Addictions: Assessment, Stages of Change, and Recovery
Core concepts
Addiction practice uses a biopsychosocial and disease-model understanding: substance use disorders are chronic, relapsing conditions, not moral failures. Know DSM-5 substance use disorder criteria conceptually (impaired control, social impairment, risky use, pharmacological criteria) and the difference between use, misuse, abuse, dependence, and remission.
Master screening and assessment (e.g., AUDIT, CAGE, DAST) and brief intervention. Understand motivational interviewing (OARS: open questions, affirmations, reflections, summaries; rolling with resistance; change talk) and the stages of change (precontemplation, contemplation, preparation, action, maintenance, relapse). Know harm reduction, abstinence-based approaches, medication-assisted treatment, withdrawal risk (alcohol and benzodiazepine withdrawal can be life-threatening), and co-occurring disorders (integrated treatment).
Understand recovery capital, relapse as part of the process, family/codependency dynamics, and confidentiality (42 CFR Part 2 protections for substance use records).
Traps in questions
- Confronting a precontemplative client - the correct approach is motivational, not confrontational.
- Treating relapse as failure rather than a stage to re-engage.
- Missing co-occurring mental illness.
- Overlooking medically dangerous withdrawal (alcohol, benzodiazepines).
Rule of thumb
Match the intervention to the stage of change. In precontemplation, build rapport and raise awareness; in preparation, plan concrete steps. Confrontation breaks engagement.
Worked example: A client says, "I don't have a problem, I just drink to relax." Best response: reflect and explore ambivalence ("You see it as a way to unwind - what would need to change for you to consider it a concern?"), not argue or lecture.