Addiction Counselor Exam Practice Questions: Addiction Counselor Practice Tests & Review for the Addiction Counseling Exam (Mometrix Test Preparation) 1630942197, 9781630942199

Table of contents :
Practice Test #1
Practice Questions
Answers and Explanations
Practice Test #2
Practice Questions
Answers and Explanations

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Addiction Counselor Exam

Practice Questions

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Addiction CounselorPractice Tests & Review for the Addiction Counseling Exam

MOMETRIX TEST

PREPARATION

Copyright © 2016 by Mometrix Media LLC. All rights reserved. Written and edited by the Mometrix Exam Secrets Test Prep Team Printed in the United States ofAmerica

Table of Contents

Practice Questions.

Answers and Explanations... Practice Test #2. Practice Questions Answers and Explanations.

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Practice Test #1 Practice Questions

1. A wife refers her husbandfor substance abusecounseling. His drug of choiceis cocaine, which he has beenusing episodically with friends at a poker game—biweekly to weekly—for someyears. She is disturbed at theillicit natureofthe drugand thelong-standinguse. He states that though he recreationallyuses, he does not crave cocaine, does notseekit out butratheruses with friends at the game whobringit, and hefeels that other than his wife being upset about him using, he has no othersocial or occupationalissues. Given the information provided, how is his use ofcocaine BEST described? a. Substance abuse b. Cocaineintoxication c. Cocaine use disorder

d. None ofthe above

2. What does the experiencedeffect of a drug depend upon? a. The amounttakenand pastdrug experiences

b. The modality of administration c. Poly druguse, setting, and circumstance d. All ofthe above

3. How is drug tolerance BEST described? a. Theinability to get intoxicated b. Theneedfor moreof a drugto get intoxicated c. Increasedsensitivity to a drug overtime d. Decreasedsensitivity to a drug over time 4. Whichofthe followingis NOT a “drug cue”? a. A prior drug-usesetting b. Drug use paraphernalia c. Seeing others use drugs d. Drug avoidancestrategies

5. What happens as tolerancefor barbiturates develops? a. The margin betweenintoxicationand lethality increases. b. The margin betweenintoxicationandlethality decreases. c. The margin betweenintoxication andlethality stays the same. d. Tolerance does not developfor barbiturates. 6. What is the MOST common symptomof Wernicke’s encephalopathy? a, New memory formation b. Loss of older memories c. Psychosis d. Confusion

a

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7.Which ofthe following conditionsdoesalcohol NOTinduce? a. Steatosis

b. Nephrosis c. Hepatitis d. Cirrhosis

8. What does formication refer to? a. Thecreation of freebase cocaine b. Sex betweentwo unmarried individuals c. A sensation of bugs crawling under the skin d. Extrapyramidal symptoms ofagitation 9, What is/are the organ(s) most damagedby cocaine abuse? a. The brain b. The lungs c. The kidneys d. The heart 10. Which ofthe following is NOTa basic chemicalclass ofamphetamines? a. Amphetamine sulphate b. Benzedrine c. Dextroamphetamine

d. Methamphetamine

11. In terms ofdifficulty quitting (dependence), which of the following four drugs ranks the highest? a. Alcohol b. Cocaine c.Heroin d. Nicotine 12, Which ofthe statements below is MOST correct? a. THC contentin all marijuana is about the same. b. THCcontent in hashish is lowerthanina joint. c. THC contentin marijuanais predictable. d. THCcontentin marijuana varies widely. 13, Regarding substance abuse, what does Convergence Theory propose? a. Rates of substanceabuse among womenareconverging with thoseof men. b. All individuals eventually narrow drug useto a drug ofchoice preference. c. Age is a key factor in eventualsubstance abuse abstinence. d. Asindividuals age, gender disparities in rates ofabuse tendto converge. 14, Amongpsychiatric disorders in the elderly, where does alcohol abuse rank? a. twenty-fifth

b.fifteenth c. fifth d. third

a

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15. Whichofthe following subcategories ofalcohol use disorderonsetis NOTfoundin the elderly? a, Late-onset alcoholism b. Delayed-onset alcoholism c. Late-onset exacerbation drinking d. Early-onset alcoholism 16. At aninitial meeting with a new client, whatis the FIRST requirement? a. Establish rapport. b. Evaluatereadiness for change. c. Review rules and expectations. d, Discuss confidentiality regulations. 17. What does motivationalinterviewingprimarily involve? a. Focused confrontation b. Behavioral accountability c. Reality testing

d. Supportive persuasion 18, What percentage ofindividuals with a dual diagnosis (co-occurring disorders [COD]—i.., substance abuse disorder and anexisting mentalillness) received treatmentforonly their mental illness? a. 32.9 percent

b.27.6 percent c. 12.4 percent

4.88 percent

19. Whatfactors can affect screeninginstrumentvalidity? a. The screeningsetting andprivacy b. Thelevels of rapport and trust c. How instructions are given andclarified d. All of the above

20. Which ofthe following functions is NOT what a Certified Alcohol and Drug Abuse Counselor can usually perform? a. Client screening b. Substance abuse assessment c. Diagnose mental disorders d. Formulatea treatmentplan 21. Whatdoes the acronym GATEstandfor?

a. Gatherinformation; Access supervision; Take responsible action; Extendthe action b. Gather resources; Access procedures; Takeclinical notes; Extendtheintervention c. Gather documentation; Access contacts; Take counsel; Extend positive outcomes d. Gather the team; Accessrecords; Take consultation; Extend documentation

22. To whichofthe following do assessmentprocesses and instruments NOT needbe sensitive? a. Political orientation

b. Age and gender c. Race andethnicity d. Disabilities

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23. Whatareserious mental health symptomsthatresolve with abstinencein thirty days orless MOSTlikely due to? a. A resolution of transient situational stressors at home, school, or work b.A serious underlying mental disorder that temporarily improved c. Substance abuse-induceddisorders that require continuedabstinence d. Malingering to manipulate circumstances for underlying goals 24, Whichone ofthe following alcoholabuse screeningtests is designedspecifically for use with adolescents? a. CAGE b. CRAFFT c. MAST d. AUDIT

25. Which ofthefollowingis the MOST importantintroductory statementor questionto askin a suicidality evaluation? a. Haveyouevertried to take your own life? b. Doyou have thoughts aboutkilling yourself? c.Ineedto ask youa few questions aboutsuicide. d. Have you ever attempted suicide? 26. Whatis the purposeof screening? a. To preparetheclient for program admission b. To determineclient readiness for change c. To establish client diagnoses andtreatmentneeds d. To determine the needfor placementorreferral 27. Whatis the primary purpose of substanceabuseassessment? a. Todetermine thecurrentlevel of health deterioration b. Toidentify a substance abuser’s drug ofchoice ¢.Toprovide co-occurring disorder(s) diagnosis d. To determinetheseverity ofthe substanceproblem 28. Whoshould create a treatmentplan? a. A multidisciplinary teamofprofessionals b. Collaborative team with the client c. The primary treatmentprovider d. professional boilerplate to ensure completeness 29. How must assessmentinformationbe handled to be the MOST effective? a. Carefully documented b. Converted into goals and objectives c. Availabletoall treatment providers d. Summarizedwith theclient for feedback

a

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30. Which ofthese key elements does NOTbolster a client's desire to complete the program? a. Knowledge ofthe benefits oftreatment b. Understandingofthe treatmentprocess

c. Fully assumingthe patientrole d. Frequentinterdisciplinary consultations 31. How manylevels oftreatment placement are recognized bythe AmericanSociety of Addiction Medicine (ASAM)? a. Two levels oftreatmentplacement b. Fourlevels oftreatmentplacement c.Six levels oftreatment placement d. Eight levels oftreatmentplacement 32. How many AssessmentDimensionsare recognized by the AmericanSociety ofAddiction Medicine (ASAM)? a. Two assessmentdimensions

b. Fourassessment dimensions c. Six assessment dimensions

d. Eight assessmentdimensions 33. The Stage Model of Change addresses how manyclientstages? a. Five stages

b. Six stages

c. Seven stages

d. Bight stages

34. Circumstances, Motivation, Readiness, and Suitability (CMRS) Scales are used for what purpose? a. Assessingclient readiness for treatment b. Assessing variousfinancial andfamily support domains c. Assessingclient suitability for research participation d. Assessingclients for treatmentlevelof care 35. Whenisa clientfully preparedto enter treatment? a. Treatmentis court ordered. b. Family pressuresa clientto enter treatment.

c.Job-based drug testing creates a clear need. d. Aclientaccepts the needfor treatment.

36. Guiding principlesin treatmentplanningareidentified by which acronym? a. MTSRA b. MATRS

c.MSRTA

d. MRAST

37. In cases involving the criminaljustice system, whatis the minimum recommendation for frequencyof updating treatmentplans? a. Followingsentencing b. Uponrelease to a community setting c.Atall transition points d. Both A and B -8GE TTTS FO BSTOTI BTSOF TSTTROTTOTTTPTT ATT

38. How many problem domainsare addressed in the Addiction Severity Index (ASI)? a. Six

b. Eight Ten d. Twelve 39. The Addiction Severity Index hasbeen formally adoptedby which organization? a. The Substance Abuse and MentalHealth Services Administration (SAMHSA) b. TheCenter on Drug and AlcoholResearch (CDAR) c. The NationalInstitute on Drug Abuse (NIDA) d. TheInstitute for GovernmentalService and Research(IGSR) 40. What doesit mean if an assessmentinstrumentis valid? a. Theinstrumentis licensedfor use by professionals. b. Theinstrument consistently provides accurate information. c. Theinstrument has been approved by the governmentfor use. d. Theinstrumentassesses whatit purports to assess.

41. All of the following are trueof depression andsubstance abuse EXCEPT that a. drugs of abusecan successfully treat depression. b. depressioncanlead to self-medication with drugs ofabuse. c. drugs of abuse can induce symptomsofdepression. d. drugs ofabuse can worsen symptomsofdepression. 42. How doesmotivation for participating in treatmentdiffer from motivation to changeproblem behaviors? a. There is no difference betweentreatment and behaviorchangemotivation. b. Motivationfor behavioral change precedes motivation for treatment. c. Motivation for changeis internal; treatment may be pushedon client. d. Motivationfor treatmentprecedes motivationfor behavioral change. 43. Whatofthe followingis NOT a key componentin a treatmentplan? a. Problem statements from the intake assessment b. Goal statements derivedfrom problem statements c. Objectives, which are whatthe clientwill do to meet treatmentgoals d. Thetheoretical approach to be operationalized via treatment 44. Whatdoes the SOAPprogressnote acronym stand for? a. Subjective, Overview, Actions, andPlan b. Subjective, Objective, Assessment, andPlan c. Subjective, Observation, Assessment, and Plan d. Subjective, Overview,Attention, and Plan

45. Whatdoes the DAPprogress note acronym stand for? a. Description, Assessment, and Progress b. Details, Assessment, and Progress c. Documentation,Actions, and Pending d. Data, Assessment, and Plan -9GE TTTS FO BSTOTI BTBOF TSST TROTTOTTTPOT ATT

46. The mnemonic DIG-FAST evaluates which psychologicalstate? a. Depression b. Anxiety c. Paranoia d. Mania

47, How doesthe Centerfor Substance Abuse Treatment(CSAT) recommendthat substance abuse be consideredandtreated? a. A psychological disorder b.An acutedisease c.A chronictreatable condition d. A degenerative treatable disorder 48. How doesthe Centerfor Substance Abuse Treatment (CSAT) indicate that treatment or interventions providedfollowing discharge from a formal inpatient oroutpatient program be referred to? a. After care b. Continuingcare c. Follow-upcare d. Post-discharge care 49. Whatis the BESTdistinction between substance abuse treatment programsand mutual-help

groups, suchas a twelve-step support groups?

a. Programs offer help, and groupsoffer support. b. Programsare expensive, and groupsare free. c. Programs arerunby professionals, and groupsare run by laypersons. d. Programsoffer treatment, and groupsoffer support.

50. According to the American Society of Addiction Medicine (ASAM), whatis the minimum of treatmenttimethe intensive outpatient treatment(IOT) mustprovide? a. Three hours of treatmentper week b. Six hours oftreatment per week c. Nine hours oftreatment per week d, Twelve hours oftreatment per week 51. Which ofthe following is NOT a corefeature orservice thatthe Centerfor Substance Abuse Treatment(CSAT) consensuspanelagreed upon? a. Biopsychosocial assessment b. Individualized treatmentplanning c. Case management d. Recreationaltherapy 52. Which form ofsubstance abuseis naltrexone used to treat? a. Alcohol dependence b. Opioid dependence c. Both Aand B d. Neither A nor B

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53. Which ofthe following is NOT a core treatmentandrecovery skill? a. Stress management

b. Substance refusal training c. Exercise and health trai d. Relaxationtraining

54, Which ofthe followingis NOT a primary learningstyle? a. Gustatory

b. Kinesthetic c. Auditory d. Visual 55. Whatis the influence offamily on treatment outcomes? a. Treatmentoutcomesareimproved with family support. b. Treatment outcomesare worse with family involvement. c.Both Aand B d. Neither A nor B 56. How many main levels exist in the substance abuse continuumof care, according to the American Society ofAddiction Medicine (ASAM)? a. Three levels of care b. Fourlevels of care c. Five levels ofcare d.Six levels of care 57. How many sequential stages mustoutpatientclients work through, regardless ofthelevel of care at which theyenter treatment?

a. Two stages b. Four stages c.Six stages d. Eight stages

58. Whatis the usual recommended minimum durationofdays forthe intensiveoutpatient treatment (IOT) phase? a. Thirty days b.Sixty days c. Ninety days d. One hundred twenty days 59, How is the MOSTeffective relapse-prevention training provided? a. Group therapyis more effective. b. Individualtherapyis moreeffective. c. Structured classes are moreeffective. d. Aand Bareroughly equal in effectiveness. 60. Which ofthe following is NOT a typeofintensive outpatient treatment (IOT) group? a. Psychoeducational groups b. Skills development groups c. Interpersonal process groups d. Transitional care groups a

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61. Whatis the MOST commondurationof counselingin anintensive outpatienttreatment(IT) program? a. Twenty to thirty minutes, onetime each week b.Thirty tofifty minutes, one time each week

c. Forty to sixty minutes, one time each week

d.Thirty tofifty minutes, two times each week

62. How are pharmacotherapy and medication managementin substanceabuse treatment described? a. Oflittle importance outside a hospitalization program b. Ofsomebutlimited value but without a centralrole c. Of moderate value in treatment but not crucial d. Of considerable, albeit limited, value in treatment 63. Topics addressedin psychoeducational groupsare typically a, sequenced by concept for maximaleffectiveness. b. presented as requested or needed by group participants. c.selected randomly by the groupeducatoror presenter. d. determinedby the group's prevailing drug of choice. 64. Whatwastheoriginal CIWA-Ar scale designedfor? a. Evaluationofopioid withdrawalrisk b. Evaluation ofamphetamine withdrawalrisk c. Evaluationof alcohol withdrawalrisk d. Evaluation ofbenzodiazepine withdrawalrisk

65. Which ofthe following substanceslackeffective treatment medications? a. Cocaine b. Marijuana c. Both of the above d. Neither ofthe above 66. Adjunctive therapies referto all EXCEPT which ofthe following? a. Vocationaltraining b. Stress management c. Meditation

d. Acupuncture 67. Dealing with smokingcessation during a substance abuse treatment program is a. somethingtoo overwhelmingfor the majority ofindividuals. b. something that should notbe broughtup by anyonebut theclient. c. somethingto be seriously considered if the client desires it. d. somethingthat shouldbe required during anytreatment program.

a

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68. Disulfiram (Antabuse)is contraindicatedfor clients whose alcoholabuse is combined with which ofthe following circumstances?

a. Cocaine use

b. Methadone use c. Both cocaine and methadone use d. None of the above

69. Whatis the sandwich technique? a. A method to increase health foodintake b. Anintake interviewing technique c. Client pairing for optimal treatment support . Staff pairing for optimaltreatment support 70. Which ofthe following was NOTidentified as being amongthe three MOST effective screening tools for substance use disorders? a. The CSAT Simple ScreeningInstrument b. TheAlcohol DependenceScale (ADS) and the Addiction Severity Index (ASI)-Drug Use Subscale combined c. The Substance Abuse ScreeningInstrument d. The Texas Christian University Drug Screen

71. Whatis the SDSS designed to measure? a, Substance-induced depressionovertime b.Variations in polysubstanceuse overtime c. Drug use disorder severity overtime d. Severity and durationofintoxication symptoms

72. Whats the primary purposeofthe Texas Christian University DrugScreen(TCUDS)? a. Toidentify those with versus those withoutissues ofdrug dependency b. To establish a rosterof the kinds andseverity of drugs used in the past c. Toevaluate dangerousness and risk taking in drug use patterns d. To correlate drug use patterns with emerging health concerns 73. What is physiological dependenceon a drug determined by? a. The addictive propertiesofthe drug b. Tolerance or symptomsofwithdrawal c.A psychological needto again use the drug d, Frequency and amountofthe drug taken 74, According the DSM-5criteria, a client that has previously metthe criteria forstimulant use disorderbut now has notmetthecriteria for stimulant usein 10 months(exceptfor craving) would be termed to be in__ remission. a. Full b. Partial c Early d. Sustained

a

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75. Whatis a client's family of choice used to describe? a, Step-parents and step- and half-siblings b. Common-law relationshipsonly c. Planned pregnancies as opposed to those unplanned d. Relationshipscreated by marriage, friendship, andotherassociations 76, Whatdoes a dualrelationshiprefer to? a. Dyadsassignedin addiction-recovery groups for added support b. The sponsor-sponseerelationship in twelve-step groupssuch as A.A. c. The mentorrelationship with those newly entering addiction treatments d. A working relationshipwith a client outside the professional domain 77. Whatis an appropriate response to a substantialgift from a client? a. "You shouldn't have!” b. "Thank you so much!” c.“Ican'taccept that, but thank you!” d.“A gift like thatis not appropriat 78. Two clients in a treatmentgroup begin dating. What would a properresponse be? a. Address program policy preventing dating amonggroup members. b. Initiate a groupactivity to acknowledge their new relationship. c. Terminate treatment for both of the members. d. Terminate treatmentfor one ofthe members. 79, Ata local dance club, a counselorspots a client drinking at the bar. What is the BEST response to

this?

a. Confront the client immediately, encouraging him or herto leave the club. b. Quietly find a momentto talk with the client privately atthe club. c. Avoid contactwith theclient, andleave the club immediately. d. Avoid contact with the client, but remain atthe club.

80. Asa substance abuse counselor, you workin a treatment program andalso personally attend a

twelve-step program in the community. A treatmentprogram client asks you to becomehis or her

twelve-stepsponsor. Whatis the proper, thoughtful response? a. Accept, knowingthatit maybenefit thetherapeutic alliance. b. Accept, knowing how muchthis client needs help. c. Decline, concerned thatthe client could bedifficult to support. d, Decline, recognizing the potential conflicts in multiple roles.

81. In providing counseling treatment, what are counselors encouraged to do? a. Select a single counseling approach, and refineitfully. b. Use multiple counseling approaches to meetclients’ needs. c. Avoid relying on any formal counseling technique. d. Recognize thatall counseling techniquesare equally effective. 82. Whatdoes the Twelve-Step Facilitation Approach refer to? a. Program counselors also serving as twelve-step group facilitators b. Twelve-step programfacilitators working within a treatment program c. Teaching twelve-stepprinciples during treatmentprogram work d. Encouragingclients to enter a community twelve-step program

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83. Which ofthe following is NOT a strength of twelve-step programs? a. Twelve-step meetings arefree, widely available, and offer ongoing support. b. The twelve-step approacheasily accommodatesclientdiversity. c. Twelve-step programs offer easy monitoring ofassigned step tasks. d. The twelve-step approachoffers recovery in cognitive, health, and spiritual areas. 84. Staff familiarity with twelve-step program facilitationis importantbecauseofall of the following EXCEPT that a.clients feel more pressureto attend twelve-step programsby these staff. b. clients are moreeasily motivated into twelve-step programs bythese staff. c.clients’ concerns are more meaningfully resolvedby these staff. d. clients generally remain abstinent longerwith twelve-step involvement. 85. Whenoutcomesfrom cognitive-behavioral coping skills therapy and motivational enhancement therapyare compared with outcomesfrom twelve-stepfacilitation, how do clients fare BEST? a. cognitive-behavioral copingskills therapy b. motivational enhancementtherapy c. Twelve-stepfacilitation d. All the above 86. Traditionally, what has the term therapeutic community (TC) referred to? a. An informalgroup organizedfor mutual support b. A court-ordered treatmentenvironment c. A formal mutual-helpor twelve-step support group d. A drug-free residential treatment environment

87. Why dotherapeutic communities (TCs) oftenfocus on habilitation instead ofrehabilitation? a. Manyclients cannot successfully be rehabilitated. b. Rehabilitation is not aseffective as habilitation. c. Habilitation helpsclients learn newskills they never had. d. Rehabilitation focuses only narrowly ondetoxification. 88. In what setting is the therapeutic community (TC) treatment model MOSTeffective? a. A formalfull-timeresidential setting b.Anintensive day treatmentsetting c. NeitherA nor B,but in a support group setting d.Aand Bequally 89. Whatis the MOSTimportant reason that ordered and routine activities are built into the

therapeutic community (TC) treatmentprocess?

a. Torelieve boredom that mayserve as a triggerfor substance abuse b. To counter thetypically disorderedlives of substance-abusingclients c.Toreduce the stress through focused programmedactivities d. Todistract from the negative thinking that may leadto substance abuse

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90. Whatis the Matrix Modeldesignedtotreat? a. Stimulant abuse b. Alcohol abuse c. Barbiturate abuse d. Inhalant abuse

91. Whataresignificant drawbacks to community reinforcement (CR) andcontingency management(CM) approaches? a. CR and CM areonly effective if used together. b.CRandCMare not enduringly effective. c.CRis laborintensive, and CMcanbe costly. d. CRrequires others’ support, and CM requires ongoing rewards. 92. With regard to co-occurringdisorders, whatdoes the term integrated treatmentrefer to? a. Meeting both medical andsubstance abuse treatment needs b. Using an eclectic treatmentparadigm in the treatmentprocess

c. Incorporating sociocultural issues in the treatmentprocess d. Treating both psychiatric andsubstanceabuseissues concurrently 93. What would be the MOSTtypicalco-occurring disorder client? a. An alcohol-abusing man b.A drug-abusing man c.Analcohol-abusing woman d. A drug-abusing woman 94. How manycategories does SAMHSA's Service Coordination Frameworkfor Co-Occurring Disorders have? a. Two categories b. Four categories c.Six categories d.

Eightcategories

95. Whenbehaviorally assessingfor a co-occurring disorder, whatis the MOST importantvariable to consider? a. Alcoholordrugtoxicity or withdrawal symptoms b. Theclient's denial ofany psychiatric problems c. The client's family history of psychiatric disorders d. Theclient’s immediate behavior 96. How are substance abusetreatment programsfor adolescents described? a. Very differentfrom treatmentprograms for adults b. Somewhat differentfrom treatment programsforadults c.Minimally different from treatment programsfor adults d. Notatall differentfrom treatment programsforadults

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97. Whatis the MOSTeffective treatment approachfor adolescents, in termsof less drug use at

treatmentcompletion?

a. Parent education

b. Peergrouptherapy c. Family therapy d. Multifamily interventions 98. How is the conceptof culture BEST described? a. A shared set ofbeliefs, norms, and values amonga racial group b.A shared set ofbeliefs, norms, and values among an ethnic group c.Ashared set of beliefs, norms, and values amongany given group d.A shared set ofbeliefs, norms, andvalues amonga given nationality 99. Whois primarily responsible for ensuring that treatmentis effective for culturally diverse clients? a. Theclient b. Theprovider c. Theinstitution

d. The family

100. Whatdoesthe term culture-boundsyndrome refer to? a. An illness (mental orphysical) uniqueto a cultural group b. Anillness presenting orinterpreted distinctively, due to cultural influence c. Both Aand B d. Neither A nor B 101. Beyond thecultureofthe client, whatis another key culturalissue? a. Client’s numberof generationsin the United States b. Clients living in cultural enclaves c. Culture of the counselor d. Client's primary language 102. Whatare the twokey mental health treatmentparadigmsof Western medicine? a. Objectivity andthe scientific method b. Theoretical and applied practice c. Pharmacological therapy and psychotherapy d. Biological and environmental perspectives 103. Racism may jeopardize the mental health of minoritiesin all of the following ways EXCEPT

that

a. negative racial images andstereotypes adversely affect social andpsychologicalfunction. b. racism and discrimination result in diminished socioeconomic status, where poverty, crime, and violence affect mentalhealth. c. racism anddiscrimination lead to physiological changes andpsychologicaldistress that affect mentalhealth. d. discrimination and racism limit recreational andleisure opportunities to improve mental health.

a

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104. Whatis the trendfor cultural diversity in the United States?

a. Decreasingslowly but steadily b. Remaining approximately unchanged c. Increasing slowly but steadily d. Increasingrapidly andsteadily

105. Whatis the difference between AIDS and HIV? a. HIV canbefatal; AIDSis a nonfatal chronic condition. b. HIVis a commonviralillness, while AIDSis a lethalinfection. c.HIV is the virusthat causes the AIDS syndrome. d. HIVissexually transmitted, while AIDSis acquiredin other ways. 106. As compared with current olderadults, whatis the upcoming baby boomergeneration (born between 1946 and 1964) expected to have? a, Muchlower treatment needs b. Somewhatlower treatmentneeds c. Somewhathigher treatmentneeds d. Muchhighertreatment needs 107. Whenolder adults enter treatment, how dotheir rates ofattendanceandincidence ofrelapse, compare to their younger cohorts? a. Muchhigherattendance and much lower relapse rates b. Somewhathigherattendance and modestly lower relapse rates c.Norealdifference in attendanceor relapse rates d. Much lowerattendance and much higherrelapse rates 108. Confidentiality requirements exist to protect client's and their personallives andinformation. Without a clientsigned information release, whatis information that can bedisclosed? a. Aclient’s enrollmentin a treatment program only b.A report ofchild abuse suspectedto be caused bythe client c.Aclient’s name, age, gender, and raceor ethnicity d. A report ofprogress to an employerpaying fortreatment 109. The CAGEquestionnaire is a four-question screening tool. Whatis this screening instrument designed to screenfor? a. Cocaine abuse b. Marijuana abuse c. Alcohol abuse d. Heroin abuse 110. The MAST screening testis a twenty-five-question instrumentthatis usedto explore the

degree andseverity of a client's problem with which type ofabuse? a. Cocaine abuse

b. Mescaline abuse c. Methamphetamine abuse d. Alcohol abuse

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111. The relapse and remitting model addresses cycles ofrelapse and recovery commonto addiction. Whatelse canit be usefully applied to? a. Medication management

b. Unemployment c. Issuesof anger and violence d. All ofthe above 112. The term authentically connectedreferral network is usedin conjunction with case management. Howis it BEST defined? a. Aresource directory of available community services to call as needed b.A set of defined relationships able to adapt andflexibly meetclient needs c.Arolodexwith key names and contacts for neededservices d. An informal consortium of providers sharing information among each other 113. In providing case managementservices, beyond providing seamless care andbeingclient focused, whatis the primary aim? a. Provide referrals to needed servicesin as timely a way as possible b. Determine how tointegrate needed referrals in a coordinated fashion c. Produce the least-restrictive level of care possible in meetingthe client's needs d. Promoteclientself-determinationin identifying andselecting needed services 114.Sensitive interviewing and engagementtechniquesare importantto optimize client

responsiveness andinvestment. Whatdoes the ask-tell-ask technique refer to? a. Askingpermissionoftheclientto talk with them,telling them of any concerns you have, and then askingfortheir thoughts on what you shared b. Askingclients whatthey understand, telling them where they are wrong, andasking again if they understand c. Askingclients fortheir opinions,telling them wheretheir opinionsare valid and workable, and thenasking them if they concur d, Asking clients to listen,telling them what they need to know, andaskingif theywill acquiesce to whatis being asked of them 115. After referrals are made,itis importantto track the associated outcomesfor measures of referral success. What are the three MOST importantevaluative aspects? a. How,where, and when b. Why, what, and where c. Where, when,and who d. Who, what, and how 116. Given a client's history, referrals for co-occurringdisorders as well as medical, educational, andpsychological needs should be ongoing as discovered. When should planningfor aftercare be engaged? a. Duringthelast few sessions, addressing specific, continuing needs b. When a clientis roughly halfway through a program c. After measurable progress has been demonstrated d. At the pointofthe initial counselor-client contact

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117. Educationregarding substance abuse includes topics such as triggers, patterns of abuse, and relapse prevention. What should treatment MOSTLYbe focused on? a. Substance abuse issues and recovery only b. Substanceabuseissues andhealthissues c. Substance abuseissues and co-occurringdisorders d. All ofthe above 118. In client's efforts to maintain emotional and psychological balance, whatdoes the term bookend referto? a, Discussinga trigger event with someone trustedbefore andafter it occurs b. Fully reading andapplyingreferenceliterature providedin the program c. Remaining steadfast evenin the face oftemptationto abuse a substance d. Keeping a difficult issue on the shelf untilit can be better dealt with 119. In working with substance-abusingclients, counselors must be aware of the applicable guidelines in CFR Title 42 Part 2. Whatdo the guidelinesdeal with? a. Substance abusetreatment program accreditation and standards b. Issues involving theillicit manufacture andsale of drugs ofabuse c. Confidentiality in areas ofalcohol and substance abuse d. Mandated client treatment undera court directive or order 120. In working with substance abuseclients, counselors must be aware specific guidelines found in the HIPAA statutes. Whatdo theseguidelines address? a. HIV counselingandpracticeguidelines

b. Health privacy and confidentiality standards c. Health, addiction, and abuse practice guidelines d. Facility intake and admissionpolicy standards 121. Confidentiality is particularly stringentin situations ofalcohol abuse, drug abuse, and HIV infection. When are limited confidentiality breaches permitted? a. In situations where anindividualis at real risk of harming him- or herself or others b. In situations ofsuspected child abuse and(in somestates) in situations of suspected elder abuse c.Neither A nor B d. Both A and B 122. Group workis utilized extensively in substanceabusetreatment. How dogroup therapy and 12-stepgroupscompare? a. Very different types of groups with very different purposes b. Somewhat different grouptypes with modestly different purposes c.Inherently similar groups, though with some different purposes d. Different names for the same groups with the same purposes 123. There arefive primary group models used in substance abuse treatment. Whichis the model that viewsdependency as learnedbehavior that can be modified? a, Psychoeducational grouptype b. Cognitive-behavioral group type

c. Interpersonal process group type

d. Support grouptype

a

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124. Matchingclients with groupsrequires careful consideration. Where would a first-generation

American Hispanic womanbe BESTassigned? a. Anall-women’s group b. An all-Hispanic, Spanish-speaking group c.A groupbasedon immediate needs d. A mixed new-immigrant group

125. Treatmentfor longerperiods oftimeis closely associated with enhanced outcomes. What is the baseline duration for improved outcomes? a. Three months b. Six months c. Twelve months d. Eighteen months 126. There are numerousclassification systemsdescribing variousstagesof recovery. However, how manystages does the most commonstage classification provide for? a. Threestages b. Four stages c.Six stages d. Eight stages 127. Beyond thefive basic therapeutic group models (psychoeducational, cognitive-behavioral, interpersonal, and support), other unique group modelsinclude: culturespecific, expressive, and relapse prevention. Whatdoes an expressive grouptherapy modelinvolve? a. Communication skill-building education b. Art, dance, and psychodrama therapies c. Addressingdistorted thinkingandself-talk d. Confrontational dialectic therapy 128, In 1965, Bruce Tuckmanproposed a modelofgroup developmentthatincluded five phases. Whatis the one phase thatis NOTpart ofTuckman’s model? a. Performing b. Storming c. Framing d. Norming 129. A productive group therapeutic engages deepissues in manyindividuals with remedial or neglected issues. This may at times induce regression. How is regression defined? a. Feelings of regret and guilt that accompanypastfailures b.A sense of emotional closure whenpainful issues are recalled c. Reverting to a prior developmental level(ie, juvenile or infantile) d. Strong feelings ofanger projected inward towardoneself 130. Substance abuse affects notonly the user butthe family as well. What areintergenerational

affects MOST commonlycaused by?

a. Thelegal system, with incarceration, unemployment, and family separation b. Compensatingissues needed to cope with addictive dysfunction c. The counseling system, pushing families to encounter an addict's issues d. Society, rejecting the addict and all those associated with him or her -21GE TTTS FO BSTOTI BTBOF TYTTROTSTTTPT ATT

131. HIV remains a profoundproblemin the United States. Whatapproximate percentage ofall HIV cases are found amongfemalesin this country? a.5 percent

b. 15 percent c.25 percent 4.35percent

132. Members ofthelesbian, gay, bisexual, and transgender(LGBT) community face many challenges,includingissuesofdiscrimination. Regarding substanceabuse as comparedwith the general population, how is the LGBT community likely to act? a. Less likely to use alcoholor drugs b. About aslikely to use alcohol or drugs c. Morelikely to use alcoholor drugs d. Insufficient data to make these comparisons 133. Although mostindividuals with cognitive andphysical disabilities desire to work, many are unable to do so. In consequence,as relatedto substance abuse and the general population, howis this population likely to act? a, More likely to use alcoholor drugs b. About as likely to use alcohol or drugs c. Lesslikely to use alcohol or drugs d. Insufficient data to make these comparisons 134. The numberof older adults is rapidly increasing in the United States and worldwide.As a group, whenreceiving appropriate treatmentfor substance abuse, how are older adults likely to act? a. Less likely to continue to use alcoholor drugs b. About as likely to continue to use alcohol or drugs c. Morelikely to continue to use alcoholor drugs d, Insufficient data to make these comparisons 135. The likelihoodof developing a substance abuse disorder fluctuates throughoutthe life course. Whatis the mostlikely period in life for a substance abuseproblemto begin? a. Middle age b. Young adulthood c. Adolescence d. Childhood 136. Research reveals that science-validated community and schoolprevention programs do work. Which ofthefollowing is NOT a category ofyouth prevention substance abuse programs? a. Universal programs

b. Selective programs c. Indicated programs d. Targeted programs

a

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137. Proper program andprogress documentationis necessary for a greatvariety of reasons. Which ofthe followingis NOT a particularly important reason? a. Ensuringtreatmentplanaccuracy andcontinuity

b. Avoiding client challenges of records and documentation c. Ensuring complianceandcontinuedagency funding d. Avoidingloss orevenretroactive return offunds 138. Accurate documentation and reports are necessary if effective treatment andrecovery plans are to be developedand implemented. Which ofthe following is NOT fundamentalassessment information at intake? a. Documentation regardingreferrals and referral outcomes b. Psychoactive substance abusehistory andpatterns of use c. Psychological health and psychiatric treatmenthistory d. Currentphysiological health and medicalhistory 139. Treatmentand recovery plans must remaincurrentandeffective for optimalclient progress andwell-being. Consequentiy, how oftenaretreatmentplanstypically updated? a. Every fourteen to twenty-one days or as changes orprogress indicate a need b. Every twenty-oneto thirty-six days or as changes orprogress indicate a need c. Every thirty to ninety days or as changes or progressindicate a need d. Every sixty to one hundred twenty days or as changes or progress indicate a need 140. Whatis the key difference betweena current treatmentplanand a currentprogress note?

a. The treatmentplanevaluatesclient achievements, while a progress note ensuresaction steps

are taken to meetobjectives. b. Thetreatment plan assesses client needs, while a progress note coordinates service providers’interventions. c. The treatmentplanrecordsevents and activities, while a progress note captures the client's currentclinical presentation. d. The treatment plan providesanaction blueprint, while the progress note captures whatdid ordid not occur. 141. Accurate records arethebasis forthe treatmentplan and measuringclient progress.If somethingis entered in a client record in error, what is the proper response? a. Linethrough theerror, writing error andinitialing and dating the change b. White-out or otherwise obscure the errorto fully eliminate it from the chart c. Removethe erroneous page and recopyall correctinformation onto a new page d. Black outtheerror using felt pen to ensure the error cannot be read 142. Clients actively in a treatment program needregular chart entries. Typically, state requirements mandate an updating entry noless often than a.daily. b. semi-weekly. c.weekly. d. monthly.

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143. Ifa client leaves a treatmentprogram early orinvoluntarily, how is the writtendischarge summary affected? a. Itis not neededaltogether. b. Itis produced as usual. cItis abbreviated orcursory. d. Itis comprised only of the terminalfacts. 144. The Code of Federal Regulations,Title 42, Part 2, addressesclient confidentiality. Other than through a written information release, when do exceptionsto confidentiality exist? a, When program funding requires it b. When a policeofficer demandsit c. When subpoenarequests it d, Noneofthe above 145. The Code of Federal Regulations, Title 42, Part 2, Subpart E, addresses situations where law enforcementor courts can breachclient confidentiality. Whatis a subpoena signed by a judge? a. Sufficientfor release ofinformation, provided it is delivered by a lawofficer b. Sufficient for informationrelease,ifsigned by a federal court judge cInsufficientfor information release, unless signed by two qualified judges d. Insufficient, unless a qualified hearingis first held in court 146. Clients with anextensive substanceabusehistory oftenstruggle with impulse control and

anger.Ifa

response?

client becomes verbally agitated, angry, and elevatedwith a counselor, whatis the BEST

a. Threaten tocall law enforcementunless he orshe calms down. b. Cite the rightto expel him orher from treatmentif he or she misbehaves. c. Validate his or her affect but not expression(ifthreatening) d. Ignore the behaviorso asnotto further escalate his or her emotions

147. Manysubstance-abusingclients sufferfrom high impulsivity. Ifa client beginsto act out inappropriately, whatis an IDEAL groundingtechnique? a. Verbal confrontation b. Anchoring exercises c. Walkingoutofthe session d. Pointing outprogram rules 148. Clients with a history of abuse havea tendency to place themselvesin situationsin which furtherabuseis likely, particularly an unsafe relationship. If this occurs, what is the counselor's, BESTresponse? a. Coach them to explorethesituation, issuesofrisk, and self-endangerment. b. Point outto them theissues that are obvioustothe counselor. c. Provide a lecture on issues ofabuse recovery and importantsafety concerns. d. Contact the unsafe individual, and interveneon the client's behalf. 149. A counselorfinds herselftreating a perpetrator ofincest abuse. A survivor ofpast abuse herself, the counselorfinds this deeply disturbing. What would be her BESTresponse? a. Ignore herpersonalfeelings, and focus ontheclient's issues and needs. b. Confrontthe client abouthispast, andpress for growthin this area. c. Referthe client to a counselor more comfortable with the client. d. Find a therapist to help her better cope with client suchasthis. -24GE TTTS FO BSTOTI BSTSOF TSTTROTSTTTTPOT ATT

150. In providingservices, an agency needsto maintain a visionofpurpose and important

objectives. Ofthe following, whatis the MOSTsignificant mission?

a. To ensurethe survival and fundingofthe agency to continue offering services b. To ensurethatstaff have jobs so that they may continue offering services c.To earn a reputation ofstability andconsistency in offering services d. Tobreakthecycle ofabuse and neglectandits negative impact on others

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Answersand Explanations 1. D. The DSMlists a set ofeleven symptoms, 2 or moreof which musthave occurredat any time

duringthe past 12 months for a diagnosis of substance use disorder. 1) Tolerance, definedas either the need for larger andlarger amountsofthe drugin question overtimeto achieve the desired result, ora decrease in the effect of the drug with continued useofthe same amount2) Withdrawal, defined byeither the knownwithdrawalsymptomsfora particular drug, or bythefact that the drug, or a similar drug, is taken to avoid withdrawal symptoms 3) An increase in the amountof the drugtaken,or the continued use ofthe drug past the intended time 4) Aninability to control usage 5) Alarge amountoftimeandeffort devotedto obtaining the drugin question,using the drug in question, or recoveringfrom its effects 6) The giving up ofimportantactivities in orderto obtain or use the drug in question,orrecoverfrom its effects 7) The continued useof the drug in question regardlessoftheill effects it has caused. 8) Craving 9) Recurrent druguse whichleadsto inability to fulful major role 10) Recurrentdrug usethoughitis physically harmful 11) Recurrent drug use despite it leading to continued social problems. He does not meetthe criteria for current intoxication either. Recreational use commonlyoccurs biweekly or weekly, and the useis typically for reasonsofsociality. Substance abuse counselingis therefore notindicated. However, counseling regardingthe potential forlife circumstances, stressors, or other unexpected losses or burdensto precipitate a future substanceabuse problem shouldbe discussed. 2. D: The amountof a drugingested will typically affect the user's experience, with higher doses often producing a greatereffect (though potentially diminishing over time astolerance develops). ‘The modality ofadministration cangreatly influencethe rate of the drug's uptakeinto the system. Normallytherate ofeffect, from greatesttoleast,is: inhalation(snorting or smoking),injection

(intravenous, intramuscular, or subcutaneous), and ingestion (sublingual or swallowingwith or without food). Generally, the faster the systemic uptake, the shorter and more intense the high experienced. Polydrug abusegreatly complicates the drug experience, particularly if the drugs used are chemical antagonists (e.g,stimulants and depressants—such as methandalcohol), additive (producing a cumulative effect), synergistic (more than cumulative), or potentiating (each enhancingeach other). The setting in whichthe substance use occurs is also often a significant contributorto the experience. The feelings engendered by the surroundings,the people with whom the experienceis shared,the attitudes andreactions ofothers involved, as well as personalpast drug experiences andindividualbiology all combineto produce a drug experience. 3. D: Whena drugis usedregularly, the bodyis gradually able to adaptto the effects ofthe drug. Evidence of toleranceis twofold: (1) greater dosesofthe drug are requiredto achieveprevious effects, and (2) doses that wouldhaveproducedprofoundphysiological compromise or even death are now readily tolerated without untoward effects. In some cases, it has been noted thatupto ten times a lethal dosage, or even more, maybetaken withoutanysigns ofsignificant physiological compromise.Tolerance developsas the body seeks homeostasis, or a functionalstate of equilibrium,in spite ofthe presenceofthe drug.

4. D: Intense drug euphoria producesextremelyintense, emotionally imprinted memory engrams,

coupledwith long-term changesin the amygdala area ofthe brain, which operate outside of conscious control. Key euphoric memories becomeintegrally connected to sights, sounds, smells, people, andplaces previously associated with drug use. The reappearance of any ofthese past drug cues will often effectively trigger intense, amygdala-driven cravings for a drug, Cravings are further intensifiedby lingering imbalances in brain metabolism patterns, receptoravailability, hormone -26GE TTTS FO BSTOTI BSTBOF TSTTROTTOTTPTT ATTTT

levels, and other hypothalamusand pituitary-mediatedsensationsof dysphoria anddistress. The cascading natureoftheseeffects frequently inducesa drug-use relapse. 5. C: While tolerance for barbiturates does develop,tolerance for an otherwise lethal dose only marginally increases and never exceeds twofold. This means thatthe likelihoodof anunintentional fatal dose increases substantially overtime as the need forthe intoxicating effect pushes that threshold evercloserto a lethal dose. Given the impairments in memory and judgment that typically accompanyCNSdepressantintoxication, simple forgetfulness can lead to a fatal overdose. Finally, using barbiturates with any other CNS depressant substance, such as alcohol, can result i anadditive CNS depression thatcanreadily be fatal. Death mostoftenoccursvia respiratory or cardiac suppression. 6. D: Other symptomsofWernicke’s encephalopathyinclude poor muscle coordination and oculomotorimpairment (problems moving theeyesin a controlledfashion). Wernicke's syndrome is a short-term condition resulting fromvitamin B1 (thiamine) deficiency, typically developing after years of drinking andpoornutrition. Of those with Wernicke’s syndrome, 80 to 90 percent will develop long-term psychosis and memory problems knownas Korsakoff syndrome. While poor coordinationis a symptom,retrograde amnesia (loss of old memories) andlearningimpairments are among the more classic hallmarks of the condition. Because they are so often foundtogether, the two syndromes are often referred to concurrently as Wernicke-Korsakoff syndrome. 7. B: Hepatitis refers to inflammation ofthe liver. Alcoholis toxic to all body tissues. Because

alcohol must be metabolized bytheliver,it is particularly susceptible to the toxic effects. Consequently, manyheavy drinkers suffer from alcoholic hepatitis, characterized by abdominal pain, nausea, vomiting, and a swollenliver. In more extreme cases, jaundice and bleeding can result. Jaundice (a yellowingoftheskin and whites ofthe eyes)is from bilirubin, a by-product of aging red bloodcells broken down in theliver, that should have beenfully metabolized by theliver. Spontaneous bleeding occurs because key clotting factors are madein theliver, but productionis ibited by hepatitis. Steatosis consistsoffatty deposits in theliverthat, if severe, can provefatal. irthosis refers to scarringoftheliver from alcohol damage, preventingits normal functioning. Highbloodtoxins can also cause hepatic encephalopathy—a reversible dementia—ifthe toxins are reduced. 8. C: Chronic users of cocaine, crack cocaine, methamphetamine, andothersuch stimulants develop a profoundly unpleasant sensation of bugs crawlingundertheirskin. They may even come to believe the bugsare present and needing to be removed.In less severe cases, users may pick at their skin to thepoint of causing sores andscabs. In more extremecases, users maycut themselves in a desperate attempt to release the bugs and find relief. The condition also knownas Magnon’s syndromeand may also be referred to colloquially as coke bugs or crank bugs, and so on. 9. D: Considerable medical research demonstratesthat cocainenot only causesarterial constriction secondary to the drug's stimulanteffects, butit also causes a cumulative effect, with more cocaine causingincreased arterial narrowing.Atherosclerosis (artery hardeningandplaquebuildup) greatly magnifies this deleterious process. The result is that permanentdisability or death dueto suddencardiac arrest or hemorrhagic cerebralstroke is an increasingly real possibility the longer the drugis abused. Finally, cocaine-induced damageto theprefrontal lobes (where behaviors are modified and controlled) often results in impaired judgment, disinhibition,loss offoresight, decisional incapacity, and chronic unpredictability andirritability. -27GE TTTS FO BSTOTI BTBOF TSST TROTTOTTTPTT ATTTT

10. B: Amphetamines consist ofa group ofsynthetic stimulants chemically similar to the body's natural adrenaline—the hormonereleased when the bodyreacts in high-threat fight-fright-flight circumstances. The three main types are: amphetamine sulphate (commonly known as speedor by its trade name, Benzedrine), dextroamphetamine (trade name Dexedrineor colloquially as Dexy’s midnight runners), and methamphetamine (Methedrine or meth, crank, speed, poor man’s cocaine, etc.). Amongthethree classes, methamphetaminehasthe greatest abuse risk duetoits extremely fense rush. While some drugs such as heroin maybe unpleasantatfirst use, amphetamines are immediately pleasurable to most users. Consequently, meth is secondonlyto marijuana as the nonalcoholic drug most abused worldwide. 11. D:In termsofdifficulty quitting, relapse rates, cravings ratings, and persistent use despite known harm, nicotineis substantially more dependency producingthan cocaine, heroin, and alcohol. In terms ofwithdrawal symptomseverity, nicotine exceeds thatof cocaine and is only slightly behind heroin. Thus, fewer than 7 percentofthosetryingto quit each year will succeed. Given that nicotine use greatly increasesthe risks of heart disease, stroke, lung diseases, and cancer, nicotine abuseis a serious public health issue. Even only occasional smokingproduces lung andvascular damage, and almostone-fifth of all heart disease deaths are linked to smoking. 12. D: Historically, the level of delta9-tetrahydrocannabinol(THC) in domestic U.S. marijuana was less than0.5 percent. Recentcultivation and cross-breedingpractices, however, have changed this, and somedomestic marijuana has substantially higherlevels. The THC in Mexican marijuana can range as high as 4 percent, and sinsemilla can reach concentrations as high as 8 percent. The potency of hashish (cannabis plantresin) can be as great as 10 percent, and hashish oil may contain as much as 20percent THC.Street marijuanaproducts maybe diluted or cut with other adulterants (oregano,catnip, etc.) and may also belaced with other undisclosed psychoactiveingredients such as opiumorLSD. Unexpectedly high dosesofTHCorthe additionof other psychoactive substances

can greatly affect the unsuspectinguserin potentially troubling ways. Thus, cautionis in order.

13. A: Convergencetheory postulates that substance abuse rates are becoming more equal during the twenty-first century—currently, 1.6 men have substance abuse issues for every 1 womanwith such issues. Others, however, suggest the data is flawed, as womenare morelikely to hide their substance abuse behaviorand lesslikely to see help. Other genderdifferences include the following: (1) men externalize accountability, womeninternalize (self-blame); (2) issues of self-esteem are more commonfor women; (3) treatmentbarriers are higher, as womentendto have pregnancy issues and childrenneeding their care; (4) womentend toincrease substance abuse when depressed, while men are morelikely to decrease use. Women prostitute to support a habit; menturn toselling drugs orother criminal behavior. Marriage is a deterrent to drug use for menbuta risk factor for women. Womendrinkers are four times morelikely to live with a drinker than is aman.

14. D:Alcoholuse disorders rank third among psychiatric disorders ofthe elderly. Some 2 to 4 percentofthe elderly have a substance usedisorder(including alcohol, drugs, or both). Approximately 15 percentofthe elderly with an alcohol disorder will also have a concurrentdrug abuse problem.Due to physical changesofage, researchers recommendonly onedrink per day as the upperlimit. Detecting alcohol and drug abusein the elderly canbe difficult as the symptomsare often very similar to other health problems associated with age.Isolation, poor health, pain, or depressionoften motivates substance abusein the elderly. Manyare ashamed ofthe abuse and further avoid family and others to hidethe problem. Suicideratesclimb aspeople growelderly, and 25 to 50 percentofall attempts bythe elderly involve alcohol. Some 10percentoftheelderly -28GE TTTS FO BSTOTI BTBOF TSOT TROTTOTTPTT ATTTT

misusetheirprescription medication,intentionally or accidentally. Substance abuse may greatly complicate a potentially tenuousstatus for many on complex medication regimens. 15. D: Early-onset alcoholism refers to an onsetofalcohol abuse in adolescenceor youngadultlife. This represents about two-thirdsofall individuals with an alcohol usedisorder. Late-onset exacerbationdrinkingrefers to individuals with an intermittenthistory ofalcohol abuse that only becamechronicin late adulthood. Late-onset alcoholism refersto individuals with no prior life history of alcohol abuse whodeveloped an alcoholproblem solely in laterlife. This category of alcoholism may be more amenable to treatmentthan the earlier-onset forms, Detoxification can be protractedin theelderly, requiring a longer treatmentstay, due to the metabolic changesof aging. Group treatmentcan be complicatedby the groupmilieu, where youngerparticipants mayleave the elderly feeling estranged andoutof sync with the otherparticipants. Carefulefforts at inclusion or an alternate group composedofolder participants may be required. 16. A: Exploring readiness for change, rules andexpectations, orissues ofconfidentiality may

otherwise serveonlyto induceclient anxiety, defensiveness,or rejection of potentialtreatment

outright. The counselor must generate an authentic andsafe environmentthatis conduciveto trust and disclosure. This can be achieved, from a motivationalperspective, by assuringthe client that he or shewill not be told what to do, but rather, help will be givenin deciding what he or she is seeking to accomplish. A direct request about whathas broughttheclientin canbe helpfulif they are ready to talk openly. Otherwise, asking abouthealth, work, or family challenges may provide an oblique entry to asking about substanceissues (eg., “How is this affected by your substance abuse?"). As rapport grows,issues of confidentiality, program requirements (e.g., whether or not sessionscan be held in spite ofintoxication,etc.), session length, evaluation of change readiness, and soon, can then more naturally unfold. 17. D: Thegoal of motivationalinterviewingis to help theclient discover his or her owndesire to change. Thus, confrontation, stern accountability, overt reality testing, and other coercive or argument-inducing approachesare avoided.Five fundamentalprinciplesto guide the motivational interviewing process are: (1) reflective and empathetic listening, (2) identification of variances between behavior and personalgoals, (3) deflection ofconfrontation or argumentto more posi goal-oriented dialogue,(4) redirectionofclientresistance to desires andgoals rather than opposing it outright, and(5) nurturing optimism and sense ofself-efficacy when confronted with obstacles, challenges, and negative expressions. 18. A: Accordingto the 2009 National Survey on Drug Use andHealth, when individuals have co-occurring disorders (dual diagnoses) consisting of substance abuse and mentalillness, only 7.4 percentwill receive treatment for both disorders, 32.9 percentwill receive only mental health treatment, and 3.8 percentwill receive only substance abuse treatment. Where mental illness is severe, the existence of a substance abuse problem is particularly likely (25.7 percent). And among individuals with a substance use disorderin the past year, 17.6 percent will have a concurrent mentalillness disorder. Thus, where either a substance abusedisorder or a mentalillness disorder is known to exist, treatment professionals shouldbeparticularly careful to screen further and ensurethat any coexisting disorderis identified,if one exists. 19. D: Experiencedcounselors and researchers are aware that the settingin which screening occurs

(home,office, clinic, or voluntary vs. involuntary facility) cansignificantly affect the results of any

screeningtool used. How instructionsare givencan substantially influence the findings as poorly chosen words and presentingattitudes can unquestionably taint client thinking, presumptions, and willingnessto disclose. The presence or absence ofprivacycanalso be a significant factor, as -29GE TTTS FO BSTOTI BSTSOF TYTTROTTOTTPTT ATT

distractions, fears ofdisclosures or being overheard, and other such elements can bias and the screening andintakeprocess.Further, the levels of rapport and trust betweenthe client and the intake counselor may also alterclientperceptions and,consequently, client responses during any screeninginterview or when completing any screening instrument. New counselors must, therefore, be alert to these factors and quickly learn to overcomeanydeleterious influences. 20. C: Certified Alcohol and Drug Abuse Counselors, absentadditional mentalhealth training and licensure, do not have the credentials and training necessary to diagnose mentaldisorders. They do havethe training andcertification necessary to diagnose substance abuse disorders and are well within their scope ofpractice to screen, assess, andotherwise evaluate clients for substance abuse issues and to formulate and carry out substance abuse treatmentplans. Because ofthe frequency with which co-occurring mentalillnesses exist within the substance abusing community, Certified Alcohol and Drug Abuse Counselors can become very familiar and proficient with numerous commonly occurring mental disorders. It can therefore seem natural to broaden the scope of practice as experience grows. However, legal scope-of-practice parameters do notprovide for Certified Alcohol and Drug Abuse Counselorsto diagnose mental illness, anditis essential that they collaborate with otherprofessionals whenever non-substance abuse mental health issues arise. 21. A: GATEwas establishedby a consensus paneladdressing the evaluation ofsuicidal ideation andbehaviors by substance abuse counselors workingwith at-risk clients. It consists ofactivities that are well within the practice scopeof a substance abusecounselor. Gathering information

involves(1) screeningforsuicidality and (2) observingfor warning signs.Screeninginvolvesdirect

questions regarding current thoughts (plans, means, or preparations) and any past history of attempts. Accessing supervision or consultation(evenif the counselor alreadyhas specialized training) ensuresissues ofrisk are fully evaluated. Taking responsible action protects client

well-being andsafety. Extending the actioninvolves securing follow-up and ongoing monitoring as

needed.In this way, GATE fully assesses and addressessuicidality. Thefinal stepis thorough documentation to secure a medical and legal record ofthe care provided.

22. A: Political orientationis not typically a sensitive issue in the assessment process. Comprehensive assessment domains include: (1) complete substance abusehistory (all substances past andrecently used, modesofuse, frequency and amounts,etc.); (2) full addiction treatment history (when, where, howlong, etc.); (3) significant physical and mentalhealth history (including medications and ongoing care needs, suicidality, etc.); (4) familial history and current issues (marital status, family supports, etc.); (5) educationalhistory; (6) employmenthistory (and current issues); (7) legal or criminal history (including any ongoing matters such as pending court, probation, parole, etc.); (8) emotional, psychological, and perceptual concerns(worldview issue: (9) spiritual orreligiousissues; (10) lifestyle concerns (sexual orientation, housing transience, etc.); (11) socioeconomic factors(finances, work benefits, insurance, etc.); (12) prior community resourceuse; (13) cognitive capacity and behavioral functioning; (14) readinessfor treatment. 23. C: Serious mentalhealth issues, such as persistent suicidality, delusions, or hallucinations that precipitously resolve with abstinence are mostlikely substance abuse-induceddisorders that will not reoccurwithouta return to the formersubstanceabuse.In like manner, serious mentalhealth issues that do not resolvein an abstinenceperiod ofthirty days orlongerare likely due to an underlying mental disorder that must be evaluated and properly treated. In certain circumstances, an underlying mental disorder becomes exacerbated by substance abuse. In these situations, some measure of improvement will be noted, but it will fall substantially short of total resolution. This reflects the persistenceofthe underlying disorder; they will still need appropriate treatmentfor meaningfulresolution ofthe condition. -30GE TTTS FO BSTOTI BTSOF TSTTROTSTPTT ATTTT

24. B: This instrumentwas designedspecifically for use with adolescents, drawinguponsituations that are commontothis age group. Theinstrument derivesits namefromthe key word in each of the screening questions: driving a car while intoxicated; using alcoholor drugs to relax, feel better, orfit in; usingalcoholor drug when alone; forgetting events that occurred while using alcoholor drugs; requests by family or friendsto limit use; and, getting into trouble while using alcohol or drugs. The otherinstruments are: AUDIT(Alcohol Use Disorders Identification Test); the CAGE {also an acronym: needing to cut down drinking, feeling annoyed at drinkingcriticism, feeling guilty at drinking, and needinga morningeye-opener drink); and, the MAST (MichiganAlcoholism ScreeningTest). 25.C: Itis importantto introducethe topic ratherthan simplylaunching into questions.In this way, the client can understandforthe questions that follow. This introduction shouldbe followed by very clear questions. Screenfor thoughts: "Have you hadthoughts about deliberately ending your life?” Screen for past attempts: “Have youevertried to endyourlife?” A past history ofattempts greatly increases thelikelihoodof future attempts. Anyaffirmative response to thoughts should lead to questionssuch as: “Have you had these thoughts for long?” “What haveyoubeenthinkingof doing?” “Have you madefirm plans about this?” “Do you have (thepills, etc.) that you've been thinking of using?” Where a client has begun to formulate clear plans and realistic means, and so on, immediateinterventionis essential.

26.D: The purposeof screeningis to methodicallyreviewa client's presentingcircumstances by

which to determine the appropriateness (orlack thereof) for placementor referral for further assessment and evaluation. Screeningtoolsare also usedto identify the presenceor absence of co-occurringdisorders, particularly those that might contribute to substance abuse. Screeningtools donot attemptto diagnose a presenting co-occurringdisorder butratherto establish the likelihood that one may bepresent. Where a client presents as potentially havinga significant co-occurring disorder, the clientis then referred to the properclinician (psychologist, psychiatric social worker, psychiatrist, etc.) for further evaluation anddiagnosis. Once a diagnosis is obtained, a treatment plan can be formulated that addresses the co-occurring disorderas well. 27.D:The primary purpose ofsubstance abuse assessmentis to developa full understanding ofthe severity andextentof a substanceuser's drugoralcohol abuse problem. However, the assessment process should alsoidentify and explore other closely related issues such as co-occurringdisorders (both mental andphysical), significant others, employmentandeducation,finances, and other social and legal concerns. The overarching goal ofassessmentis to gathersufficientinformationto establish (1) a workingdiagnosis ofcurrent substanceabuse,(2) significant co-occurringdisorders, (3) the quality andavailability of important supports, (4) readiness for change, and (5)all other necessary information sufficientto establish a meaningfuland successfultreatmentplan. 28. B: Client collaborationin treatmentplanning is essential as client buy-in is essentialto ultimate success. While various generic treatmentplans maybe usefulin ensuringthatall essential elements ofplanning havebeenaddressed, boilerplate plans should not be used to short-cut the planning process.Theinclusionofthe client’s most importantpersonal goals may wellbecrucial to the buy-in required. The outcomeshould bea written documentthatincludes: (1) treatmentgoals, (2) action steps that are both measurable andtimesensitive, (3) clearly defined expected outcomes,

and (4) explicit verbal or even written agreementbetween the counselorandclient.

29. B: Careful assessment documentation,information sharing, and summarizing withtheclient for feedbackcanhelp ensure that the assessmentinformationis accurate andreadily available.

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However, to be mosteffective, assessmentinformation must be converted into cleargoals, objectives, and action steps. Beyondthis, the assessment must be recorded in clinically useful, reliable, and valid manner.In this way, the information anddata can bereadily understood and replicated and applied in a uniform mannermostrelevantto treatment.Simplistic labels, unidimensionalscores, and checklists will not alone achievethese ends. The record must include adequately organized narration and summation to be fully effective. 30. D: Clients are largely unawareofthe consultations that treatment team members engage in

throughoutthe treatmentprocess. However,an awarenessofthe benefitsof treatment—notonly

for the issue ofsubstance abuseor alcoholbutfor otherrelated life concerns—cansubstantially increase a client's commitmentto a treatment program.In like manner, the client needsto fully understand the treatment process. In this way, the purpose andgoals ofinterventionscan be clear, andmotivationto adhere to treatment consequently increases. Finally, fully assuming the patient role is important because,in this way, theclient resolves to put him- or herself completely into the hands oftreatmentprovides. A relinquishmentofthis nature removes attitude and behavioral barriers andresults in moreeffective treatment functioning. 31. B: The AmericanSociety ofAddiction Medicine (ASAM) recognizes four levels of treatment placementand five specific levels of care. The lowest level (referredto as Level 0.5)is designated as early intervention, which refers to education and other services for individuals with at-risk behaviors but for whom a substance abuse diagnosis cannot beconfirmed. LevelI consists of basic nonresidential outpatient services, primarily education, counseling, and behavioral change. Level II offers Intensiveoutpatientorpartial hospitalization (inpatient evenings or weekends, etc.). The

focusis on comprehensive biopsychosocial assessments and individualized treatmentplans. Level III consists of residential orinpatienttreatmentandoffers a plannedregimenofcare in a

twenty-four-hourlive-in setting. Level IV is medically managed intensive inpatient treatment. Level IV provides twenty-four-hour medically directed evaluation and treatment ofsubstance-related and mentaldisorders in an acute caresetting. 32. C: In assessingclients, the AmericanSociety ofAddiction Medicine (ASAM) encourages evaluationsusingsix interactive dimensions:(1) acute intoxication or withdrawal potential(the levelofintoxicationor risk ofsevere withdrawal symptomsorseizures andexploringinpatient or ambulatory detoxification);(2) biomedicalconditions and complications(otherillnesses that may create risk or complicate treatment); (3) emotional, behavioral orcognitive conditions and complications (diagnosable mentaldisorders or mild, undiagnosable mentalproblemsthat complicate treatment); (4) readiness to change(openor resisting treatment, acknowledging or

denying addiction, high or low motivations, etc,;(5) relapse, continued use orcontinued problem potential(immediate orlowrisk of substanceuse; goodor poorcoping orrelapsepreventionskills; severity ofcollateral problemssuchas suicidal behavior; etc.); (6) recovery environment(influence or proximity ofpeople,resources, andsituations that mayhelporpose threatto safety or continuedtreatment).

33. B: Thefirst stagein thestages of changeis precontemplation.This stageis characterized by: (1) giving no thought to change,(2) feeling resigned to substance abuse, (3) a sense ofloss of control, (4)denial (thereis no personal problem), and (5) minimizationof consequencesexperienced. The second stageis contemplation. This stage is characterized by evaluation ofthe costs, benefits, and burdens associatedwith the substance abuse behavior as well as thoseinvolvedin any proposed change. The third stage is preparation. This stage involves early experimentation with minor changesin usepatternsto better evaluate the idea ofchange proposal. The fourth stageis action. -32GE TTTS FO BSTOTI BSTBOF TSTTTOTSTTTTPT ATTTT

This stage involves takingdirect actionin pursuit of change. Thefifth stage is maintenance.This

stageis characterized byefforts to maintain the change achieved. Finally, the sixth stageis relapse. ‘This stageis initially demoralizing, thoughitis a normalpart of change.Ideally, it culminates in a return to the contemplationoraction stages.

34. A: CMRS scales, by G. De Leon, were developedto aid in determiningclient readiness for substance abuse treatment. The scales measure client perceptionsin fourinterrelated domains: circumstances (the externalpressuresinfluencing substanceabuse change), motivation(internal pressures driving change), readiness (perception and acceptanceofthe need for treatment), and suitability (the client's perception ofthe appropriatenessofthe treatment modality or setting) for community orresidential treatment. CMRS scales consist ofeighteenLikert-type(five-point, strongly disagree to strongly agree) responseitems. The scores are summedto derive a total score. Research on validity and reliability has offered strong support for the CMRS scales. 35. D: Externalevents andpressures may persuadeor even compela clientto enter treatment, and treatment admission mayfollow. However, true readiness is whena clientperceives and then accepts the need fortreatment. This typically requires the client to possess atleast some insight into his or her condition, the associated costs and consequences, anda recognition thatself-induced efforts have been unsuccessful. Finally, readiness involves a meaningful desire to effect change. The use of assessmentinstruments, such as the use ofcircumstances, motivation, readiness, and suitability scales canbeparticularly helpful in judging readiness for change. 36. B: This acronym represents the following guiding treatment planningprinciples: M = measurable.Goals andobjectives mustbeclearly measurableso that progress and other changes can beidentified readily and documented.A = attainable. Goals and objectives, andinterventionsas well, must be achievable (attainable) during the active treatment phase. T time limited. The active focus of treatmentshould be onshort-term ortime-limited goals andobjectives. R = realistic. It mustberealistic for a client to complete the identified objectives ofeach goal within the specified time period. S = specific. Objectives, and associatedinterventions, must be sufficiently specific and goal focused to ensure progress toward attainment. A key elementis involving theclient directly in the planningprocess to ensurethatthe goals, objectives, and actionsteps are mutually derivedto ensure client buy-in and commitment. 37. C: Treatment may be begunduring incarceration, continued at transfer to minimum security, then toa halfway house, and finally out to homeon probation orparole. Atall transition points, treatmentplansshould be updated.This needis particularly acute because an offender’s level of treatment needs, due to potentialproblemswith motivation andenvironmentalstressors, may significantly change at each ofthese junctures. Case managementis typically required to ensure comprehensiveservices, and commonparticipants includecriminal justice staff, prerelease

planners, halfway housestaff, vocational or educationalstaff, health providers, and involved family. Becauseofthe frequency ofco-occurring disorders in this population, numerous professionals use the Integrated Screening, Assessment, andTreatmentPlanning modelasit providesfor evaluation of both substance abuse and mentalhealth issues. 38. A: The Addiction Severity Index (ASI) addresses six problem domains:(1) medicalstatus, (2)

employmentand supports, (3) alcohol anddrug use,(4) legal status, (5) family andsocialstatus, and (6) psychiatric status. At times, alcohol and drug abuse are separated, resultingin a total of seven domains. It is important, however, to emphasize thatthe ASI is not a comprehensive instrument. For example,it does not ask questionsregarding pregnancy or homelessness, for example, even thougheitherof these issues maybe of crucial importanceto the client. The ASI was -33GE TTTS FO BSTOTI BTBOF TSTTROTTOTTPTTTTT

designed to primarily explore issues ofaddiction andother common,closely related issues. The goal of the ASIis to produce a standardizedbaseline, ensuringthatall counselors consistently ask the basic questions (animportantconstruct of research reliability in data gathering). Additional questions mayneed to be asked to ensure thatthe client's needs are fully understood and incorporatedinto any forthcomingtreatmentplan.

39. C: The Addiction Severity Index (ASI) was first releasedin 1977 and formally adopted for use by the NationalInstitute on Drug Abusein 1980. The ASIwas developed bythe DrugEvaluation NetworkSystems, which wassponsoredin this endeavorbythe White HouseOffice of National DrugControlPolicy (ONDCP) andthe Centerfor Substance Abuse Treatment (CSAT). Since that time, the ASI has become the mostwidely used assessmentinstrumentin thefield ofaddictions. It is recommend as a baselineinstrumentfor addiction assessmentby a great many governmental andprivate substance abusetreatment organizations, and due to its standardized questions, itis particularly useful for research.A teenversion (T-ASI) and a shortenedversion (ASI-Lite) are also available. Currentlyin its fifth iteration, version six is in development. 40. D: Reliability addresses how well an instrumentconsistently gives accurate information. Accuracy is oflittle value if the aspects or issues being measured arenot those theinstrumentwas intended to measure. In like manner, an instrument that accurately addressesthe intended aspects orissuesis still oflittle valueif the measurements taken byit are inaccurate. Thus, to betruly useful andeffective, assessmentinstruments andtools must be both reliable and valid. In multiple studies, the Addiction Severity Index has beenprovenboth reliable andvalid. 41. A: Drugs ofabuse are not able to successfully treat depression. While transientrelief can be experienced, the subsequentwithdrawaldepression invariably serves to worsen theoriginal

symptoms. Amongthe most commonassessmenttools for depressionis the twenty-one-item Beck

Depression Inventory, now in its second revision (BDI-II). The BDI is designed for use with individuals betweenthe agesofthirteen and eighty. It can beutilized as a self-report instrument, or administration maybe providedby a verbally trained administrator. The new formatis inclusive of a prior two-weekperiod, andotheritems were revisedto assess bothincreases anddecreases in sleep andappetite, better allowing formulation of a DSMdiagnosis. 42. C:Clients may enter treatmentby court orderor family pressure. Motivation for behavioral changeis a personal andinternal matter, with a greater likelihood of ultimate success. Assessing motivation may be pursuedvia the Stages of Change Readinessand Treatment Eagerness Scale (SOCRATES). It is a nineteen-itemself-report instrumentcomprised of three main scales—recognition, ambivalence, andtaking Steps—requiring approximatelythree minutes to complete, SOCRATES identifies client states on a continuum betweennotprepared to change and already changing. Thosein the pre-contemplation stagetypically denythe problem.Clients in the preparation and actionstagestypically admitthatthey have a problem. Optimal treatment planning requires an understanding ofwhere clientis in the change readiness process, which also promotes moreeffective explorationofthecurrent barriers to further change. There are two versions of SOCRATES.Oneversionis usedto assess alcoholissues and the other addresses

personal drug use.

43, D: The key components ofa treatmentplaninclude:(1) problem statements, which are based on information obtained duringthe assessment;(2) goal statements, whichare derivedfrom the

problem statements; (3) objectives, which consist ofwhatthe clientwill do to meettreatment goals; and (4) interventions, which are defined as what the staffwill do to assist the client. Relevant client strengths are often a required component. It is often useful to drawproblemsfrom a master -34GE TTTS FO BSTOTI BTBOF TSTTTOTTOTTPT ATT

problemlist. The list should include all identified problems, regardless of available program services, and whetherthey should be immediately addressedor deferred. Identification of problemsis a shared client-counselor endeavor. Problem statements shouldbe nonjudgmental, jargon-free, and written in complete sentences. Couch problem statements in behavioral specifics to ease writinggoals,objectives, and interventions.

44, B: The SOAPnote was first generated by Dr. Lawrence Weed, MD,in the 1970s to provide physicianswith rigor, structure, and a wayfor practices to communicate with each other. Subjective provides a narrative summary ofthe client's current condition, usually including the presenting problem (whythey cameto be seen). Commonelements include:(1) onset(ifapplicable); (2) chronology (improvements or worsening, variations in the problem, etc.); (3) symptom qualities (the natureof the symptoms,etc,); (4) severity (degreesofdistress); (5) modifying factors (what helps or worsensthecondition,etc.); (6) additional symptoms(whetherrelatedorunrelated to the presenting problem); and (7) treatments (prior treatments, ifthe client has previously been seen elsewhere). Objective captures keyfacts that are measurable, quantifiable, andrepeatable aspects of the client's situation (physical symptoms,lab results, weight, etc.). Assessmentrefers to the clinician's early diagnostic impressions.Plan describes the clinician's next steps in response to the formationobtained (further assessments, referrals, medications,interventions, etc.). 45. D: DAPnotesassistclinicians record clear and organized notesto better understand client thinking, select appropriate goals, and track client progress. The data sectionincludesfacts such as client statements, observations regarding mood andbehavior, past assignmentreviews, and so on. This sectionis typically the longest portion ofa DAPnote. The assessmentsectionincludes client currentstatus andevaluationof treatmentprogress.It may alsoincludetentative or working

diagnoses, potential treatmentrequirements, andinformation regardinga client's motivation or ability to proceed. Theplansectionincludessessionscheduling andthe expected focusfor

upcomingtreatmentsessions.In this area, updatesoralterationsin treatmentare recorded, along

with comments regarding homework assignments. DAPnotes allow others to understandevents during each therapysession andevolutionsin treatment andcanaid in tracking long-term progress andprogram andintervention effectiveness in a consistent manner. 46. D: The acronym DIG-FAST is a tool promptingthe full evaluation ofthe symptoms of mania. Eachletter addresses one ofthe keypotential features of mania: distractibility (easily distracted as evidenced by an inability to concentrate), indiscretion (excessive pleasure activities), grandiosity (larger-than-life feelings of superiority, wealth, power,etc,, often experienced during manic, hypomanic or mixed episodes), flights of ideas (mind is racing, seemingly unable to control or slow down thoughts), activity (markedly increased activity, with weightloss andincreasedlibido), sleep deficit (unable to sleep for extendedperiodswell below normal sleep needs but not drug induced), talkativeness (pressured speech:rapid, virtually nonstop,oftenloud and emphatic, seemingly driven, and usually hardtointerrupt).

47. C: The Center for Substance Abuse Treatment (CSAT)—part ofthe Substance Abuse and Mental Health Services Administration within the U.S. Departmentof Health and HumanServices—notes

that substance abuse has beentreated as an acute disorder for most ofthe twentieth century. This shaped treatment, which was typically short term andintensive, muchlike treating an acute infection. Detoxification occurred, information was shared, and the individualwas discharged to manage independently. They now recommend that substance abuse be treatedlike a chronic condition, such as diabetesor hypertension. Tothis end, treatment needsto be realigned to allow for a gradual recovery with regular checkupsto ensurethatthe condition remainsin control. -35GE TTTS FO BSTOTI BTBOF TSTTROTTOTTPTT ATTTT

48. B: In keepingwith the chronicity modeloftreatment (suggesting that substance abuse treatmentrequiresa long-termtreatment model, much like a chronicillness) as opposedto the acute treatmentmodel, the Centerfor Substance Abuse Treatment (CSAT) recommendsthat treatments or othercare providedfollowing program discharge be referred to as continuing care. Thus, the termsaftercare andfollow-up care are to be discouraged.In this way, care provider models can betterperceive the need to realign themselves from an acute care model to a chronic care model. Theresult is expectedto be better and moreenduring care and support for those workingto overcomeissues of addiction and compulsion. Examples of continuing care include mutual-help groups(including twelve-step andother support groups) available in the community andfollow-up client appointments for episodic checkups,similar to typical medical checkupsfor otherchronic diseases). 49. D: The policy ofthe American Medical Association (AMA)is that clients coping with substance abusedisorders should receive formal treatmentfrom qualified professionals. Mutual-help groups mayprovide adjunctive services and maybe part of a successful treatmentplan. The American Psychiatric Association (APA), the American AcademyofAddiction Psychiatry (AAAP), and the AmericanSocietyofAddiction Medicine (ASAM)have concurred, assertingin a jointpolicy statementthattreatmentinvolvesat least: (1) a qualified professional providing services; (2) a

thorough evaluationto determinethe severity and stageoftheillness andto screen forother mentaland medical disorders; (3) a properly developedtreatmentplan;(4) thatthe treating professional or program remainsaccountable for the treatmentandadditional servicereferrals as necessary; (5) that the treatmentprofessional or program remainsin contactwith theclient until the recovery process is complete. While mutual-help groupsare important, they cannotsubstitute forprofessional treatment. 50. C: Intensive outpatienttreatment(IOT)hastraditionallyconsisted ofa minimumofnine hours

of weekly treatmentprovided in three three-hour sessions. However, some programsprovide more contact hours andothers as few as six contact hours per week. Even so, accordingto the American Society ofAddiction Medicine (ASAM)'s Patient PlacementCriteria, [OT programs must provide nine or more structured contacthours each week andtreatmentat six or more hours per day during a partial hospitalization program.TheCenter for Substance Abuse Treatment(CSAT) consensus panel agreed that IOT key featuresinclude:(1) six to thirty contact hours each week;(2) step-upandstep-down carewith varyingintensity; (3) a minimumofninety days continuing care followingdischarge; and (4) various additional core featuresand services. 51. D: Recreational therapy was not oneofthe core features andservices referenced by the Center for Substance Abuse Treatment (CSAT). The CAST consensuspanel agreedthatintensive outpatient treatment(IT) core features and services mustincludethe following: intake and orientation; full biopsychosocial assessment;individualized treatment planning; individual, family, and group counseling; psychoeducational programming; case management;linkages with mutual-help and community-based support groups; twenty-four-hourcrisis support; medical treatment; formal drug screening andmonitoring(urine or breath tests); educational and vocationalservices; psychiatric evaluation andpsychotherapy; medication management; anddischarge planning andtransition (discharge) services. They further defined potential enhancedservicesto include: adult education; recreationalactivities; housing and food resources, smokingcessation treatment; transportation

referrals; child care; and parentingskills education.

52. C: Naltrexoneis effective for some people with alcohol dependency.It has also been noted, however,that naltrexone may not beeffective in treating menwith chronic, severe alcohol dependence.In certain circumstances, naltrexonehas alsobeeneffective in treating opioids -36-

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addiction. Disulfiram (Antabuse) is anotheradjunctive medication used in the treatmentof

alcoholism. Naloxone(Narcan), a shorter-acting agentsimilarto naltrexone,is used primarily in situations ofopioid overdose, though it is also usedin the treatmentofalcoholism to lower cravings. Buprenorphine and buprenorphine combined with naloxoneare now also available for the treatment of opioid dependence andcan beprescribed in programs that have medical personnelonstaff. 53. C:Althoughexercise can be an important stress reducer, and health improvementis also meaningful, these are not core treatmentand recovery skills. Substance refusal training is crucial as developmentofthis skill helps clientsto practice and become comfortable with refusing addictive substances. Outside of the program,it is inevitable that clients will at times be offeredillicit substances, and they needtheskills to reflexively but politely refuse without returning to substance abuse. Stress managementand relaxation trainingare both important as unmanaged stressis a significanttrigger for relapse. Assertiveness training teachesindividuals how to get their needs met proactively (but not aggressively) and to avoid allowingothers to take advantage ofthem. Unmet needs can be a powerful trigger to relapse, thus this is an important skill. 54. A: Gustatory refersto the sense oftaste and is nota learningstyle. To learn, we utilize our senses to process information around us. When learning, mostpeople use oneoftheir senses more thanthe others. There are actually seven learningstyles: (1) aural(auditory-musical): learning through sound; (2) visual(spatial): learningvia images; (3) verbal(linguistic):

learning through

words; (4) physical (kinesthetic): learningvia touch; (5) logical (mathematical): learning through logic; (6) social (interpersonal): learningbest with others; (7) solitary (intrapersonal): learning throughself-study. The three most commonlearningstylesare visual, auditory, and kinesthetic. Consequently, programs should explore the useof videotapes, behavioral rehearsals orrole plays, written materials, lectures, discussions, workbookassignments, anddaily logsor journals.In this way,all primary learning modes can be met. 55. C:It has been noted that substance abuse treatment outcomescan be substantially improved whensupportive family members are involved. However,itis also truethat problematic family relationships cangreatly hamperthe treatmentprocess and reducethelikelihoodof enduring recovery. Thisis particularly true where family culture andtraditions runcounterto treatment and recovery processes.Ideally, family therapy will be available as an adjunct to the treatment process, as necessary. Where program resourceslack this componentofcare,referrals to therapists or organizations that provide family therapy should be considered. Involved family memberswill also needto be educated regarding the addiction process as well as learning howto optimally support their loved one’s recovery. Balanceis importantas attempts to exert too muchcontrol can drive their lovedone awayor even backinto abuse. Conversely, where family involvementis too limited, the client may lack the support necessary to sustain themselves into recovery and beyond. 56. C: Thefive mainlevels in the substance abuse continuumofcare, asidentified by the American

Society ofAddiction Medicine (ASAM)are:Level 0.5:early interventionservices (subclinical or pretreatment, exploring risks and addressing problemsorrisk factors that appearto berelated to substanceuse); LevelI: outpatientservices (nonresidential,less than nine hours per week); Level

Il: intensive outpatient orpartial hospitalization services— nonresidential, a minimumofnine hours per week(LevelII is subdividedintolevels II.1 andII.5); LevelIII: residential or inpatient services—minimumoftwenty-five hours per week(LevelIII is subdividedintolevels II1.1,111.3,

IILS, andIIL.7); and Level IV: medically managedintensiveinpatientservices (subacute,with daily physiciansupervision). Theselevels are not discrete butratherpoints on a treatmentcontinuum. -37GE TTTS FO BSTOTI BTBOF TSTTROTTOTTTPTT ATTTT

57. B: Independentofthe levels ofcare defined by the AmericanSociety of Addiction Medicine

(ASAM),outpatientclients must workthroughfour sequential stages of treatment, regardless of the entry treatmentlevel ofcare. Thestagesconsistof: Stage 1—treatment engagement(establish a

treatmentcontract includinggoals andclient responsibilities; resolve acute crises; develop a

therapeutic alliance; and prepare a treatmentplan); Stage 2—early recovery (continueabstinence; sustain behavioral changes;terminate a drug-usinglifestyle and developdrug-freealternatives; learn relapsetriggers and preventionstrategies;identify andresolvecontributingpersonal problems;andbegin a twelve-step or mutual-help program); Stage 3—maintenance(solidify abstinence; deepen relapse prevention skills; enhance emotionalfunctioning; increasesobersocial networks; and address other problem areas); Stage 4—community support (sustain abstinence and a healthy lifestyle; establish treatment independence; extendsocial networkand support group connections; pursuehealthy community activities; and solidify importantoutletactivities and pursue newinterests).

58. C: The most commonrecommended minimum duration ofdays in anintensive outpatient treatment (IT) phase is ninety days. However, researchreveals that longer duration ofcareis relatedto better treatment outcomes—specifically, less substanceuse andbettersocial functioning in clients overtime. Consequently, it may be both advantageousand cost-effective to plan lower-intensity outpatienttreatmentover a longer timeperiod to enhancetreatmentoutcomes.

Theultimateduration should be adjusted to meet the client's rate ofprogress,psychiatric status,

support system,clinical needs, andso on. [OT programmingis commonlyprovidedfor nine or more

hours overthreeto five days per week. The consensuspanel recommendssix to thirty hours, dependinguponclient needs. For some clients, more frequent, shorter visits maybe ofgreater benefit than fewer, longersessions. Forotherclients, more orlongersessions, approachingthe intensity ofpartial hospitalization, may be needed.

59. D: Research reveals thatthe effectiveness ofgrouptherapyis on a par with that of individual therapy. In addition, group therapyallows for a more effective balanceofcostly individual counseling services. Intensive outpatient treatment(IOT,LevelII care) is typically delivered in sequentialstages, with greater serviceintensity and structuregradually reduced asclients progress.This allowsfor increasingpersonal responsibility even as structure and staffsupervision is reduced. However,it is importantto beable to return to moreintensiveservicesif changing

client circumstances require it. The sequenced nature of JOT can motivate clients toward recovery milestones and stage completion criteria. Celebrating or otherwise marking the transition between IOTstages can provide further motivation.Finally, complexinformationcan bebetterdelivered via sequenced stages as this allows for conceptual units that are moreeasily understood and that can be revised to meet the unique cognitive, psychological, and transition readiness of each client. 60. D:Psychoeducational groupsteach key concepts regarding substanceuse disorder andits consequences. Time-limited, these groups areideal for education at theoutset of treatment. The low-key educational nature(as opposed to emotionally intense therapy groups) allows more objective examination ofdysfunctionalbeliefs, problem thinking patterns, alongwith relapse preventionandskills training. Skills-development groupsfocus onrefusal training, relapse prevention,assertivenesstraining, and stress management. Support groupsaddress immediate

issues alongwith waysto changenegative thinking, emotions, andbehavior,learning new waysof relating, managingconflict withoutviolence or relapse, and evaluating how actions affect others. Interpersonalprocess groups include single-interest groups(focused onspecialized issues, usually laterin treatment) and family or couples groupsthat explore the effects of substance use on relationships. -38GE TTTS FO BSTOTI BTBOF TSTTROTTOTTPTT ATTTT

61. B: Individual counselingis typically scheduled for thirty to fifty minutes at least weekly in the initial treatmentstage.Sessions are held with a primary counselorto help facilitate a meaningful, collaborative therapeutic alliance. A commonsession formatinvolves: (1) asking for reactions to recentgroup meetings;(2) reviewingoutside activities since the last session; (3) asking about

currentfeelings; (4) exploring anyinterim drug andalcoholuse; and (5) inquiring about any urgent issues, Recent group topics, treatmentplans, and copingstrategies are reviewed. Fears and anxieties about changeare explored, and drugtesting feedbackis provided.Sensitive issues not appropriate for the group are discussed. However, no effort is made to address any underlying conscious and subconsciousissues contributing to substanceuse. Assistance with access to needed services outside the program's scope is given, and planningfortransitions betweenlevels ofcare or for dischargeis completed. The session concludes with a review ofthe client's plansandtreatment schedule. Clients with co-occurring disorders may require primarily individualcounseling. 62. D: Pharmacotherapy and medication managementareofcritical importancein effective substance abuse treatment. They must notbeoverlooked orisolated from othertherapies and interventions. Evenso, medicationscannotalterlifestyles or recoverthe functional damage that results from drug abuse. Dueto the three- to five-day weekly schedules ofmostintensive outpatient treatment (IOT) programs, they are an ideal setting foridentifying medication needs and then initiating and monitoringthe necessary medications. IOT program-based pharmacotherapy and

medication managementcanfacilitate: (1) ambulatory detoxification; (2) withdrawal symptom relief; (3) craving reduction; (4) blocking thereinforcing effects ofdrugs; (5) reducingthe health risks that accompanythe use orinjectionofillicit drugs; (6) mitigation of certain underlying psychopathologies that maypredispose substance abuse orrelapse; (7) the monitoring and treatmentof numerouspotential medical conditionsthat may result from acute or long-standing substance abuse. 63. A: Substance abuse andrecovery topics addressed in psychoeducationalgroups are presented in a sequential, building order ofconcepts to ensureoptimum learning. Core topics include: (1) understandingthe relapse process; (2) relapse preventiontools; (3) creating a personalrelapse plan; (4) managing euphoria anddesires to test control; (5) stress management andcoping skills; (6) anger managementandrelaxationtechniques; (7) self-efficacy in relapse-risk situations; (8) managingslips and avoiding escalation; (9) recovery resources; (10) structuring leisure and recreation; (11)essentials ofpersonal health; (12) regular personal inventory; (13) managing emotional triggers (shame, guilt, depression, andanxiety); (14) problem family dynamics(enabling andsabotaging); (15) restoring personalrelationships; (16) healthy sexuality; (17) essential educational andvocational skills; (18) essential living skills (financial management, housing, and legal assistance); (19) finding meaningin life (spirituality); (20) grief and loss and substanceuse; (21)parenting essentials (children’s needs, developmental stages, and tasks); (22) maintaining balancein life. 64. C: The Clinical Institute Withdrawal Assessment-Alcohol, Revised (CIWA-Ar) scale assists identifying which alcohol-dependentclients can receive ambulatory detoxificationversus inpatient care. The CIWA-Arcan be administered in minutesbystaff with a minimumof three hourstr: Thereis somedisagreementaboutcutoff points on the scale. Numerous physicians concur that scores of twenty or higher shouldbe treated in a medicalinpatientsetting. Other specialists su: thatclients with scores intothe low twentiescan besafely managedin an outpatientsetting,

providingthere is proper monitoring, medications supervision, and so on. Consequently, medical staff must rely on their best judgmentor program policy and procedures, The CIWA-Ar also guides

the administration ofmedicationsatthirty- to sixty-minuteintervals. Dosesare only given in

-39GE TTTS FO BSTOTI BTBOF TSTTROTTOTTPT ATTTT

response to observed withdrawalsignsata specified intensity. The CIWA-Ar has reduced both client numbersreceiving medications and the amounts ofmedications given. Revisionsof the instrumenthave enabled the monitoring ofboth benzodiazepineandopioid withdrawal symptoms. 65. C: There are effective medications for the treatmentofalcohol andopioid addictions. The

medications reduce cravings, inhibit the intoxicating effects, produce aversion, and lessen the desire to usethe target substance. However,in spite ofconsiderable laboratory research and extensive clinicaltrials, no effective medicationsforthe treatmentofdependenceon stimulants such as cocaine, marijuana,inhalants,or hallucinogenshasbeen discovered. There are medications to modestly mitigate thedifficult withdrawal symptomscaused bythese substances. For example, symptomsofstimulant withdrawal include insomnia,agitation, anxiety, and evendelirium, psychosis, and hyperthermiain particularly acute cases. Neuroleptic medicationscan lessen the symptomsofpsychosis anddelirium, and benzodiazepinescan reduce the symptomsofagitation andanxiety. Beyond symptom management, however, there are notarget treatmentdrugsfor these substances. 66. A: Education, vocationaltraining, and employmentissuesare core support concernsbut do not constitute adjunctive therapies. Adjunctivetherapiesare usedto enhance the emotional and psychological functioning ofclients laboring to overcomeanaddiction.Giventhe pressuresof foregoing their substance ofchoice, individuals in recovery needalternativeoutlets for stress as well as betterself-care skills. Tothis end, creative media groups (e.g, dance, drama, music, crafts, and arts) can bevery therapeutic and helpfulin the recovery process. Otheralternative therapies include acupuncture andbiofeedback therapy. Both ofthese can aid in reducing stress andin learningrelaxation skills. Similarly, a variety of meditation techniques can be particularly helpful. Mediation techniques include approaches such as mindfulness(learning to appreciate the present), visualization (positive imagery), breath meditation (learningto focus and controlthinking andthe body), andtranscendental meditation (deep awareness andconsciousness). As an adjunct to substance abuse treatment, meditationis in harmonywith theintent andphilosophy oftwelve-step andother mutualself-help groups. 67. C: The majority ofdrug- or alcohol-dependentindividuals are also smokers. And, morein this group die from smoking-related conditions than from their substance abuse.Treatingstaff believe that smoking cessation may complicate drugor alcoholabstinence. However,clients may feel otherwise—believing thebesttime to quit would be duringtreatmentfortheir drug or alcoholuse. Fewer than 10percentofclients would object to a clinic's smokingbanif nicotine replacement therapywas available. Smoking cessation successis highest whencoupled with behavioral therapy and nicotine replacementtherapy. Thus,treatmentprogramsareidealsettings for smoking cessation.Finally, there are strong associations between reduced smoking and reductions in substance abuse. Numerousforms of nicotine replacementare available, and clients are encouraged to try various products before deciding what works best for them.The antidepressant medications bupropion and nortriptyline help to reduce nicotine cravings, probably because they help reduce depression—which is a major causeof relapse. 68. D: Disulfiram (Antabuse)is indicated even with cocaine use or methadone maintenance.

Disulfiram interferes with acetaldehyde metabolism, which produces a profoundphysical reaction if drinking occurs within twelve hours to sevendays, depending on dose. The reactioninvolves facial flushing, followedby a throbbing headache, tachycardia, tachypnea, andsweating. Some thirty to sixty minutes later, nausea and vomiting occur, often accompaniedby hypotension, dizziness, fainting, and collapse. The full cycle takesone to three hours. Careful blood alcohol -40GE TTTS FO BSTOTI BTBOTSTTROTTOTTPTT ATT

monitoring is needed to ensure that noalcoholis presentbefore administering disulfiram. Low doses (125 mg)can be given as quickly as the blood alcohol reaches zero.An initial dose of 250 to 500 mgmaybe used, though lower doses maybe better for small women, the elderly, andthose with liver impairment. Clients have takenthe drug as long assixteen years. Episodic useis effective to guard againstdrinking in high-risksituations(e.g,,

special events orcelebrations, etc.). Food that

containsalcohol usually does notcause a problem if it has been evaporated duringthe cooking process.

69. B: Optimizingtheintake process enhances thelikelihood thatthe client will both disclose crucial intake information and accept treatment. Overly formalintake questioningis likely to be off-putting and maywell inhibit self-disclosure and engagement. Both research and anecdotal evidence suggest that less-formal approaches canbetter build and support rapport between the counselor and client. Oneless formal approachis the sandwich technique. It involves sandwiching the standard screeningandassessmentquestions betweentwo less-formal discussions. Forfifteen to thirty minutes, the counselor: (1) addresses perceptions ofthe problems that motivated the clientto explore treatment;(2)elicits the client's expectationsof treatment; (3) supports the commitment to change; (4) offers encouragement that changecan be achieved; and(5) explores readiness to change. Next, the formalscreening and assessment are conducted,followedby: (1) a less-formal summarizingoffindings; (2) initial treatment planningappropriateto the client's changestage; and (3) addressingtheindividual's expectationsfor treatment. 70. C: Researchers have comparedeight commonlyused screeninginstruments for efficacy in determining the presence of substance use disorders. Only three possessed optimal accuracy,

positive predictive value, diagnostic sensitivity. These three instruments are: (1) the Centerfor

Substance Abuse Treatment (CSAT) Simple Screening Instrument; (2) the combinedAlcohol

DependenceScale (ADS)andthe Addiction Severity Index (ASI)-Drug Use Subscale; and (3) the

TexasChristian University Drug Screen. Otherpopular briefscreeninginstruments include the Substance Abuse Screening Instrument, the CAGE Questionnaire, and the OffenderProfile Index. Eachofthese instruments is in the public domainandthus may be reproduced and usedfreely. 71. C: The Substance DependenceSeverity Scale (SDSS)is a structuredinterview that provides current(lastthirty days) DSM and ICD-10substance use disorders and harmful use diagnoses. The instrumentmeasuresthe quantity andfrequency of recent drug use, which directly translatesinto variationsin clients’ clinical status. Following the usual two to three days oftraining (for those with a preexistingclinical assessment and diagnosis background), the SDSS canbe administered in thirty to forty-five minutes. Past research indicates that the SDSS dependence scales are reliable andvalid measuresof DSMdiagnosticseverity. More recentinvestigations into test-retest reliabilities for the

ICD-10 dependencescales yielded goodto excellentresults for alcohol, cannabis, cocaine, and heroin. Test-retestreliabilities for the ICD-10 harmful use scalesfellin the goodrange for alcohol, cocaine, and heroin butwerepoortofair for cannabis. Concurrentvalidity, diagnostic concordance, andinternal consistency results were similar to the test-retestfindings. Thesefindings support the use of the SDSSin assessing DSM and ICD-10 dependence and harmful use diagnoses. 72. A: The Texas Christian University Drug Screen (TCUDS)scaleis able to distinguish between individuals with drug use disorders as opposed to those who misuse drugs butare notphysically and psychologically dependent. The TCUDSinstrumentconsists of twenty-five questions

administeredinless thanfive minutes. The TCUDSis frequentlyusedin adult criminal justice

settings. However,itis also appropriate for use in the general population. The TCUDrugScreenII (TCUDS11) is a standardized fifteen-item screeningtool also designed to identify any current history ofheavy drug use or dependency.Itemsonthe TCUDSII are designedto meetthecriteria a

-41RTEOa AIFOTTER TSRRTORIANRET

foundin the Diagnostic andStatistical Manual (DSM)andthe NIMHDiagnostic Interview Schedule

(NIMHDISC). Thescale is divided into two parts, with thefirst assessing drug and alcohol use problemsandthe secondaddressingfrequency of use and theindividual's readiness for treatment. ‘The TCUDSII can be used in aninterview setting, or it can be self-administered. 73. B: Physiological dependenceexists if tolerance or withdrawalis in evidence. Tolerance is in evidenceifthereis a need forsignificantly more oftheinvolved substance to achieve a desired effect orintoxicationorif the effects ofthe substancearesignificantly diminished whenthe same amountofthe substance is used. Withdrawalis in evidenceif abstinence induces a withdrawal syndrome asexpected for the substance or the same substance(or oneclosely related chemically) is used to relieve or ward off withdrawal symptoms. TheDSM lists a set of eleven symptoms, 2 or moreof which must have occurred at anytime duringthe past 12 months for a diagnosis of substanceuse disorder. 1) Tolerance, defined as eitherthe need forlarger and larger amounts of the drug in question over timeto achievethe desired result, or a decreasein theeffect of the drug with continueduse of the same amount; 2) Withdrawal, defined byeither the known withdrawal symptomsfor a particular drug, orbythefact that the drug, or a similar drug, is taken to avoid withdrawal symptoms; 3) An increase in the amountofthe drug taken,orthe continued use ofthe drugpast theintended time; 4) An inability to controlusage; 5) A large amountoftimeandeffort devotedto obtainingthe drug in question,usingthe drug in question, or recoveringfrom its effects; 6) Thegiving upof important activities in orderto obtainoruse thedrugin question, orrecover

from its effects; 7) The continueduseofthe drug in question regardlessoftheill effects it has caused; 8) Craving; 9) Recurrentdruguse which leadsto inability to fulful major role; 10)

Recurrent drug use thoughit is physically harmful; 11) Recurrent drug use despite it leading to continuedsocial problems 74.C: Early. Early remissionis no stimulantusecriteria being met(except for craving) for at least 3

butless than12 months. Sustained remission is no stimulantuse criteria being met(except for cravings) for 12 months orlonger. The termsfull and partial are no longerused to describe remission.

75. D: The family oforigin refersto blood relationships(parents,siblings, cousins, grandparents, etc,). The relationships in both family types are importantin substance abuse treatment. Either groupmaybring factors andinfluences that contribute to substance abuse(e.g.,alcoholism, culture ortraditions supportive of drug experimentation, etc.). Where outright drugor alcoholuse was not condoned,families mayhaveinteractivepatternsthat predispose substance abuse. Troubled families often have too few ortoorigid rules,difficulties with intimacy, andineffective problem solving. Such families often perpetuate a don’t-trust-don't feel-don’t-talk paradigm that allows isolation, damagingalliances, enmeshment, or other dysfunctionsto persist. It is essential for counselors to learn about both thepositive and negative resourcesin a client's family. Referrals for family counseling may beessentialto this end. When the family becomes readyto changenegative behaviors and adopt new, healthierones, they becomesupporters in the treatmentprocess. 76. D: Dualrelationshipsare unethical during and immediatelyfollowing the course ofany counselor-counselee relationship. More broadly, dualrelationshipsarise when multiple roles are created outside the therapeutic-fiduciary relationship. Examples include: (1) allowing a client to provide automobile repair work for a therapist, whetheritis paid or not; (2) hiringa clientto paint a therapist's home; (3) allowinga client to provide volunteerclerical work in the program office; and soon, Multiple roles such as these compromise the integrity of the therapeutic process, making moredifficult to provide client servicesthatare untainted by the ancillary roles. Working through difficult issues becomeshighly problematic—isit really about theissue at handor thequality or -42GE TTTS FO BSTOTI BTBOF TYTTTOTTOTTPT ATTTT

willingness with whichthe ancillary role is carried out? Termination,closure,referrals, andso on all becomeladenandtroublesome. 77.C: A substantial gift maybe loosely defined as one exceeding $20in value. The giving of small gifts is not uncommon,and thesegifts are usually acceptable—particularlyif they can be shared by allstaff or clients. At times, gifts may also be culturally significant, and extra care may be needed to. ensure no offense occurs. These are often handmadeitemsoritemsrepresentative of a culture, ethnicity, or home country. Manywill have unique meanings and background stories. Certain cultures view gift giving as a demonstration of respect and gratitude fora valuable service. Failure to accept could result in termination oftreatment. Such gifts should be accepted whenever possible. Theyare nottypically given with any ulterior motives. Inappropriategifts (e.g,, those that are too personal, too costly, or offered in exchange for favors,etc.) shouldbetactfully andpolitely refused. Citing program rules can help to explain and preventproblems.All gifts should be reported to supervisingstaff and enteredinto the case record. 78. A: Mosttreatmentprogramshavepolicies that preventclients from engagingin intimate

relationships that might underminetreatment. This typically includesprohibiting clients and counselors fromsocializing outside the confinesof the program. Some programs also discourage any contact betweenclients outside the program's structured activities. Virtuallyall programs discouragedating, sexualrelationships, movingin together, and otherforms ofsignificant involvement. However, manyprogramsdo encourage clients to collaborate in mutual-help group attendance, and someeven encourage mutualsupport in other meaningful aspectsoftheirlives. Where boundary issues occur, options include assigning oneofthe clients to another group or providingindividualcounseling to one while waitingfor the other to complete the program. Should mutual substance abuse occur, recommitmentcontracts and renewedabstinence contracts may be needed. Regardless,it is importantfor counselorsto fully understand the boundarieswithin the treatmentprogram andto consistently apply these guidelines. 79. C: No effort should be madeto engage the clientin such a public setting. Remaining at the club would likely precipitate some sort ofcontact. Therefore, leaving without contact would be best. Then,later, when the client returnsto the program, a private conversation should be engaged. During this discussion,the client can be informedof the unexpected contact and what was witnessed. In this way,the client is able to privately disclose his or herissues regarding the lapse (or relapse, as the case may be) with regard to the return to using alcohol. This discussion can then build to include thoseissues, experiences, and triggers that may havecontributed to the occurrence. In this way,the client can use the experienceto build uponthose skills neededto increase his or her abstinencegoals and the stepsneeded to achieve them. 80. D: Manysubstanceabusecounselors have a past history of substanceuse andthus also hold membership in mutual-help programs. Wherea clientfrom a treatmentprogramis encounteredin a mutual-helpsetting, it is essentialfor a counselor to maintain appropriate boundaries between theseseparateroles (professional vs. consumer). Tothis end, it would not be properfor a counselor to becomea client's sponsor.To minimize potential conflicts, counselors should not attend meetings wherecurrentorformerclients attend. Wherethis cannotbe avoided, the counselor

shouldnotsharehis or herpersonalissuesat that meeting.If a counselorneedsto talk, he or she

should share with other non-clients privately after a meetingor contact his or her sponsor. To preventsuchdilemmas, somecities host counselor-only meetings. Thesearetypically notlisted in the general mutual-helpdirectories. To locate a mutual-help program ofthis composition, a counselorshouldcontact the intergroupoffice orconsult with othercounselors in the area. -43GE TTTS FO BSTOTI BTBOF TSTTOTTOTTTPTT ATT

81. B: Research is unable to confirm any optimal counseling approach as numerous factors, such as the substances used, degrees of dependency,treatmentduration, irregular client characteristics, and soon,will inevitably shaperesearch outcomes. Further, clients typically have complex psychosocial needs and unique personal and emotional factors that require considerable creativity by involved providers. Consequently, counselors increasingly use a variety of approaches that are revised and tailoredto meet each client's singular needs. This kindoftheoretical accommodation and modificationis a hallmarkofeffective treatment. However, when altering or combiningapproaches, counselors will need to recognizethat theoretical conflicts mayarise. In somecases, these conflicts could attenuate oreven extinguish the success ofthe approach. Consequently, counselors must have a competentgrasp ofthe approaches beingutilized to ensure that ineffective or untoward outcomesare not unintentionally produced. 82. D: Using a modified Minnesota Modelof treatment(i.e,first used at Hazelden Foundation and Willmar State Hospital in Minnesota in the late 1940s), twelve-stepfacilitation, involves a thorough introduction to twelve-stepprinciples, education aboutthe disease ofalcoholism (or other drugs), and strongencouragementtowardparticipationin twelve-step groups. Twelve-stepfellowships, such as Alcoholics Anonymous(AA), are guidedby the philosophy that alcoholism (orother addiction)is a progressive disease with psychological, biological, and spiritual aspects. The twelve-step approach gradually evolved for use with drug addictions and various compulsive disorders (e.g,, eating disorders). Treatment programs that use twelve-stepfacilitation teach twelve-stepprinciples, begin working the twelve steps, achieve abstinence, and moveclients to. community-based twelve-Step groups(e.g., AA, Cocaine Anonymous[CA]or Narcotics Anonymous

[NA]). In these programs, educationalefforts present alcoholism as a disease marked bydenial and loss of control. Outside work includes reading twelve-step materials, journal writing, and other personal recovery-oriented tasks. 83. C: Twelve-stepprogramsoffer easy monitoring ofassigned step tasks. Amongthe many benefits of twelve-step programparticipationare: (1) cost—meetings area free, available virtually worldwide, and theyprovidea source of continuous support; (2) many largercities offer specialized meetingsfor those with unique needs(e.g, youth, women, specific sexualorientations, treatmentbeginners, foreign language speakers, etc.); (3) the twelve-step approach addresses recovery in varied domains, such as cognitive health, spiritual health, and physical health realms, accommodatinga focusof almost anypotential participant; (4) the twelve-step approacheasily accommodates clients from diverse ethnic, cultural, and other backgrounds. These benefits make the twelve-step approach uniquely beneficial as an importantadjunct to comprehensive treatment.

Primary drawbacks include:(1) itis difficult to accurately monitorclient compliancewith step tasks or even meeting attendance; (2) the emphasis on a higher power may be problematic for someclients; (3) smaller communities may not be able to sustain ongoingtwelve-step meetings, issue-specific groups, or meetings well suited to dual-diagnosed (psychiatric disordered)clients.

84. A: Clients are less likely to feel pressure to attend twelve-stepgroupsbystaff very familiar with the twelve-step approach.Rather, they are morelikely tofeel they receive useful encouragement andsupport from these staff persons.To ensure adequate familiarity, staff (particularly those with nopast experience receiving substance abuse treatment) are encouragedto:(1) read Alcoholics Anonymous(AA), Narcotics Anonymous(NA), Cocaine Anonymous(CA), andother twelve-step

programliterature; (2) frequently attend open twelve-step meetings; (3) attend a diversity of twelve-step groupsto better identify the uniquemilieu of those programsavailable (especially groupsthat are opento clients with co-occurringpsychiatric disorders); and (4) study thoughtfully to ensure thatthey deeply understandthe beliefs, values, and mores that undergird the twelve-step -44GE TTTS FO BSTOTI BTBOF TSTTROTTOTTPTT ATT

fellowships. In this way,staffcan be particularly supportive and directive as clients explore the twelve-step approach to recovery and ongoing abstinence. 85. C: The three approachesall produced positive outcomesin improving drinking from admission baselineto one yearin follow-up. However, twelve-stepfacilitation showed a measurable advantage whenclients were followed forthree years post treatment. Other studies have comparatively investigated the outcomesofaftercare by way ofstructured relapse prevention and twelve-stepfacilitation. Of importance, the twelve-stepfacilitation approachhasprovided more positive overall outcomesfor the greater share ofpeople who abuse substances. The findings were particularlypositive for: (1) clients who wereexperiencinghigh levels of psychologicaldistress; (2) substanceusers who were women;and(3) clients who reported the use of multiple substances at the outset oftreatment. Specifically, these three groupsclearly remained abstinent for more extensiveperiods followingtreatmentwith twelve-step facilitation, as comparedto structured relapse prevention.In pointoffact, both approaches have contributionsto maketo the recovery process. However, wherelimitationsin resources, time, andotherobstacles exist, itis particularly importantto ensurethat members ofthese three groupsare meaningfully encouragedto participatein available twelve-step programs. 86. D: From thefirst therapeutic community (Synanon, foundedin 1958in California by Chuck Dederich), treatment communities (TCs) were organized as controlled, drug-free residential treatmentsettings providing intensive and comprehensive treatment. The central goalis to produce a holistically healthylifestyle, engaging emotional, psychological, and social issues that maylead to substanceuse. Residents learn from eachother, staff members, and other authority figures. This has cometo bereferred to as community-as-methodperspective, which sees the whole community (clients, staff, social structure, and daily activities) as the active therapeutic agent. Manyearly TCs utilized punitive contracts, privilege losses, and extremepeerpressure to produce change. The more harshaspects have since been significantly modified, though peer pressure remains a key motivator. The TC model has been expanded to includeadditionalservices, such as mentalhealth andmedical services, educational andvocationalservices, and family education andtherapy. Today, manyTCprograms are carried out in intensive outpatient treatment (IOT) programs, serving clients transitioning outofresidential or incarcerationsettings or bypassing residential treatment altogether. 87. C: Rehabilitation refers to the recovery ofskills and abilities that have beenlost. Due to extended andsevere drug use, criminal behavior, or co-occurringdisorders, manytherapeutic community (TC) clients need to develop skills and abilities they neverpreviously properly possessed. The TC model views substance abuse asa holistic (whole person) disorder rather than as anisolated disorder. Consequently, TC clients are assessed across an interrelated continuum of psychological andsocial deficits (e.g,, dishonesty, poor impulse control, angerissues,etc.), along with their substance abusepatterns. The key beliefs and values necessary for recovery include: (1) complete honesty;(2) reality orientation to the here andnow;(3) personal accountability for all behavior; (4) empathyand concern forothers; (5) a strong work ethic andrealization that rewards must be earned; (6) properdifferentiation betweenexternal behavior andtheinnerself; (7) understanding that changeis always occurring; (8) understandingthatlearning has value; (9) developing economicself-sufficiency; (10) community involvementis important; and (11) quality

citizenshipmatters.

88. D:Researchers investigating therapeutic community (TC) treatmenthavefound thatresidential and day-only TC treatment program outcomes are not significantly different. Consequently, trends toward intensive outpatient treatment(IOT) using the TC treatment modelshould beeffective. -45GE TTTS FO BSTOTI BTBOF TSTTTOTTOPTT ATT

Studies fundedbythe NationalInstitute on Drug Abuse (NIDA) haverevealedthatparticipation in

TCtreatmentis correlated with measurably positive outcomes. For example, treatment outcome data from the longitudinal Drug Abuse Treatment OutcomeStudyfoundthat completing TC treatmentwas associated with reduced use ofalcohol, cocaine, and heroin, as well as reductions in depression, criminal behavior, and unemployment, as comparedagainst levels experienced prior to treatment. Further, a study of inmates transitionedfrom aninstitutional TC program toa TC-orientedoutpatient work-release program experienced lowerrates ofrecidivism (re-incarceration) and druguse thanthosereceiving institutional TC treatmentalone. Thus, TC treatment appears to be an effective approachto reducing substance abuse, criminal activity, depression, and unemployment amongindividuals with positive criminal and drug usehistories. 89. B: A key feature of therapeutic communities (TCs)is structured programming. Thisinvolves scheduledactivities and routines thathelp clients learn to avoid chaotic lifestyles and focus on daily activities that preventthe boredom and negative thinking that so often accompanies relapse behavior. TC treatmentprotocols consist of phases and stages that allow the trackingofclient activities and measurementofprogress. Treatment durationis dependentuponsuccessful client progress. Staffand peer networks offer support, and other community-based services are ‘egratedas needed to sustain recovery. The TCtreatmentapproachis idealfor clients with past criminal issues, educational and employmentdeficits, relationship problems, and a history offailed treatment. Because ofthe focused, hierarchical, andoften confrontational features ofthis treatment modality, it must be modified for those with co-occurring psychiatric disorders, antisocial personality traits, andvarious other dysfunctionalbehaviors. When usedin an intensive outpatient program, a drug-free environment mustbe ensured. 90. A: The Matrix Model(alsoreferredto as neurobehavioraltreatment) was formulated during the 1980s’ spikein cocaine and methamphetamineabuse. The modelutilizes a complementary set of evidence-basedpractices coordinatedanddelivered as a program. Drawing upon cognitive-behavioral therapy, motivationalinterviewing, and findings from relapse prevention literature, combined with educational support and twelve-step program involvement, the model seeks to coordinate and optimize evidence-based treatments and support resources. Guiding principles include: (1) developinga positive therapeutic relationship; (2) applying a scheduled structure and expectations; (3) educating participants and families regarding brain chemistry, cravings, recovery, and relapseprevention;(4) incorporating cognitive-behavioral concepts for change; (5) reinforcing positive behavioral changes; (6) outlining the expected courseof treatment and recovery; (7) promotingself-help (twelve-step)participation; and (8) using regular drug testing (urinalyses)to track progress. 91. C: Considerable research has demonstratedthat community reinforcement (CR) and contingency management(CM)are both independent-effect treatmentinterventions. Further research, however, does support that CR and CMare mosteffective whenused in conjunction with each other. Because a return to baseline drug use can follow the termination ofCM,in particular, more long-term supports (such as twelve-step program involvement) maybe needed for more enduringsuccess. Maximum benefits accruewith larger rewards that increasein value to maintain CM motivation. By contrast, CR typically involves rewards from more-enduring sources(family, job, pleasurable activities, etc.) that can morenaturally persist after treatment completion. Even so, educationin relationship enhancement,goalsetting and attainment, balancedlifestyle, and so on, can more fully ensure long-term treatment benefits. Finally, rewardsandother reinforcements must be consistently applied and mustonly be provided in response to measurable successes (e.g., extended negative-result urinescreens,etc.). -46GR TRFO BSTBTETA RTO TYOTTOTTITTPTT ART

92. D: The old view that one disordershould bestabilized before anothercan betreated has been found to be flawed.It is importantto coordinate the treatmentof co-occurring disorders as treatment may otherwise be counterproductive and otherwise ineffective. For example, many substance abuse treatments are confrontational, tightly scheduled, and semi-authoritarianin nature—particularly those programsfor court-ordered clients. However,clients with psychiatric disorders may do very poorly in such treatmentparadigms.Many sufferfrom depression, anxiety, paranoia,self-abuse (cutting, etc.), suicidal ideation,or personality disorders, among otherpossible symptomatology. Others struggle with fears aboutpsychotropic medicationsto treat their co-occurring conditions and may also resist pharmacological treatment oftheir substance abuse. Clients struggling with such issuesarefarlesslikely to cope well with commonsubstance abuse treatmentapproaches. Consequently, program adaptationandspecialized staff training may be required. 93. C:Individuals admitted for substance abuse treatmentwhoalso have a co-occurring psychiatric disorderare morelikely to be female alcohol abusers than female drug users or male users ofeither alcoholor drugs. While most drug abusers are referred for treatmentthrough the criminaljustice system, female alcohol users are mosttypically referred through health care providers. Multiple studies reveal that the rates ofco-occurring disorders are roughly that about 39 percent admitted forsubstance abuse treatment programswill meet Diagnostic and Statistical Manual of Mental Disorders (DSM)criteria for antisocialpersonality disorder; 11.7 percent are suffering with major

depression, and 3.7 percent are struggling with a general anxiety disorder. Other challenges commonamongclients with dual-diagnoses (co-occurring disorders) include:chronic unemploymentand homelessness, family conflict and disruption, incarceration andsubsequentlaw enforcementinvolvement(probationorparole), andviolentvictimization. Further, complex

problems such assuicidal ideation and attempts, medication noncompliance, highself-medication needs, emotional issues, significant medical problems, and a hostofother challenges often complicatethe treatmentprocess.

94. B: The Substance Abuse and Mental Health Services Administration (SAMHSA)hasoffered a Service Coordination Framework for Co-Occurring Disorders, whichoffers four categories by which to indicate the level of care a given clientneeds:Category I—mentaldisorders, less severe + substanceusedisorders, less severe; locusofcare is a primary health care setting; Category 1—mental disorders, more severe + substanceuse disorders,less severe; locus of care is a mental health system; category III—mental disorders,less severe + substanceuse disorders, more severe; locusofcare is a substance use treatment system; and Category IV—mentaldisorders, more severe + substance use disorders, more severe;locusofcareis state hospitals,jails or prisons, emergency rooms, and so on.In thefirst category (low severity mental health and substance use), the bias is for basic primary care. The middle twocategories involvea biasfor treatmentin concert with the severity level ofthe primary diagnosis. The last category recognizes that, when both psychiatric disturbances anddrug use are severe, clients tend to need highly integrated, even locked, care settings.

95. A: Client information,immediate behaviors, current medications, family history, and so on may

well be indicative ofa co-occurring disorder. However, theyare not definitive criteria. The diagnosis must be provenorvalidated bythe client's ongoingclinicalpresentation. Symptomsof withdrawal, as well as those of acute orchronic alcohol anddrug toxicity, can readily present as a psychiatric disorder. They can also mask underlying psychiatric symptoms.True psychiatric symptomsoften becomeapparent during the early stagesof abstinence. Program staff should recognize that co-occurring disorders are common. Beyond the client'sclinical presentation, additional attention should begiven to: (1) the psychiatric history ofthe client and his or her -47GE TTTS FO BSTOTI BTBOF TSTTROTTOTTPTT ATT

family, especially documented diagnoses, prior treatment, andanypsychiatric hospitalizations; (2)

medications and medication compliance; and (3) ongoing symptomsand mentalstatus changes overtime.As the assessmentproceeds, caution must betakento ensure theclient is properly treated for any serious medical withdrawalproblems. Other safety issues, such as suicidality or homicidality andanyinability to function, communicate, or carefor oneselfalso should be respondedto aggressively.

96. A: The physical, emotional, and cognitive changesof this developmental period maketreatment more complex. Physical changes are marked by rapid growth, hormonalfluctuations, andthe developmentof secondary sex characteristics. Cognitively, attention spans are shorter, projected awarenessofthe futureis poor,abstract thinking skills are inconsistent, and impulsivityis high. Ideals, morals, andvaluesarestill developing, and intellectualinterests are expanding. Not until late adolescence do youth become substantially aware ofthe consequencesoftheir actions, thus allowing meaningfulgoalsetting. The onset of substance abusein this populationis frequently associated with family dysfunction, parental substance use, peer influence, andtroubled personal choices. Genetic background and cognitive dysfunction may also playa role. Other risk factors include:(1) a history ofpersonality problems, poorparental or guardianrelationships, academic failure, family disruption, and past victimization. An adolescent treatment provider must successfully cope with developmental, behavioral, psychiatric, family, andothertreatment challenges. Most will only superficially resemble the challengesof adult clients. 97. C: Familytherapyposits that conditions leading to adolescentdrug use began in the home, and thus, the family can help with recovery. Family-based therapeutic approachesinclude multidimensional family therapy and multisystemic therapy. These approachesextendclassic family therapy models to promotechangein fourareas: (1) the adolescent, (2) family members, (3)

familyinteractionpatterns, and(4)outside (nonfamily)influences. The family cognitive-behavioral

therapy approach combinesfamily systems theory with cognitive-behavioral therapy. The premise is that family cues and contingencies reinforcethe conditioned behaviorof adolescent substance abuse. Adolescent community reinforcementfocuses onaltering environmentalinfluences that perpetuate substance use while also teaching enhancedcoping skills for betterself-management. ‘The family support network develops a support group for parents, augmented with group and hometherapy sessions. The family intervention program focuses on the family and other systems that affect the family (e.g, schools and the community). It partners a family therapistwith a community resource specialist to address key family issues thatarise whenan adolescent uses substances.

98. C: Culture is best understood broadly, referring to a shared setofvalues, norms, and beliefs commonto any group ofpeople, whetherit is based on race,ethnicity, nationality, or any other shared identity or affiliation. According to 2010 CensusBureaufigurescited by the Brookings Institute, approximately 12.9 percentofthe current US.populationis foreign born (ofnote, the figure exceeded 13 percent during every decadefrom 1860-1920). Beyondcountry of birth, however, there are many othervariables that can shape a client's culture and worldview. Diverse

client populationsinclude: non-white HispanicsandLatinos;African Americans; Native Americans;

Asian Americans andPacific Islanders; personswith human immunodeficiency virus/acquired immunodeficiency syndrome(HIV/AIDS); lesbian,gay, bisexual, andtranssexual (LGBT)

populations; those with disabilities; rural populations; homeless populations; andolderadults. Counselors must navigate betweenthe prevailing culture, treatmentculture, and theclient's culture as copingstyles, social supports, stigma, and a myriadofother factors canbeprofoundly influenced by aclient’sculture. -48GE TTTS FO BSTOTI BTBOF TSTTROTTOTTPTT ATT

99.B:It is the provider whois primarilyresponsible to ensure that treatmentis effective for clients

ofculturaldiversity. Ensuring effective treatment requires two separate understandings: (1) how to properly communicate and interact with personsfrom differing cultures and(2) knowledge the specific culture from of the person receivingservice. In truth, every competent and caring clinician should always lookpaststereotypes, seek shared understandings, treat clients with respect, maintain an openmind, ask questions when needed (both ofclients and other involvedproviders), and remain willingto learn. Thus, being culturally competent merely makes explicit this ongoing duty andobligation. Beyondthis, however, providersshould diligently endeavorto acquire a deeperand broader understandingofthe majorvalues, mores, standards, and expectationsof those cultureshe orshe routinely serves—whilestill, however, allowingforidiosyncratic variations within that cultural paradigm. In this way, culturally diverse clients canreceiveeffective, meaningful, and culturally acceptable servicesin a sensitive and kind way. Doingsoensures even greatertreatmentefficacy and more enduringpositive outcomes. 100. C: Theterm culture-bound syndrome has beenused in different ways. First, it can refer to an illness truly bound toa specific culture. For example, the mottled discoloration on the thighs caused bythe heatofa laptoprestingon thelegsof an excessive techie computeruserorthefatal brain disorder(kuru) causedby now-bannedcannibalism amongthe South Foré peopleof the eastern New Guinea Highlands. Second,it can refer to otherwise commonmentalorphysicalillnesses that are subsequently construed as unusual becauseofthe pathoplastic influenceof culture. For example, interpreting the hallucinatory symptomsofschizophrenia as evidence of demonic possessionorconsidering the apparently other worldly experience ofgrand mal seizures to be a sacred disease—as described by Hippocrates—andmorerecently by the animistic Hmong, who maythenrevere andelevate such personsto thestation ofshaman. 101. C: Not only doclients bringtheircultureto the treatmentexperience,but counselors do as

well. A group ofprofessionals also hasa culture thatconsists of sharedvalues, norms,andbeliefs.

Complicatingthe clinician's culture furtheris the language(jargon) used,an emphasis onbooks,the professional mind-set (way of lookingatthings), and so on.Health institutions andtraining facilities are grounded in Western medicine, launchedin ancient Greece, emphasizing the central

role the humanbody in disease.Further, objectivity andscientific and empirical methodsare the only trusted source of knowledgeaboutdiseases and treatment. By 1900, Western medicine began to recognize socialcontributionsto disease, widening the view to issuesofdiet, lifestyle,

employment andincome,and family structure, whichled tothefield of public health. These cultural

views make it harder for counselors to recognize symptomscouchedin non-Western medical languageorto understanda client’s concerns and needs.Finally, different assumptionsaboutthe

clinician-client role model,the etiology ofillness, and acceptable treatments offer further relational barriers.

102. C: Biological psychiatry is focused on the biological causes and treatments of psychiatric disorders.Thefirst forms ofbiological psychiatry appearedin the mid-nineteenth century and paved the way for pharmacological therapy for mentalillness. The practice of psychotherapy (or talk therapy) emergednear the endofthe nineteenth century with the establishmentof psychotherapy (originally psychoanalysis) by SigmundFreud. Although numerousdisparate forms of psychotherapy nowexist, all emphasize verbal communication as the basis for treatment. Most modern approaches now combinepharmacological therapy and psychotherapy, referred to as multimodal therapy. However, the emphasis onverbal communicationretains the potential for miscommunication and more especially so whencounselor and client comefrom differentcultures. Misunderstandings can result in misdiagnoses, treatmentconflicts, and noncompliance. Thus, the importance ofeffective cross-cultural communication continues to assumegreatersignificance. -49GE TTTS FO BSTOTI BTBOF TSTTROTTOTTPOT TTT

103. D: Discrimination andracism limit recreational andleisure opportunities to improve mental health. While leisure andrecreationalactivities are importantto mentalhealth, racism and other

formsofdiscriminationare not typicalsources oflimiting these resources and opportunities. The

terms racism and discriminationrefer to attitudes,beliefs, and practices that prejudge and

denigrateindividuals or groupssolely basedon disparate phenotypic characteristics(e.g, skin color, hairtexture, facial features, etc.) or ethnic minority groupaffiliation. Despite some

improvements,racialdiscrimination continues and has been documentedin the areaofhealth care. Examplesinclude fewer medical diagnostic and treatment proceduresfor African Americans as

compared with whites, demeaningandbelittling expressions, andless timeandattentiongiven to eliciting and addressingotherhealth care needs.Racism anddiscrimination can beintentionalor

unintentionalandcan be perpetratedby individuals, groups, and institutions. Because racism and discriminationcan beit

ious and go unrecognized,it is crucial thatit be continuouslyevaluated,

especially in cross-culturalsituations.

104. D: As recently as 1990, about 23 percentofadults werefrom ethnic andracial minority groups. By 2025,it is estimated that 40 percent ofadults (and 48 percentofchildren) will be from these samegroups. Even amongthe four most representative ethnic andracial minority groups, great diversity exists. For example, Asians and Pacific Islanders consistofat least forty-three distinct subgroupsspeaking more thanone hundred different languages. Hispanics may be further divided into Central and South Americans, Cubans, Mexican, and Puerto Ricans, among manyothers. More thanfive hundred tribes fall underthe headingofAmerican Indian or AlaskanNatives, each with different ancestry, cultures, and languages. African Americansarealso anincreasingly diverse group as immigrants continueto arrive from Africa, the Caribbean, and South America. Degrees of acculturation and mainstream assimilation vary widely. Higherbirth and immigration rates have resultedin a 56 percentincreasein Hispanics—thefastest-growing minority groupin the United States.

105. C: Human immunodeficiency virus HIVis the virus that causes the acquired immunodeficiency syndrome(AIDS) syndrome. HIV is the viral agent that causes AIDS,whichis the final stagein the HIV disease process. The Centers for Disease Control and Prevention reports that more than 918,000 people have AIDS at any giventime(2004). The disease continuesto be mostprevalent among menwhohave sex with menandintravenous drug users, with these groups collectively accounting for almostfour-fifths ofall cases of HIV/AIDS. Thedisease disproportionatelyaffects minorities. While13 percent of the U.S. population is African American, they represented 50 percent ofall new HIVinfections in 2004. HIV is also spreadingrapidly among womenand adolescents, with nearly halfof new HIVcases reported amongfemales agethirteento twenty-four, and more than 60 percent amongfemales agethirteento nineteen. Gay substance abusers areat high risk because they more frequently engage in high-risk sexual behaviors whenintoxicated. Although new medications have significantly extendedlife for many with HIV/AIDS,the treatmentprotocols are burdensomeandexpensive. HIV alsocontributes to poverty, homelessness, and other medical problems. 106. D: Ithas been estimated that, not only will there be a 50 percentincrease in the numberof seniors needing substance abuse treatment, buttherewill also be a 70percentrate of increase in the treatmentneeded bythese olderadults. In part, this may be because baby boomers have had a higher baselineof use throughouttheir lives than the generationsthatpreceded them.In addition, the baby boomergeneration and beyond is more racially and ethnicallydiverse, with all the unique needsthis entails. Barriersto treatment among older adults include: (1) high levels ofshame; (2) relatives who either rationalize the problem away orare ashamed to acknowledgeit on behalf of -50GE TTTS FO BSTOTI BSTBOF TSTTROTTOTTPOT ATT

their lovedone; (3) diagnosis andtreatment is more difficult becauseofcollateral mental and physical health problems; (4) transportationis more limited; (5) social networks are dwindling; and (6) financial constraints aretighter. 107. A: When the manybarriers to enteringtreatment are overcome, older adults tend to have substantially better attendance and a significantly lowerrate of relapse that are found among youngeradults in treatment. Research also indicates that thesepositive performance measures continue, evenif older adults are brought into mixed-age treatmentsettings. However, the optimum outcomesare dependent uponseniors receiving age-appropriate, individualized treatment services. Seniors often do notenvision themselves as abusers—particularly when over-the-counteror prescription drugs are at issue—andthey often misunderstandproblemsarising from alcohol and druginteractions. Consequently, many will need to be reachedthroughhealth promotion, wellness, social services, and otherresources that workwith older adults. To this end, program providers needto be involvedactively with local aging networks, including home- and community-based short- andlong-term care providers. These sameexternal resources can often also assist with specialized cultural, ethnic, and language resourcesas needed. 108. B: Only mandated reporting information, such as child abuse, canbe disclosed withouta client's written consent. This includes any information about whetheror nota clientis receiving

treatmentor whatheor she maybereceivingtreatmentfor, even to an employerpayingfor the

treatment. Further, non-court-ordered information cannotbereleased evento a law enforcement agency or to anyotherinterested party withoutthe client's written consent. A properly informed

clientis one who is aware of: (1) to whom orwhatentity the informationis being released; (2) the full purposefor the release; (3) the specific information to be released; and (4) whenthe information release expires. Client confidentiality regarding substance abuse treatmentis protected by the Substance Abuse Confidentiality Regulations 42 CFR (CodeofFederal Regulations) Part 2 (codified as 42 U.S.C. [United States Code] §290dd-2 and 42 CFR Part 2 (Part 2) and the Health InsurancePortability and Accountability Act (HIPAA, codified as 42 U.S.C. §1320d et seq., 45 CFR Parts 160 and 164).

109. C: The CAGE questionnaire effective and quickly screens for alcohol abusebyasking for a yes or no responseto four questions: (1) Have you everfelt the needto cut downonyourdrinking; (2) doyoufeel annoyed by people complaining aboutyour drinking; (3) do youever feel guilty about your drinking; and (4) do you ever drink an eye-openerin the morningto relieve the shakes? Extensive studies reveal that twoyes responses will accurately identify 75 percentof the alcoholics whohonestly respondtoit (and correctly rule out 96 percentofnonalcoholics). The CAGE has been modifiedto screenfor drug abusebysimply replacingthe worddrinking with drug usein the initial three questions andthen delivering the fourth question: Do you use one drug to change the effects of anotherdrug, or do you ever use drugsfirst thing the morningto take the edgeoff? 110. D: The MichiganAlcoholism Screening Test (MAST) is used in more in-depth interviewsaswell asin confinementorbrief holding scenarios.It is administered to explore a numberofimportant treatmentissues:(1) the severity of the alcohol abuse problem; (2) a client's maturity and readiness for treatment; (3) the potential existence of a co-occurring psychiatric disorder; (4) the intervention technique needed to addressthe presenting problem; (5) the extentofpotential support resources (includingfamily, social, educational, and employment resources, along with individual motivationfor change); and(6)facilitation ofthe engagementprocessleadingto

treatment. MAST is among the oldest and most accuratealcoholscreeninginstruments and is able to identify dependent drinkers with as much as 98 percentaccuracy. -51GE TTTS FO BSTOTI BTBOTSOT TROTTOPOT ATTTT

Its two drawbacks are(1) it is longerthan manyotherscreeningtools, and (2) MAST questions

explore drinking overa client'slifetime (not just currently), which makes thetest lesslikely to detect early-stage drinking problems. Severalvariations ofthe MASThave been developed, includingthe brief MAST, the short MAST, and the self-administered MAST.

111. D: The relapse and remitting model of addiction has been successfully applied toa great many othersituations, such as unemployment, poor medication compliance, anger management, and so on,Indeed,virtually any situation that tends to return (relapse) canbenefit from this model. The relapse and remitting model recognizesthat some issues tendto return cyclically overtime. Recognizingthis can help both the counselor and theclient make advancecontingency plans to avoid having a brief lapse returnto a full relapse in negative circumstancesor behaviors. This is particularly importantin addiction managementas lapses or relapses in any areaoflife tend to draw clients back into addiction relapses as well. Therefore, careful recognitionandfollowing of relapse-proneissuescanresult in quality advanceplanning, promptresponses,and minimization

or outright prevention offurther concurrentaddiction relapse problems aswell.

112. B: The term authentically connectedreferral network refers to a carefully establishedset of service providers prepared to meetclient needs asthey evolve. Key elements to the network are: (1) established communication linkagesto facilitate timely sharing ofinformation with client consent; (2) a focus on community-wide outcomes, ensuring thatbest interests are being met and that community education ensures understandings about substance abuse; (3) a primary focus on meetingclient needs through collaboration as opposedto exclusionary rules; (4) consistency and credibility in conduct to ensure both interagency and clientconfidenceandtrust. The goalis for all network agencies and providers to recognizetheir valuedandessential rolesin the addiction treatmentprocess andfor clients to recognize this and respondwith similar trust and confidence. 113. C:Althoughit is importantto provide timely and well-coordinatedreferrals andto encourage client self-determination in this process,it is most important to secure the least-restrictive level of care. In this way, clientself-determinationis also ensured. To achievethis, clients and case managers mustcollaborate in selecting amongavailable options.Self-determinationis most fully ensured when clients are allowed to take the lead in identifying their needs andin choosing from among resourceoptionsthat most fully meettheir personalgoals andlifestyle. Flexibility is important, as is adaptability, to ensure thatreferral providers and agencies are adequately responsive. Clients should be assessedfortheir ability to apply for, access, andfollow through with selectedreferrals, with the case managerproviding assistance where needed.Informing,educating, andguiding clients through this process can help to ensure an overallleast-restrictivelevel ofcare. 114, A: When makingreferrals,it is importantto carefully inform clients ofyourconcerns and reasons and thento engage themin ways thatdo notinduceobstruction. The ask-tell-ask technique can assist in this. Further, providing ample information, background, and personal insights into referrals can also assist. To this end,itis importantfor case managers to beintimately familiar with their referrals, having completed site visits, meeting withproviderstaff, andin other ways becoming well preparedto putclients’ concernsto rest. Finally, all substance abuse communicationsshould be conducted away from clients’families and otherstaff, and anyfurther sharing should take place only after receiving clients’ express permissionto that end. 115. D: Referrals areoflimited valueifthey do not contribute measurably to importantgoals and neededoutcomes. These measures of success are evaluated by tracking the results ofthe referral—ideally, by meansof a referral form. The whoportionofthe form identifies the client and the involved counselor. It may also include demographic information aswell as information on the ~52GR TRFO BSTBTRTB TYOTTSOTRTISTTPTT ATT

substances theclient uses, any legalissues, andfamily concerns. The whatsection addresses the ues that generated the needforthe referral—substance issues (and symptomatology), work issues, family issues, goals and commitments, and soon. The form’s how section should address howthe client was engaged and dealt with.In this way, the referrals madefor any givenclient in the how section canbeevaluated for interventions provided and outcomesrealized. 116. D:Theinitial contact provides the counselorwith the opportunity to gather both positive and negative clienthistory, which should notonly beusedin treatmentplan developmentand ongoing modification over time but which will be relevantin the aftercare planningprocess aswell. Family members should be drawn into aftercare planning and educationearly onto ensure ongoing understanding and support. Aftercare planning should also include education regardinghealth maintenanceandprevention against sexually transmitted infections(STIs) - especially human immunodeficiency virus (HIV), tuberculosis, and hepatitis C, among others. Screening for STIs and tuberculosis shouldbe animportantpart of programming as substanceabuseclients may well not recall high-risk behaviors and thus may have encountered diseases ofwhich they are not aware. 117. D: Clients needpositive education andskills in substance abuse triggers, patternsof use, and relapse prevention. However,failures in otherkey areas of clients’lives canalsotrigger substance abuse relapses. Consequently, holistic treatmentplanning andinterventionsare essential to the recovery process. Establishingroutine schedulesearly on can helpclients to better organize their lives andsustain abstinence following program completion.Efforts directed toward improvement in the developmentoflife skills can be especially important. Examples include counseling and education in areas suchas self-esteemand assertiveness training, communication and anger managementskills, relationship training, counselingfor co-occurring disorders and personal psychological issues, vocational-educationaltrainingand interviewing skills, as well as home maintenance, budgeting and personalhygieneinstruction—all are importantcontributors to

clients’ abilities to maintain clean andsoberlifestyles.

118. A: Trigger events areoftencrisis stressors or situations (e.g,, notice of divorce,jobloss, an impendingholiday oranniversary, orvisiting someoneinan old neighborhood where pastfriends may againinvite and encourageusing, etc.). Clients are encouraged to anticipate such events and then bookend them—talking about them with a trusted friend (e.g,, a twelve-step sponsor, close confidant, trustedfriend, etc.) both before and after they occur.In this way, the client can prepare to remain strong andthen debrief and decompress emotionally in orderto continue strongin his or her abstinence commitments.A counselor canbe offurther assistance, addressing the client's specific strengths and weaknessesin orderto shoreupthe client's resolve. In this way,the client can beassisted in avoiding a return to past familiar dysfunctional responses. 119. C: The Code of Federal Regulations (CFR) Title 42 Part 2 deals with issues ofconfidentiality when working with clients coping with drug oralcohol use and abuse. The confidentiality restrictions apply: (1) to records, which maynotbe disclosed evenin administrative, civil, criminal, orlegislative proceedingsby any governmental authority; (2) to communications, evenif the personseekinginformation alreadyhas it, could otherwise obtainit, is anofficial or lawofficer, has a subpoena, or otherwiseclaims the right of informationreleasenot permitted in the CFR; and(3) to acknowledgements, such as regarding the presence ofa client (unless heorsheis in a facility or facility area not dedicatedsolely to alcoholordrug abusetreatment, andno mentionof drug or alcohol treatmentis made), whetherpast, current, or anticipatedin the future withoutthe client's written consent. A subpoenawill be valid for information release only if a court of competent jurisdictionalso explicitly enters an order authorizing informationrelease specific to these regulations. ~53GE TTTS FO BSTOTI BSTBOF TSTTROTTOTTPTT ATT

120. B: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) allows workers

andfamilies to retain their health insurancecoverage whenchangingorbetween jobs. HIPAA also governs the managementandreleaseof Protected Health Information (PHI). The act ensures the rightto privacy forall adults and minorsagestwelveto eighteen. The act requires a signed

disclosure before any health care information canbedisclosed to anyentity, agency, orindividual, includingparents of minors overthe age oftwelve. The more stringent guidelines, however,arise from the Code ofFederal Regulations(CFRTitle 42 Part 2). In 2000, the Departmentof Health and Human Services (DHHS)issuedthe Standardsfor PrivacyofIndividually Identifiable Health

Information. The DHHSPrivacy Rule imposedthree additionalprivacy protectionsteps: (1) consent forinformation release must comply with 45 CFR §164.508;(2) clients must be given a copyofthe signedform; and(3) a copy ofeach signed form must be keptforsix years from its expiration date.

121. D: Every state and all federal regulationsallow the limitedbreachofconfidentiality in situationsofcredible suicidality and threats of serious harm to others. Credible suicidality is a plan for self-harm andthe meansto carry out the plan. Dangerousnessto others typically involves voiced threats regarding a third party and thereal intentionof harm (possibly including intentional human immunodeficiency virus [HIV] exposures). Tarasoff regulations require a counselor to notify the intended victim or someone reasonablyable to notify the intended victim as well as law enforcement. Mandated reporting ofchild abuse typically involves physical or sexual abuse, though other conditions mayapply. Manystates have similar laws governingreporting abuseofthe elderly or dependent adults. Finally, conditionsofgrave disability may also require that confidentiality be breachedto keepan individual and others safe. Grave disability tends to be defined as compromise from a mental disorder to the extent anindividualis not able to pursue basic personal needs(food, clothing, or shelter) or otherwise sustain health andpersonalsafety. 122. A: Just asindividual therapyis a far moreprivate, personal, and in-depth therapeutic modality, so is grouptherapy very differentfrom twelve-step programming. Although both groups are complementary andimportant, a therapygroup focuses onhelpingindividuals to examine, understand, andinterpret the intrapsychic andinterpersonal influences and conflicts that motivate andperpetuate substanceabuse.In contrastto this, twelve-step program practicesare centered on

drawing uponfocusessuch asaffiliation, peer confrontation and support, and creating a culture of abstinence and the mutual accountability to sustainit. While both modalities can, for example, address denial, the twelve-step process confronts andbreaks it down, while grouptherapy explores whatproduceditin thefirst place. Thus, group therapyis far more complex and requireshighly specialized skills and experiencesto effectively carry it out. Borrowing from twelve-step programmingdilutes the group therapyventureandcanlead to partial or complete failure ofthe grouptherapyprocess as the profoundpotential for psychological growth, emotional healing, and self-understanding remain neglected. 123. B: The cognitive-behavioral group modelviews substance abuse as anissueof dependency and dependencyas a learned behaviorthat can be modified. Modificationis accomplished through a variety ofinterventionssuch as:(1) identifying the conditioned stimuli that trigger specific addictive behaviors; (2) producing waysto avoid conditioned stimuli; (3) creating contingency managementstrategies(relapse preventionstrategies); and (4) desensitizing stimuli-response

patterns.The cognitive-behavioral approachrecognizes dependencyasarisingfrom theinterplay of numerous contributingfactors, including: (1) neurobehavioral, (2) biopsychosocial, and (3) genetic andphysiological(ice., the disease model). Cognitive-behavioral therapy groupschangeperceptions, beliefs, andthinkingpatternsto alter relapse behaviors and developsocial networks to offer support for change. a

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124. There is a myriad offactorsto considerin assigning a clientto anygiven group. These include: group availability, client stage in recovery, client preference, gender and culture issues, substanceofabuse, and so on. Further, changesin groupassignments may be neededepisodically as clients progress,relapse, gain motivation, develop newinsights needing address, and so on. Diversity issuesinclude age, gender, race, ethnicity, education, language, sexual orientation, religion, and culture, amongothers. Cultural competencerequires a counselor to recognize that:(1) a youngAsian male may be unable to express himselfopenly among older Asiansdue to issues of respect; (2) many HispanicsorLatinosare adverse to rules and the authority figuresthat sustain them;(3) womenmay contendwith the needto nurture andinvest emotional energy in men; and so on. Adaptations, accommodations, andskillful group leadership will be required to optimize all participants’ group opportunities.

125.A: While longeris generally better,the positiveeffects oftreatment duration typically beginto emergeat aroundthree months. In planningtreatment, the Institute of Medicineadds: (1) there is noonebesttreatmentapproach;(2) inpatient(residential) has not been proven superior to

outpatientapproaches;(3) outcomesimproveif otherrelated life problemsarealso treated; (4) outcomes are influenced bythetreatmentprocess, client-therapist characteristics, aftercare adjustment, andinteractions amongthesevariables; (5) manylife areas improve with significant reductions in useor total abstinence. Finally, when comparingthe managementsuccessofchronic ongoing-maintenance medical conditions (asthma,diabetes, and hypertension) with relapse rates for cocaine,nicotine, and opiates, the overall treatmentresponserates weresimilar, highlighting the similar compliance and behavioral change requirements involved and humannaturein meeting these requirements.

126. A: The three most commonrecovery stages are described as: early recovery, middle recovery, andlate recovery or maintenance. Key featuresofearly recovery includeentering treatment, embarking on abstinence, and staying sober. Early recovery, however,is very fragile, and relapse vulnerability remainshigh. This stage of recovery typically lasts from one month to one year. Key featuresof middle recovery include: greater confidence in abstinencegrows; cravings persist but are recognized anddeflected successfully; lifestyle and personality trait changes are progressing; and although relapse vulnerability persists, it is becomingless significant. Middle recoverylasts at least a year but may continue indefinitely (failing to progress or serial relapsing). Key features of late recovery or the maintenancestage are: maintaining abstinence while also improvinglife in other related areas; addressing psychologicalorrelationship issuesthat becameapparent through abstinence; and continuing all relapse prevention behaviors and skills previously learned. 127. B: Other expressive therapiesinclude writing (stories, poetry, etc.) and music. Expressive group therapyallows clients various ways ofexpressing themselves via alternative methods and allowsgreaterexplorationoftheir thoughts, bodies, andfeelings. Through creative expression, clients cantap into their imaginationsto better and moresafely examinetheir bodies, feelings, emotions, andthought processes. Culturally specific groupsprovide opportunities to explore the role ofculture in substance abuse and the strengths and handicapsit may produceduringthe changeprocess. Relapseprevention groupsoffer clients the opportunity to focus intensely on developingthe skills they need to identify, understand, and managethesituations, people, and thoughts that maytrigger a return to substance abuse. Each ofthese groups can be used

concurrently with client participationin other groups, augmentingandenhancingthe learning and

changeprocesses.

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128. C:All groupspass through five phases to accomplish their purposes: forming, storming, norming, performing, and adjourning(last phase addedin 1977). Forminginvolves engaging, exchanginginformation, and creating bonds. The key characteristics are tentative overtures, polite exchanges, and worries aboutfitting in. Storminginvolves dissatisfaction, disagreement, competition, andconflict. Key characteristics are criticizingideas, interrupting, hostility, and

attendanceissues. Norminginvolves forminggroup structure, establishing roles and relationships, developing cohesion, and creating harmony. Key characteristics are seeking consensus, reaching agreements, creating support, andachieving a sense ofwe in endeavors. Performinginvolves task focus, emphasizing productivity, andidentifying achievements. Key characteristics are cooperation, problem solving, anddecision making. Adjourning involves completing tasks, endingduties, and dropping dependency. Key characteristics are feeling regrets, managing emotions, and disbanding. 129. C: Productive groups not infrequently elicit strong responses. The groupexperience is enhanced by:(1) self-disclosure thatis genuinerather than contrived, honestly reflecting feelings, attitudes, andstruggles; (2) authentic behaviorthatreflects the realselfas opposedto thesocially sented self, or thefrontused to avoid criticism andrejection;(3) personalrisk taking, usually tiated by a leader, leading to the openness andcandorthatallowsfor actual growth and progress; (4) personal privacy, secured by group consensus and commitment to such a degree that self-disclosure, authentic behavior, and risk taking are possible,It should be noted that the key contributions already noted are to be exercisedin balance and moderation. All expressions should be self-oriented, revealing oneself rather than pushing throughinto the private space ofothers. In this way, negative exchanges among group members can be avoided.Group leaders, while modeling, shouldbe careful not to over-disclose to avoid damaging confidence and trust. 130. B: Families alter normal behaviors in many ways to copewith substance abuseandaddiction. Childrenarelikely to assumeroles andresponsibilities beyond thoseoftheir normal maturational development. They maymissouton their childhood, havingto cope with insecurities and anxieties that are distorting and deformingof the normal developmental processes. Spouses and intimate others develop compensating behaviors such as denial andcover-upstrategiesto try and cope socially. Aging parents have to skip the normal launching phasethat most young adults prepare for and achieve.Friends, neighbors, and coworkers have to adjust to their unreliability. Moreover, abusers often abandonor estrange themselves from their families, choosing reinforcing associationswith otherusersin order to copewith their increasingantisocialandisolating needs.

Children,in particular, are likely to telescope theseissuesintergenerationally as they grow upto becomeoverprotective, overly controlling, dependent, or otherwise unbalanced in their own marriages (which maythenfail) and in their parenting practices (which distort the experiences of

the next generation, etc.).

131. C: Approximately 25% ofall human immunodeficiency virus (HIV) cases are amongadolescent and adult femalesin the United States. Although HIV continues to predominantly affect men who are sexually active with other men(homosexual or bisexual gay males), women areparticularly susceptible to contracting the HIVvirus. Due to many factors, African American andHispanic or Latina womenaccountfor more thanfour-fifths ofall HIV cases among women. Athighestrisk of newinfection, however, are gay people whoabuse substances as this groupis also mostlikely to engagein risky sexual behavior. Otherfactorsthat contribute to issuesofrisk are: substance abuse, homelessness and poverty, psychiatric disorders, living in chaotic and high-crimeareas, and soon. ‘The incidenceof substance abuse amongthose with HIVis higher than the national average,in part, no doubt, to issues ofstress and depression that accompanythe diagnosis. Although newer treatmentoptions improvethe overall outcome somewhat,obtaining treatmentand maintaining -56GE TTTS FO BSTOTI BSTSF TSST TROTTOTTPTTTTT

the complex treatmentregimenrequired is far more difficult among those whoabuse alcohol and other substances.

132. C: On all measures ofalcohol anddruguse and abuse,the incidence ofoccurrenceis higher. Thelesbian,gay, bisexual, and transgender (LGBT) community has a greaterlikelihoodof alcohol and drug use generally, are morelikely to abusethese substances,areless likely to maintain abstinence, and continue alcohol use longerinto their later years. Research reveals that as high as 30 percentofthe lesbian community may have a drinkingproblem.In addition, LGBT substance abusers tendto use more frequently and more kindsofdrugs. In particular, judgment-altering drugs are also more common(e.g, amylnitrite, gammahydroxybutyrate, ketamine, and ecstasy). The more frequent useofjudge-altering drugs such as those at raves andparties appears to be correlated with the higherrates of human immunodeficiency virus (HIV) infection due to a greater frequencyof higher-risk sexual behaviors. Unquestionably, this community would benefit from greatereducation, services, and specially oriented groups andservices. 133. A: Given their disabilities, those who are cognitive orphysically disabled are unable to find workandyet also spenda largershare oftheir income to meetthe needsoftheir disabilities. Consequently, poverty, depression, unmedicatedpain, functional limits, and vocationaldifficulties leavethis groupparticularly vulnerable to drug and alcohol abuse. Further, becauseof these same cognitive orfunctionaldisabilities, coupled with limitationsin networks andresources, members of this group are notonly morelikely to develop a substance abuse problembutlesslikely to receive treatmentfor the problemsthey do develop.In particular, learning disabilities are common among this population,and these learningobstacles also make whattreatmenttheydo receive less effective. In consequence, programs morecarefully tailored to the needs ofthis populationare very muchneeded. 134. A: Older adults are particularly receptive to treatment for drugand alcohol abuse. However, theyarelesslikely to beidentified as having a problem comparedwith the general population. The reasonsforthis include: (1) they are morelikely to feel shameoverthe problem; (2) they are more likely to be covert about any substance abuse problems; (3) they are less likely to recognize they havea problem as muchof the abuse may involveprescription medications, which theytend to justify; (4) they are unawareofinteraction problems betweenalcohol andprescription drugs; (5) they often havephysical conditions that may obscure their substance abuse, makingit difficult to diagnose. Becauseof these factors, abuse among the elderly may morelikely be spottedvia screenings at wellnesscenters than by drug abuseoutreach programs.Finally, this population has special needs, and age-appropriate treatmentis essential for optimal outcomes. 135. C: Substanceabuse issues may develop at any timethroughoutthe life course, especially

duringtimesofstress, divorce, family discord, unemployment, pain-inducinginjury, depression,

andotherparticularly vulnerableperiods. Overall, however, the period of greatestrisk is adolescence. This groupis particularly vulnerable for numerous reasons, including: (1) the developingbrain (during childhoodand adolescence) is more susceptible to the changesinduced by addiction;(2) the likelihoodofexposure to substances ofabuseincreases at this time; (3) immaturity makesit more difficult to cope with peerpressure; (4) underdeveloped judgment (typically generatinga sense ofinvulnerability) makes thedesire forrisk taking greater; (5) transitionalstressors moving toward adulthoodincrease the need foralternativecopingoptions, particularly those with little developmental demands; (6) the social demandsofschool and relationships become more acute; (7) hormonal andotherdevelopmental changesinduce further instability. Programs sensitive to these needs are greatly neededin the substance abuse treatment field. a

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136. D: A great manyscience-informed,effective prevention programshavebeendesignedto target youth ofvaryingagesin a variety ofsettings. Thereare three types ofyouth substance abuse prevention programs:(1) universal programs—designedto address both risk andprotective factors in the general community orin schoolsettings; (2) selective programs—orientedto engage

youth thatpossess specifically identified risk factorsthatincrease their likelihood of developing a substance abuse disorder; and(3) indicated programs—designed to addressissues relevant to youth whohavealready allowed substance abuseintotheir lives. When programs such as these are properlyapplied to age-appropriate target audiences, research reveals that abuseofdrugs,alcohol, and tobaccoareall reduced. Centralto all these programsis education regarding the harmscaused by substance abuse as such education has provento reduce experimentationandlower the rates of continued substance abuse in youth. 137. B: Clients are not a party to documentationin records exceptin therarest of circumstances. Rather, the need for accurate documentationis essential in determining a propertreatment plan andensuringthat the plan evolves appropriately as the client makes continuedprogress. Further, funding agencies require documentation to ensure that funds entrustedto the programare being utilized as agreed upon the funding process. Overall, essential documentation competencies include:(1) recordingofintake andscreening; (2) client assessment; treatmentplan formulation and goals; (3) clinical reports; (4) clinician progress notes; (5) a comprehensive discharge summary; and (6) anyother client-relatedinformation or data necessary to ensure appropriate compliance,understanding, and treatmentselection (e.g, consent forms, etc.). Client records should be safely maintained andstored in accordancewith existingcity, county, state, and federal regulations. 138. A: Itis very important to documentall referrals made along with related outcomes. In this way, the full rangeofservicesa clientis receiving and has received is known,and the effectiveness ofany referral services can also be followed and measured over time. However,referrals are not part of the intake andevaluationprocess. Essential intake assessmentinformation includes: (1) psychoactive substance abuse history andpatterns ofuse; (2) psychological health andpsychiatric treatmenthistory; (3) currentphysiological health, nutrition, and medicalhistory; (4) medications history and current medications;(5) basic demographicandsocial information; (6) legal history (arrests, sentences, probationor parole status,etc.); (7) educationalhistory; (8) recreational activity history; (9) religiousor spiritual history and currentbeliefs; (10) sexualorientation; (11) high-risk sexual and substance usepractices,if any; and (12) family history and current support network.

139, C: Relevant changes mightarise ifclienttestspositive for an addictive substance,if mandatory meetingsare missed, if an ancillary support program terminates services, or where substantial progressis noted. While formats mayvary, theflow ofinformationin a treatment or recovery plan remainsconsistent: (1) alcohol or drug-related problems arelisted, includingsocial, vocational, family, and medical problems; (2) current short- andlong-term objectives; (3) action plans thatwill meetshort-term goals; (4) client progress measures toward identified goals; and (5) updates to the discharge summary orcontinuing care plan as ongoingchanges warrant.In this way, the treatment and recovery plan remainsactively applicable, and client progress can be carefully monitoredandfollowed. 140. D: Properly written progress notes chart thetrajectory of the client's progress toward the goals, objectives, and actionstepsthat make up the treatmentplan. Progress notes are used to explain andinform anychangesto the treatmentplan in the context of whatis actually happening -58GE TTTS FO BSTOTI BSTSOFTTTR0 TTI TTTPTT ATTTT

in theclient's daily lived experiences, behaviors, and level of functioning. In order to maintain a current andeffective treatment plan, progress notes must be recorded withinfourteen days orless of counseling sessions andfully reviewedatthe time ofa treatmentplan update. These updates occur atregularly scheduledintervals or wheneverit becomes apparent that changesin client functioning, behavior, motivation,orintent warrantthe update. In this way,the treatmentplan

remainsinformative, effective, and transformational.

141. A: Noinformation should be obliterated in a client record.It is only appropriateto lineit out with a single line and indicate that the information was entered in error, when, and by whom. Generally, black ink should be used, every page should have a headerwith theclient's name, andall notes shouldbe concluded with the author's signature andanyrelevant acronym indicating a relevant degree, certification, orlicensure. All notes should address interventions and client responses along with referencesto anyrelatedgoals or objectives. No otherclients should be namedin anotherclient's record,limiting referencesto others bythe first nameorinitials only,if necessary, or byrelationship status if adequately clear. Blank areas on a page should be avoided. If a blank spaceisleft, it should belined through with oneor morediagonallines. Charts should never leavea facility except for purposes of audit. 142. Whethertheclient's treatmentincludesgroup orindividualsession counseling, most states require an updating entry at least weekly. Entries should includesession dates andattendance status as well as clientprogress in terms of recovery phase and movementtoward (or away from) recovery ortreatmentgoals and objectives. Entries should clearly indicate whetherthe progress (or lack of progress) leaves the clienton orofftrack in regards to achieving necessary progress, especially ifan associatedincrease in relapserisk has beenidentified. Issues ofclient responsiveness to program staff, involvedfamily, referral services, as well as attendance complianceshould be noted in an ongoingfashion.Finally, planned or expectedinterventions and recommendationsshould alsobe included in the weekly update or summary entry. 143. B: A comprehensivedischarge summary is always produced,regardless of how long orshort the client's involvementwasin the treatment program.Specifically required contentincludes: (1) whetherthe program was or was not completed successfully; (2) the reasonsorrationale that resultedin client discharge; (3) whetherthe discharge was voluntary orinvoluntary; (4) any transferorreferrals involvedin the discharge, with specific information abouteach,including transferorreferral rationale; (5) summary information on treatments offered andrecovery level achieved; (6) the client's status in abstinence or continuedsubstance use; (7) educational or vocational accomplishments; (8) legalstatusat the pointof discharge; (9) relevant continuing medicalissues,if any; and (10) anyinvolved supports orservicesthat are expectedto be continued beyonddischarge. 144, D: In general, the language in 42 CFRPart 2 preventsall information releases(as well as. client-identifyinginformation), evento otheruninvolved staff. Key exceptions do, however,exist: (1)writteninformation releases—if properly completed—oral consent, however, is not permitted; (2) emergency medical situations—limited essentialinformation maybegivento treating medical

personnelbut not to law enforcementdirectly; (3) other agencies workingwith a client—ifa

Qualified Service Organization Agreement(QSOA)thatguaranteesconfidentiality at the samelevel

hasbeensigned; (4) mandated reports—notifying authoritiesofchild abuse, and (sometimes) dependentadult andelder abuse,releasing only limited essential information; (5) qualified researchers underlimited conditions; (6) crime on site or against staff—limited release to law enforcement; and (7) court orderor subpoena, search warrant, or arrest warrant—onlyifit also -59GE TTTS FO BSTOTI BSTBOF TSTTROTSTTTTPTT ATTTT

meets 42 CFRPart 2 criteria. Language in 42 CFRPart 2 also applies to all staff and volunteers as well as past, current, and even potential (applicant) clients,living or deceased.

145. D: The CodeofFederal Regulations, Part 2, Subpart E, requires that information, even about

the mere presenceofa clientin treatment, is notto be released underanycircumstances unless a

qualified court hearing hasfirst been held wherein the issue ofconfidentiality andclient needs have first been addressed. Following this, a special authorizing order mustbeissued. At a hearing, the court must determine:(1) if the alleged crimeis sufficiently seriousto warrant breaching confidentiality in this sensitive area (e.g, homicide, rape, assault with a deadly weapon,etc.); (2) if the records disclosurewill be ofsufficient value in theinvestigation; (3)if other reasonably effective options exist; (4) ifthe potential for damageto theclient, to the client-provider relationship, and to the program's ability to continue providingservices outweighsthe release of this very sensitive information; and (5) if the applicantis acting in a true law enforcementfunction andif adequate counsel has beenobtained by the records holder or agency. 146. C: Substance abuse clients, especially those with a history ofabuse themselves, can struggle with impulse control andemotions,especially anger. Acting out anger cannot be tolerated. Usually, however,there are signsofagitation, elevation, and anger well beforephysical acting out occurs. At this earlier juncture,it can be helpful for the counselortovalidate their affect withoutvalidating any givenverbal expression(“I can seethis is somethingdifficult for you ...” or “This brings up a lot of emotion for you, doesn't it?"). In this way, the counselor moves to constructive address ofthe client’s emotions, defusing the needto act outphysically. Prevention is particularly valuable—ground rules for conduct in group,withstaff andonsite, should be providedatthe point ofintake. Language, breach of confidentiality, threats, and physical aggression cannotbetolerated. Lawenforcement may needto be called if safety becomesanissue. Clients should know in advance that seriousthreats are taken seriously andwill be reported. 147. B: Many substance-abusingclients suffer from low self-esteem, poorself-control, deficient boundaries, and high impulsivity. Wherethis behavioris the result of poor emotional control, various interventions may help. Where the problemarises from underlying pathology (eg., posttraumatic stress disorder [PTSD], bipolardisorder, psychosis, intoxication, etc.), rap de-escalation and backupsupport maybe immediately necessary. Where the behavior is simply developmentalimmaturity, grounding techniques are often beneficial. In anchoring, the counselor leadsthe clientto relax, close his or her eyes, and focus on breathing and the immediate environment(thechair, the room, the quiet, etc.). Then, the counselorhas the client recognize that, in spite of worries aboutthepastorfuture, the immediate presentis safe. The counselor must support this by avoiding sudden movements, pressuredspeech, and so on, so as to avoid any hypervigilant response from theclient. In mirroring, the counselorhastheclient synchronize his or herbreathing with the counselor's, leadingto a calm rate (counselors avoidthis techniqueif transferenceintimacy has beenan issue). In timeout, the counselorallows the client to take a break from thetopic, leaving the room if necessary, to relax before continuing. 148. A: Manysurvivors ofsignificant abusetendto put themselvesin further high-risksituations.

Their countertransference issues with the counselor may draw the counselorinto the role of rescueras they seek the safety, nurturance, andsecurity they deeplydesire. If the counselor is not fully self-aware, he orshe can bepulled into this dynamic in seeking to defend andsupport the client. In doing so, however, the client moves into dependency andfails to learn how toidentify and set appropriate boundaries in his or her own life. Overtime, the concerned counselor may over treat, lendfunds, arrangechild care, and otherwise inappropriately respond. The counselor may also attempttointervenewith others onthe client's behalf and find him- or herself polarized from a -60GE TTTS FO BSTOTI BSTBOF TYTTROTTOTTPTT ATTTT

clientthat is now angry with the counselorfor intrudinginto importantfamily orother relationships. While rescuing may temporarily relieve the counselor'sconcernsandfrustrations,it will neverprovide long-term resolution of the problems. 149. Counselors mustrecognize thatthey are also entitled to limits. While working with difficult clients is a part ofthe job,it does not require workingin situations that are personally deeply disturbingortroubling. It can also leadto substandard service forthe client, whois entitled to receive counselingfrom a professional whois not compromised byhis or her past history. In situationssuchasthis, it may be helpfulto seek supervisory consultation to better determine what occurring and the degree ofthe associated problem. The client shouldbenotified in advance of the need(but not the direct reason) for a transfer to avoid generatingissues of rejection or abandonment. He orshe should beinformedthat anotherclinician bettersuited to meeting his or herneedsis available. Any subsequentissues aboutthetransfer should also be addressed in the newtherapeutic relationship. 150. D: While an agency mustcontinuetoreceiving funding, provide employment, and maintain a

consistent reputationin orderto continue offering services,its mostimportant purpose and functionisto break the cycle of abuse andrelieve theindividual, involvedfamilies, andsociety as a whole from the suffering involved. To accomplish this, staffmust receive appropriate support. This involves proper supervisionandtraining, avoiding over-schedulingcaseloads, allowingtime for colleague consultationsandsupport, facilitating quality outside support and consultation as needed, providingpolicies and procedures that ensurea safe, effective, and positive work environment, and so on.In this way, staff can be supported, quality services will be provided, agency longevity will be maintained, and turnoverandburnout will be kept to a minimum. Administrators must recognizethatcounselors can onlybe expectedto perform optimally if agency leadership provides adequate support.

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Practice Test #2 Practice Questions

1. Whatare withdrawal symptoms, characterized by severe flu-like symptoms(nausea, vomiting, runny nose, watery eyes,chills, abdominal cramps, anorexia, weakness, tremors, sweating, etc.), MOST characteristic? a. Opioid withdrawal b. Hallucinogenic withdrawal c. Barbiturate withdrawal d. Benzodiazepine withdrawal 2. Genetic factors makeup roughly what proportion ofthe risk for addiction? a. Less than one-tenth b. One-quarter c.One-half d. Three-quarters 3. Whatis the adolescenttendency to impulsivity and risk taking due to primarily? a. Poorparenting b. Prior abuse c. Neurological immaturity d. Influences of puberty 4. Whatare depressantdrugs (e.g. alcohol, opiates, barbiturates, and benzodiazepines) typically used to cope with? a. Excitement

b. Fatigue c. Stress

d. Boredom 5. Past which point is benzodiazepine treatmentofanxiety NOT effective? a. Six weeks

b. Four months c.One year d. Eighteen months 6. Atlow doses, what does alcohol act as physiologically? a. Stimulant

b. Psychedelic c.Depressant d. Hallucinogenic 7. Amongthefollowing, whatis the MOST harmfuldrug a mothercan abuse during pregnancy? a. Heroin b. Lysergic Acid (LSD) c. Alcohol d. Methamphetamine a

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8. Theorists posit that stimulant abuse often occurs to compensate for deficienciesin all ofthe following neurotransmitters EXCEPT

a. norepinephrine. b. acetylcholine. c. serotonin.

d. dopamine. 9, What is the euphoria experienced when underthe influence ofcocaine caused by? a. A cascade-effect of endorphins b.A suddenrelease ofadrenalin c. Increasedbasal metabolic rate d. A buildup of neurotransmitters 10. What kind of drug doesthe term nootropic refer to? a. Memory enhancing b. Mood stabilizing c. Hallucinogenic d. Psychedelic 11. Whichofthe following is NOT a stage in the developmentofalcoholism? a. Dependentdrinking b. Morning drinking c. Socialdrinking d. Heavy drinking 12. In thelifecycle of heroin addiction, whatis the stage known asdisjunction characterized by? a. Entrance intothe addiction subculture b. Episodic bingeuse of heroin in social settings c. Serial treatment, abstinence and relapses d. Crime, arrests, imprisonment, and serial treatment 13. Which ofthe followingis NOT a typicalstagein the developmentofcocaine addiction? a. Compulsive use b. Experimental use c. Isolated use d. Dysfunctional use 14. Social controltheorists suggest that devianceresults from which TWOofthefollowing? a, Poorsocioeconomic conditions b, Weaksocietalties with the individual c. Weak familialties with the individual d. Confiningsocietal expectations

15. Withdrawal symptomsfrom anabolic steroids most closely resemblethose of which drug? a. Marijuana b. Heroin

c. Amphetamines d. Cocaine a

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16. Whichis the MOSTcorrect statement regarding individuals voluntarily entering treatment for substance? a. They are committedto change. b. Theyarefully ready to change. c. Theyare at varyingstages ofchange readiness. d. Theyare primarily in need of encouragement. 17. Whatis ambivalence about substance abuse treatment symptomatic? a. Resistance b. Denial c. Uncertainty d. Confrontation 18. Whatis the primary goal ofscreeninga client with a known substance abuse disorder? a. Get rid ofthoseclients with serious problems b. Determinea bestinitial treatment course

c. Discover any dual diagnoses d. Evaluatethelikely length oftreatmentneeded 19. In screeningclients, what does a cutoff scorereferto? a. A criteria-based score beyond which a client must be turned away b. Thethreshold above which a morethoroughassessmentis indicated c.Ascore thatis incomplete, having beencut off prematurely d. Thefinal score that supersedes anyother screening score obtained 20. Whatis the suicide risk for individuals treated for alcoholuse disorder? a, Aboutthe sameasfor the general population b. Two times as high as among the generalpopulation c. Five times as high as amongthe general population d. Ten times as high as amongthe general population 21. Whichone ofthe following MOSTproperly defines screening andassessment? a, Screening evaluates a problem; assessmentdiagnosesit. b. Screeningidentifies a problem; assessmenttreats it c. Screening looks for a problem; assessment definesit. d. Screening reveals a problem;assessmentresolvesit. 22. Whendoes assessmentofa client with co-occurring disorders occur? a. Followinganinitial screening b. During the process ofintake c. Uponconfirmation of diagnosis d. Regularly over time 23. Whichis the gold standard assessmenttool for co-occurring disorders?

a. TheAddiction Severity Index (ASI) b. The Minnesota Multiphasic Personality Inventory (MMPI) c. The MentalStatus Exam (MSE) d. None ofthe above

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24. During assessment, whatdoes the term collateral contacts refer to? a. Contacts with family b. Contacts with friends c. Contacts with treatmentproviders d. All ofthe above

25. Which ofthe following is NOT includedin basic intake information? a. Feelings aboutinstitutional treatment(treatmentreadiness,etc.)

b. Background (family, legal, employment, etc.)

c. Substanceuse (first use, current drugs,treatment, etc.)

d. Mental health (diagnoses, hospitalizations, treatment, etc.) 26. Which ofthe followinginstrumentsis used to screenfor substance abusein individuals who frequentlydistort or misrepresentthe truth? a. MAST b. SASSI c.SBIRT ASI 27. Which ofthe following is NOT a key informational outcome of screening and assessment? a, Measures of client treatmentcompliance b. Essentialconsents and authorizations c. Substance abuse disorderseverity d. Clientstrengths andavailable supports 28. Which ofthe following is NOT a key goal andpurposes ofassessment? a, Identifying the optimum form ofintervention forthe presenting problem b, Identifying the resources available for successful problem resolution c. Whetheror nota substance oralcohol problemexists d. Extent andseverity of the substanceor alcohol abuse problem 29. What must treatmentplanningdiscussionswith clients belike? a. Appropriateto client age and developmentallevel b, Sensitive to issues ofrace, ethnicity, and culture c. Free oftechnical jargon and obscure acronyms d. All ofthe above 30. Why should data andfindingsfrom the assessment bepresented to the client and his or her significant others? a. Theclientis paying for the service. b. Staff needto justify what theyare doing. c. Client understandingaffects treatment. d. Clientproblemsneedto be aired openly. 31. Whatdoesthe treatment term matchingrefer to?

a, Selecting resourcesby client needs and preferences b, Pairingclients into supportive treatment dyads

c. Sequencingtreatmentmodalities for maximum benefit d. Reciprocal communicationto ensure client support -65GE TTTS FO BSTOTI BSTBOF TSTTOTTOTTPTT ATT

32. Which ofthe following does NOTaddresspatient placementcriteria (PPC)? a, Substance abuse admissioncriteri b. Continuingstaycriteria c. Outcome measurementcriteria

d. Dischargeortransfercriteria

33. Whats a client's readiness for treatment strongly associated? a. Duration oftime abusing a drug ofchoice b. Theperceptionof needing helpin change c. Numberof deteriorative health changesencountered d. Increased cost ofthe primary drug ofchoice 34, Whatdoestheterm treatmentsequencing refer to? a. The order of medications administration b. Movementthroughthelevels of care c. Usingcredentialedstaff before non-credentialedstaff d, Prioritizing client needsin the treatmentprocess 35. How is Maslow’s Hierarchyof Needs BEST described? a. A fundamental rankingofessential needs b. The waya client selects a drug ofchoice c.Ascale for determiningtreatmentreadiness

d. A model oftheprocesses involved in change 36. Which ofthe following levels was NOT proposed by Abraham Maslow in his Hierarchy of Needs? a. Basic needs b.Safety needs c. Recreational needs d. Esteem needs 37. Informationgathering and assessmentcanbebiased ifclinician a. uses very general questions. b. uses open-endedleading questions. c. uses professionaljargon. d. uses all of the above. 38. Whatdoes the Biopsychosocial Model suggest thatproblems have? a. Both mental andphysical aspects andorigins b. An underlying medical or physical etiology c. Sociocultural and biological causative factors d. Numerous causalfactors that are interconnected 39. Whatis the Chemical Use, Abuse, and Dependence (CUAD) Scale BEST known for?

a.Its use in substance abusescreening and assessment b.Its utility in assessing substance abusein mentallyill clients cIts ability to producing a Diagnostic andStatistical Manual of Mental Disorders (DSM) diagnosis of substance abuse disorder d.Its brevity and the minimal administration training required -66GE TTTS FO BSTOTI BSTBOF TYTTRTTTTTPTT ATT

40. Whatis the Symptom Checklist-90-R (SCL-90-R) used for? a. Anin-depth assessmentof physiol b. Anin-depth assessmentofpsychological health c. Trackingclient progress or treatmentoutcomes d. Both B and C 41, What is the COPESscale used for? a. Helpingclients learn how to cope with transitions b. Exploringclient readiness for treatment c. Assessingclient support systems and resources d. Assessing community-based treatmentprograms 42. Whatdoes the TSR assessmentinstrument measure? a. Therapeuticintensity and problem severity b. Solution-oriented therapeutic resistance c. Natureandintensity of treatmentservices d. Topic-specific remedial outcomes

43, What doesthe BIRPprogress note acronymstand for? a. Behavior, Interview, Reaction, Purpose

b. Behavior, Integrate, Review, Propose

c. Behavior, Intervention, Response,Plan

d. Behavior, Intervene, Revise, Program

44, What doesthe CHEAPprogress note acronym standfor? a. Chief complaint, History, Evaluation,Action, and Plan b. Chief complaint, History, Exam, Assessment, and Plan c. Chief complaint, History, Evidence, Attention, and Plan d. Chief complaint, History, Evaluation, Axes, and Plan 45. The mnemonic SIGECAPSevaluates which psychological state? a. Depression b. Anxiety c. Paranoia d. Mania 46. Whatdothe acronyms CART and CHARTboth refer to? a. Treatmentinterventions

b. Diagnostic assessments c. Progress note formats d. Assessments for symptoms

47. What doestheterm client matching refer to? a. Tailoring resources andservices to the client needs b. Obtaining a sponsorfor mutual-help program enrollment c. Findinga treatmentbuddyduringa residential stay d. Picking the properlevelof service intensity

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48. Thestatement“Clients must alwayshit bottom to be readyfortreatment" is

a. absolutely true. b. partly true. c.absolutely false. d. partly false.

49. Howisclient motivation for treatment BEST maintained?

a. Declarationsof serious consequences b. Fear of failure and the results that follow c. Remindersof whatbrought them to treatment d. Devil's advocatestatements that they'll never makeit

50. Whatdoesclientresistance to treatment MOSTlikely indicate? a. Theclient is being pressured to change too quickly. b. Theclient simply doesn’t care to overcomethe problem. c. The

t has beencoercedinto treatment.

d. Theclient is embarrassed aboutpast relapses. 51. Whatis the factorthat contributes MOST meaningfullyto client treatmentretention? a. Program location andtransportation support

b. Thetherapeutic alliance c. Family insistence ontreatment d. Court orders for treatment

52. Whichofthe followingtreatmentepisodes is associated with better outcomes?

a. Longerepisodesare superiorto shorter episodes.

b. Shorterepisodesare superiorto longerepisodes.

c. Thelength ofthe treatmentepisodeis notrelevant.

d. Completion ofany length episode is mostimportant.

53. What shouldthe position oftreatmentprogramstowardtwelve-step programsbe? a. Clients should not bediscouraged from twelve-step programs. b. Clients should be encouraged to participatein twelve-step programs. c. Twelve-step programs are a helpfulsocial toolbut have no otherimpact. d. Twelve-step programsare an integral part of overall client success. 54. Which statementBESTreflects the natureofmutual-help groupssuch as twelve-step programs? a. These programsvary greatly andshould be carefully chosen. b. Theseprograms are generally very much the same. c. These programsareonly for substance abusers. d. These programs areprimarily religious in nature andorientation.

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55. How is the properrole for mental health medicationsin individuals with co-occurring disorders BESTdescribed? a. Thereis no place for mental health medications in the treatmentofclients with a substance abuse problem. b. Clients with a substance abuse disorder and a co-occurring mentalhealth disorder can benefit from medications. c. Clients with a substance abusedisorder and a co-occurring mental health disorder can take mentalhealth medications without any concern. d. Clients with a substance abuse disorder and a co-occurring mental health disorder will always benefit from long-term pharmacotherapy. 56. Whatis the purposeofopen-ended heterogeneousgroups? a. To allow flexibility in new member assignments b. To keepdifficult clients away from eachother c.Toputclients together with similar issues d. To meetthe needs ofclients with special problems 57. Whatis the purpose ofclient-specific groups? a. To meetunique client needs b. Tofacilitate the counseling process c.Both Aand B d. Neither A or B 58. Clients that should neverbe assigned to the samegroupincludealof the following EXCEPT a. abuse perpetrators andvictims. b. neighbors andrelatives. c. schizophrenia andantisocial disordered. d. opioid and amphetamineabusers. 59. Duringtheinitial treatment phase, how manytherapeutic contact hours per week does the American Society ofAddiction Medicine (ASAM)requireforintensive outpatient treatment(IOT) participants? a. Three hours b. Five hours c. Seven hours d. Nine hours 60. Optimal group size in a typical treatment groupinvolves how many members? a. Eightto fifteen members b.Six to Twelve members c. Five to ten members

d. Fourto eight members 61. Which ofthe following medicationsis NOT commonlyusedin the treatmentofalcohol abuse? a. Disulfiram b. Buprenorphine c.Acamprosate d. Naltrexone

a

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62. Which ofthe following medicationsis NOT commonly used in the treatmentofopioid abuse? a. Luminal b. Methadone c. Buprenorphine d. Levo-alpha acetyl methadol 63. The AmericanSociety ofAddiction Medicine (ASAM) recommends patients with co-occurring disorders be placedin a specialty addiction and mental health treatment program at which level of mentalillness severity? a, No co-occurring disorder b. Mild to low co-occurring severity c. Moderateco-occurring severity d. High co-occurringseverity 64. What are the most common biological samplesused for treatmentprogram drug testing? a. Hair and sweat b. Blood and saliva c.Urine andbreath d. Noneofthe above 65. Which one ofthe following is not an established twelve-step program? a. Narcotics Anonymous

b. Cocaine Anonymous

c. Hallucinogens Anonymous

d. Alcoholics Anonymous

66. Whatis the ADSscale used to measure? a. Alcohol dependence b. Anomalous drug use c. Readiness for treatment d. Substance use minimization 67. Whatis the CIDI instrumentis used to measure? a. Psychiatric disorders b. Substanceuse disorders c. Both Aand B d. Neither A nor B

68. Which ofthe following is NOT measuredbythe DIS schedule? a, Substanceuse disorders b. Alcohol use disorders c. Psychiatric disorders d. Physical health disorders 69. For which ofthe following setting is the MINI designed? a. Clinicaltrials b. Treatment outcomeassessments c. Epidemiological studies d. All ofthe above a

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70. Psychiatric Research Interview for Substance and MentalDisorders (PRISM)evaluates for

which ofthe following distinct personality disorders? a. Paranoid and obsessive-compulsive b. Antisocial and borderline c. Histrionic andnarcissistic

d. Avoidant and dependent

71. How is the term genogram BESTdefined? a. A diagram offamily relationships b.A genetic predisposition to addiction c. A pictogram of intergenerationaladdiction d. A phenotypepredisposing alcoholism 72. How is the CRAFT program orapproachBESTdescribed? a. A consensus approachto motivating a client into treatment

b.A confrontational approach to motivatinga clientinto treatment

c.Acommunity or family approachto motivating a clientinto treatment

d. A consciousness-raising approachto motivating clientinto treatment

73. Whatarefamily education groups primarily designedto do? a, Providefamily and couples therapy b. Resolve situations ofdomestic abuse c. Teach anger management and coping d. Educate families about addiction 74. Whatis the difference betweena lapse andrelapse? a, Insignificant, as they are interchangeable terms b.A single use episodeversus prolonged use c. Using a drug ofchoice versus polydrug use d. Prolongeddrug use versus a single episode. 75. Whatis the influenceofa famousclient in group MOST likely to be? a.Positive, increasing group morale

b. Neutral, becomingjust another group member c. Negative,disrupting group dynamics

d. Uncertain, depending uponthe personality 76. A potential client enters a program for treatmentand a counselor recognizes him from Little League team in which their sons are both still active. Whatis the BEST response bythe counselor? a. Pretendto have not seen the acquaintance, andneverspeak ofit to them. b. Speakwith the clientprivately, and offer assurancesof confidentiality. c. Seekto be assigned asthe client's counselor to ease tension and show support. d. Referthe client to anothertreatmentprogram.

77. Whatis the ASEscale used to determineor evaluate? a. Alcohol abstinence commitmentin high-relapse situations b. Activities andactions usedto ensure substance abstinence c. Assessmentofassociations for substance experimentation d. Alcohol associations andeffects in varyingintoxicated states -71GE TTTS FO BSTOTI BSTSOTTTROTSTPTT ATTTT

78. Whatis the purposeof the AEQ instrument?

a. To evaluate the quality and efficacy of abstinence b. To assesses expected positive and negative effects ofalcohol c. To assessthe qualities of a client's social support network d. Toquestion the effects ofabstinence educationon treatmentacceptance

79. Whatis the ASRPT instrument used for? a. To determine whetherposttraumatic stressis a componentindrinking b. To gauge theeffectivenessof relaxationtherapyin maintaining abstinence c. Toevaluate stress responsefeatures in alcohol relapse situations d. To role-play client responsesto situations that pose a threatof relapse 80. Whatis the SCQ designedto do? a. Reveala client's situational confidence in high-risk drinking situations b. Evaluatea client’s susceptibility to emotional pressures to drink c. Assessa client's self-control quotient whenexperiencing key triggers d. Evaluate the qualities driving the context ofa client's substance use 81. Cognitive-behavioral therapy (CBT) does NOT address which ofthe following? a. Replacing substance abuse coping with more effective coping skills b. Identifying personal cuesor triggers thatlead to substance abuse c. Learning new problem-solvingskills andstrategies to counteract substance abuse urges d. The role of a higher power in achieving and maintainingabstinence 82. Which ofthe following is NOT a strength ofcognitive-behavioral therapy (CBT)? a. Itis suitable for clients from diverse culturesand other unique backgrounds. b. CBT wasdeveloped as an effective group counseling approach. c.It provides an understanding ofrelapse triggers and relapsesituations. d. Itaccommodates clients with widely varying histories of alcohol and drug use. 83. Which ofthe following statements is true regarding cognitive-behavioraltherapy (CBT)? a. Itis about as effective as minimal or no therapy at all. b.Itis inferior to motivational enhancement therapy (MET). c.It is superiorto contingency managementapproaches. d.Itis less effective than twelve-stepfacilitation for reducing alcoholuse. 84. In motivationalinterviewing (MI), whatis therole of the counselor?

a. An expert, providing unilateraldirection and guidance b.A subordinate,primarily listening andreflecting c.Acoachorconsultant, asking key questions for learning d. An authority figure, creating a professionaltreatment plan

85. How is motivational enhancementtherapy (MET) different from motivationalinterviewing (MI? a. MET incorporatesstructured assessments andfollow-up sessions.

b. MET is more unstructuredandfree-flowingas comparedwith MI. c. MET is entirely reflective and non-determinative as compared with MI. d. METrequires considerable confrontation and counselor assertiveness. -72GE TTTS FO BSTOTI BSTBOTYTTROTTOTTPT ATTTT

86. How manytreatment weeks are involved in the current Matrix Model program? a. Twelve weeks b, Sixteen weeks c. Twenty-four weeks d. Thirty-two weeks

87. Which ofthe followingis NOT a groupin the Matrix Model of treatment? a. Early recovery skills groups b. Relapse prevention groups c. Family education groups d. Stress managementgroups 88. Whathaveefficacy studiesof the Matrix Modeloftreatment found? a. The modelis no moreeffective than other treatmentprograms. b. The modelis neutral in outcomeefficacy. c. The modelis marginally positive in termsofefficacy. d, The modelis significantly positive in measures ofefficacy. 89. Ofthe following, what are the TWO mostsignificant drawbacks to the Matrix Model? a. Cognitively impaired clients may havedifficulty with somematerials, and some clients may be adverse to the highly structured content andscheduling.

b. Significantstafftraining andongoingsupervisionis required, and theintensestructure and

scheduling mayinterfere with fully addressing otherimportant nondrugissues. c. Monitoring progress in twelve-step programscan bedifficult, and failing to schedule in leisure activities can lead to noncompliancewith the schedule. d. Manyclients may struggle with creating and maintaining an hour-by-hour schedule, and family orothers may seek to impose a schedule notdesired bythe client.

90. Whattheory is community reinforcement(CR) and contingency management(CM) based upon? a, Social learning theory b. Operantconditioning theory c. Family systemstheory d. Biological-genetic theory 91. Osher and Kofoed developed a staged approach tothe treatmentofco-occurringdisorders that incorporates how many stages? a. Two stages

b. Fourstages c. Six stages

d. Eight stages 92. Whydoclients with co-occurring psychiatric disorders respondpoorly to confrontational counseling approaches? a. They can’t comprehendwhatis being askedofthem. b. Theyarenot properly medicatedpsychiatrically. c. Theyare passive-aggressive anddeliberately obstruct. d. They decompensatein stressful interpersonalsituations.

a

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93. How is theuse ofgrouptherapywith co-occurring disorders clients BEST described?

a. Controversial and complicated b. Contraindicated and counterproductive c. Of uncertain efficacy in this population d. Widely accepted andeffective

94. The term double trouble, in reference to mutual-help groups, refers to what? a. Groupsfor clients with both psychiatric and substance abuse issues b. Groupsforclients with both legal and substanceabuse issues c. Groupsforclients with polysubstance abuse concerns d. Groupsforclients with a personality disorder and substanceabuse 95. Why are medication management groupscreated primarily? a. To administer medications to noncompliantclients

b. To allowclients to participate in medication research trials c. Totransitionclients from onemedication to another d. To offer educationand address compliance concerns 96. Among the following mental health disorders, which one is the MOST influenced by culture? a. Schizophrenia b.Bipolar disorder c. Panic disorder d. Depression 97. For the counselor,in whichofthe following is the influenceofculture is MOSTlikely to be

apparent? a. Symptom presentation b. Screening responses c. Mental status examination d. Substances used

98. What cultural groupis least susceptible to suicide? a. Rates are lowestfor Hispanic men. b. Ratesare lowestfor African American women, c. Rates are lowest for Caucasian men. d. Rates are lowestfor Pacific Islander women. 99. Whenexperiencing mental health concerns, from whomare racial and ethnic minorities LEAST likely to seek help? a. A primary care physician b.A counselor c. Religious clergy d. traditional healer 100. Whatis the GREATESTcultural barrierto receiving mentalhealth treatment? a. The stigma of mental illness b. Mistrust of mental health providers

c. Readily available alternatives(healers, clergy, etc.) d. lackoffamily support -74I

101. Whatdostudiesindicate aboutlesbian, gay, bisexual, and transgender (LGBT) individuals?

a. They are morelikely to abuse alcohol and drugs than the generalpopulation. b. Theyare similar to the general population in their use of alcohol and drugs. c. They are morelikely to use drugs but not morelikely to use alcoholthanothers. d. Theyarelesslikely to abuse alcohol and drugs than thegeneral population.

102. Whatdoes the termcultural brokering referto? a. Immigration andnaturalization assistance b. Financial managersfor ethnic andracial minorities c. Housingservices for ethnic andracial minorities d. Liaison work betweencultures to meet needs 103. Howdotherates of heavy alcoholuse amongyouthages twelve to seventeenin rural areas compare? a, Double the rates in metropolitan areas b.Slightly higherthan therates in metropolitan areas c. About the same as theratesin metropolitan areas d. Halfthe rates foundin metropolitan areas 104. Although homeless individuals are morelikely to receive detoxificationservices than people not homeless, what percentage will receivefull treatmentfortheir alcoholor substance abuse problems? a. 15 percent b.25 percent c.35 percent d. 45 percent

105. Homeless individuals are particularly susceptible to substance abusedue to the stress and hopelessness oftheir currentsituation. Whatare the three most commonsubstances of abuse among this population? a. Alcohol, crack cocaine, and marijuana b. Alcohol, opioids, and marijuana c. Alcohol, opioids, and crack cocaine d. Alcohol, marijuana, and inhalants 106. Whatis the case management modelthat seeks to identify clients’ needsandassist clients in obtaining access variousidentified resources known as? a. Brokerage orGeneralist Model b. ProgramofAssertive Community Treatment Model c. Strengths-Based Perspective d. Clinical or Rehabilitation Model 107. Which is the ONLY case management modelthatspecifically addresses making contact with

clients in their homesandother naturalsettings? a. Clinical or Rehabilitation Model

b. Strengths-BasedPerspective

c. Program of Assertive Community Treatment Model d. Brokerage or Generalist Model

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108. Whatis the case managementapproach thatfocuses onhelpingclients assert direct and personalcontrolin the search for resources? a. Program ofAssertive Community Treatment Model b. Clinical or Rehabilitation model c. Brokerageor Generalist Model d. Strengths-Based Perspective 109. Whatis the case management modelthatintegrates therapeutic andresourceacquisition activities known as? a, Strengths-BasedPerspective . Clinical or Rehabilitation Model c. Brokerage orGeneralist model d, Program ofAssertive Community Treatment Model 110. Amongthe numerousprinciples that are essentialto effective case management, how is the principle ofadvocacy BEST described? a. Taking theclient's sidein situations of conflict b. Ensuringtheclient understandsinstitutionalrules c. Helping aninstitution to meeta client's desires d. Advocatingfor theclient's bestinterests 111, How aretheclinical, evaluative, and administrativeactivities that link clients with treatment, community services, and other resources needed to carry outa treatment plan MOST comprehensively referredto? a, Case management b, Client advocacy

c. Service coordination d. Resourcelinkage

112, Howistheindividual whois responsible to carry out the clinical monitoring andcollaborative client assessments, evaluations, referrals, treatment coordination, and goodness-of-fit appraisals of the treatmentplan to client goals and objectives BEST known as? a. Case manager b. Service coordinator c. Therapist d, Administrator 113. A program oragency at times mayrequire outside services to continue functioning properly. Whenanoutsideofficial or agency provides servicessolely to maintain thefunctionandviability of a treating agency or program, confidentiality is maintained whenservice providers sign a a. Contractual Agreementfor LimitedServices (CALS). b. Qualified Service Organization Agreement (QSOA). c. Confidentiality and Privacy Service Agreement(CPSA).

d. Consent andDisclosureLimitations Contract (CDLC).

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114. Whatis a brief, but comprehensively integrated public health approachto early substance abuse intervention andtreatment knownas? a. Treatment, BriefIntervention, Referral, and Screening (TBIRS) b.BriefIntervention, Screening, Referral, and Treatment(BISRT) c Referral, Screening, Brief Intervention, and Treatment(RSBIT) d. Screening, Brief Intervention, andReferralto Treatment (SBIRT)

115. Whats the key featurethatdifferentiates a substanceabuse counselor whomerelypractices in the field from one whosucceeds in changingclients’lives? a. The knowledge of addictionissues b. The ability to be empathetic c. The skill to set clear boundaries d. The capacity to firmly confront 116. A great deal is communicated nonverballyin the counseling process. How much communication does nonverbal bodylanguage accountfor, according to research? a. 10 percent b.25 percent ¢.50 percent 4.75 percent 117. During theintake process,it is importantforclients to sign aninformedconsentform. Ofthe

following, whatis the MOSTsignificant reasonfor signingthis form? a. To acquaint clients with program rules, regulations, and boundaries b. To ensure full compliance with program accreditation standards c.Tobetter develop a meaningful treatmentplan d. Toensure client commitmentto and readiness for treatment

118. The Substance Abuse and MentalHealth Services Administration (SAMHSA) maintains a national registry knownas NREPP.What does this acronymrefer to? a. National Registry of Examinations for Psychological Practices b. National Registry of Excellencein Program Practicum c. National Registry of Evidence-Based Programs andPractices d. NationalRegistry of Examiners for Program Procedures 119. It is importantto determinea client's readiness for change at the outsetoftreatment. From among thefollowing, whatis the BEST indicator of readiness? a. A client's statementofhis or herreadiness for change b. Theclient andfamily’s level of emotional andphysicalpain c. The client and family’s admission thatthereis a substance abuse problem d.A client's changesin finances requiredto continuethe substance abuse 120.Significant substanceabuse canarrestpersonal progress and growth in many ways. Howwill

emotional and other normal developmental stages MOSTlikely be affected? a. They will progress more slowly dueto significant substance abuse. b. Theywill progress more rapidly due to significant substance abuse. c. They will belargely skippeddueto significant substance abuse. d. They remainunchanged dueto significant substance abuse.

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121. The impact of substanceabuse in the family varies based on theuser’s familyposition,role,

age, and so on. Whatisonereasonsubstance abusein the family is NOTinitiated or maintained? a. The needto exert controlover other family members

b. The needto producea crisis to get any meaningful attention c. The needto cope with severe depression or anxiety

d. The needto cope with unrealistic expectations

122. There are numerous methods used to encourage a substance abuserto enter treatment. Who carries out a programmedconfrontation? a. A trained addictions counselor b.A primary care physician c.A psychotherapist d. A family member 123. Substance abuse takes a toll on all involved. How is community reinforcement training (CRT) used? a. To assist a substanceuser to reduce his or herlevel of use b. To keepdruguse paraphernalia clean anddisease free c. To motivate a substanceuserto enter a treatment program

d. Topersuade heroinusers notto share needles with others

124. Motivatingan addict to entertreatmentisoftendifficult. Which treatmententry method uses

the intervention network as part ofits motivational process? a. The Johnson Method b. Community reinforcementtraining (CRT) c. The ARISE Method

d. The community reinforcement approach (CRA) 125. Families have muchto offer the treatmentprocess. Beyond client abstinence, what is the main goal ofinvolvingthe family in treatment? a. To corner an addict into making changes by escalating family pressure b. To help the family to better copewith the client's addictive behaviors and the related consequences ¢.Toteach the family aboutthe biological processesthat underlie addiction d. Toeducate the family about substance abuse as a chronic disorder req inglifelong changes 126. There are numerousreasonsfor not involvingthe family in treatment. Who are thefamily members MOST likely to participate in treatment? a. Adult children b. Adult siblings c. Adult women d. Adult men 127. There are manyapproaches andtechniques that may be used to help families understand addiction and support sobriety. How doesthe Bowenfamily systemstheory view the family? a. Aninterdependentemotionalunit b. Autonomous membersin a collective c. Functional co-participantsin limited endeavors d. Disparate participants seeking harmony -78GE TTTS FO BSTOTI BTBOF TSOT TROTTOPT ATTTT

128. Whenhelpingfamilies adjust to and maintain in-homesobriety, whatis the therapeutic intervention that draws upon extended support linkages to produce motivation and reinforcement known as? a. Structural or strategic systems therapy

b, Networktherapy c. Cognitive-behavioral therapy d, Multidimensional family therapy

129, Many therapeutic approaches might be helpful in working with families ofaddicts. Of those commonly used, whichbrief therapeutic approachusesthe miracle question technique? a. Cognitive-behavioraltherapy b. Bowen family systemstherapy ¢. Multidimensional family therapy d. Solution-focusedfamily therapy 130. Genetic factors canplay a significantrole in anindividual's susceptibility to substance abuse andaddiction, It is estimatedthat genetic factors account for a. 20 to 40 percentof addiction vulnerability. b. 30 to 50 percentof addiction vulnerability. c.40 to 60 percent ofaddiction vulnerability. d. 50 to 70percentof addiction vulnerability. 131, Numerous factors have protective influences against the developmentofsubstanceabuse and addiction. If the homeitselfis a high-risk environment(parental druguse,etc.), how can a minor's healthy developmentbe optimized? a. They distance themselves fromtheir dysfunctionalfamilies. b. Theydevelopa talent, skill, or somethingvalued by others. c. Theydo neither A norB. d. Theydo both A and B. 132. Howisthe conceptofresilience, from the perspectiveof mental health, BEST described? a, Internalstrengths necessary to cope with challenging events b. Adequate resources to drawuponin timesof emotional compromise c. Social networks that can offer support during timesofdistress d. Intellectualfund ofinformation to reasonandcopewell with problems 133. Culture canplay a significant role in substance abuse. How do Hispanic andLatino populations, in general, tend to respondto alcohol problemsin the family? a. Bylashing out andaggressively confronting the drinking problem b. By attempting to ignore and avoid discussing the drinking problem c. By seekingout authority figures to help them engagethe drinking problem d. By seeking outreligious leaders to help them engagethe drinking problem 134. African Americans have a significant presencein the United States. Whatis the percentage of the population thatidentifies themselvesas black? a.8 percent b. 11 percent

c.13 percent d. 16 percent a

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135, Native Americans (AmericanIndians and Alaska natives) havedistinct cultures, particularly amongthoseliving on reservations ortrust lands. What percentagereport alcohol use? a. 15 percent

b. 25percent c.35 percent d.20 percent

136. The racial mix of the United States continuesto shift substantially. Whatis the fastest-growing minority groupin the nation? a. Hispanics and Latinos b. Asians andPacific Islanders c. African Americans d. Native Americans 137. Soonerorlater,all treatment programsend,and a discharge summary andcontinuing care planwill then be required. Whatis the key difference betweena discharge summary and a continuing care plan? a. A dischargeplanprovides directions for further treatment, while the continuing care plan addressesthe client's clinical presentation at discharge. b.A discharge plan provides an overview oftreatment andoutcomes, while the continuing care plan addressesaftercare optionsbased on theclient's response to treatment. c.A dischargeplanprovidesa roster ofprior professionals involved, while the continuing care plan proposesfurtherprofessionals to engagein the treatmentprocess.

d. A dischargeplan provides a theoreticalorientationto a client's presentation, while a continuing care plan offers a modelforfurtherintervention. 138. Tracking client progress longitudinallyis important to measure progress and document programeffectiveness. How oftenis client data typically reviewed? a. Annually b. Biannually c.Semiannually d. Quarterly 139, Ideally, a treatmentplan should be developed with which ofthe following sets of people? a. A consultant and the primary counselor b. Theprimary counselorand anassigned treatment team member c. The counselor andtheclient together d. A program administratorand a consultant 140. Treatmentplans should refer to the type ofprogram service modality being offered. Which of the following is NOT a common modality? a. Residential b. Outpatient

c. Scholastic d. Perinatal

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141. Fundamental ethicalprinciples governthe addiction treatmentprocess,especially in situations

of medication-assisted treatment(MAT) foropioid addiction. What doestheprinciple of nonmaleficencerefer to? a, Preserving client autonomy b. Workingto a client’s benefit c. Doing no harm to a client d. Faithfully honoring commitments

142. The capacity to be empathetic is important in counseling. What musta counselor do when relating to clients overissuesof their past? a. Avoid anykind of emotional connectionthat compromises objectivity. b. Avoid becomingoverly drawninto the client's history andissues. c. Ensure total emersionin the client's issues to properly relate and understand. d. Ensure every detailof past pain and traumais relieved andreleased. 143. The counselor-client relationship can bevery complex. Whatdoes the term transference refer

to?

a. Feelings from the client that the counseloruses to strengthen the relationship b. Feelings from the counselorthatthe client accepts to growand improve c. Feelings from a pastrelationshipthat are projected onto the counselor d. Feelings from currentrelationshipsthat are added to the counseling experience

144. The therapeutic relationshipcan producefeelings that are challenging. What does the term

countertransferencerefer to?

a, Feelingsfrom the client that are projected onto the counselor b. Feelings from the counselor that are projectedonto theclient c. Feelings thatthe client openly shares with the counselor d. Feelings from the counselorthat are used to promoteresolution

145. Working with substance-abusingclients can result in a variety ofemotive experiences. What doesthe term secondary traumareferto? a. Theoverlay ofemotional abuse in a physically abusive relationship b. The medical sequelae that mayarise after years of emotional abuse c. Entering a relationship with abusive features like those experienced before d. Symptomsin the counselor emergingfrom high exposure to client traumas 146. Substance-abusingclients canbe clinically and personally challenging. Ofwhat is compassion fatigue a key symptom? a. Counselor burnout b. Clients with high-abuse histories c. Counselor apathy d. Clients with multimodalissues 147. Whatdoes a treatmentframeassist both the counselor andclients to establish and maintain? a. An effective theoretical orientation b. Healthy boundariesin treatment c. Shared meanings and definitions d. Aneffective treatment focus -81GE TTTS FO BSTOTI BTBOF TSTTROTTOTTPT TTT

148.Trustis anessential componentofa productive counseling relationship. Whichof the

following is NOTa key counselor contribution to the developmentoftrust? a. Unconditionalpositive regard

b. Nonjudgmental attitudes c. Greaterlatitude in boundary setting d. Ongoing commitmentto client success 149. Counselor-clientrelationships can at times becomeinappropriately intimate andintense. Whatis oneparticularly problematic potential fromthis? it rejection ofthe counselor b, Client romantic feelings for a counselor c. Client apathyregarding a counselor d, Clientfeelings ofangertoward a counselor 150. Clients with a history of sexual abuse may have poor boundaries with others. Ifa counselor becomes sexually involved with a client, whatare the consequences? a. Termination of employment b. Loss oflicensure c. Potential prosecution d. All ofthe above

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Answersand Explanations 1. A: Opioids (heroin, morphine, codeine, etc.) and the semisynthetic andsyntheticderivatives have

a withdrawal syndrome generally characterized by nausea, vomiting, runnynose, watery eyes, chills, abdominalcramps, anorexia, weakness,bone pains, tremors, sweating, feelings ofpanic, and persistent yawning.Moreserious symptoms suchas convulsions and cardiovascularcollapse are very rare, Hallucinogenics and psychedelicstypically do not have a withdrawalsyndrome, though flashbacks of past trips may well occur. Barbiturate withdrawal symptoms include:insomnia, anxiety, delirium andtremors, and the possibility of convulsions(seizures) and death. Benzodiazepine withdrawal symptomsare similar to those of barbiturate withdrawalbut potentially at least somewhatless severe.

2. C: Studies reveal that major factors in drug abuse vulnerability include social, family, culture, and otherfactors. However, epidemiological studies reveal that genetic factors contribute as much as half ofan individual's risk for drug abuse. Theroleofgeneticsis slightly higherfor males than females, and therole of genetics in heroin abuse exceedsthat ofany other drug. Further, the greater andmoresevere the manifestationof drug abuse, the more predominantthe role of genetics in the predispositionfor substance abuse. Theorists suggest a malfunction in neurotransmitter production results in a potentially profound need to self-medicate to compensate. 3. C: There are numerousfactors that contribute to the tendency ofadolescents to impulsiveness, unruly behavior, andrisk taking. These includelimitedlife experience, high energy, a concomitant desire for external stimuli and engagement, a predisposition toward peerinfluences, and so on. Of primary influence, however,is the issue of neurological immaturity. Key portions ofthe brain that managejudgment and emotional control are amongthe last to mature. The prefrontal cortex, where impulse control, reasoning, and foresight are managed, does not mature until early adulthood. Further, the adolescent brain appears to be morereceptive to the effects of substances ofabuse as. well as morevulnerable to subsequentphysiological consequences. 4. C: Depressantdrugs reduce levels ofstress-related neurotransmitters and inhibit stress-accelerating hormones (e.g,, adrenalin andcortisol). This is accomplished,in part, by mimicking the body's three natural stress-reducing analgesics knownas endorphins (a contraction ofthe term endogenous morphine). Lacking symptoms ofstress, depressant abusers such asheroin users may use the drug infrequently for years withoutdeveloping an addiction. Should significant stress arise, however,the abuse of depressant drugs becomes highly likely. Itis further theorized that addiction potential is enhanced where biological factors may make stress susceptibility greater.

5. B: Benzodiazepine tolerance developsfairly rapidly. Consequently, anxiety cannotbe treated effectively beyondfour months, regardless ofthe dosage. Polydrug useis particularly problematic

asusing benzodiazepinesin conjunction with pain medications, alcohol, and antihistamines can

produce severe respiratory depression and evendeath. In the United States, the second-leading cause of drug-related emergency department admissionis benzodiazepine overdose. Due to the developmentoftolerance, evenafter use for aslittle as two to three weeks, individuals must be weanedawayfrom benzodiazepines under medical supervision, most commonly over a period of months. 6. A: Low-doseingestion ofalcohol has stimulant effects, producing euphoria andexcitability. This occurs as a result of low-dose alcoholtriggering the brain’s the dopaminergic rewardpathway. At -83GE TTTS FO BSTOTI BTBOF TSTTROTTOTTTPTT ATTTT

higherdoses, alcoholis a powerfulcentral nervous system depressant, producing drowsiness and sedation.Very high levels can induce stupor, coma, and evendeath. Body weight andfood intake can substantiallyaffect bloodalcohollevels and absorptionrates. Food canslow absorption, and bodyweight can dilute the alcoholtaken in. Age, however, can play a meaningful role as well. The elderly have less lean body mass and muscle and morefat. Nonfat body mass contains water, which dilutes alcohol; alcoholis not solublein fat. Thus, the elderly becomeintoxicated morereadily than youngerindividuals oftheir sameheight andweight. 7.C: Virtuallyall drugs that cross the blood-brain barrierwill affect the fetus, and fetal addiction can result, requiring suffering withdrawals at birth. However,ofall drugs of abuse, alcoholis the most dangerousto the developingfetus. Even moderate drinking during pregnancy (particularly during the first three months) can resultin birth defects such as organ andskeletal malformations andintellectual impairment. Somebabies appearnormalat birth and subsequently developserious learningandbehavioral problems as they grow older. More regular alcohol abuse may result in fetal alcohol syndrome(FAS), often with characteristic head andfacial deformities, intellectual disability, heart defects, stunted growth, and so on. Whenthetypicalfacial characteristics are lacking, the disorderis called fetal alcoholeffects. 8. B: In most people, monoamineoxidases (MAOs) regulate the levels ofserotonin, dopamine, and norepinephrine. Those with an excess of MAO may experience endogenous depression due to

reduced key neurotransmitter levels. These individuals appearto self-medicate byusing stimulant drugs. Their goalis to lift depression, increase energy, and reduceinward tension. Otherpeople with unique genetic dopaminereceptorvariations maybe particularly susceptible to addiction due to their tendency towardimpulsivity, anger, agitation, and boredom. Manyin this group are drawn to high-risk activities such as extreme sports as well as drug abuse.Forthis group,stimulants are uniquely rewarding and thus profoundly compelling andaddictive. 9. D: Whethersnorted,injected, or smoked(oralingestionis not effective), cocaine triggers the release ofdopamine, serotonin, and norepinephrine.The primary effect occurs through the buildup of dopamine, thoughall neurotransmitters involved contributeto the subsequent euphoria. Not only does cocaine stimulate the release of these key neurotransmitters, butit also blocks their natural reabsorption by inhibiting a reuptake transporterfrom carrying outits normalfunctions. After the euphoria passes, neurotransmitter depletion induces a sense of profound dysphoria and depression, thus generating a needfor furtheruse of the drug. Individuals who are naturally deficient in serotonin appearto beparticularly at risk for cocaineaddiction. 10. A: Nootropicsare drugsdesignedto boost cognitive performance. These neuro-enhancingdrugs tend to be usedbyhighly competitive and overcommitted individuals to enhance concentration, focus, and memory andto help ward off fatigue and somnolence. Among the more popular of these medications are Provigil (generic: mondafinil) and Adderall (generic: dextroamphetamine saccharate, amphetamineaspartate, dextroamphetaminesulfate, and amphetaminesulfate—or, sometimes,just amphetamine/dextroamphetamine). Adderall contains amphetaminesalts designedto increase dopamineandnorepinephrine levels in the brain andis used in the treatment ofattentiondeficit hyperactivity disorder (ADHD). Provigil is a stimulantusedin the treatment of sleep disorders.Another nootropic,Piracetam (or Nootrapil;

generic: 2-oxo-1-pyrrolidine

acetamide), is sold as a supplement. Used widely in Europe,it has not received Foodand Drug

Administration (FDA)approval. Chemically,it influences neuronalandvascular functions and

thereby enhances cognitive function withoutacting as a sedative or stimulant. It has beenusedto treat depression,the disabling effects ofstroke, and a variety ofother neurological disorders. -84GR TTFO BSTBTETRTB TYOT TSOTRISTTPTT ART

11. B: Use ofalcoholearly in the day, including a first drink to cope with a hangover,is one symptomin the progression tothe heavy drinking stage. Thefirst stage in the developmentof alcoholismis social drinking. Theseindividuals drink for enjoymentandrelaxation and remain within the conventions ofexpected use and behavior. Manyindividualsrarely,if ever, step outside this category of drinking. Most whodofind thetrigger to be unexpected or unusually burdensome stress. With theonsetof a sufficient stressor, some individuals will progress to the secondstage of heavy drinking.In this stage, drinkers violate norms and expected alcohol use behaviors and begin to experience negative consequences.If heavy drinking continues, drinkers enter thefinalstage of dependentdrinking, characterizedby out-of-controldrinking and obsessionwith the use ofalcohol. High-functioning alcoholics (HFA) are able to compartmentalize their alcoholuseand thereby functionwell socially, thoughpoorly privately and intimately. 12. D: Thefive stages in the life cycle of heroin addiction consist ofthe following: (1) experimentation—dabbling in many drugs,including snorting or subcutaneous heroin injection; (2) jation—a typically unpleasantfirst experience (nausea and vomiting) followedbyincreasingly enjoyable subsequentinjections; (3) commitment—assuming the identity ofthe heroin subculture and orientinglife toward habit maintenance;(4) disjunction—crime, arrests, imprisonment, court-orderedtreatment, andefforts to reduce the habit to a more manageable extent or to deal with physicalillness and compromise; (5) maturation—phasingout drugs(usually at an age closer to forty than twenty, thoughpotentially into thefifties orsixties) or dying from the abuse. 13. C: The first step towardcocaineabuse begins with experimentaluse. Most relationships are

with nonusers, and no apparentconsequences from experimentationare observed. The second

stageis compulsive use.Inthis stage,cocaine is used to cope with depression, mood swings and

stress and to cope with coming down from a desirable high. The numberoffriends whouse increases, and nonuserfriends begin to be avoided. Financial problemsbeginto appear. The third andfinal stage, dysfunctional use, is characterized by preoccupation with the use ofthe drug, chronic sleep andhealth problems, serious disruptionsin social and familylife, and work and financial devastation. Treatment maybe soughtas the consequences mount and the compulsion to use becomesoverwhelming, Trading sex for drugs is common, lending to high-risk ofexposure to sexually transmitted infections(STIs).

14. Band C: Weak family tieslead to a loss of normally internalized behavioral and decision-making restraints. Feelings of familial estrangementlend to poor family and community socialization and an absenceofprosocial constructs. Highly chaotic, disorganized, and disadvantaged communities are particularly lackingin the ability to exert positive, conforming influences and to create broader community ties and commitment. Weak societalties resultin a loss of obligation to the community and society at large. Externalrestraints are then reducedor removed entirely when closerties are madewith individuals espousing andliving the norms ofa drug subculture. In such circumstances, the usualrestraintsof social disapproval and fearofpunishment are bypassedas the subcultural norms replace andobviate those ofthe usually prevailing broadersocial structure. In overly affluent communities, absent, neglectful, and emotionally unavailable adults leave their youth unduly susceptible to peerpressure, consumerism, and hedonistic pursuits, including drug use and abuse.Thus,in both disadvantagedand affluent communities, weak family andsocietal ties can lead

to substanceabuseissues.

15. D: Anabolic steroids are typically used for their muscle-enhancing benefits. This produces an aspect of psychological dependence as individuals use them to achievesocial benefits—to look better and tosustain enhanced athletic prowess, and soon,Issuesoftolerance to the drugleadto higher dosages over time. At both medical and higher doses, anabolic steroids can inducesignificant -85GE TTTS FO BSTOTI BTBOF TSTTROTTOTTPTT ATRTT

euphoria. It appearsthat steroids engageboth opioid and dopamine neurotransmission systems in

the brain. In consequence, the use of opiates to deal with overexertionpain can more readily lead to opiate addiction as well. Anabolic steroid addictive potential appears on a parwith caffein nicotine, andthe benzodiazepines. Symptoms ofwithdrawal are very muchlike those experienced bycocaineusers, including insomnia, anorexia, headaches, restlessness, poorlibido, and dysphoria. Depressive symptoms can be significant enough to approachsuicidality. Appropriate titration and weaning maybe required to manageissues ofwithdrawal. 16, C: Individuals present for treatment for a great variety of reasons. Amongthese are:(1) a need for transientrelief from the effects of their substanceabuse butstill intendingto return; (2) a desire to modify their substance abuse but recognizing only mildly associated problems from the abuse; (3) primary desire to maintain employment, a marriage, physical health, mental health, or for other situationally driven reasons; (4) ambivalentfeelings about their substance abuse and unsure whatthey really want; (5) a genuinedesire to change but with a senseoffearthattheywill be unable to produce the commitment needed tofully realize it; and so on. Determining where client readiness for changeis crucial to producing a treatment approach that can optimizehis or her potential for ultimate success. 17. C: Client ambivalence about substance abuse is natural and unavoidable. If this ambivalence is misinterpretedto be denial, resistance, or confrontation, the counselor-client relationship may becomeunnecessarily conflicted andpolarized. Indeed, commonmotivational conflicts include: (1) pre-contemplation—"I'm notconcerned, but others in mylife will feel reassured ifwetalk”; (2) contemplation—"Stopping druguse might help mefeel better about myself, butI still can't see neverusing again”; (3) preparation—I'll set a quit date, but I don’t know if | am strong enoughto follow through’; (4) action—"T've been soberfor three weeks, and now myold selfwants to.

celebrate by getting high”;(5) maintenance—"“After monthsofsobriety, | still sometimes wonderif

total abstinenceis really require

18. B: This primary goalis bestrealized by reviewing andevaluating symptoms, thecurrent situation, available resources, amenability to treatment, readiness for change, program goodness of fit, possible dual diagnoses, potential referral needs, andso on. During screeningand intake evaluation, a great manythings will be learned, butall information should primarily be usedto determinean optimuminitialcourseofintervention andtreatment, giventheclient's

characteristics and needs. There may besituations where client characteristics require referral to anothertreatmentprovided, but merely off-loadingdifficult clients should never be a goalofthe screening process. Medical needs,in particular, may necessitate hospitalization, inpatient detoxification, or referral to a programsetting with a higher level of care or with the capacity to better evaluate and treat certain dual diagnoses. Otherwise, however, screening should remain focusedondesigning a treatmentprogram thatwill optimize theclient's potential for eventual success. 19. B: Intake screeningtools are designedto identify thoseclients requiring a more thorough assessmentin targetedmatters of concern. In substanceabuse,this involves screeningfor the presence of a pattern of use worthyof concern, an outright disorder requiring treatment, orthe likely presence ofco-occurringdisorders (CODs), such as possible underlying mentalillness, that should also be assessed further. Screeningtools are nottypically designed to define any particular mentaldisorder but ratherthe likelihoodthat a co-occurring mentaldisorder mayexist. Screeners should befamiliar with specific protocols for properly scoring screeninginstruments aswell as protocols for specific stepsto take when anindividual breaches the cutoff threshold for substance abuse or a co-occurring mental disorder. -86GE TTTS FO BSTOTI BTSOTSST TRAOTTOTTTPT ATTTT

20. D: Individuals with substanceuse disordersalso run a muchhigherrisk of eventual death by

suicide. Indeed,those whoinject drugs run a risk fourteentimes higher than those in the general population.Of further importance, individuals in treatmentcontinueto run a substantially elevated risk ofsuicide, thus treatmentstaff should be continuously awareofindicators ofcascadingrisk

(eg,ideation, gestures,isolation, mood changes, etc.). Therisk ofsuicide in treatmenttypically

arises from factors concurrentwith the decision to enter treatment. Specially: (1) they typically enter treatment when circumstancesare outof control; (b) treatmentis usually accepted in the face

of multiple otherlife crises (job, marriage, health,etc.); and (3) seeking treatmentoftencoincides with peakperiodsof concurrentdepression.

21. C:Screeningisa process of examining a clientfor one or more specific potentialproblems, while assessment defines the nature andextentofthe problemandoffers treatmentrecommendations. Assessmentinvolves a clinical evaluationofclient functioning andpresenting well-being. A basic assessment includes fundamental information gathering and examinationofclient problems, strengths, disabilities, co-occurring disorders, and readiness for change. Co-occurring disorders (CODs) are obtainedvia referral to a qualified health care professional(licensedclinicalsocial worker, psychologist, psychiatrist, etc.). Once formalized,relevantaspects of CODsareintegrated into the treatmentplanformulation andapplication. 22. D:It is importantto identify and measure the changingnature ofevery client's status as related to issues of addiction andanyotherco-occurring mentalillness. Only by tracking changeovertime it possible to determine theeffectivenessofthe treatments being provided as well as the degree ofthe client's continuing commitmentto change. Objective measurementtools include:Addiction Severity Index (ASI), Mental Health Screening Form-III, Symptom Distress Scale (SDS), and University of RhodeIsland Change AssessmentScale (URICA).

23. D: Thereis no single gold standardassessmenttoolfor theidentificationof co-occurring disorders (CODs). Rather,it is importantfor the counselorto be able screenfor CODsandthen select one or more appropriate assessmenttools by which to more extensively assess the presence or absenceofa true COD.Consequently, depression might be assessed using the twenty-one-question Beck Depression Inventory (BDI), and a standardized mental status examination (MSE) mayberequiredto explore possible thought disorders andotherpotential mentalfunctioningirregularities (e.g,, hallucinations, delusions,suicidality, etc.). In concert with this, careful attentiontocorollaries betweensubstances abused and mental functioning changes, particularly during extended periods of abstinence, can aid in determining whetheror not mental disorders areactually transient sequelae from substances abuse ortrue underlyingdisorders. 24. D:Obtaininginformationfrom collateral contacts is an essential step in the twelve-step assessmentprocess required for investigating primary and co-occurring disorders (CODs). Clients may minimize, omit, alter, or otherwise revise informationcrucial to the assessment. By making

collateral contacts, the likelihood ofincomplete, skewed, or outrightfabricated informationis greatly reduced. Thefull twelve-step assessment process includes: (1) engagingthe client; (2) makingcollateral contacts (with properclient authorization); (3) screening for CODs;(4) assessing substanceuse and mentaldisorderseverity; (5) identifying the optimalcare setting(e.g, day

treatment, outpatient, inpatient, etc.); (6) establishing the diagnosis; (7) identifying impairments and disabilities; (8) determining strengths and supports; (9) determining any special languageor cultural needs and supports; (10) determining other problem areas(health, finances, education, etc,); (11) identifying readiness for change; and(12) treatmentplanning. -87GE TTTS FO BSTOTI BTBOTSTTROTSTTTPTT ATT

25.A: Intake is focusedon fundamental information gathering as opposed to exploring feelings, attitudes, and readiness for change. Afterbasic informationhas been gathered,intakeinformation can beextended and augmented by theuse ofobjective measurementtools such as: (1) the Addiction Severity Index (ASI), the MentalHealth Screening Form-IIl, the Symptom Distress Scale

(SDS), andthe University of RhodeIsland Change AssessmentScale (URICA). Oncethis information

has beenassembled,the counselor must organize it in such a waythatall meaningfulfindings can be integratedinto the treatment planning andinterventionprocess.

26. B: The SubstanceAbuse Subtle ScreeningInventory (SASSI) has beenextensively researched andrevised. Now in its third edition (SASSI-3), is composed ofboth obvious andsubtle items. This makesit particularly usefulin situations where individuals are either unwilling or unable to acknowledge substance abuse problems.It is comprisedofsixty-seven true-false items as well as a twenty-six-item self-report section onsubstanceuse andtakesless thanfifteen minutes to complete. Designed clinical use,it is not appropriate for preemploymentscreeningorother nonclinical applications. The Michigan AlcoholScreening Test (MAST) is one ofthe oldest and most accurate alcoholscreeningtests available, butit offers nospecial tools for ferreting outissues of truth. The Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a quick and simple toolfor identifying those whouse substances atat-risk levels and thosealreadyexperiencing substanceuseissues. However,it offers no specialtools for circumventing compromised truth telling. The Addiction Severity Index (ASI) is not a screeningtool but a tool for assessment and treatmentplanning.

27. A: Measures ofclient's complianceare derived throughthe treatmentprocess, not through the

screeningor assessmentprocesses.Key screening and assessmentoutcomesinclude: (1) positive

client engagement; (2) essential authorizations and consents for treatment and collateral contacts; (3) diagnosis and severity of substance abuse and related co-occurringdisorders; (4) the proper levelof care (inpatientvs. outpatient, etc.); (5) pertinentdisabilities and functional impairments; (6) understandingofclient strengths and available supports; (7) culturalor linguistic needs and resources; (8) other unique problemsrelated to health, housing, education andvocationaltraining, cognitive capacity, social needs, and spiritualneeds.

28. C: The presence or absenceof a substance oralcohol abuse problem is determined duringthe screening process, not during the assessmentprocess. During assessment, the presence of a problem is refined to reveal the nature ofthe problem,its diagnosis, and its extent and severity. Key goals and purposes ofassessmentinclude:(1) substance abuse history; (2) the severity and extent ofthe presenting substanceor alcohol abuse problem; (3) co-occurring mental disorders; (4) legal issues that maycontribute to or impedethe treatmentprocess(e.g., court-ordered treatment vs.

detention or work-release issues, severefinancial burdensoffines and court costs, etc.); (5) health problems and stability for treatment; (6) available resourcesto help resolve the problem(family, social, employment-related,etc,); (7) clientstrengths, maturity, motivation, and readinessfor treatment; and(8) the ideal treatment approach foroptimalodds of success. 29. D: Treatmentplanning communications with clients (andinvolvedsignificant others) must be

appropriate to age and developmental level to ensure optimal comprehension and commitment. Counselors must also besensitiveto issues ofrace, ethnicity, and culture. Indeed, these issues may, at times, be paramountforsuccessfultreatment. For example, substance abuse in someinstances maybeculturally sanctioned (orrejected harshly), andracialor ethnic tensionsordisparities may

at times becomebarriers to successful treatment.Finally, communications must be free oftechnical jargonandobscure acronyms. This may bedifficult for some professionals as treatment providers at timesutilize professionally obscure wording andreferences that have become commonto them. -88GE TTTS FO BSTOTI BTBOF TSST TROTTOTTPTT ATT

30. C: When clients understandthe data and findings from the assessment, they morefully understand whatchallenges they face and theimportance andvalue oftheinterventions being selected. Client buy-in to the treatmentplanis essential to its optimum success. Therefore, assessmentfindings need to be thoroughlyexplained andclearly related to proposedtreatments in wordsand ways that meet the communication style and patternsofthe client and his or her significantothers (involved family,friends, etc.). Sharing with significantothers is importantso that they maybetteroffer the clienteffective support and to avoidunintentionally undermining treatmentefforts. In sharing this information, feedback should beelicited from the client and involved others to ensure theirfull understandingofthe available informationand ofthe treatment processes and purposes. Feedback can also ensure thatall intake and assessmentinformation was accurately obtainedandproperly recorded. 31. A: Historically,clients have been provided bundledservices in a one-size-fits-all approachthat was notindividualized. Newerresearch reveals that unbundling services to pick and choose those most appropriate for the clientis far better. Therefore,theclient assessmentprocess should not only identify client needs butclient preferences as well. With this information, a treatmentplan should be formulated to meets both theclient's needs andpreferences. Subsequently, theclient's needs and preferences should be optimally matchedwith available resources, intervention types, level ofcare, andservice intensity.Doing sonotonlyincreasesclientretentionin the treatment

programbut improvesthe overall successofthe treatmentprovided. In this way, treatment outcomescan be optimizedfor treatmentsuccess.

32. C: Patientplacementcriteria (PPC) provide guidelinesfortheconditions required for substance

abusetreatment admission (admissioncriteria), criteria for continuingtreatmentat each

designatedlevel ofcare (continuing carecriteria), andthecriteria that mustguideclient movement

betweenvariouslevels ofcare or release from a given treatmentprogramorfacility (discharge and transfercriteria). Overall, PPC standards address appropriate treatmentsettings andfacilities, staffing levels and the skill mix, and the requisite kinds ofservices for treatments at any givenlevel of care. The guidelines are based on specific areas ofclient assessment, including relevant substance abusediagnoses.

33. B: Theclients most ready for change are those who perceive theneedfor help with theprocess of change andparticularly when otheroptions are perceived as comparatively less attractive. Further, treatmentprogram retention appears to be closely relatedto a client's perceptions of his or her substance abuseproblem as well as the extent of understandingofavailable treatment options. Readiness is compromised whenothernontreatmentalternatives seem acceptable and whentheclient hassignificantfeelings of ambivalence aboutthe need for change. In situations of high ambivalenceor where theclientis a nonvoluntary participant, the engagementorcreation ofa motivationalcrisis may assist him or her in becoming moreaccepting of treatment. 34. D:Treatmentsequencingensures a continuum ofcare andtreatmentwill be prioritized in such away as to meet a client's mostbasic needs before less-fundamental needsare addressed. This typically requires a case managementcare model, which offers a coordinated approach to service delivery. Case managementrequires a holistic approach, ensuring that not only substance abuse issues are addressed but that physical and mental health andspiritual and social needs are also being adequately evaluated and met throughoutthetreatmentprocess. This requiresfive key evaluative and engagementprocesses: (1) assessment, (2) planning, (3) linkage (especially when multidisciplinary or evenoutsideservices needed), (4) monitoring(including documentation), and (5) advocacy. -89GE TTTS FO BSTOTI BTBOF TYOT TROTSTTTPTT TTT

35. A: Abraham Maslow proposed the Hierarchy of Needs 1943, which has become a foundational understandingin psychology. The conceptindicates that an individual's needs areprioritized in importance, with morebasic needs suchas survival, security, and sociality holding higher order portance thanlove, belonging, self-esteem, purpose, and self-actualization. An understanding of this paradigm is importantin treatmentplanning. Specifically, if basic survival andsafety needs remain unmet, efforts to meetotherneedswill not elicit a sense of optimal responsiveness and wholenessfrom the client. This incongruence can negatively affect the treatmentofthe substance disorderas well. 36. C: Abraham Maslow’s Hierarchyof Needs has been presented in varying ways but essentially includes the following:(1) physiological needs (basic needsfor survival); (2) security needs(safety andprotection as a family and society); (3) love and belonging needs(social needs such as friendship, love, appreciation, etc.); (4) esteem needs(self-respect, recognition as unique, personal value,etc.); (5) the need for purpose (meaningtolife, finding and meetingone’s inner potential, etc,); (6) self-actualization (creativity, morality, wisdom,etc.). Until lower-orderneeds are met, itis difficult to investin or even fully appreciate higher-orderneeds. Substance abusetransiently obviates any awareness of needs andattimes evenartificially substitutes for them (feelings of well-being, status, creativity, etc.). Consequently, until substantial progress is made in meeting hierarchicalneeds, problemswith extinguishing substanceabusearelikely to persist. 37. D: Howtheclinician asks questionscan make a substantial difference. For example, the general question “Are you depressed?”can easily be deniedoutright (based upon a sense ofnegative judgment)or misunderstood(if the client does not understandprecisely whatthe clinician is asking). Clearer and more specific clinical questioning might be: “Doyou feel sad, hopeless, too tired, or have problemsconcentrating?” Open-endedquestioningis goodas it allowsthe client to answerfreely and broadly. However, leading questions are nothelpful, even if open-ended in nature(ie., "You're not feeling depressed, are you?"). Finally, professional jargon may make a clinician feel proficient and empowered,butit leavesclients confused andfeeling vulnerable.It is always important to speak in easily understood terms. 38. D: A psychiatrist, George Engel, coined the term biopsychosocialin 1977to support the interrelated andinterconnectedcausalfactors necessary to explain mental health disorders. The Biopsychosocial Modelis widely used in the substance abusefield asit offers a more comprehensive way of explaining the numerous elements that contribute to developing and sustaining anaddictiondisorder.Useofthis modelallows for the concurrent application of numerous differenttheories andinterventions, therebyoffering a more comprehensive treatment approach, A unique strength ofthis modelis that no single theory orintervention is necessarily superiorto anyother. In this way, differing views are seen as complementary and meaningful, even while highlighting the differences necessary to adequately identify and address the treatment complexity in managing multiple disorders. 39. B: The Chemical Use, Abuse, and Dependence (CUAD)Scale is used in substance abuse

assessment, and it does derive a Diagnostic andStatistical Manual of Mental Disorders (DSM)

diagnosis ofsubstanceusedisorder.It is relatively brief (a five-to thirty-minuteinterview, dependingonthe degreeandkindsof substancesused)andit also requires limited training.

However,it is best knownforits utility in assessing substance abusein mentallyill clients. It has.

most commonly beenstudiedin clients with depression andschizophrenia,thusits applicability in otherpopulations (eg., bipolardisorder,etc.) less well documented.It is a dependable andvalid diagnostic instrumentfor determining the extentof substance abuse. The CUADuses a short, partly -90GE TTTS FO BSTOTI BSTBOF TSTTROTTOTTPTT ATTTT

structuredinterview thatis far less time-consumingthanearlier assessmentmethods such asthe AddictionSeverity Index (ASI). Researchers have confirmedthe CUAD’s accuracy. 40. D: The Symptom Checklist-90-R (SCL-90-R)is used to assess a broad rangeof psychological problemsand key symptoms of psychopathology. Theinstrumentis also used to measure client progress or treatment outcomes.Containingonlyninety itemsanda five-pointratingscale, the

SCL-90-R canbe completed in aslittle as twelveto fifteen minutes. Normedfor individuals ages thirteen and older, the test producesan overviewof symptomsand associated intensity ata specific point in time. The nine primary symptom dimensions measuredare: somatization, obsessive-compulsive, interpersonalsensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. The index of symptomseverity facilitates treatmentdecisions andidentifies problemsbefore they become acute. The GlobalSeverity Index serves as a summary. Thereliability and validity of the instrument have been confirmedin morethan 1,000separate studies.

41. D: The COPESis used to measure theactual, preferred, and expected treatment environmentor socialclimate ofcommunity treatment programs.Theseinclude residentialfacilities, rehabilitation centers, halfway houses, and care homes. COPESdrawsuponthe opinionsofboth clients and staff using three key dimensions:(1) relationship dimensions, (2) personal growthdimensions, and (3) system maintenance dimensions. The relationship dimensionsare assessedvia threesubscales: (1) involvement, (2) support, and (3) spontaneity. Four subscales are used to evaluate the personal

growth dimensions:(1) autonomy,(2) practicalorientation, (3) personalproblemsorientation, and

(4)anger and aggression. Thesystem maintenance dimensionsare assessed via three subscales: (1) order and organization, (2) program clarity, and(3) staff control. Research reveals that these dimensionsare directly relatedto objective indicators of treatment outcomesuch as drop-outrate, release rate, and community tenure. The regular use of COPEScan leadto important program and service outcome measures andindices ofprogram andservice progress.

42. C: The TreatmentServices Review (TSR) is designedfor use in conjunction with the Addiction Severity Index (ASI). The TSRis a ten-minute structuredinterview that assesses the nature and frequency oftreatmentservices providedfora clientin the following domains: (1) medical problems; (2) substance use (alcohol and drug) problems; (3) employment and support problems; (4) family problems; (5) legal problems; and (6) psychological or emotional problems. Each domain is comprised of three sections. Thefirst section reports the numberofdays that a target behavioror problem occurred. The secondsection records the numberoftimes (per week) that a professional has providedservices. Thethird section captures the numberofstructured sessions that were held for a particular problem duringthe prior week—whetherthrough theindex treatment program (in-program) orby others (out-program). The TSRprovides a continuousrecordof the number and typesofservices provided, the rate at which these identified problems show change, and measures cost-effectiveness amongthepatient population that actually receives theservices. 43. C: The behavior componentof BIRP progress recording is focused on counselorobservations andclientstatements. It beginswith subjective data (the client's observations, thoughts, and direct quotes) and movesto objective data (counselor observationsofclientaffect, mood, appearance, etc,). The interventionsection captures the counselor'sefforts toward goals andobjectives (counselor understandings and working hypotheses, etc, general session content, whether homework was reviewed,e.g,, journal, reading assignments,etc,, if any) andthe goals and objectives addressedthis session. Responserefers to the client's intervention response and treatmentplan goals and objectives progress. Planinvolves documentationofwhatis to happen -91GE TTTS FO BSTOTI BSTBOF TSTTROTTOTTPT ATT

next, goals andobjectives revisions, scheduled activities (sessions, group work, etc), and any new orupdatedinterventions. 44, B: The chief complaintis the presenting problem oranysignificantissues requiring primary

attention. History is anyrelevanthistoricalinformation—deephistory atintake or recenthistory as

relevant to the chiefcomplaint or presentingproblem. Examis any change or lack of change in mental status (MMSE), mood, and behavior—current appearance, speech changes, psychomotor (agitated or retarded), moodor affect(in client's words), observed expressionsandemotive range, thought contentandprocesses, insight, judgment, and impulse control. Assessmentis any positive diagnostic studies, medicationissues, or consultation summaries, along with comments from other service providers; five axes diagnoses; and a briefstatementof overall impression. Theplanis justification for any changesin the treatment plan andongoinginterventions, medication changes, orprogram changes, placementconsiderations, and so on, with the rationale for each.

45. A: The acronym SIGECAPSis a tool prompting thefull evaluationof the symptoms of depression. Each letter addresses one ofthe keypotential features ofdepression:sleep(anysignificant increase ordecrease), interests (decreaseorloss ofinterestin previously pleasurable activities or events), guilt (feelings ofguilt and burdenwithoutanyrealculpability orfeelings that are disproportionate to actual circumstances), energy (decreased energy orfeelings oflistlessness, wearinessorfatigue), concentration (decreasedability to focus and cognitively pursue thoughts in a meaningful way),

appetite(increased or decreasedappetite, as evidenced by weightloss or weight gain), psychomotoragitationor retardation (jittery tension and agitationorlethargy and sluggishnessin movements), andsuicidal ideation(persistent thoughts ofself-harm,potentially escalating into increasingly detailed plans over time). 46. C: Both of these formats wereoriginated Rogetand Johnson. CARTrefers to client condition

(presentation, presenting problem,chief complaint, etc.), actions (actions the counselordid in response to theclient's condition, response(client responseto the actions orintervention), and treatmentplan (how the responseinforms, extends, orclarifies the treatment plan). CHARTrefers to client condition (presentation, presenting problem, chief complaint, etc), historical significance (of the client's condition), actions (actions takenby the counselorin responseto theclient's condition), response (client responseto the actions orintervention), and treatmentplan (how the client's response informs, extends, modifies, orclarifies the treatment plan). 47. A: A full biopsychosocial assessment shouldrevealspecific client needs, strengths, weaknesses, andreadiness for change. Matchingclients with well-selected andtailored servicessignificantly improvesclient outcomes.In a six-month study, researchers revealedthatclients with case managers whohelpedcoordinate treatment with medical care, employment needs, housing resources, and parenting needs(child care, skills training, etc.) had reducedsubstance use and lowerincidence of mental and physical problems. This has been emphasized bythe National

Institute on Drug Abuse, which states that “matching treatmentsettings, interventions, and services

to each individual's particular problemsand needsis critical tohis or her ultimate successin returning to productivefunctioningin the family, workplace, andsociety.” Clearly, having a broad array oftreatment optionsand ensuringthatindividuals are receiving optimal care are in the best interests of clients.

48. C: The idea that every individual musthit bottom in orderto be ready to successfully complete treatmentis a profound butstill commonmisconception amongthe generalpopulation andevenin the substance abuse treatmentfield. Research reveals that, even when individuals enter treatment for the “wrongreasons" (e.g,, because of externalpressures), their treatment outcomes are roughly -92GE TTTS FO BSTOTI BTBOF TSTTROTTOTTTPT ATT

equivalent to those entering forthe“right reasons” (e.g,, a true desire to change). External pressuressuch as negative personal, employment, orlegal consequences may ultimately produce the internal motivations to changethat are needed.In recognitionofthis, substance abuse treatmentstaffshould generally deem a potential client's presence in theoffice as anindicator ofa workable levelofdesire for treatment services. 49. C: Virtually every client will repeatedly waverin motivation and commitmentat times. The best motivators to continuein treatment and to overcomeaddictiontend to be those thingsthatclients have previously declared as being ofimportanceto them.This can be honoringfamily relationships orwishes, avoiding legal problems, maintaining employment, maintaining health, or any numberof other motivators. Regardlessofthe desired goal, client reminders aboutthe personal motivators they alreadyhavetendto offer them thebest long-term support. In contrast to this, playing to a client'sfears tends to have an inuring and accommodatingeffect, losingits power overtime. ‘Threats also tendto polarize and drive clients away from their immediate commitments. Playing devil's advocate(i.e, I knew youcouldn't doit”) typically only confirmsa client's already deep fear offailure. Instead, positive reminders and encouragementinducea greater sense of motivation and more enduring commitment, especially if relapses occur. 50. A: In becoming ready to seek change and overcomepast habits and addictions,clients typically go through five stages of change: (1) pre-contemplation, (2) contemplation,(3) action, (4) relapse, and (5) maintenance. By virtue of having entered treatment,theclientis alreadyat the action stage in the readinessprocess. Consequently, whenclientresistanceto treatmentis encountered,this

resistance most likely indicatesthatthe client has beenpressured to movetoo quickly through the changeprocess, leaving him or herlittle opportunity to respondwith anythingbutresistance. Exploringthe client's current rationale and determination to change can reveal wherehe orshe is onthe change continuum,enabling the counselorto better support theclient alongthe way. 51. B: Research consistently reveals that the therapeutic allianceis of primary importancein clients achieving positive outcome. Among the many positive effects of the therapeutic alliance, treatment retentionis one ofthe mostsignificant. Consequently, achieving and maintaining a therapeutic alliance is crucial. Thefour key components ofaneffective therapeutic alliance are:(1)the client's capacity to purposefully workon the problem (providing a shared goal and commonground); (2) the affective (emotional) bond betweentheclient andthe therapist; (3) the therapist's possession of an empathic understandingof the client; and (4) agreement onthe primary goals and between client and therapist. Counselors can enhancethe therapeutic alliance by being empathic, nonjudgmental, and active listeners andby actively presenting the treatmentprocess as a collaborative venture,rather than as oneconsistingof unilateral directives. 52. D: Researchers reveal that completion ofany prescribed episode of treatmentis a key to improved outcomes. Thelengthof the episodeis not thecritical feature. Success produces meaningful momentum.In recognitionofthis,it is particularly importanttoretainclients in

treatmentprograms, avoiding the high drop-outrates so common in the first few weeks of treatment. Steps to reduce drop-outinclude:

preadmissioninterviewsto ensureclient readinessfor

treatment, the useoftelephone andmail reminders of ongoing appointments and program

activities, offeringtelephoneorientationsfor timely program accommodation, and decreasing any

delaysin call-to-appointment scheduling, Finally, helping clients understandthe underlying rationale behind lifestyle changesimproves behavioral adherence and program retention.

53. D:Participationin twelve-step andother mutual-help programsis associated with better outcomesthan participation in treatment programs alone. Indeed,clients who join a twelve-step -93GE TTTS FO BSTOTI BSTBOF TYTTROTSTTTTPTT ATTTT

programafter treatment tend to do significantly better than those not soinvolved, researchers have found. Consequently, treatment providers should actually facilitate clientintegrationinto appropriate community-based mutual-helpgroups,includingassistingclients to locate a groupand a sponsor. This should involve more thanreferral. Counselors shouldhelp clientsfind the right groupmeeting milieu as well as helping them determinethe optimalfrequency ofattendance. Clients who begin attending twelve-step groupsfrequently experience some minor negative side effects. These can be minimizedby ensuringselection of an optimal group,along with adequate orientation and support.

54. A: The original twelve-step program,Alcoholics Anonymous(AA, wwwalcoholics-anonymous.org) had a significantreligious orientation. Since that time, however, referencesto deity andreligion in general have been moderatedto betterallow for individual values andbeliefs. A group similar to AA but oriented toward those using narcotics is known as Narcotics Anonymous(NA, www.na.org). Some clients may also benefit from twelve-step support groupalternatives such as Rational Recovery (www.rational.org), Smart Recovery (wwwsmartrecovery.org), or Womenfor Sobriety (www.womenforsobriety.org). Offering clients a variety ofchoices empowers them to make informeddecisions, Thereare also twelve-step meetings designed to support the family members ofloved ones sufferingfrom substance abuse. These include: Al-Anon/Alateen (www.al-anon.alateen.org) and Nar-Anon(naranon.com). Other twelve-step groupsexist for individuals coping with compulsive behaviors such as sex, gambling, spending, and eating. Helpingclients andtheir family members to find and join appropriate mutual-help organizations can be an importantpart of treatmentplanningandcontinuingcare. 55. B: Notall mental health conditions require long-term pharmacotherapy. In somecases, traditional pharmacotherapy mayinvolve the use ofdependency-producing medicationsthat may

notbe appropriatefor certainindividuals. However, most individuals with co-occurring substance

abuse and mental health disorders can receive well-chosen medications appropriateto their conditions, It is important notto rule out medication therapy out ofhand as untreated mental health conditions can contribute greatly to substance abuse relapse. This can occur both in aneffort to self-medicate and because untreated mental health problemscan reduce otherwise adequate defenses against a returnto substance abuse. Consequently, mutual-help groupshave become more amenable to the use of necessary psychiatric medications. 56. A: Open-ended heterogeneous groupsallow clinicians some flexibility in assigning newclients to ongoing groups. This permits immediate responsiveness to new andearly client needs. However, those in these open-ended heterogeneousgroups vary in their recognition and acceptance oftheir substance abuse. Thus, over time, it usually becomes necessary to move clients into progress- or issue-specific groupsas unique needs andprogress becomeapparent. Someclients makerapid progress from onestageto another, while others mayneedtoreturn to anearlier treatmentstage

dueto relapse or encountering other problems. In this way, the treatment process can be meaningfully individualized andtailored to the unique and changing needsofeach client. Because ofthis, the group to which a givenclient wasinitially assignedis unlikely to remain unchanged

throughoutthe treatmentepisode.

57. C: Treatmentprograms maychooseto organize various homogeneous groupsbasedonone or more demographicor therapeutically relevantissues fora uniquesubsetofclients. Therapeutically relevantissues mayinclude:thosenotfully readyfor treatment(pre-contemplators and

contemplators), similar drugs ofchoice, histories of sexualor physical abuse, single parenting, humanimmunodeficiencyvirus/acquired immunodeficiency syndrome (HIV/AIDS), and gender issues. Demographically unique groupsinclude those organizedsolely for men or women,minority -94GE TTTS FO BSTOTI BTBOF TSTTROTTOTTPTT ATTT

populations,or elderly persons. Other potential demographic groupsincludethose based on socioeconomic status, legal issues(i.e., driving under theinfluence [DUI], probation, etc.), professions, or unemployment. Clients in these groups benefit from shared perspective in working together. Other unique populationsinclude clients with transientor enduring cognitive impairments, illiteracy, or secondlanguage needs. Programs should regularly assess their educational materials to ensure that they remain appropriate foreach of the various groups involved.

58. D: Although these populations may benefit from same-drug-of-choice groups, thereis no fundamental barrier to them beingassignedto the same treatmentgroup. However, abuse perpetratorsand victims ofabuse should never be assigned to the same group as the psychological impactandinteractive dynamics would be profoundly detrimental, particularly for those with a history ofsignificantvictimization, Neighbors and relatives (including spouses) should also never share the same group asissuesofdisclosure, confidentiality, and otherinteractive inhibitions would likely become counterproductive over time. Clients with schizophrenia and those with antisocial disorders are not compatible group members as their psychological dynamics would inhibit or entirely thwart the treatmentprocess. Indeed,clients with severepsychiatric disorders mayrequire solely individual therapy. Clients that mayneed to be withdrawn from groupinclude those who violate group standardsandagreements, those whoregularly drop out, and clients with significant impulse-controlissues.

59. D: A commonintensive outpatient treatment(IOT) programinvolvesthree hoursof treatment

onthree days or evenings each week. Other programsmeetfive days or evenings per week. The schedule mightinvolve back-to-back ninety-minute groupsontwo evenings. One provides opportunitiesfor those in a similar recovery stage to share daily concerns, and theother might wvolve a psychoeducationaltopic. A third evening might include an hour-longskills training group, thirty minutes ofindividual counseling, and a ninety-minute family session. Group sessions are often ninety minutes, though the duration mayvary according to needandgroup responsiveness. Psychoeducationalsessionsoften consist ofthirty-minute lecturesfollowedby fifteen-minute question-and-answerperiods. The shorter duration ensures client attention to instruction. Interactive grouptreatment periods are more engaging andthus moreeasily sustained for longer sessions. Theexpected duration ofactive treatment in IOT programsvaries, but manyspan twelve to sixteen weeks.After active treatmentconcludes,clients step downto a maintenance phase that

mayextendfor six monthsor more.

60. A: Thissize facilitates optimal treatment engagementwithout permitting individual neglect. Process-oriented groups may be moreeffective with only six to eight members as these middle- to late-phase groupsfocus more on daily issues, thoughts, emotions, behavior management, and new ways ofrelatingto others. Psychoeducationalgroups canbe largeras they primarily involve didactic content. Many groupsessions are structured using a rule of thirds. Thefirst third involves sharing currentissues or experiences; the secondthird addresses a particular issue or skill; and, the final third is used to summarize learnings andassign anexercise. An alternative structureinvolves a problem-solving process: (1) anissue ofconcernis identified; (2) options andsolutions are

explored; (3) an optimal courseis identified; and (4) an action planis developed.Thisis followed bysoliciting commitments from group members to attempt the solution and report the outcome. Finally, many recovery groupsutilize opening andclosingrituals that enhance commitments and groupsolidarity. 61. B: Buprenorphineis used in the treatmentof physical opioid dependence as a neweralternative to Methadone.Disulfiram (Antabuse) and naltrexone (ReVia) are medications usedin the treatment -95GE TTTS FO BSTOTI BTBOF TSTTROTTTTTPOT ATT

of alcohol dependenceand most particularly in the avoidance ofrelapse. Disulfiram doses are effective for three days. Clients can receive the medication during groupsessions,with additional doses sent homefor use overthe weekends. While early studies indicate that naltrexone does not reduce thefrequency ofrelapses,it does appearto reduce the overall duration ofrelapse.It also helps to reduce the amountofalcoholconsumed in a relapse episode. Of note, however, recent data suggest that naltrexonemight not beeffective for men with chronic andsevere alcohol dependence. Anotheralcoholtreatment medication, acamprosate (Campral), has been FoodandDrug Administration (FDA)-approved for alcohol abstinence maintenancesince 2004. Acamprosate decreases the amount, frequency, and duration ofalcohol consumptionduring episodes ofalcohol relapse.It also helpsto reduce cravings, evenif clients resume drinking. 62. A: Luminal is a barbiturate with no opioid managementrole. Opioid use disorderis very difficult to treat. Detoxificationis insufficient, and relapse is common. Consequently, many clients may need maintenance on opioid substitutes thatstill enable them to function productively. These substitutes include methadone,buprenorphine (Subutex), and joint buprenorphineandnaloxone preparations (sublingual Suboxonefilm and Zubsolvtablets). Ifcrushed and injected, the naloxone precipitates opioid withdrawal but with no sucheffect sublingually. Frequently, clients are started on methadone, moved to Subutex, and thentransitioned to Suboxone for maintenance. For those who desire eventual abstinence, gradual weaningfrom buprenorphineis much easier than from methadone.Anotheropioid substitute, levo-alpha acetyl methadol(LAAM),is still Food and Drug Administration (FDA)-approved,but the United States manufacturer ceased productionin 2005. Both LAAMandmethadone must be administeredatlimited-licensedclinics, while buprenorphine preparations can beprescribed at a doctor's office. This greatly reduces treatment burdens andhas significantly benefittedclients. 63. D: Substance abusedisorders are commonlyfound in concert with other mental disorders. American Society ofAddiction Medicine (ASAM)patientplacementcriteria recommendthat individuals with no-, low-, and moderate-severity disorders be treated in standard intensive outpatient treatmentprograms(I0T)—provided they are capable ofreasonably close coordination and collaboration with necessary mental health services.In this way, clients canstill effectively receive psychological assessmentandconsultations, psychopharmacologic monitoring, and treatmentof substance use disorders. In situations ofhigh-severity psychiatric diagnoses,clients should be treated in programswith on-site dual mental health and substance use treatment programsand cross-trained staff. Low- to moderate-severity co-occurring mental disorders include anxiety and otherstable mooddisorders. High-severity disorders include mooddisorders with psychotic features, schizophrenia, and borderline personality disorder. 64. C: Urinetesting canidentify a great numberof substances. A breathalyzer can helpidentify alcohol, thoughits short biological life makes timely detection difficult. Monitoringofclients’ substance useis essential to learnif theselectedtherapyis being successful. Objectivetests, as opposed to self-reports, are typically neededto reliably and accurately monitor progress and increase the accuracy ofself-reports. Monitoring helpsidentify the needfor treatmentplan

modifications,assists familiesin reestablishing trust, aids clients in avoidingslipsor lapses, and

discourages substitution of anothersubstance fortheir primary drugof choice. However, the purposeoftestingis to limit substance useratherthanto punish orproduce shameandguilt. To this end, rewards for successfultesting are preferred to punishmentasthis reinforces the desired

behaviors rather focusingonfailures. Ifpositive tests must bereportedoutside the program,clients

must befully informed. In this way,trust can better be maintained, and thetherapeutic alliance may be less negatively impacted. -96GE TTTS FO BSTOTI BTBOF TSTTROTTOTTPTT ATTTT

65. C: There is no twelve-step group for hallucinogenabuse, probably because, other than PCP, hallucinogensdo not produce a withdrawalsyndrome. Participation in community twelve-step and other mutual-help groupsis an important part ofthe treatmentprocess. Help motivates clients through groupandindividualdiscussionsregarding available programs. Clients should,in particular, understandthat there are numerousprogram formats. For example, there are step meetings, open speaker meetings, and openandclosed discussion meetings. Further, there are specialized groups such as those for women;the hearingimpaired; for the lesbian, gay, bisexual, and transgender(LGBT) communities; for race and ethnicity groups; language-specific groups (eg., Spanish); for agnostics; for youth; and for beginners. Finally, for those less comfortable with a twelve-step approach, there are alternatives suchas: (1) self-managementandrecovery training (wwwsmartrecovery.org); (2) secular organizations for sobriety (wwwsecularhumanism.org); and (3) Save OurSelves (www.secularsobriety.org)—which all use a twelve-step-like process to promoteindividual empowerment,self-determination, and self-affirmation. 66. A: The copyrighted Alcohol DependenceScale (ADS)is composed oftwenty-five items that provide a quantitative measureofalcohol dependence,with a scoreof ninebeing highlypredictive of a Diagnostic andStatistical Manualof Mental Disorders (DSM)-supporteddiagnosis. The five-minutetest can beself-administered and covers: (1) alcohol withdrawal symptoms, (2) reduced controloverdrinking, (3) compulsive drinking awareness, (4)increasedalcoholtolerance, and(5) key drink-seeking behaviors. The ADShasbeen widely usedin researchandin clinical settings, and numerousstudies have determinedthatthe instrumentis both valid andreliable. The

ADSoffers excellentpredictive value in establishing a DSMdiagnosis. It also produces a measure of dependenceseverity that is needed in treatmentplanning, particularly regardingtheintensity of treatmentneeded.ADSinstructions for administration requestresponsesregardingalcohol used during the immediatepast twelve months. However,other selectedintervals (e.g., six months,

twelve months, or twenty-four months) maybe appliedfollowing treatment. Use ofthe ADS has primarily been amongclinical adult samples. However,studies havealso used the ADS with adolescents.

67. C: The Composite International Diagnostic Interview (CIDI) covers both Diagnostic and Statistical Manualof Mental Disorders (DSM)and InternationalClassification of Diseases (ICD-10) criteria for substanceusedisorders.It also addresses the consequences of substanceuse, the onset of some symptoms, including withdrawal, andvarious psychiatric diagnoses.Lifetime and twelve-month versions are available in multiple languages.Both interviewand self-administered versionsare available, requiring approximately seventy minutes to complete. While primarily designed as an epidemiologicaltool, the CIDI canreadily be used for clinical tasks. Psychiatrically, the interview covers anxiety disorders, cognitive impairment, depressive disorders, eating disorders, mania, schizophrenia, somatoform disorders, and substanceuse disorders. Highly structuredand complex,the interview canstill be carried outreliably by trained non-clinicians. Computerizedscoringyields DSMand InternationalClassification ofDiseases (ICD)-10 diagnoses. Reliability and validity have both been demonstratedin a variety of studies. 68. D:The Diagnostic Interview Schedule (DIS) provides diagnostic information about alcohol and other substance-use disorders as well as anxiety disorders, depression, eating disorders, schizophrenia, and antisocial personality disorder, amongotherpsychiatric conditions. The instrumentexplores syndromes meetingDiagnosticandStatistical Manualof MentalDisorders

(DSM)criteria over thepast year along with information aboutthe courseofthedisorders, functionalimpairments, and any perceived needfor treatment, treatmentutilization, and potential links betweenpsychiatric and physical symptoms.It also establishes dates for morerecent -97GE TTTS FO BSTOTI BTBOF TSTTROTTOTTPTT TTT

symptomsandrisk factors. Primary concernsare:(1) it requires more than the ninety to one hundred twenty estimated minutesto administer(averagingtwoandone-halfhours, per one study);and(2)it fails to consistently identify clients with depressionor schizophrenia. However, the highly structured content and administration guidelinesdoallow trained non-clinicians to

administerit accurately.

69. D:This instrumentscreensfor major psychiatric disorders, based uponDiagnostic and Statistical Manualof Mental Disorders (DSM)andInternationalClassification of Diseases (ICD)-10 criteria,It explores sixteento twenty-four diagnostic concerns, depending upon theversion being used. Theseinclude: depression, anxiety, mania, eatingdisorders, phobias, alcohol and drug abuse, antisocial personality, posttraumatic stress disorder (PTSD), and psychosis. The goal was to. developa structuredinterview tool shorter than mostused in clinicaltrials and yet longer and moreeffective than the many briefscreensbeing used—especially when used to track treatment outcomes. Carefully structured, it can be administered by non-clinician interviewers. For brevity, thefocusis on current disorders. Using oneor twoscreening questions, the diagnosis is promptly ruledout with negative answers. Inter-rater and test-retest reliability of the MINI was compared against the Composite International Diagnostic Interview (CIDI) andthe Structured Clinical Interview for DSM patients (SCID). Kappacoefficient, sensitivity, and specificity were goodorvery goodforall diagnoses, except for: (1) generalized anxiety disorder, (2) agoraphobia, and(3) bulimia. The MINI providedreliable diagnoseswithina very brieftimeframe.

70. B: Antisocial personality disorderconsists of a pervasivepattern ofdisregardforandviolation

ofthe rights of others, and a lackof empathy. Borderline personality disorder involves a pervasive pattern ofinstability in relationships, self-image, identity, behavior and affects, often leadingto self-harm andimpulsivity. The Psychiatric Research Interview for Substance and MentalDisorders

(PRISM)instrumentwas designedto differentiate primary psychiatric disorders suchas these from

substance-relateddisorders. Specifically,it can be difficult to determine where psychiatric problemsare either covered by or inducedby a substance disorder and vice versa. Consequently, PRISMoffers proceduresfor differentiating primary disorders, substance-induceddisorders, and the effects ofintoxication and withdrawal. Requiring betweenoneandthree hours to administer, PRISMcan beparticularlyhelpful efforts to properly plan, refine, and focus needed treatment. Dueto its complexity, interviewertrainingis required, and the scoring is computerized.

71. A: A genogramis a family relationship mapthatutilizes special symbols to trace consanguineousrelationships, major events, and family dynamics over multiple generations. Genogramsare often usedtoidentify patterns of mental and physicalillnesses, including issues of

addiction. A genogramis dynamicas itis revised asoften as new information is discovered.

Genograms can also be createdfor a family ofchoice (nonbiologicalrelationships, such as spouses, significantothers, friends, etc.) from which similar patterns can be derived. Another mappingtoolis thefamily social network map,which traces family and nonfamily communications, behaviors, emotionalties, social status, functions, and other connections.In substance abuse treatment, a social network assessmentallows counselors to identify significant parties with key roles ina client's substance abuse trajectory. Because the conceptoffamily has significantly expanded in modern timesto include nonrelatives of considerable importance(a boyfriendor girlfriend or same-sex partner, friends,religious leaders, formal andinformalsocial groups,etc), social network mappingandanalysis can beof considerable additional importance. 72. C: Community reinforcement training (CRT) improvesthelikelihoodof entering and remaining treatment. The community-reinforcement approach (CRA) supports abstinenceby eliminating reinforcements for drinking and enhancing reinforcements for sobriety. An extension ofthis, the -98GE TTTS FO BSTOTI BTBOF TSTTROTTOTTPTT ATTTT

community reinforcementandfamily training (CRAFT) program teachespositive behavior rewards

to encourage and support treatment. Families learn how to make soberactivities more attractive anddrug- oralcohol-using activities less inviting. They also learn to stop rescuingtheir loved one andinsteadallow theuserto fully experience natural consequences.Clients entering treatment through confrontation are morelikely to relapse thanthose encouragedinto treatment. Family members alsobenefit by developinggreater independence andlearningskills that reduce symptomsofanger, anxiety and depression, evenif their loved onedoesnotaccept treatment. CRAFT is culturally sensitive and works within a client's values andbeliefs to develop a successful treatmentplan, CRAFT research reveals that nearly sevenoften people using the program will successfully motivate a substance-usinglovedoneto attend treatment.

73. D: Family education groupspresentinformation about substance abuse andits effects onthe client and others, the issues of relapse and recovery,and family dynamics that may contribute to substanceuse. Families typically become more involved in treatment and moresuccessfulin wholesomely supporting the substance user. Groupstypically meet two to three hours each week, often on weekends or evenings.Groupsize is normally betweentenand forty individuals. Facilitated by a counselor, commontopics covered include: beginning stage (oneto five weeks)—(1) commit to treatment, (2) the chronicity ofa substance disorder, (3) ways to support abstinence,(4) identifying and eliminating behaviors that support substanceuse, and(5) other family resources (Al-Anon, Alateen, Nar-Anon, Families Anonymous,etc.); middle-stage work (six to twenty weeks) (1) relationship assessment, (2) eliminating enabling behaviors, (3) codependence, and(4) new communication methods; and advancedstage (twenty-on weeks and more) (1)

developmentofa balanced lifestyle, (2) learningpatience with recovery, and (3) evaluating and

accepting limitations, adaptations, and changesovertime.

74. B: A client whohasexperienced a lapse (sometimescalled a slip)will: (1) have sustained

abstinencefor sometime (a monthor more; (2) return to treatment accountable anddistressed because ofthe substanceuse; (3) be concerned regarding the potential consequences(legal issues, etc.); and (4) be opento talking aboutthe episodeandusingit as an opportunity to better understandrelapse triggers and pressures and to enhance relapse-preventionskills. Specifically, the client remains committedto recovery andis able to reassert control. When a relapse occurs:(1) the client avoids returning to treatment(and mayreturnintoxicated); (2) there is a compulsive needto use; (3) the return to substance abuseis prolonged(days or more); and (4) theclient is closed to intervention or learning. A relapse may well lead to treatment dropout and a renewed struggle bythe client with his or herdisease. 75. C: The entry of a client of some renown intoa treatmentgroupwill typically have a numberof disruptive dynamics. These mayinclude: (1) increasedrisks to privacy and confidentiality (especially via the media); (2) feelings ofprivilege (regarding keeping program requirements); and (3)treatmentmilieu compromise (reductionsin group cohesion,focus,trust, etc.). To mitigate problems,counselors mustfacilitate groupassimilation as rapidly as possible by: (1) focusing on the privateindividual ratherthan his or herpublic persona;(2)clarifying treatmentstandards and requirements;and(3)obtaininga signed behavioral contract regardingconfidentiality, privacy, and so on. Theissue of a dualrelationship may ariseas a high-profile client mayofferfinancial perks andpersonal appearancesfor the program orattemptto wield undueinfluence in other ways. Dual relationshipsare unethical, and nogifts or favors maybeaccepted beyondthepublished fee schedules. Onlyaftera client has beenoutoftreatmentfor an extendedperiod (typically one year

orlonger) could program endorsements evenbe considered.

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76. B: Thepotentialclient should notfeel thatit is required for him orher to seek treatment elsewhere, thoughheorshe may choose to do so. Regardless,it is importantfor the counselor and the potentialclient to address any immediate concerns. This is usually handledbest by way ofa brief, private conversation betweenthe two—perhapsin the privacyof the counselor'soffice. There, the existence ofa priorsocial relationshipcanbe acknowledged, and the potential client can be assuredthat the counselor will notinvolve him- orherselfin the client's treatmentin any way. Further, standards of confidentiality can also be explained,and the acquaintance canalso be assuredthat heorsheis fully in control of how to deal with this shared knowledgeoutside the treatmentsetting. To ensure the client's comfort and confidentiality asfully as possible, he or she must also discloses the acquaintanceto supervisingstaff. In this way, the counselorcan ensurethat heorshe will not everbe involved in the client's treatment in any way. 77. A: The AlcoholAbstinence Self-Efficacy Scale (AASE)is used to assessthe level ofa client's confidence in being able to abstain from alcoholusein twenty situations that include common king cues. Theinstrumentusesforty itemsaggregated into four scales to determinea client's risk of relapse in the twenty situations. The fourscales address: (1) situations of negative emotions that can readily trigger drinking(e.g,, discouragement,depression,orfrustration); (2) positive or excitingsituationsorfeelings that may generate a desire to drink (eg., vacations,holidays, celebrations,etc.); (3) circumstances ofphysical pain ordistress that drinking mightrelieve (e.g, fatigue, headache,etc.); and (4) coping with cravings (e.g,testingone’s willpower, just one drink, experimentation, etc.). The AASEcan be administered via paperandpenandscoredin about

twenty minutes. Thereis no specializedtraining necessary to useit. Commonuses include:(1) to

evaluate clients at the time ofprogram admission;(2) to evaluate andguidetreatment; and (3)to create customizedrelapse preventionstrategies; and so on.

78. B: TheAlcoholEffects Questionnaire (AEQ)exploresa client's expectations regarding both the

positive and negative effects of drinking, Clients are asked to respondtoforty exploratory statements about theeffects ofalcoholon them personally (rather than people in general). The AEQ instrumentthen provides scoresin eight separate expectation categories: (1) generally positive feelings; (2) physical and social pleasure; (3) sexual enhancement; (4) increased feelings of power and aggression; (5) enhanced social expressiveness; (6) stress reductionandrelaxation; (7) decreases in physical and cognitive capacity; and (8) careless unconcern (e.g, regardingactions, consequences,etc.). The AEQ can be administered and scored in about ten minutes,with no need for specialized training. Althoughtypically used in research, the AEQcanalsobe used to assess a client's motivationsfor drinking and to explore alternative waysto more meaningfully achieve those effects. The AEQhas beenparticularly helpful in evaluating andredirecting the motivations of college students in their use of alcohol. 79. D: The Alcohol-Specific Role Play Test (ASRPT)uses powerful role-playing scripts to evaluate client responsesto tendifferent high-risk relapse situations. The ASRPTguides clients through a series oftaped prompts to which theyact outtheir responses. Each responseis videotapedfor scoring purposes. In five ofthe situations, the client mustrole-play a response with anotherperson. For example, the clientis presented with a situation where a business contact insists that they completea business deal over drinks at a bar. The clientoffers a videotaped response. Theother five situations explorethe client's responses to an internal conflict. For example, the client is presented with the scenario ofa fully day's yard work, followedby a suddendesire to relax with a cold beer. The ASRPT can be administered in aslittle as twenty minutes and can accommodate

either male orfemale role-play partners. Administration requirestraining, as does the scoring. It also requires the support ofa videotape technician. -100-

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80. A: TheSituationalConfidence Questionnaire (SCQ) is a thirty-nine-item self-report

questionnaire that exploresself-efficacy each ofeightalcohol-related scenarios. Clients imagine themselvesin eachsituation andthenindicate on a six-point scale how confidentthey are in their ability to resist the urge to drink heavilyin that situation. The responses produce a measurementof the developmentofa client's self-efficacy in specific drinkingsituations overthe course of treatment. It is particularly useful identifying situations with the greatest risk ofrelapse, thus guiding relapse-preventionplanning. Subscales help to identify pleasant or unpleasantemotions, physical discomfort, self-controltesting, urges andtemptations,conflict with others, social pressuresto drink, and pleasant timeswith others. Each of these subscales can help the counselor andclient to betteridentify whatis driving the need to drink. The SCQ can be administered in about eight minutes. The minimaltraining required is available from a user’s guide that can be obtained with the SCQ. 81. D: The higherpower concept arisesfrom twelve-step programs themselves. Cognitive-behavioral therapy (CBT) posits emotional and behavioral reactionsarelargely learned responses andthat alternative responses can belearned. Thus, the CBT approach teachesclients howto recognize and limit relapse risks, behaviors to maintainabstinence, and techniques to improve self-efficacy while identifyingcuesortriggers (feelings,situations, and people) that may promote substanceuse. Triggers are eitherinternal (e.g, stress responses,cravings, etc.) or external (e.g,, people, places,orsituations in which drugs were used). By analyzingtriggers, adopting new recovery-oriented responses, and role-playing high-risk scenarios, clients develop the skills to resist substance useurges. CBT approaches also work well for other recovery challenges (e.g,relationships, mood management, etc.). CBT andtwelve-step approaches complementeach other well. Thus, many CBT-oriented programsencourage twelve-step program participation.

82. B: In pointoffact, cognitive-behavioral therapy (CBT) was developed as anindividual counseling approach.Its key strengths are: (1) its capacity to readily engageclients in therapeutic andexperiential learning processes; (2)the ease with which it accommodates clients from very diverse experiences, beliefs, cultures, and other backgrounds, includingthose with great variation oftheir histories of alcohol and drug use (e.g, new single-substance users vs. long-term multi-substanceabusers, etc.); and (3)it offers a clear understanding ofrelapse triggers and situationsandreadily enables alternative options.Its drawbacks include:(1) low suitability for clients with limitedreading or cognitive skills (e.g, alternatives to written assignments may be necessary); (2)fairly extensive counselortrainingin CBTprinciples and techniquesis necessary;

and(3) clients must be motivated to changeasrelatively extensive homeworkis required.

83. C: Research reveals thatclients provided with cognitive-behavioral therapy (CBT) more frequently reported substance-abuseavoidance strategies as long at one yearfollowing treatment, as comparedwith those clients who weretaught contingency managementtechniques alone. Extensive randomizedclinicaltrials have demonstrated that CBT relapse preventiontreatmentis unquestionably superior to only minimaltreatment or notreatmentatall in helping clients to avoid

alcoholand druguse and maintain abstinence.Findings from the multiyear Project MATCHstudy

foundCBT to be as effective as both motivational enhancementtherapy (MET) and twelve-step facilitation in reducing drinking and otheralcohol-related problems.All threetherapies resulted in positive improvements in participants’ outcomesthatpersisted for as long asthree years following

treatment.

84. C: Motivationalinterviewing (MI) was developedbyMiller and Rollnick.It utilizes techniques derivedfrom numerous theoretical approachesthatclarify the progressive stages of recovery. Mlis -101-

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designedto explore andlessen the uncertainty about accepting treatmentbyusingan empathic, client-centered, yetdirective counseling approach.This frequently involves building onclients’ prior successes and the problem-solvingstrategies andsolutions that supportedthose achievements. To be successful, MI requires a nonjudgmental, collaborativestyle that reveals the often disguised negative hazards andeffects ofsubstance abuse. Thus, the counselorserves as a coach or consultant, not as an expert or authority figure. Four basic MI principlesare:(1) empathy—acknowledging and respectingthe client's decisions yet noting theclient's accountability for change; (2) discrepancy identification—contrasting currentbehavior with expressedideals and goals; (3) resistance reduction—remainingneutral toclient resistance, rather than confronting or correcting, toallow resistance to recede in theface ofavailable information; (4) supporting self-efficacy—reflecting client strengths and encouraging a conviction that change can be achieved. 85. A: Motivational enhancementtherapy (MET) is an adaptation ofmotivational interviewing(MI). METuses MIstrategies andtechniques but also incorporates structured assessments andfollow-up sessions. In these sessions, clients are provided feedback regarding substance use in multiple areas (eg. societal normsandtheir level of use, physical andsocial consequences, relevant family history, readiness for change, and associatedrisk factors). This normative feedbackis reviewedin a nonconfrontational manner by meansofMI techniques(client-centered counseling to explore and resolve treatment ambivalenceand achievelasting changes). In this way, MET informs while also eliciting motivationto changeby resolving ambivalence, evoking self-motivational statements, revealing a commitmentto change, and rolling with resistance (e.g., responding neutrally to resistance ratherthancontradicting orcorrecting). METis effective all degrees of substance abuse, and court-mandated clients appear to benefit as much asself-referred clients. A four-session

version of MET was foundto beas effective as the other, more intensiveinterventions(i.e.,

cognitive-behavioral therapy [CBT] and twelve-stepfacilitation). Clients with angerissues achieved significantly more abstinentdays.

86. B: The earliest Matrix Modelwas developed as a twelve-month version that included six months ofintensive treatment with fifty-six individual or family counselingsessions. Counseling was provided threeor fourtimes each week, augmented with educational, family, relapse prevention, andsocial support groups. Thefirst cocaine-specific treatmentprotocol was eventually revisedto address alcohol and opioid use as well. Ultimately, cost constraints led to the development ofa sixteen-week model that reduced individualsessionsto three andfocused more on group work. Theindividual program eventually expanded to include a twelve-weekfamily and patient education groupseriesandcontinuingcarevia an ongoing weekly social support groupfor continuingcare.

Theprogram is roundedoutwith weekly drug testing (urinalysis) and encouragementto attend

twelve-step meetings to supplementthe intensive treatmentandprovide a continuing source of

positive emotional and social support.

87. D:Stress and emotion managementskills are integratedinto the treatmentprocess. Early recovery groupstypically consist ofnew clients (first month of treatment)or those needing additional (or repeated) abstinenceskills training. The primary goalis to educate clients about: (1) cognitive tools to reduce cravings; (2) classically conditionedbiologicalcravings; (3) time

managementandschedulingskills; (4) essentials of secondary substance abstinence; and(5) needed community serviceslinkages. Relapse prevention groupsoffer relapse education and supportive sharing. Topics focus on behavior change, altering cognitive andaffective orientations, and establishing twelve-step program linkages. Social support groups consistofclients in thefinal month oftreatment and focus onidentifying drug-free activities and establishing and extending friendships with drug-free people. These groups are less structured, with contentdetermined by group members’ needs. Family education groups meetfor twelve weeks to address topics such as: -102-

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(1)addictionbiology); (2) conditioned cues, extinction, andconditioned abstinence;(3) substance abuse health effects; and (4) addiction effects on thefamily.

88. D: A study reportedsignificantly less cocaine use bythe Matrix patients at eight months after treatmentadmission (monthly or more frequentcocaine use wasfourofthirty in the Matrix group, as comparedto tenof twenty-three following inpatient treatment, and fourteenofthirty receiving noformal treatment). Anotherstudy revealed dramatic methamphetamineuse reductions during treatment(elevendays of usein the pastthirty at enrollment, reduced to about four days at treatment's end,decreasing to three days at twelve-month follow-up). A study of one hundred cocaine-dependent subjects randomlyassignedto a six-month Matrix treatmentconditionversus other available community resources revealed fewerpositive urine tests for Matrix subjects but not for community resource subjects at three and six-month follow-ups. Similarly, improved scores on the Addiction Severity Index (ASI) employment and family scales, and on a depressionscale, were noted. Finally, in an eight-site studycoordinatedbythe University of California, Los Angeles (UCLA),the program completion rate for Matrix participants was significantly higher(40.9 percent) thanfor treatment-as-usualparticipants (34.2 percent). 89. A: Some materials will require modification to work well for cognitively impaired clients, and retention can be a problemiftheintense scheduling andstructureis off-putting to clients. These are among the mostproblematic elements of the Matrix Modeloftreatment. Other problemscan be morereadily controlled or resolved. Amongthe manykeypositivesof the Matrix Modelare: (1) the modelsuccessfully integrates cognitive-behavioral therapy, routineurine testing, family involvement, psychosocial education, and twelve-step support—all of which areevidence-based steps to higherrates ofabstinence over time; (2) the program is well structured, with a manual, predesigned handouts, complete educational components, and soon, allowingfor successfulstaff application, and the model has beenproven to beeffective in numerousefficacy studies; and (3) the programis culturally responsive andsensitive to various other special-needs groups. 90. B: This theory posits that present andfuture behaviorarisesfromthe consequences (positive or negative) of past behavior. Substancesused canprovide both positively reinforcing effects (euphoria, etc.) and negativereinforcement(relief of psychic pain, avoidanceofwithdrawal, etc). Desire for abstinenceis typically aninsufficient motivation,particularly at the outset. Therefore, other rewards thatreinforce abstinence and a positive lifestyle change are usually required. Both community reinforcement (CR) andcontingency management(CM) approaches motivate behavioral change and support abstinence by consistently rewardingdesirable behaviors and ignoring or punishingother negative behaviors. CR uses relationshipsand otherimportantlife aspects—family andfriends, job, hobbies, social events— to producepositive reinforcement. CM uses tangible rewards(events or objects) and punishments (fines,losses ofprivileges, etc.) to extinguish desires for substanceabuse. Quitting one substancefirst maybe a better goal than attemptingto abstain from all substances. Starting with small changes can bea very effective strategy. Further, more frequentreinforcers (evenif small), may be moreeffective than larger, more-distant rewardsor punishments. 91. B: Co-occurring disorders require intensiveprimary treatmentthatis individualized according to diagnosis, phase oftreatment, leveloffunctioning, and level of care. Otherfactors include disorderacuteness, severity, medical safety, motivation, andavailability of recovery support. Osher and Kofoed developeda staged-approach model with four overlappingstages geared to theclient's current motivation andrecovery level while also addressing varying degrees of severity and disability. The four stages are: (1) engagement, (2) persuasion, (3) active treatment, and (4) relapse prevention. The model consists of low-intensity but highly structured treatment, detoxification, -103-

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toxicology screening, family involvement, and mutual-help groupsupport. Italso hasa case management componentto link clients with outside resources. Treatmentofclients with substance use and high-severity psychiatric disorders (e.g,, schizophrenia or bipolar disorder) differs markedly from treatmentfor anxiety or mood disorders. The more successful approachesintegrate psychiatric and substance abuse treatments to meetthe needsoftheclient. Approaches such as cognitive-behavioral therapy address bothdisorders, as does relaxation training, stress management, andskillstraining.

92. D: These clients are often unable to copewithstressful interpersonal experiences. Where depression andanxiety are predominant symptoms,theyeasily become overwhelmed. Where majorpsychiatric symptomsexist, internal stimuli (e.g,hallucinations, delusions, etc.) may surface and overwhelm them. Dual-diagnosis clients respondbest whenthecounseloris both empathic and firm. The empathic approachreduces stress, andfirm expressionshelpset boundaries and structure the experience. Further, feedback thataddresses conflicting thoughts or problem behavior shouldbe offered in a very factual and straightforwardway.If delivered thoughtfully, the feedback can be both confrontive (compelling) and supportive. Approaches such as these are essential to a positive therapeutic alliance. Dual-diagnosedclients are prone to demoralization and despair becausethey experience especially slow improvementdue to complex coping with two (or more)disorders. Instilling hopeis an essential clinician task. Suggestionsinclude: (1) show acceptance and understanding; (2) assist the client to express genuine concerns; (3) empower the client to help him- or herself; and (4) listen well and express empathy often. 93. D:Group treatmentwith clients with co-occurring disordersis well accepted and widely used. Group therapy has succeeded in increasing abstinence rates and in decreasing the needfor hospitalization. However, groupprocesses and approaches may require modification to meet the needsofdual-diagnosedclients. Augmentinggroup processes with individual counseling may be particularly helpful. The capacity to participate in counseling depends upona client's level of functioning, symptom stability, medication compliance and responses, and potentialcycles in mentalstatus. Some dual-diagnosed clients may be unableto cope with the emotionalintensity of group interactions; others mayfindit difficult to focus enough to meaningfully participate, Clients with serious mentalillnesses such as schizophrenia or paranoid personality may need to be gradually incorporated into a groupattheir ownpace. Suggestions for group work with co-occurring disorders include: (1) keep communicationsbrief, simple, concrete, and repetitive as needed; (2) focus on accomplishments rather thanfailures, and resolve negative behaviors quickly and positively; (3) be responsive and sensitive to the client's needs,use shortersessions and smaller groups, and use gentle, focuseddirectional techniques. 94, A: Many dual-diagnosed clients fare best in mutual-help groups specifically geared to those with co-occurring disorders. As all group members have co-occurringdisorders,theseso called double-trouble groups do a better job ofaccommodating psychiatric symptomsand supporting the use of necessary psychotropic medications. Double-trouble groups are not structuredto offer formal counseling butinstead allow members to support one anotherin achieving and maintaining recovery and holdingeach other accountable. Someof the more widelyrecognized groupsinclude: (1) Double Trouble in Recovery (www.doubletroubleinrecovery.org); (2) Dual Disorders

Anonymous; (3) Dual Recovery Anonymous (www.draonline.org);

and(4) Dual Diagnosis

Anonymous. Early research suggests that traditional twelve-step groups maybebeneficial for clients with mild-to-moderate co-occurringpsychiatric disorders. However,in cases of severe

mentaldisorders, manyclients may havedifficulty attendingtraditional twelve-step groups. Some clients maychooseto participate in both dualdisorder and traditional mutual-help groups. Where -104-

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theydo, studies reveal that most Alcoholics Anonymous (AA) members respondpositively, and as many93 percent support theindividual's adherence to his or her psychotropic medication regimen. 95. D: Medication managementgroups may offer a great manyopportunities and services. However,theyare primarily createdto help clients learn aboutmedications theytake, the intended effects and possible side effects, how to use the medicationssafely, and how to better understand the need for compliance. Other kinds of groupsthat may be created in substance abuse treatment programsinclude:(1) onsite support groupsthat provide a forum for exploring problems, enhancing and maintaining treatmentprogress, andpracticing new skills; (2) psychoeducational groups that are designed increase clients’ awareness ofboth substance abuse andanypsychological problemsin a supportive, safe, and information-rich environment; (3) psychiatric disorders groups that address co-occurringdisorder topics such as signs and symptoms ofmental disorders, the proper andnecessary use of medications, and the potential effects ofsubstances ofabuse on mental disorders and the treatmentprocess; and (4) socialskills training groupsthatoffer trainingin managing abstinence-aversesocial situations byteachingclients to seeksupport, refine refusal skills, and create ways to ensure compliancewith prescribed treatmentmedications. 96. D: Studies indicate that the prevalence rates for major depression mayvary from 2 to 19 percent acrossdifferent countries. Studiesindicateless heritability for major depression thanfor conditions such as schizophrenia and bipolar disorder. Instead, the evidencepoints to cultural factors, such as poverty, violence, andotherstressfulsocial factors primarily contributing to the

onsetof major depression.By contrast, studies in Europe, North America, andparts ofAsia reveal

that the prevalence ofschizophreniais similar worldwide (approximately 1 percent of a

population),as is the lifetime prevalenceofpanic disorder(0.4-2.9 percent) andbipolardisorder

(0.3-1.5 percent). The consistencyin prevalence and symptomsofthese disorders, coupled with the results of numerous family and molecular genetic studies, reveals a high heritability. In other words,it appears thatculture andsocial factors are not generally causative ofthese disorders.

97. A: They waysthatclients describe(or present) their symptomsmayvary substantially across cultures, Asianclients, for example, are more likely to report somatic (physical) symptoms while omitting those ofan emotionalnature. Yet, when questionedspecifically about emotional symptoms, these same clients will acknowledgethem. Thus,clients from differing cultures may chooseto selectively identify or omit symptomsin culturally acceptable ways. Cultures mayalso ascribedifferent meaningsto anillness. These are typically derived from deep-seated attitudes and beliefs about whetheranillness is real or imagined, arisingfrom the body orthe mind (or both), whetherit mayelicit sympathy, the potential degree ofstigma attendingit, potential causalfactors, and a senseofthe kindofperson that might contract or succumbto it. These meanings ultimately determine whetheror not client feels motivated to seek treatment, ways they maycopewith their symptoms, whetheror not their family and community will be supportive, and from whom they seek help (doctor, counselor, religiousleaderor traditional healer, etc.). 98. B: Suicide rates are lowest for African American womenand highest for American Indian and AlaskanNative males. While the exact etiology for the wide divergencein rates is unknown,itis expected that cultural and social contexts in each subgroupwill be explanatory. Mentalillness arises from a complex interaction betweencultural, social, psychological, and biologicalfactors. Overall, research reveals that approximately 20 percentofthe U.S. population(children and adults) will have a diagnosable mental health disorderat any giventime.Insufficient studies have been conducted to determineprevalencebyethnic or othersocioculturalfactors. Early studies do, however, support socioculturaldifferences. For example,following treatmentfor schizophrenia, people whoreturnedto families where criticism, hostility, or intensely expressed emotions had -105-

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higher relapse rates than those whosefamily members expressed less negative emotion. Further, a study comparing Mexican American andwhite families found that, among Mexican American families, interaction patterns that weredistantorlacking warmth predictedrelapse better than interactions featuringcriticism. 99. B: Racial and ethnic minorities are less inclined to seek treatmentfrom mental health specialists. They turn more often to primary care medical providers. Other more frequently selected sources ofsupport includeclergy, traditionalhealers, family, andfriends. African Americansoftenrely on ministers, who may carry out a variety of mental health roles(e.g, counselor, diagnostician, andreferral provider). Whenthey do utilize mental health services, many African Americansprefer counselors of the sameraceor ethnicity. African Americans often prefer counseling overdrug therapy,citing concernsof addiction,sideeffects, and effectiveness.In avoiding mental health professionals, 50 percentofAfrican Americanscited a fearoftreatment and hospitalization, as comparedto 20 percentof whites with similar concerns. Mistrustarises from both historical and present-day struggles with racism anddiscrimination, including perceptionsof mistreatmentby medical and mental health professionals. A recent surveyrevealed that 15 percent of Latinos and 12 percentofAfrican Americansfelt a doctoror health provider hadjudged them unfairly or treated them withdisrespect because oftheir race or ethnic background, as compared with 1 percent of whites expressing such feelings. 100. A: The U.S. surgeongeneral portrayed stigmaas the most formidable obstacle to mentalillness and health.Stigma consists ofnegative beliefs and attitudes that cause others to avoid,discriminate, fear, or reject individuals with mentalillness. To escape the shameand embarrassmentofstigma, those with mentalproblems mayconceal symptoms and avoid treatment. This limits their access to resources andopportunities andleads to hopelessness, poorself-esteem, andisolation. Many Asian culturesfeel that mentalillness reflects poorly on one’s family lineage, ultimately diminishing marriage and economicprospects for other membersofthe family in the process. A Los Angeles study revealed thatonly 12 percent of Asians would share fears ofmental health problems with a friend or relative (compared with 25 percentofwhites). And, only 4 percent would seek help from a mentalhealth specialist (compared with 26percent ofwhites). And only 3 percent wouldseek help from a physician (versus 13 percent ofwhites). Clearly, the cultural sense ofstigmahasfar-reaching effects. 101. A: Because many research instruments do not ask about sexualorientation,very little reliable information is available on substance abuse amonglesbian,gay, or bisexual (LGB) individuals. However, research doesindicate that lesbian, gay, bisexual, and transsexual (LGBT) individuals use alcohol and drugs moreoften than the general population. They are also morelikely than the general population to persist in drinking heavily into laterlife and lesslikely to stop using drugs. On average, members ofthe LGBT community also use more kinds of drugs, including those that more profoundly impairjudgment, such as amylnitrite (poppers), Ecstasy, ketamine(Special K), and gammahydroxybutyrate. These drugsare frequently usedatparties and raves,during andafter whichincreased risky sexual behavior maylead to human immunodeficiency virus/acquired munodeficiency syndrome(HIV/AIDS)orhepatitis infections. Culturalgroupsdiffer in how they

view their LGBT members. In Hispanic culture, matters of sexual orientationtend not to be discussed openly. LGB members of minority groupsoftenfind themselves targets ofdiscrimination within their minority culture andofracism in the general culture.

102. D: The culture brokering approachwas conceived to mediate the difficult gap betweenthe needsofforeign-born people and the U.S.health care system. This modelcan also help clients with disabilities andimpairments. Almost one-sixth ofall U.S.citizens have some functionaldisability. OF - 106 -

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these, morethan 30percentlive below the poverty line, and most expend considerable financial resourcesontheirdisability-related needs. The combinationofdepression,frequentpain, employmentdifficulties, and functional limitationsleaves the cognitively andphysically disabled vulnerable to substance abuse. Yet, research reveals, they are less likely to receiveeffective treatmentthan those without anydisability. Further, many disabled (and other) individuals struggling with addiction have unidentified learning disabilities that can impair successful treatment. Even individuals with the samedisability maydiffer in their functional capabilities and limits. Consequently, treatmentproviders must carefully assess theseclients andtailor treatments to meet their unique needs. 103. A: The rate of alcoholuse amongadults overthe age twenty-five is lowerin rural areas than that foundin metropolitan areas. However, youth between the ages of twelve andseventeen have rates ofheavy alcoholuse that are almost double thosein metropolitanareas. Further, rates of alcoholuse andalcoholism among womenin rural areas are higherthan rates among womenin metropolitan areas. Evenso,at least onestudy reveals that individuals living in urban settings were treated for substance abuse more than twice as often as thoseliving in a rural setting. It was concluded thatthe stigma of substance abusetreatmentand the availability oftreatment combined to substantially limit the treatmentrate. Giventhat 20 percent ofthe U‘S. populationlives outside of metropolitan areas, understanding the unique needsofrural populationsis important. 104. B: In other words, 75 percent will notreceive proper treatment. Althoughthe homeless receive detox services more than threetimesas often as people who are not homeless (45 percent vs. 14 percent), this is likely due to unexpectedhospitalizations, psychiatric facility transitioning, and vagrancy and drug possessionarrests that resultin an involuntary detox and loose medical supervision. Of the approximately six hundredthousand homeless at anygiventime, about 41 percentare white, 40percentare African-American, 11 percentareHispanic,and8 percent are

Native American—disproportionate minority representation. The homeless maybe:(1) transient—temporarily with others and at high risk of suddenly being onthestreet; (2) recently displaced—dueto evictionor otherfinancialproblems (potentially due to substance abuse; or (3) chronically homeless—often with severe substanceuse and mental disorders, they are difficult to draw into treatment and arein needofcreative outreach and programminginitiatives. 105. C: Alcoholis the primary substanceof abuse for 50 percentof the homeless admitted to treatment, with 18 percent abusingopioids (pain meds, heroin, etc) and 17 percent abusing crack cocaine. Nearly one-quarterof the homeless (23 percent) have co-occurring disorders, while 20 percentofthose not homeless also suffer with a co-occurring disorder. Recommendationsfor retaining homelessclients in treatmentinclude:(1) meettheir survival needs(food,clothing, warmth, and safe shelter) in addition to treatmentandextensive continuing care; (2) optimally, early intensive treatment(clients attending4.1 days per week have better outcomesthanthose attending fewer days); and (3) case management, which is neededto: (1) arrange safe and drug-free housing (which powerfullyinfluences recovery, especially ifhousing is contingent on abstinence), (2) coordinate psychiatric and medical care, and (3) locate vocationaltraining or educationto helpindividuals becomeself-sufficient. The AlcoholSeverity Index, the Alcohol DependenceScale, and thepersonalhistory form haveall been deemed valid andreliable screening tools forthis population, especially wheninterviewedin a protected setting, with factual questions based on a recenttime period. 106. A: This approach endeavors to evaluate anddetermineclients’ needsin order to help them access specific resources.Client contacts are minimal, and planningis brief, asthe goal is prompt andaccurate referral withoutestablishing an intensive, long-termrelationship. Consequently, there -107-

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is little to no monitoringor proactive advocacy. Becauseofthis, the Brokerage or Generalist model not alwaysideal, yet the limitedrelationship allows for cost-effective rendering ofservices toa greater numbersofclients. This approach works best when treatmentandsocial services are well integrated, thuslimiting the needfor advocacy and monitoring. Theoptimal client is not economically deprived, has otherwise adequate resources, and is notin late-stage addiction. Smaller agencies thatoffer narrowly definedservices maybenefit most from this model. In some situations, case managers may also serve as educators,offering sessionson substance abuse and related high-risk behaviors. 107. Developed as a mentalhealth treatment model, key elements of PACT include: (1) meeting clients in homes and other natural settings; (2) addressing practical daily problems; (3) advocating assertively; (4) limiting caseloadsto ensure effectiveness; (5) regular client-case manager contacts; (6) caseloadsshared by a team; and(7) long-term client services. First adapted for use with chronic alcoholics, the modeldeviated from a typical approach in twoways: (1) case managers used an enforced contact strategy to meetclients at home andinthefield, and (2) the focus was on alleviating suffering rather than requiringa pledgeoftotal abstinence. An adaptation of PACT, the Assertive Community Treatment(ACT) modelis used to providedirect counseling andthe skills needed to succeedin a community setting. Case managers providecrisis intervention, family consultation, and group facilitation—teaching about humanimmunodeficiency virus/acquired immunodeficiency syndrome(HIV/AIDS), work skills, and relapse prevention. As opposedto PACT, the ACT modelis timelimited, and extended abstinenceandtreatment completion is expected. ACT can be implemented aloneorin concert with a therapeutic community. 108. D: This approach was developedto assist those with persistent mental illness to transition

from institutional careto independentliving. Twofoundational principlesare: (1) assisting clients in assumingdirect control overtheir ownsearchfor resources (e.g,, transportation, housing,

employment, etc.), and (2) drawing uponclients’ strengthsin the acquisitionof resources. This modelfocuses oninformal helping networks (rather than institutional networks), supported throughthe client-case managerrelationship. To achievegoals, the case manager maintains an active client outreach.The strengths case managementperspective is used with substance abusers for three reasons: (1) case managementfacilitates client responsibility in finding and accessing resources neededfor an enduring recovery; (2) the advocacy componentcounters thebeliefthat substance abusers are morally deficientor in denial and thus unworthyof support; and (3) the emphasis onclientstrengths,assets, andabilities counterbalances treatment models that emphasize pathology anddisease. Advocacy andclient-driven goal planning canattimes cause stress betweenthe case manager and other members ofa treatment team,but the approach clearly leadsto improved client outcomes. 109. B: The case managementclinical or rehabilitation approachesintegrate clinical therapy and resource activities together. Both needs are met by the case managerratherthan separate providers. Researchers have posited thatit is notfeasible or functionalto divide these two activities for an extended time. To this end,the Clinical or Rehabilitation model merges these two activities bytrainingcase managersto see beyond solely environmentalissuesto otherclient-focused needs. Tothis end,the case manageris positionedto provide psychotherapeutic services,offer family therapy, and teach essential skills in a variety of areas, includingrelapse prevention, and so on. Beyondtheusual repertoire of case managementfunctions (assessment, planning,linkage, monitoring, and advocacy [pertheJoint Commission on Accreditation of Healthcare Organizations]

or assessing, arranging, coordinating, monitoring, evaluating, and advocacy [per the National Association of Social Workers}), the case managershould also addressissues of transference, countertransference,client internalizations of observations, theories of ego functioning, and soon. -108-

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In this waytheclient's needs can be metin a moreholistic and integrated fashion, which should lead to enhanced outcomes.

110. The case manager's advocacyroleis to identify and secure a client's bestinterests. This is involves a dualresponsibility—advocating fora client’s genuine needsto be met andholdingclients accountable when necessary. Thereare times whenan institutionis overlookingits responsibilities orevenfailing to meetthose duties ascribedto it by contract, law,or legislative policy, and so on.In such situations, the case manager must advocate for theservices that shouldbeprovided to the client, evenif it requires confronting theinstitution or agency. In like manner, there are times when a clientis failing to meetresponsibilities and mustbe held accountable. At such times, may be necessary for the case managerto advocatefor sanctions, reporting, or otherexclusions in orderto ensuretheclient recognizes the neglected responsibilities, compliance, or performancesthat are required. 111. C: Both case managementandclient advocacy are subsets ofservice coordination, and resourcelinkageis oneofthe direct activities involved in eachofthese endeavors. Service coordination provides anactionframeworkby which client is enabled to achieve thespecific goals identified in a treatmentplan.It requires collaborative efforts notonly between a case manageror counselor and a clientbut alsowith significant others as well as liaison activities with available agencies, service providers, managedcare systems, and other community resources. Fundamental to service coordination is ongoing evaluationofclient needs and treatmentprogress as well as resource referrals and advocacy as needed. The coordination andintegration of treatmentactivities shared among variousprovidersis a central feature ofservice coordination. 112. A: This individual is the one most comprehensively responsible to evaluate, track, and coordinate the broadarray ofresources and services that a clientis receiving in the treatment process. A service coordinator may assume some ofthese roles butis less involved in the clinical assessment and evaluation processes. A counseloror therapist may be very involved in clinical evaluations and assessments but would nottypically be asinvolvedinservice coordination.Finally, an administratorlooks after the managementofa program or agency and thus would nottypically be involvedin frontlineclient evaluations and assessments orreferrals andservice coordination. Case management, however, addresses: assessment andevaluation(client capacity, progress and readiness,as well as agency, program, andresource availability andeffectiveness), service coordination,referrals and referral network management, monitoring, tracking, problem solving, advocating, negotiating, offering liaisonservices, and arrangingandcarryingoutthe resource needs ofa treatmentplan.

113. B: Theuse ofa QualifiedService Organization Agreement (QSOA) is only indicated when an outsideofficial or agency is providing servicesdirectly to a treatmentprogram oragency itself. Any disclosure underthe auspices ofa QSOAisstrictly limited to that information necessary for the service providerto ensurethat the programor agency is able to function effectively. In turn, the QSOA stipulatesthatthe service provider(i.., the official or the contracted agency) is legally bound to resist anyjudicial proceedings seekingclient informationoutside federal confidentiality standards andto maintain these sameconfidentiality standardsin managing, processing, storing, and releasing anyclient information. In this way, the service provideris properly informed of relevant informationtooffer advice, consultations, and administrative insights necessary for the programor agency to efficiently and effectively carry outits necessary functions. 114. D: The Screening, BriefIntervention, andReferral to Treatment (SBIRT)public health

approachis de:

ied for use in hospital emergency departments,traumacenters, primary care -109-

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clinics, and other health caresettings. The goalis to identify diagnosable substance abusedisorders as well as those at-risk for developing a disorderbefore serious consequences develop. Each key component has a specific function toward this end:(1) screening—identifying andrapidly assessingsubstanceuse severity and determining the appropriate treatmentlevel needed;(2) brief intervention—enhancingclients’ awareness and insights regarding substance abuse consequences as well as motivating the client toward behavioral change; (3) referral to treatment—linkingclients to specialized substance abuse treatmentoptions as assessmentindicatesis needed and appropriate.

115. B: The ability to workwith genuinecompassion forclientsis thefirst essential feature of successful counseling, provided appropriate boundariesare also maintained.Skills, knowledge, and formation specific to the client's situation andneedsare essential but are substantially ineffective ‘not managedwith compassion and care. The renowned psychologist Carl Rogers taught that every individual has a positive, trustworthycenterif this psychological core canbeaccessed. Connecting with this centertaps into an individual's resourcefulness and capability for self-understanding andpositive self-direction. To this end, he promoted three keys: (1) congruence (genuineness); (2) unconditionalpositive regard (caring concern and compassion); and(3) accurate, empathetic understanding (the ability to meaningfully assumetheclient's subjective perspective). Using these tools, clients can be reached and motivated toward positive change. 116. C: Thepioneering University of California, Los Angeles (UCLA) nonverbal communication researcher Albert Mehrabian has revealedthat approximately 50percentofall communication is exchangednonverbally in the form ofbody language.According to Mehrabian, there are three fundamentalelements in face-to-face communication:(1) the actual words used;(2)the tone of voice used; and (3) nonverbal behaviors (e.g. facial expression, body posture, gestures,etc.). If the nonverbal elements are incongruent, the behaviorand tonality tend to be seen as more genuine

than any wordsexpressed.Given the importanceof genuine compassion and empathyin the therapeutic process, body languageisparticularly important. To optimize nonverbal communication, the counselor should be seated twotofour feet from theclient,

nointervening

barrier(e.g, a desk), leaning forward,legs and armsuncrossed,hands open, nodding to communications expressed, and makingdirecteyecontact(if cultural permits it). The client's body movements (including micro-movements, such asnostril flaring or quiveringchin) should be noted andrespondedto appropriately.

117. A: Individuals with a history of substance abuseoften come outoffamilies, relationships, and environments with few if any boundariesor rules. Further, due to long-standingissues of shame and embarrassmentoversubstance abuse, clientsare often overly sensitiveto feelings ofcritique andfailure. Consequently,it is particularly importantforclients to becomeawareofthe rules, regulations, and boundariesof treatment program participationin advance.In this way,clients need not be surprised whenredirectedto existing boundaries andstandardsof conduct. In turn, this consistency creates an environmentthatfeels morestable, predictable, and safe from the clients’ perspective, which is important as they workto muster and maintainthe motivation to makeimportant changesin their lives. The program's informed consentprocess alsoleads naturally ‘0 identifying andestablishing the early treatment goals needed to motivate, shape, and monitor clients’ success.

118. C: The Substance Abuse and Mental Health Services Administration (SAMHSA)maintains the

National Registry of Evidence-Based ProgramsandPractices (NREPP), which is a database of evidence-supported approaches to substance abuse counseling, The goal is to make available those theories, strategies, programs, andpractices that havebeenproveneffective in the treatment of -110-

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substance abusedisorders. The database includes approaches such as twelve-step facilitation therapy, cognitive-behavioraltherapy (CBT), and motivationalinterviewing (MI), amongothers. ‘The database offers evaluations, recommendations, and suggestions to optimize the effectiveness of the various programsreviewed. The databaseis readily accessible via the Internet, and counselors should becomefamiliar with the variousprograms, techniques, theories, and approachesoffered to ensureoptimalpractices and program outcomeeffectiveness. 119. B: There are many things that offer indication of readiness for change.Clients havinghit bottom andfamilies that have reacheda breaking point are often poisedfor change. A skilled counselor can sometimescreatea false bottom by breaking through denialusing a pointed but caring presentationofreality in such a way as to motivate change. Engagingthe family in the recovery processis often as importantas engagingthe clientin recovery. Families haveto deal with their own emotionalpain and shameand learn how to make choicesfrom the perspective of whetheror not each choice will help or hinderthe recovery oftheir loved one. Learning to avoid enablingpatternsis also crucial, along with family referrals to support groups andliterature sourcesthat will ensure understanding andenduring commitmentto the recovery process. 120. C: commonrule of thumbin thefield of substance abuse treatmentis that the age at which significant substance abuse beganis the point at which personal progress through normal developmental stageswasarrested or missed altogether. Thus, people whobegan heavy drug use in their mid-teenswill often have failed to masterthe developmental stages from that pointforward until they returned to sobriety. Thus, teen issuesofself-esteem,self-image, balancedrelationships with the opposite sex, responding to authority, impulse control, and so on,will likely still need to be mastered. Onerole ofthe counselor will be to identify, inventory, and produce a learningplanto belatedly secure these importantdevelopmental learning tasks. To morefully structure the process of growth,clients will need to learn to adhereto a healthyliving schedule—including timely morning wake-up, personal hygiene andliving space cleanup, set mealtimes, work, group meetings, personal exercise and meditation, and wholesome bedtimes. 121, A: Issues ofcontrol over others are not prominentin reasonsto begin or continue using drugs. Patternsofintrafamilial interactionthat are commonin families with substance abuse include:(1) negativity—criticism, complaints, and expressions of displeasure dominate, which may then reinforce the need for substance abuse; (2) misdirected anger—resentmentover an emotionally deprived homeruledbyfear encouragesdrug use to cope; (3) boundary inconsistency—unpredictable rules, inconsistent responses, and erratic boundaries leadto family memberstress (especially amongchildren), misbehavior, and a greaterlikelihoodofsubstance abuse; (4) self-medication—coping with anxiety, depression, or intrusive thoughts canlead to substance abuse; (5) unrealistic expectations—leadsfamily members to opt out through druguse; (6) denial—excusingor denying substanceabuseallowsits perpetuation. Wherepresent, a completerestructuring ofthe family system, with education andinterventions, is needed to abate anyofthese highly problematic issues. 122. D: Programmedconfrontationis a method usedto mobilize a substance user(typically a

husband) to accept treatment. It is carried out by a family member(typically a wife). To effectively engage programmedconfrontation,the family memberreceivestrainingin Unilateral Family

‘Therapy (UFT). The trainingis conducted over a periodof months, coveringimportantissues such as personal coping(with the addict’s abuse), helpinghim orhercut back on substanceuse, and ways to encourage treatment acceptance. By thefifth month, the addict is typically prepared. UFT wasinfluenced bythe community reinforcementapproach (CRA), and the JohnsonIntervention. The Johnson Interventionutilizes family mobilization, coaching, and rehearsing to motivate a -111-

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potentialclient into treatment—usually using an elementofsurprise. The model focuses onthe addict's positive traits and the negative changes thatresult from addiction.Specific examples of behaviorissues are presentedin a loving, caring mannerto break through theaddict's denial and encourage treatment. The UFT successrate is 37 percent entering treatment, compared to 11 percent where no UFT techniques were involved. 123. C: Community reinforcementtraining (CRT)is an approachusedbyfamilies to hasten a user into treatment. Theinitial step involves seeingusers’ loved ones whocall for help on a same-day basis, At this first contact, they are enrolled in a training program to learn the steps needed to producemotivation and change. The program beginsbyteaching the family members how to producea safety plan for themselvesif they are in any wayat risk of physical abuse. Thenthey are taught how to encourage abstinence,followed by ways to encouragetreatmentseeking. Finally, whenthe addict reaches a crisis point, the program is structuredto bring him orherinto treatment virtually immediately, regardless ofthe timeof day or night. In one study, this nonconfrontational andexpedited approach resulted in 86 percent of users entering treatment,while none ofthose using a traditional approach weresuccessfully engaged. 124. C: The ARISE methodusesa three-level approach to motivate an addict to enter treatment. Level 1 (The First Call) beginswith a telephoneconsultation,followed bya first meeting ofan intervention network (IN). The IN consists ofimmediately involved significant others (spouse, family, andclose friends) whothen meet with the addict to encouragetreatment. Faced with the collective encouragementofthe IN, approximately 56 percent ofaddicts will thenenter treatment. Level 2 (Strength in Numbers) expandsthe IN to include more family,friends, potentially even employers, and a therapist, citing specific examplesof concerns andthe needfor treatment. The IN actsin concert to avoid no-win one-on-one contacts. Within twoto five meetings 80 percent will

entertreatment. Level3 (FormalIntervention)is moreconfrontational, as significant consequences

of avoiding treatmentare spelledout(all enabling behaviorsto stop with more serious consequencesto follow). Another3 percent (i.e., 83 percentin total) will then accept treatment, and 61 percentofall will still be soberby theendofthefirst year. 125. D: This education can help the family to collaboratein the changes neededfor the client to achieve andsustainsobriety throughouthis orherlife, Other benefits of drawing the family in include:(1) increase the client's motivationto change; (2) alter family patterns that may be obstacles to recovery; (3) help the family anticipate needs and issues throughthe various recovery stages; (4) teach relapse warningsignsthey can identify; (5) teach a family perspective onthe causes and effects ofsubstance abuse; (6) coopting family strengths on behalfofthe client; and(7) help the family to find long-term support. In this way, support is optimized, client progress is maximized, family welfare is preserved, andoutcomes are improved. 126. C: Men are muchlesslikely to participatein the treatmentoftheir female partners. Common obstacles to family involvementinclude:(1) resistance from the addict; (2) domestic violence issues; (3) family secrets that might comeout; and (4) family resource burdens. Approaches to overcomeresistance to family involvementinclude: (1) requestfamily participationin intake

(encouragingthis with theclient as well), citing policy, history intake needs, help forthe client, and family support as reasons; (2) ask the clientto collaborate in planningthe family engagement; (3) sendfamily a writteninvitation; (4) provide incentives (refreshments, coupons,etc.); (5) offer food (picnics, dinners, etc.); (6) program resources(babysitting, children’s toys,flexible hours, etc.); (6)

welcome environment(clean, cheerful, etc.); (7) ice-breaking activities (games, role-play,activities, etc,); (8) use community reinforcement training (CRT) to teach that the family is not to blame and that substance abuseisn't a moral flaw in additionto teaching them how to meet personal and -112-

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family needs, howto supportthe client, and so on,to help increase understanding and make them feel more welcome and positive. 127. A: Bowenfamily systemstheory views the family as anintegrated emotional unit, best described andunderstoodvia a systemsperspective when attemptingto describe the complex interactions that arise in the unit. Family members areintensely emotionally connected and profoundlyinfluence the feelings, thoughts, and actionsofeach other. They seek attention, support, and approval from each other and respondto one another's distress, needs, and expectations. Changesin the functioning of any one memberwill be followed by reciprocal changes in theothers. Fromthis perspective, family genograms, disruption history (e.g, immigration, holocaust, etc.), individual questioning, and orienting the members toward facts (versus reactions) can help improve family understandings and function. Coaching individualsinto changesin interaction patterns can reduce triangulationandoverall family anxiety. 128, B: Networktherapy builds an extended collection ofinvolved persons(social workers, school counselors,legal representatives, therapists, etc.) to meet, motivate, andreinforce changes and progress in the family. Extensive interviews help determinefamily needs and appropriate referrals to resources such as support groups, counseling, andso on,to help break the cycle ofaddiction. Othertherapeutic options include: (1) Multidimensionalfamily therapy uses support groups, erviews, and therapeutic interactionsto discover issues, mapoutresponses,andcontract with

involved family members to address, curtail, or resolve key family issues. New family skills, such as better communication and conflict resolution,relapseprevention, and coping strategies for any psychiatric disorders in thefamily, are all needed for enhanced familyfunctioning. (2) Cognitive-behavioral family therapyusesfactualconstructs, improved communication and negotiation skills, contingency contracting, and better problem definitionsto produce enhanced family functioning. (3) Structuralorstrategic systemstherapyrestructuresroles, realigns

subsystemsand boundaries, and reestablishes more extended intergenerational boundaries to improve family function and cohesion. 129. D: This form ofbrief therapy focuseson helpingclients to identify solutions to vexing problems.Askingclients to recall a time when the problem was notpresent or so severe, andthen asking what they or others had donedifferently, can helpin identifying potential solutions.Further, asking about exceptionsto the problem (whenit could have occurred butdidn’t) can also be helpful. Using the miracle question involves askingthis: “Ifa miracle occurred and the problem wentaway, whatwould bethe first sign (andthen whatsigns would follow)?”Scaling questions allow clients to scale a problem from 0 (worst) to 10 (resolved) and then to discuss whythey selected that numbertofind clarity (comparing couples orfamily answerscan also help). Coping questions ask “How have you managed to carry ontothis point?”to find strengths. Using consultation breaks at the half-session mark andponderingthe answers,followed by compliments, encouragement, andideas, can also help. Compliments and a future focus(insteadofthe past) keep the work positive and solution focused. 130. C: Whileno single factor can accountforall vulnerability, genetics appears to play significant

role, Other potential factors include gender, developmentstage,social environment, and culture or ethnicity. Known environmentalrisk factorsinclude: unemployment or underemployment, high neighborhood crimerates, prevalence ofillicit drugs (including cost andease of procurement), poor housing (dilapidatedor overcrowded), peerpressures, community attitudes, and lowsocial achievement expectations. Known cultural or ethnic/racial risk factorsinclude: minority status, discrimination based onrace,intergenerational assimilation disparity, language and cultural barriers to social services and health care, pooreducational achievement, cultural devaluationin -113-

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the dominant society, and cultural alienation. Known family risk factors include: poorbonding, highly chaotic home,family conflict andviolence, financial strain, homestress, parental substance abuse, parental neglect, and parental mental illness. Known emotionalor behavioralrisk factors include: low self-esteem, aggression, rebelliousness, high independence needs, nonconformity, shyness, delinquency, emotional problems,suicidality, relationship problems, using gatewaydrugs, and academic and drop-out problems. 131. D: Wherea high-risk homelife exists, a minorchild will fare betterif he or she is able to distance him-or herself from the troubled home,and ifhe or she can developa talent, skill, or somethingthatis valued by othersin thesocial circle and community. Otherfactors that are protective against substance abuse and addiction are: community factors—a positive neighborhood, low levels ofcrime, adequate housing, and highrates of employment; family environment—adequateparental attention(especially during thefirst yearoflife), a nurturing family with appropriate structure, parents who encourage learning, andadequate household income;innate strengths—physically healthy,positive temperamentandemotionalwell-being, and above-average intelligence; personality—flexible and adaptable, upbeat nature,self-

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