I have a greater degree of empathy toward those struggling with addictions because for the first time in my life, I am aware of my own weakness (addictions) and aware of just how difficult the dynamic of change truly is…My entire outlook on addiction and recovery process has been challenged and changed through this semester and this project.
  • This project has assisted me in having more compassion, grace, and empathy for the client going through the change process.
  • As I face clients I will have a greater level of empathy and compassion for the struggle they are facing as a direct result of this project – I loved it and I hated it!
  • I will remember my own struggles…to ensure I show compassion and understanding. I have learned to be empathic from this project.
  • Completing this project has challenged me to look past the conservative “moral model” of addiction…It has instigated a greater compassion in me for those suffering from addictions, helped me develop a deeper level of personal humility, and provided the opportunity for me to attain a more intimate understanding of addiction and God’s amazing grace.
  • As a direct consequence of this project, my understanding of what an addicted person struggles against to achieve genuine freedom has been completely revolutionized.
  • Change is hard!!!

Other outside activities include assisting with National Alcohol Screening Day (NASD) which occurs each April. This is a great way for students to see how Brief Interventions work and to get experience in using the AUDIT and conducting brief interventions. Also, each semester I have the students develop a community-based group project. This group project requires 3-4 hours per person and usually relates to a community-based need they have identified and would like to contribute their time to.             

Results

In the first of class students take an anonymous “pretest.” This pretest is designed to determine their baseline of knowledge and attitudes about addictive behaviors. The knowledge portion of the pretest is based on the cognitive learning objectives for the course. The attitudes portion of the pretest asks several questions similar to the following:  

1.   On a scale of 1 to 10 please indicate how much responsibility you believe that the addicted individual has in causing his/her addiction - 1 means little or no responsibility and 10 means they are totally responsible for their addiction.

  • On a scale of 1 to 10, please indicate how much empathy you have for an individual who is addicted to a drug such as cocaine, alcohol, or heroin – 1 meaning you have a great amount of empathy and 10 meaning you have little or no empathy.

The purpose of these questions is to help the instructor to understand the level of stigma or bias the students, as a group, might possess at the beginning of the course.

Stigmatization by society and unfortunately by “helping” professionals is an enormous burden that alcoholics and drug addicts must face (Crisp, 2001; Dean & Rud, 1984; Dean & Poremba, 1983). One of the objectives of an addictive behaviors course should be to allow the students to understand their role in the stigmatization process and how they can lessen this burden by not being judgmental and stigmatizing those with additive behaviors. This is accomplished by discovering their biases and stigmatization tendencies and adjusting these behaviors based on accurate and more complete information.

For the two questions above, the following results were obtained:  

Question 1             Pretest               Post-test

                                  7.3                   4.5

Question 2                5.8                   2.2

When using a repeated-measures t-test, the results show statistical significance at the p < .01 level, but the practical significance is even greater. As these results show, the students modified their belief as to assigning responsibility for addictive behavior and their ability to be empathic. The following are several comments that were captured from the anonymous post-course evaluations. All of these comments were taken from a single class that had 17 students:

  • Going to the AA meetings was life-changing in regard to my empathy for alcoholics.
  • The AA meeting experience has changed my views on people with substance abuse issues.
  • The personal change project and attending AA meetings both were very important for my learning to have compassion for addicted individuals.  
  • The most significant learning experience in this course was attending NA meetings. This experience totally change my view of drug addicts.
  • I wouldn't want to change anything about the course it was very experiential, I learned a lot more than in other class that I have ever taken. I wish it wasn’t over, I truly enjoyed this course.
  • The personal change project was very enlightening. I learned a great deal about myself and now have more empathy towards those who are attempting to change because of this project.
  • Both the AA meeting assignment and the personal change project, provided excellent opportunities to increase my understanding and compassion for those with addictions.
  • The AA/NA meetings were very helpful. At first I thought the required four meetings were a lot to ask, but after completing them, I can not put into words the benefit that I got from attending them. It was a real eye opening experience.

Other comments could have been included, but these were the most representative comments from this particular class.

Conclusion

Although eager and bright, many students come into a “required” addictive behaviors course with strongly held opinions on the subject. These opinions, though based on their life experiences, are generally incomplete or inaccurate. This incomplete or inaccurate information interferes with one of the major objectives of an addictive behaviors course, and that is to establish an effective counseling relationship with an addicted person. Also, inaccurate or incomplete information ensures stereotypical thinking will be maintained and as a result the addicted person will be stigmatized and marginalized by the very professionals they are receiving help from. Through the use of experiential learning, students have an opportunity to make corrections in their beliefs and attitudes with the outcome of a more facilitative understanding of addiction.

References

Crisp, A. (2001). The tendency to stigmatise. British Journal of Psychiatry, 178, 197-      199.

Dean, J.C. & Poremba, G.A. (1983). The alcoholic stigma and the disease concept.   International Journal of Addictions, 18, 739-751.

Dean, J.C. & Rud, F. (1984). The drug addict and the stigma of addiction. International Journal of Addictions, 19, 859-869.

Diller, J.V. (1999). Cultural diversity: A primer for the human services. Belmont, CA: Wadsworth Publishing.

Fisher, G.L. & Harrison, T.C. (2005). Substance abuse: Information for school counselors, social workers, therapists, and counselors (3 rd ed.). Boston: Allyn & Bacon.

Hagedorn, W.B. & Juhnke, G.A. (2005). Treating the sexually addicted client: Establishing a need for increased counselor awareness. Journal of Addictions & Offender Counseling, 25, 44-65.

Lee, C. C., & Richardson, B.L. (Eds.). (1991). Multicultural issues in counseling: New approaches to diversity. Alexandria, VA: American Association for Counseling and Development.

Leshner, A.I. (1999). Science-based views of drug addiction and its treatment. Journal of the American Medical Association, 282, 1314-1316.

May, G.G. (1991). Addiction and grace. New York: Harper.

McAuliffe, G.J. (2002). Student changes, program influences, and adult development in one program of counselor training: An exploratory inductive inquiry. Journal of Adult Development, 9, 205-216.

McLellan, A.T., Lewis, D.C., O’Brien, C.P. & Kleber, H.D. (2000). Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. Journal of the American Medical Association, 284, 1689-1695.

Miller, W.R. (2000). Rediscovering fire: Small interventions, large effects. Psychology of Addictive Behaviors, 14, 6-18.

Osborn, C.J. & Lewis, T.F. (2004). Experiential training in substance abuse counseling: Curricular design and instructional practices. Teaching in the addictions, 3, 41-56.

Proudman, B. (1992). Experiential education as emotionally-engaged learning. The Journal of Experiential Education, 15, 19-23.

Salyers, K.M., Ritchie, M.H., Luellen, W.S. & Roseman, C.P. (2005). Inclusion of substance abuse training in CACREP-accredited programs. Counselor Educationa & Supervision, 45, 30-42.   

Salyers, K.M., Ritchie, M.H., Cochrane, W.S. & Roseman, C.P. (2006). Inclusion of substance abuse training in CACREP-accredited programs. Jornal of Addictions & Offender Counseling, 27, 47-58.

Sue, D.W. & Sue, D. (2003). Counseling the culturally diverse: Theory and Practice (4 th ed.). New York: Wiley.

White, W.L. (2005). Recovery: Its history and renaissance as an organizing construct concerning alcohol and other drug problems. Alcoholism Treatment Quarterly, 23, 3-15.  


VISTAS 2007 Online