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Review the Theories and Research word document. Address each bullet point and elaborate, please. As these bullet points are critical for the paper. NO INTRODUCTION REQUIRED

Theories and Research Methods-Substance Abuse Counselor

The practice of psychology involves the use of theories to guide research and interpretation and implementation of findings. In psychology, these theories are scientifically-supported explanations for a given set of circumstances, and they ideally establish a cause-and-effect relationship. Theories are based on studies conducted using the scientific method to determine whether hypotheses can be supported. This type of research can be analyzed in many ways to inform a wide range of psychological areas. For this Assignment, you will examine theories and the types of research related to the particular psychological professionof a Substance Abuse Counselor.

To prepare:

Research several of the theories used in the practice of Substance Abuse Counseling. Determine how these theories were developed, and investigate the types of research methods used.

Note: You are reviewing theories, not therapies. If you discuss therapies, be sure to discuss the theories behind those therapies. Use peer-reviewed sources outside of the course to find theories related to your field.

Submit a 2-page paper that highlights 

· two key theories that are used in your chosen profession(Social Learning and Sociocultural Theories).

· If these theories have changed over time, explain how they have changed.

· In addition, select a once-popular theory that is no longer accepted, and explain what led to the change. Refer to the note regarding theories versus therapies.

Next, briefly describe

· The primary research areas used in Substance Abuse Counseling. For example, the foundational research areas for developmental psychologists are cognitive, behavioral, and emotional development.(Cognitive, Behavioral, Physiological)

· Explain at least one research method used in the professional role and how the method is used to guide research. For example, developmental psychologists primarily use the experimental method and naturalistic observation.

· You would then describe, in some detail, what experimental and naturalistic methods are and how they are implemented in research.

· Finally, identify a scholarly research article from the last 5 to 7 years that employs a commonly-used research method as a Substance Abuse Counselor

· Discuss what was under investigation in the study and how that particular research method was used to investigate it.

Additional Materials:

https://americanaddictioncenters.org/therapy-treatment/

Health Counseling: Assessment and Intervention

Perhaps no area of intervention for women offers greater promise of empowerment than counseling services aimed at addressing health-related concerns. This empowerment has been long awaited, as health care traditionally overlooked women’s biopsychosocial concerns in favor of a medical model approach to treatment. This model defined all concerns related to women’s health, including normal developmental transitions such as menopause, as “medical issues” with a matching medical treatment. In addition, until recently, most health care providers were men, and most of the research that informed health care decisions was predicated on clinical trials that included only male participants. Indeed, it is only recently that large-scale clinical trials, such as the Women’s Health Initiative (

www.nhlbi.nih.gov/whi

) and the Study of Women Across the Nation (

www.swanstudy.org

), have placed women’s health care and wellness issues at the forefront. Newer developments in medicine and in allied health-provider disciplines have increased the likelihood that health care providers will be sensitive to the range of concerns presented by women, and that a variety of interventions that enhance women’s overall health will be available.

This chapter introduces the reader to primary issues in counseling women for health-related concerns. Because other chapters in this volume provide information concerning specific disease entities, our aim is to provide general, but practical, information to facilitate your developing useful treatment plans when working with women who present with health-related issues. We begin with the biopsychosocial model of assessment. Given that health issues are always embedded within the context of a woman’s life, this section pays particular attention to the significance of her life roles, examining how her roles may be affected by the diagnosis, the disease process, and the medical treatment of the disease. We also examine the role of culture in her experience, with particular emphasis on multicultural perspectives on health and illness. Next, we discuss treatment planning: identification of suitable treatment goals and establishment of an appropriate plan with the client. A variety of treatment approaches, including those commonly integrated into counseling for health issues, are reviewed. Monitoring compliance and addressing noncompliance are of paramount concern for the provider, and part of this chapter is devoted specifically to this issue.

BIOPSYCHOSOCIAL ASSESSMENT

The biomedical model, which focuses on pathophysiological explanations of disease and health, has slowly begun to be replaced by a more comprehensive perspective. The biopsychosocial model is the typical frame-work used by psychologists working in a medical setting to assess, conceptualize, and treat people with health problems. Initially articulated by Engel (1977), the biopsychosocial model seeks to understand health as a complex interaction of biological, psychological, and social variables. This framework is akin to a feedback loop in which changes in one part of the system produce changes in another part of the system. The premise of this model is that no single factor in isolation can adequately explain health or illness. For instance, biological factors may initially cause physical symptoms, psychological factors affect the appraisal and perception of the physical symptoms, and social factors shape behavioral responses to the perceptions of physical symptoms (Turk, 1996). Thus, the biopsychosocial model offers a useful framework for viewing the client through a broader lens. This framework can be applied to all aspects of the therapy process from assessment to conceptualization, goal setting, and intervention.

Although deemed a comprehensive model by many, it has been argued that the biopsychosocial model does not consider the possible relevance of spirituality to health. Kuhn (1988) suggested the model be renamed the biopsychosocial-spiritual model to take into account such factors. Recent research has shown that spirituality and religion are associated with various physical health outcomes, including lower morbidity and mortality rates, improved coping, better recovery from physical illness, improved medical compliance, and lower medical service use (Koenig, McCullough, & Larson, 2001). Moreover, the majority of Americans identify themselves as spiritual/religious as reported by Gallup data (1995), indicating the importance of assessing such beliefs in the lives of our clients. In this chapter, the term biopsychosocial model is used for the sake of brevity, with the assumption that spirituality is subsumed under the “social” part of the model.

For psychologists and health professionals working in medical settings, the biopsychosocial model is an indispensable framework for providing comprehensive evaluation and care to patients. First, this model allows professionals to address more than the biological aspect of the patient’s problem, thoroughly assessing all the factors in a person’s life that may be contributing to health status. It has been estimated that approximately 60% of ambulatory care visits involve problems with psychosocial components (Belar, 1996), and up to 80% of medical patients show evidence of significant psychosocial distress (Barsky, 1981). Second, the model recognizes the relationship among health attitudes, beliefs, andhabits; physical illness; and mortality. In 2002, 4 of the top 10 leading causes of death in the United States were chronic health conditions either caused or exacerbated by unhealthy behaviors, such as smoking, poor diet, lack of exercise, excessive substance abuse, and high stress levels (Centers for Disease Control and Prevention [CDC], 2002). Third, a biopsychosocial perspective can guide professionals in developing needed programs that target prevention and behavior change as health care costs continue to increase. Finally, this perspective is compatible with the current trend in medicine toward a greater concern with maintaining quality of life.

Psychologists conducting health counseling are in a unique position to contribute to health and well-being by thoroughly assessing all the factors in a person’s life that may be contributing to health status. In fact, a complete biopsychosocial assessment may be the most useful contribution a psychologist can make to a medical team. Prior to planning an assessment strategy, it is useful to articulate the purpose of the assessment. Is it for diagnostic reasons? Is it for initial information gathering to aid in treatment planning? Is it to monitor treatment progress and assess treatment outcome? Is the assessment to answer a consultation question from the patient’s physician? Is the assessment needed to screen for particular medical procedures? Pinpointing the purpose of the assessment will help focus the interview.

There are several ways to approach a biopsychosocial assessment. One method generally called “high fidelity” assessment is aimed at specific patient populations (Turk & Kerns, 1985; Van Egeren & Striepe, 1998). These various structured assessments have been created to gather information pertinent to certain illnesses. The Clinical Handbook of Health Psychology (Camic & Knight, 1998) provides specific assessment strategies for medical populations, including cardiac disease, pulmonary disease, chronic pain, diabetes, gastrointestinal disorders, HIV/ AIDS, and oncology/hematology. Focused assessments can also be used to obtain specific information about a patient’s candidacy for particular surgeries or organ transplantations. Understanding a person’s psychosocial status is useful in such instances because of the relationship between negative affect and poor prognostic outcomes in certain surgeries (Herron, Turner, Clancy, & Weiner, 1986). A second approach to gathering biopsychosocial information is through the use of psychometric tests. Many of the traditional psychometric tests used with mental health populations may be applicable to a medical population; such tests, however, must be used with caution. There is debate regarding the appropriateness of psychiatric norms with medical patients due to overdiagnosis of psychopathology in such populations (Turk & Kerns, 1985). Clearly, the use of instruments designed specifically for medical populations is preferred, although instruments of this type are rare. For thorough reviews of psychometric tests useful in medical settings, see Green (1982), Wright, Johnston, and Weinman (1995), Belar and Deardorff (1995), and Johnston and Johnston (2001).

The type of biopsychosocial assessment described in most detail here is the focused clinical interview because this is the most likely way in which a psychologist will contribute to a patient’s care in a multidisciplinary context and is the starting point for care done only by the psychologist. A general framework is presented for conducting an interview that can then be combined with structured questions for specific health populations or with psychometric tests or both. Figure 21.1 provides a biopsychosocial-spiritual flowchart to help clinicians identify the many variables needed to define the complex interplay among physical, psychological, and social factors.

A focused clinical interview with medical patients requires the same basic clinical skills needed to evaluate patients in any setting (Van Egern & Striepe, 1998). The quick establishment of rapport, provision of accurate empathy, and gathering of relevant information are all necessary components. Using the biopsychosocial model as a theoretical framework during the assessment process ensures that information is collected in each of the areas that can then be integrated to produce a comprehensive understanding of the patient.

Physical/Biological

Assessment of this domain can be done through self-report of physical symptoms, previous medical history and treatment, health habits, and current use of medications. Gathering information in this domain can be challenging because relying on patients’ self-reports is often not sufficient. A succinct but thorough medical history can be difficult for a patient to articulate or may not be reliable. It must be taken into consideration that many patients do not fully understand their medical diagnosis or, in some cases, may not know their medical status. In addition, patients often may not be able to identify the medications they currently take, especially if they are taking numerous medications.

For psychologists working in a hospital setting, the medical chart can be a source of valuable information and should always be reviewed. When the medical chart is not available, obtaining a release of information to speak with the patient’s medical provider is imperative. Medical texts that can be helpful to psychologists in understanding medical terminology, common medical abbreviations, medications, and prognosis and treatment for various diseases include Dorland’s Illustrated Medical Dictionary (1999), the Physicians’ Desk Reference (2002), and the Merck Manual of Diagnosis and Therapy (1999).

Psychological

Assessing for the presence of mood, anxiety, or adjustment disorders is necessary to understand how a person is coping with physical illness. In addition, gaining a better understanding of a person’s personality or any psychopathology present can shed light on how he or she typically adjusts to life stressors. Biopsychosocial assessment differs from a general mental health assessment by making clear the association between how a person’s psychological health may be impacting physical health and vice versa. Information not included in a mental health assessment, but useful in a biopsychosocial assessment, includes how patients have been coping with their health problem, attitudes or beliefs about their illness, the meaning of their illness, self-efficacy about health improvement, hopefulness, the presence of learned helplessness, the presence of secondary gains from the illness, and willingness to work with a psychologist regarding behavior change and adjustment.

Although a brief cognitive screen is not routinely done in mental health assessments, it should be included in a biopsychosocial assessment with medical populations. Medical procedures, illness, and the use of medications can impair cognitive status, which in turn can alter adherence to medical treatment regimens and decrease the ability to make complex medical decisions. The modified Mini-Mental State Examination (3MS, an improvement on the commonly used Folstein Mini-Mental State Examination; Teng & Chui, 1987) is a quick and effective screen for moderate or gross impairment of cognitive function (Tombaugh, McDowell, Kristjansson, & Hubley, 1996). The Mini-Mental State Examination is commonly used in hospital settings by a variety of health providers; thus, nonpsychology staff will be more likely to understand a 3MS score than other neuropsychological screening measures. A more thorough neuropsychological battery may be appropriate for patients displaying severe cognitive deficits.

Social

Similar to the psychological domain, the information gathered in the social domain needs to be understood in the context of how it impacts patients’ physical health. Patients’ social relationships can indicate how they are dealing with their illness and how much support they are receiving in this process. Kerns (1995) noted that health psychology, as a field, has been slow to recognize the role of families in conceptualizations of health and illness. Including a family member in the biopsychosocial interview can be especially helpful for understanding family functioning in relation to illness. Other relationships to explore are those with medical staff, especially if the patient has spent an extended amount of time as an inpatient. Patients’ relationships with their health care providers play a major role in how they think about their current health status. Such relationships may be providing needed support or, in some situations, could be increasing the patients’ distress levels if the patients are not receiving the care or time they believe they deserve.

Cultural variables and the worldview of the patient likely impact health and are important to assess. In some cultures, it is not acceptable to have psychological symptoms; thus, depression or anxiety may be manifested through somatic symptoms, such as headaches, fatigue, or pain. Rodriguez (1998) suggests that the following information be elicited to enhance assessment in racial/ethnic populations: racial/ethnic identity, acculturation, language, nontraditional family arrangements, support networks, future aspirations, migration history, and socioeconomic issues. Racial/ethnic groups may hold certain beliefs about healing and illness and may prefer to rely on traditional healing systems. When health providers ignore patients’ worldview, value system, or subjective culture, patients’ decisions to use traditional healing may be labeled as noncompliance. Integrating cultural coping strategies or treatment options more congruent with patients’ belief systems is a necessary component of providing culturally sensitive treatment.

An understanding of the importance of spirituality and religion in a person’s life should also be part of the biopsychosocial assessment. For many persons, religion/spirituality is a central element of their world-view. Understanding a person’s belief system can promote clearer communication and offer contextual information important to the process of treatment (Gorsuch & Miller, 1999). Spirituality/religion can be quickly assessed using the FICA technique (Pulchalski & Romer, 2000). This acronym stands for asking patients about their faith/beliefs, the importance of it in their life, if they are part of a spiritual or religious community, and how to address it in treatment.

The biopsychosocial model provides great utility in understanding the broad health picture. Using it as a framework to gather information from multiple domains will lead to accurate diagnosis, improved treatment planning, better patient care, and positive health outcomes.

ASSESSMENT OF ROLES WITHIN THE FAMILY CONTEXT

Familial, occupational, societal, and personal roles are widely recognized as important life roles to most individuals. Life roles are related to status and social power in most societies (Clemson, Fitzgerald, & Mullavey-O’Byrne, 1999). The appropriateness of holding a particular role and the duties that accompany certain roles are often dictated by societal values, norms, and expectations. Women tend to occupy a wide range of roles, including mother, wife, homemaker, child care provider, religious group member, and employee. Varvaro (2000) notes that for women, not only do life roles help one feel valued and accepted by others but also through life roles women help significant others meet their needs. Multiple life roles, however, can also be a source of stress. Bankoff (1994) studied 379 women seeking psychotherapy concerning their needs in therapy; the number and types of roles of these women differed. Bankoff found that the two most psychologically distressed groups were women with too many roles (e.g., single mothers) and those with too few roles (e.g., those who lacked major roles of spouse, worker, or student).

When women experience health problems, either temporary or permanent, life roles often change. Given that role strain is already a source of stress for many women, role changes resulting from health problems can be particularly challenging. Most researchers agree that the ability to perform duties associated with various roles cannot help but be affected by illness, whether chronic pain (Roy, 1990), head injury (Kneipp, 1991), myocardial infarction (Varvaro, 2000), stroke (Clemson et al., 1999), or spinal cord injury (Chan, 2000). It is likely, however, that most individuals have never considered what life roles they hold and how these overlap with the roles of others in the family (Grahame, 1991); thus, the impact of illness on usual role functioning is a significant disruption.

Role changes affect both the woman and the significant others in her life. Tunks and Roy (1990) describe this as a parallel shift in roles, and they suggest that treating the family or couple together can more directly address the practical implications of role changes. In a study on stroke rehabilitation,

Clemson et al. (1999) recommend that the needs of the entire family should be considered, and the whole family should be considered the “client.” Chan (2000) stresses the importance of emotional changes that the unit experiences when roles are altered. A related issue to systemic role changes is that many health problems and conditions are unpredictable and will involve several sequential changes in family roles during the course of the illness. Flexibility, touted by Doherty (1992) as the new postmodern family value, is essential for family adaptation to these unpredictable changes.

Role changes related to health problems and conditions can occur in any capacity of daily functioning. Whatever the role expectations before the onset of illness, the physical, physiological, and psychological elements of illness or disability may make a prior role impossible or simply much more difficult to perform without assistance. In addition to task-related role changes, many individuals with chronic health problems experience a shift in social roles due to various physical and psychological barriers to maintaining prior relationships outside the immediate family (Chan, 2000). Varvaro (2000) describes many role losses for a group of women who experienced a myocardial infarction. Issues raised by these women included loss of comfort over role in the family, feelings of isolation from the family, changes in capacity to perform usual family duties, difficulty in role perception of self in relation to others in family, relegating tasks to others (often at the request of a the physician), managing role reversal, and learning new aspects of changed roles. This study also found reluctance among patients to make lifestyle changes that disrupt roles or routines within the family. In this case, it is not necessarily physical limitations that caused the need for role change but, rather, the need to prevent further health problems.

One role change discussed frequently in the health literature is that of losing the role of provider. Whether one works inside or outside the home, work can fulfill many individual needs in addition to providing financial support, such as altruism, status, respect, security, relationships with coworkers, and an outlet for creativity (Silver, Price, & Barrett, 1991). It is also possible that the provider role may be overemphasized, either by the family or by health care providers. Chan (2000) notes that within some cultures, productivity and money are emphasized over other life tasks; therefore, losing the ability to work may be more devastating and shameful for a family. In other instances, the occupational role is overemphasized as a criterion for rehabilitation outcome, regardless of the family’s view of the importance or purpose of work (Tunks & Roy, 1990).

A new and usually unfamiliar role is created during an acute or chronic illness the “sick” role. Clemson et al. (1999) define this as a temporary disengagement from normal roles and occupations in which the patient’s primary tasks are focused on the illness. This may be a challenging adjustment for the patient due to an increased dependence on medical professionals. Tunks and Roy (1990) distinguish acute sick role from chronic sick role. This distinction is important because it allows professionals to recognize that some individuals may have an incentive to remain longer in a sick role due to secondary gain. Secondary gains include the receipt of work compensation benefits, attention from others, more affectionate responses from others, or control in what may be perceived as a disempowering situation (Roy, 1990).

Role Assessment

There are several general considerations in considering role assessment for women with health problems. As many family members as possible should be involved in the assessment of family adaptation. Generally, this assessment should include evaluation of family role functions, the nature of the occupational role (i.e., how the patient and family feel about work or work in the home), and how the illness role is viewed (Tunks & Roy, 1990). DePompei and Zarski (1991) stress that individuals or families may be experiencing other normal developmental events while dealing with the illness, and assessment must allow for this as well. Life transitions, such as marriage, birth, children leaving home, and the onset of menopausal changes, may be differentially important to various members of the family. These authors also note that behavioral observations of individual and family reactions to the assessment may provide useful information about family dynamics and attitudes toward potential new roles.

The timing of assessment is also important to take into consideration. Some researchers suggest that if a patient is in rehabilitation or spends an extended time in the hospital, role changes may not become relevant until discharge (Chan, 2000; Varvaro, 2000). Kneipp (1991) labels this time “community reentry” and notes that families and patients feel changes most intensely at this time. Another challenge during this time period is that the family may have found new ways of functioning during the hospitalization and must change again when the patient comes home (Williams, 1991). To address this timing issue, Varvaro recommends addressing role alterations during the discharge phase and then again 6 weeks following discharge. This follow-up assessment allows emotional reactions to certain role changes, such as feelings of guilt or inadequacy that tend to be common for the patient, to be discussed (Chan, 2000). Home visits are considered important as well. Kneipp suggests that home visits should be conducted on a frequent basis to develop sufficient rapport with the family and to gain information on usual family functioning.

Multicultural Considerations

Although traditional gender roles are still prevalent in many communities, individual cultural differences may be another component that makes role change unique to each woman and each family. Clemson et al. (1999) note that gender-related family roles such as division of labor vary greatly within and across cultures and must be considered in the assessment of family roles. These authors suggest that adapting to a chronic illness is similar to the process of adapting to another culture but without the support of others dealing with the same acculturation process. Chan (2000) provides an extreme example from a study on spinal cord-injured individuals living in Hong Kong. Traditional Chinese culture views illness as a weakness that brings shame and guilt on the entire family. Individuals with spinal cord injury are seen as careless, ignorant, and living inappropriately. Although this example is more extreme than may be seen in some Western health care settings, it does highlight the importance of assessing cultural ideas of roles and the perception of disease and illness. Inattention to cultural differences may even hinder functioning if treatment recommendations are rejected due to cultural inappropriateness.

Assessment Tools and Treatment

The Perceived Role Adaptation Scale is a measure of role adjustment that can be used with a wide range of populations (Varvaro, 1991). This scale examines perceived role adjustment and targets the roles of family member, marital/ sexual partner, homemaker, and paid worker. DePompei and Zarski (1991) provide an evaluation of several assessment tools and interview protocols for families dealing with those with head injuries and other illnesses.

Aside from continued assessment of adaptation to new and possibly still changing roles, there appear to be no widely accepted intervention techniques that specifically address role change. Research, however, has suggested general guidelines that may supplement traditional health psychology approaches. Scharloo et al. (1998) conducted a study of role and social functioning in individuals with rheumatoid arthritis, chronic obstructive lung disease, and psoriasis. Strong illness identity, passive coping, belief in long illness duration, and belief in negative consequences were all associated with poorer role and social functioning. These findings suggest that interventions should focus on increasing beliefs of personal control and developing realistic conceptualizations about the course and consequences of illness.

Another consideration presented by Varvaro (2000) is that changes over time may be related to specific time frames. In her sample of cardiac patients, the first year anniversary of the myocardial infarction caused role disruption for many patients because these women believed that they should be out of their “recovery period” and able to return to their previous lifestyle. The treatment group in this study that participated in a nursing intervention to increase adaptation to role changes demonstrated higher adaptation in work and family roles.

Role changes, whether temporary or permanent, are inevitable with the onset of acute or chronic illness. Although many women experience some level of role strain due to multiple life roles and responsibilities, illness adds another strain for the women and their significant others. Addressing individuals within the family unit in assessment and treatment is essential for encouraging the flexibility that is necessary for healthy adaptation to role change.

THE ROLE OF CULTURE IN HEALTH COUNSELING: DIVERSITY ISSUES IN ASSESSMENT AND INTERVENTION

As noted previously, health behaviors and beliefs about illness are often a product of a specific cultural context (Maclachlan, 2000). Western societies base their health beliefs, practices, and treatments on the Western cultural context (Marks, 1996), which typically centered on the values and traditions of White males. As Western societies become increasingly diverse, the framework in which health assessment and treatment have traditionally been conceptualized becomes less relevant (Kazarian & Evans, 2001). Therefore, a chapter focusing on assessment and intervention in health counseling would be incomplete without a discussion of the role of diversity/multiculturalism in the development of health assessment and intervention strategies.

One of the major criticisms of the current training of traditional health psychologists and other health professionals is the lack of attention to the promotion of culturally competent health science and practice (Kazarian & Evans, 2001; Maclachlan, 2000; Marks, 1996). Marks outlined key issues in the field of health psychology with respect to cultural context. Some of these issues emphasize the nature of health psychology’s major theories, which are based on social and cognitive theories and have an individualistic bias. These theories, adopted from mainstream psychology and applied to health behavior in an uncritical and unquestioning manner, tend to ignore cultural, sociopolitical, and economic conditions related to health behavior. They have been further criticized for (a) being based on the convenience of medical personnel and not patients, (b) being detached from social policy, and (c) failing to deal with inequalities and disparities in health care of racial minorities and individuals from lower socioeconomic status. Benzeval, Judge, and Whitehead (1995) note that a great deal of attention has been paid to the health experiences of working White males at the expense of women, older people, and ethnic or racial minority groups. In addition, there has been a failure of health psychology to develop appropriate assessment methods for culturally diverse groups. This last criticism is of particular interest because of its relevance to culturally competent health assessment. According to Marks (1996),

Health psychologists place a heavy reliance on self-completion questionnaire instruments, many developed in the United States, frequently with student samples. Problems of measurement incongruence often arise when these instruments are used in other countries, especially with patient or community samples, (p. 15)

Mulatu and Berry (2001) note that health practices in a pluralistic society are complex, consisting of “indigenous and foreign activities aimed at maintaining, promoting, and restoring health” (p. 58). Currently, health psychologists lack appropriate assessments that reflect the diversity of health practices, which include popular, folk, and diverse professional health perspectives. The assessment techniques that are currently employed are based on the Western biomedical system, which takes a mechanistic approach to health care. In contrast, indigenous and traditional health care systems tend to take a more holistic approach to medicine, in which the goal of any assessment or intervention is to promote a harmonious relationship between the elements of the mind, body, and spirit (Mulatu & Berry, 2001). Cultures that favor holistic medicine are generally more collectivistic in nature and rely more on cultural and spiritual communities in the treatment of illnesses. Often, people who favor such treatment options will seek assistance from a traditional healer because of their fear that a health care professional trained in the Western biomedical model will not take seriously their desire to include traditional practices in their treatment. This is one likely explanation for the underuse of health care professionals by ethnic minorities, especially ethnic minority women (Wise et al., 2001).

Health professionals’ understanding of cultural factors of health can also have an effect on patients’ adherence to treatment. If patients do not believe that their cultural beliefs are being considered by their primary health care professional, they are less likely to adhere to the treatment regimen (Shearer & Evans, 2001). In general, health care professionals and health psychologists are in need of more culturally sensitive and responsive health assessment and intervention strategies.

It is especially important to take into account research on culturally diverse women. Wise, Carmichael, Belar, Jordan, and Berlant (2001) outline many issues concerning cultural perspectives on women’s health, although they caution that research focusing on the relationships among culture/ethnic diversity variables and health behavior is sparse due to the fact that women in general have been largely ignored in medical research. There does seem to be limited evidence, however, that women from the four major ethnic groups (Hispanic, Asian, African, and Native American) in the United States and Canada have higher rates of morbidity, mortality from pregnancy, cardiovascular disease, cancer, diabetes, and HIV/AIDS.

As previously discussed, a major factor that may be responsible for the higher risk of health-related problems for minority women is stress from multiple roles. This is especially true for ethnic women. Wise et al. (2001) suggest that common risk factors among women who belong to the four major ethnic groups include increased exposure to psychosocial stressors, such as racism and sexism, and the fact that these women are often the sole source of support for their families. For example, many African American women are responsible for multiple roles, including mother, wage earner, parental care provider, and care provider for grandchildren. In addition to these psychosocial stressors, minority working women often experience workplace health risks, such as exposure to physical, biological, and chemical hazardous materials (Swanson, Piotrkowski, Keita, & Becker, 1997). Wise et al. (2001) argue that several other risk variables may have an effect on minority women’s health, such as overrepresentation in lower socioeconomic groups; engagement in high-risk health behaviors, such as smoking, alcohol consumption, and poor diet; and genetic predisposition for certain illnesses, such as heart disease.

Although Wise et al. (2001) call for more research on minority women’s health issues, they also warn against creating “health profiles” of each minority group because of the substantial heterogeneity within each of these groups. Their recommendation is that instead of focusing on race/ethnicity as an objective variable, health psychology researchers should examine the “meaning of ethnicity with respect to biological, psychological, and social components” (p. 464).

Despite the paucity of research on the health issues of ethnically and racially diverse women, there have been some attempts to design culturally relevant intervention programs for these women. For example, spiritual and religious interventions have been associated with positive health outcomes for Hispanic and African American women (Musgrave, Allen, & Allen, 2002). Musgrave et al. describe several “faith-based programs” to promote positive health behaviors for African and Hispanic American women. These interventions include programs focused on increasing mammography and breast self-examination (the Witness Program). Another successful program described by the authors is the HIV Prevention Faith Initiative of the CDC, which is a government- and faith-based partnership among several groups (e.g., the surgeon general, the Congressional Black Caucus, and gospel artists) in which the groups work together to dispel myths and encourage audiences to take HIV tests. Musgrave et al. also discuss the popularity of parish nursing, in which nurses promote health and healing “within the context of the values, beliefs, and practices of a faith community” (p. 5). Parish nursing is generally practiced in a church setting in which members of the congregation are able to obtain access to health care in a convenient, interactive, and faith-connected way.

Socioeconomic diversity among minority women is also an important consideration in the development of interventions. Zuckerman, Brennan, Holahan, Kenney, and Rajan (1999) found that lower-income women younger than age 65 do not have the same access to health care as women with higher incomes or those with Medicare benefits. Esser-Stuart and Lyons (2002) conducted a study to identify and describe barriers to seeking health care; to determine perceptions of confidence in health care practitioners; and to explore strategies to enhance, promote, and improve early health care intervention among low-income minority women. Results of this study indicated that participants did feel confident in their health care practitioners and identified few barriers to seeking health care. One explanation for the results of this study is that all the participants were enrolled in a program (Foster Grandparents) that provided some access to health care. The authors identified the importance of connecting low-income women with interventions designed to improve access to health care services, and they identified one national exemplar. The National Breast and Cervical Cancer Early Detection Program (established under the CDC in 1999) involves state and community partnerships that focus on increasing cancer screening for underserved women. Esser-Stuart and Lyons also highlighted the importance of incorporating spirituality and family into any interventions designed to increase positive health behaviors among aging minority women.

Increasing positive health outcomes among underserved and minority women should be a major initiative among counseling health psychologists, considering the health risks that exist for these women. To effectively design interventions that target these women, more research on the contextual and individual variables that determine the health status of women needs to be conducted. We suggest that this begin by examining how race/ethnic background, socioeconomic status, sexual orientation, and gender interact to determine access to health care and positive health behaviors.

DEVELOPING AN INTERVENTION/TREATMENT PLAN

Information obtained using the biopsychosocial assessment delineated previously is the foundation for identifying and implementing effective treatment interventions for a particular client. The plan for treatment will typically be developed collaboratively with the client and should include a set of realistic, measurable therapy goals designed to meet her identified needs. Although the specific goals of treatment will be shaped by a number of interacting forces (e.g., therapist theoretical orientation; therapist multicultural competence; client expectations, style, and needs; client worldview; client-therapist alliance; and managed care restrictions), progress will generally be defined as promoting the client’s commitment to a way of life that will allow her to adaptively manage health-related distress. Treatment is intended to help the client adjust to life changes that follow the onset of health concerns (e.g., lifestyle changes, marital adjustment, decrease in physical strength or endurance, restrictions in dietary behaviors, or altered physical appearance) or to cope with preexisting issues exacerbated by the onset of health-related stress.

Women with health concerns present with a wide range of diagnoses and comorbid disorders. These include, but are certainly not limited to, chronic pain, arthritis, breast cancer, menopause, diabetes, asthma, obesity, eating disorders, chronic fatigue syndrome, fibromyalgia, chronic or migraine headache, insomnia, and cardiovascular disease. Here, we provide an overview of several commonly employed treatments, including psychobiological, psychological, and psychosocial interventions, for assisting women in managing symptoms associated with these medical diagnoses. It is important to note that the interventions described here are frequently integrated with other treatment modalities to meet the specific needs of the client. Indeed, many of the treatments supported in the literature are a therapeutic integration of several of the interventions outlined here.

Relaxation Training

Relaxation training procedures are well researched and can be effectively applied across a broad range of women’s health issues. Relaxation as a treatment for arthritis, hypertension, tension headache, chronic pain, irritable bowel, chronic fatigue syndrome, and presurgical anxiety has been well documented. Through instruction, demonstration, and rehearsal, relaxation skills can assist clients in moderating physiological arousal, diminishing subjective distress, and enhancing a sense of mastery or control over symptoms. Although several variations of relaxation procedures exist, the most widely used are diaphragmatic breathing, progressive muscle relaxation, and autogenic training (Davis, Eshelman, & McKay, 1988; Ott, 1992).

The use of hypnosis in the treatment of women’s health concerns is increasing. With the requisite training, hypnotic procedures facilitate a general sense of relaxation, alter the client’s perceptions of a symptom, and evoke insight about symptom onset or symptom etiology. Hypnosis has been used in the treatment of pain, eating disorders, breast cancer, gynecologic cancer, infertility, cardiac disorders, and adjustment to chronic illness (Hornyak & Green, 2000).

Like relaxation, biofeedback targets physiological aspects of a client’s distress but often elicits positive modifications within the cognitive and affective domains of client functioning as well. Biofeedback is frequently used in combination with other techniques, such as relaxation, imagery, and diaphragmatic breathing, which are aimed at regulating autonomic nervous system responses. Because the client is able to monitor changes in body functioning, biofeedback procedures facilitate a client’s awareness of physiological arousal; teach voluntary control over physiological processes; and enhance perceived control in managing responses to tension, fear, and anxiety. Among the myriad disorders that biofeedback has been found to be effective in treating are anxiety, asthma, and chronic pain. A special form of biofeedback, thermal biofeedback, has also been shown to be effective with tension and migraine headache sufferers (Blanchard, 1998).

Operant Techniques

In health counseling, the central aim of operant conditioning is to increase the frequency of wellness behaviors while decreasing the frequency of illness behaviors, both of which are assumed to a large extent learned or conditioned. Under this paradigm, wellness behaviors are consistently and reliably reinforced either by the therapist or by trained family members, whereas attention is withdrawn during the presence of illness behaviors. For women experiencing chronic pain, for example, behaviors such as increased physical activity or decreased reliance on analgesics may be reinforced, whereas attention is withdrawn during inactivity, bed rest, or facial grimacing (Ott, 1992; Wilkie & Schmidt, 1998). It is important to note that the intention is not to eliminate the client’s symptom entirely (e.g., remove the pain) but, rather, to assist the client to adaptively cope with symptoms and to eventually resume a more productive life. Wellness behaviors may be further reinforced by charting the client’s progress toward increases in wellness behaviors (e.g., completion of a daily exercise routine) or providing a reward that is contingent on completion of some predetermined goal (Lewis, Sperry, & Carlson, 1993).

Cognitive Methods

The research literature is replete with studies supporting the effectiveness of a range of cognitive interventions. Distraction-based methods, such as the use of imagery to evoke pleasant thoughts that interrupt the client’s focus on distressing symptoms, can be useful for clients experiencing headaches and chronic pain. Cognitive restructuring techniques allow the therapist to reframe the client’s experience, thus altering her perception or understanding of a symptom, stressor, situation, or attribute. Behavioral pattern identification may facilitate the client’s recognition of external events, bodily responses, or thoughts that proceed or follow the onset of symptoms. This skill increases the client’s self-awareness and allows her to purposefully modify her environment and initiate useful coping strategies early on. Cognitive stress coping strategies facilitate the client’s ability to identify fears or concerns that exacerbate symptoms. Once identified, the client can initiate self-soothing strategies (e.g., thought stopping and positive self-statements) to counter her perceived distress. Skills training interventions have also been identified as an effective intervention. Some clients will benefit from learning and practicing communication and problem-solving skills. Communicating with greater clarity, managing emotions while communicating, expressing needs more directly, using appropriate assertion, and solving problems effectively may be helpful to clients both in their personal relationships and in their interactions within the health care arena.

These strategies are often used in combination with behavioral interventions. Variants of cognitive-behavioral treatments have been found useful in addressing psychosocial aspects of the breast cancer experience (Antoni et al., 2001), chronic fatigue syndrome (Deale, Husain, Chalder, & Wessely, 2001), noncardiac chest pain (Nezu, Maguth-Nezu, & Lombardo, 2001), fibromyalgia (Rossy et al., 1999), insomnia (Espie, Inglis, & Harvey, 2001; Morin & Wooten, 1996), chronic pain (Ott, 1992), and binge eating and obesity (Sammons & Schmidt, 2001).

Supportive Counseling

For women, the counseling relationship can provide needed emotional support, offer a sense of safety, and provide reassurance that they are not alone. Through supportive counseling, clients have the opportunity to be heard and understood. Clients may begin to communicate distress through the creation of a narrative of their health experiences and recognize the normalcy of responses to the experiences.

There are a variety of individual approaches to therapy (e.g., interpersonal, psychodynamic, narrative, existential, and systems focused), and for each of these approaches there is great diversity in how therapy proceeds. Despite these differences, interventions are aimed at establishing a relationship with the client that will facilitate self-discovery, self-regulation, self-care, and the client’s search for meaning. Although a large portion of the psychotherapy outcome research uses symptom reduction as the primary outcome measure, the positive effects of psychotherapy go far beyond diminishing symptoms to include a reduction in the amount of medical and surgical interventions used and a decrease in medical care expenses (Rainer, 1996).

Psychoeducation

Psychoeducation has been shown to increase the accuracy of clients’ knowledge about their own disorders and to show positive effects on treatment compliance among some patients (Stewart & Stotland, 1993). Mental health providers are in a unique position to assess the accuracy of clients’ knowledge about their diseases, supplement this information if deemed appropriate, and dispel misconceptions that may impede client progress. This aspect of treatment may involve didactic interventions during the course of treatment (e.g., the use of books, media, or other forms of information) or directing the client to practical resources to address issues as they emerge.

The information provided may serve to enhance the client’s understanding of the typical course of a particular illness, offer a conceptual framework for understanding symptoms, increase awareness of treatment alternatives, or normalize common psychological responses to a particular disease experience. Providing conceptual explanations for pain, such as the gate control theory, stress-pain-stress cycle, muscle tension-pain cycle (Ott, 1992), and blood flow theory for pelvic pain (Steege & Stout, 1993), has been shown to help chronic pain sufferers by validating that their pain is indeed real and by fostering an understanding of pain as multiply determined and within their control. In addition, there is preliminary support for the use of video education in helping breast cancer survivors adjust during each stage of the cancer experience (Hoskins et al., 2002).

Inclusion of an educational component in treatment offers the client anticipatory guidance necessary to continue her progression through successive phases of the treatment process; to confront new, potentially threatening experiences (e.g., medical procedures or seeking a second opinion); and to assist her in developing daily wellness routines (e.g., sleep hygiene for insomnia). It may be helpful to explore past as well as current wellness behaviors and supplement therapeutic interventions with basic health education. Should the information needed by the client extend beyond the psychologist’s level of competence, referral and collaboration with other professionals may be necessary (e.g., a nutritionist for a client diagnosed with anorexia nervosa).

Although the interventions previously described can be used in the context of individual and group therapy, it is important to recognize that the group environment offers a number of elements that are not part of the individual therapy experience. Yalom’s (1985) research on the dynamics of group therapy identified several valuable elements acquired through the experience. Members develop a sense of cohesiveness, experience altruism, cultivate hope, feel understood, and engage in sharing information. Group members are reminded that they are not experiencing this illness alone, and they model for one another a range of adaptive wellness behaviors. The group provides a socialization experienceone that may actually counteract unconstructive responses received from one’s primary support network. The positive effects of group therapy have been demonstrated among breast cancer survivors (Spiegel, Bloom, Kraemer, & Gottheil, 1994), clients with chronic fatigue syndrome (Soederberg & Evengard, 2001), and women with eating disorders (White & Freeman, 2000).

A broader approach may be necessary for some clients, particularly if the therapist identifies pathogenic aspects of the client’s life situation that are impeding her progress (Worell, 2001). Interventions can target environmental changes within the family, health care system, or the broader sociocultural context (Belar & Deardorff, 1995). Inviting the client’s significant other or family to become involved in treatment is an important consideration. Together, the client and therapist may decide to involve family members, and involvement may range from limited (e.g., a family member completes forms during the assessment phase or attends a single session) to active (e.g., a family member attends several sessions as a “collateral” client, trains as a contingency manager, or engages in family-centered therapy). Conceivably, family members also benefit from receiving timely and accurate information because they may lack information about the client’s symptoms, the course of the disease, or the client’s primary needs throughout various phases of illness. Family members may be in need of psychological support as they confront their own questions, fears, ambivalence, and confusion concerning the client’s health problem. In addition, a couple or family unit may benefit from focused therapy addressing relationship or family-related issues that have been exacerbated by the client’s current circumstances, such as changes in sexual activity, financial stability, and child rearing. Many authors have specifically addressed the significance of attending to sexual adjustment issues in counseling women. Wiejmar, van de Wiel, Hahn, and Wouda (1995) identified two provisions, patient information and counseling, as key to assisting women with sexual adjustment following treatment for gynecological and breast cancer, although it seems likely that these two provisions apply more broadly to a variety of health concerns.

In summary, it is becoming increasingly clear that attending to the psychological and psychosocial issues involved in women’s health early in the evaluation process, concurrently with the evaluation of organic factors, may lead to greater satisfaction with care and improved outcomes (LeResch, 1998; Rowland, 1998; Steege & Stout, 1993). When possible, clinicians should strive to maintain collaborative relations with providers of medical services offered to women.

COMPLIANCE

Noncompliance is an obstacle that affects both patients and health professionals. Patients who are noncompliant have great difficulty in changing their maladaptive health behaviors. As a result, health professionals who manage such patients are hindered in their ability to facilitate treatment. In treating women with health concerns, it is important to consider variables that may interfere with or enhance adherence to treatment regimens. Variables discussed here are social support, cognitive and emotional components, patient beliefs, and environmental variables.

Social support has been studied extensively with regard to its effect on treatment adherence. A study examining the effects of this and other variables on exercise behavior in older women found that women who had social support specific to exercise behavior were more compliant to the prescribed treatment regimen (Litt, Kleppinger, & Judge, 2002). In another study examining factors related to completion of a substance abuse treatment regimen, those who completed treatment had social support specifically related to the treatment (Kelly, Blacksin, & Mason, 2001). These findings, however, do not discount sources of support that are more general and do not specifically target the patient’s desired behavior change. For example, women with high-risk pregnancies who had higher levels of general social support were more accepting of long-term home visitation (Navaie-Wilson, & Martin, 2000). With regard to various forms of social support, close relationships with significant others can serve to increase motivation to comply with certain health behaviors. In a study examining women’s likelihood to participate in cervical cancer screening, it was found that those with positive relationships with their husbands were more likely to attend screenings (Wilson & Fazey, 1995).

Compliance is also affected by cognitive and emotional components of patients’ experiences. Constructs such as self-efficacy, self-esteem, and patient beliefs can serve to help clinicians understand a patient’s hesitance to initiate/maintain a particular treatment regimen. In a study examining exercise behavior in older women, self-efficacy was found to be a significant predictor of those who maintained exercise throughout treatment and at follow-up (Litt et al., 2002). A related concept, self-esteem also helps to increase adherence to treatment regimens, although the mechanisms through which this concept is hypothesized to work continue to be debated. Wilson and Fazey (1995) found that women with higher levels of self-esteem were more likely to get screened for cervical cancer. The authors concluded that this construct, when present, facilitates preventive health behaviors.

Patient beliefs can also serve to challenge clinicians’ attempts to facilitate compliance. Noncompliant patients often have irrational health beliefs concerning side effects of treatment (Leung, Haines, & Chung, 2001). In a study of noncompliance in hormone replacement therapy, one fourth of women who did not complete the entire regimen reported that they feared adverse side effects (Leung et al., 2001). In addition, the presence of a psychological disorder is related to poorer adherence in many forms of treatment regimens. For example, women with HIV who reported depressive symptoms had low levels of adherence (Schuman et al., 2001). Safren et al. (2001) report a similar finding in this population in that greater depressed mood was associated with poorer adherence in taking HIV medications. As noted previously, it is important to assess the cultural beliefs of the client and incorporate these beliefs into the treatment process to increase compliance.

Environmental variables should also be assessed by clinicians when dealing with issues of compliance. For example, transportation to and from a clinic can be a major impediment to receiving treatment. In one study, accessibility of treatment facilities influenced treatment acceptance for patients with breast cancer (Simmons & Lindsay, 2001). Arranging breast cancer screening appointments can be an obstacle for some women due to factors such as arranging time off work, organizing transportation, and finding child care (Rutter, 2000). Child care seems to be an especially salient factor in addressing compliance for women. The responsibilities of juggling child care, household, and occupational tasks make adherence to any treatment regimen difficult (Roberts & Johnson, 2000). Roberts and Johnson found that among women with HIV, compliance was of secondary importance to these responsibilities. In another study, women with chaotic family lives that involved high levels of domestic abuse and engagement with child protective services were not able to complete their substance abuse treatment regimens (Kelly et al., 2001).

To increase adherence, Martin et al. (2001) suggest the following: simple and short treatments, maintaining a good relationship with the treating physician, greater accessibility to primary care consultants, and educational interventions. Litt et al. (2002) noted that booster sessions after the initial prescription of a treatment regimen can increase self-efficacy. In addition, all health care providers should explore patients’ anxieties about treatment to prevent premature termination (Leung et al., 2001). Finally, enlisting social support specific to the treatment regimen can be helpful because patients who receive this support have a better chance of success (Litt et al., 2002).

CONCLUSION

In this chapter, we considered three aspects of counseling women with health concerns. First, we reviewed assessment, which forms the foundation of the counseling relationship and directs the initial contact with women clients. In some settings, the assessment may be the only “intervention,” in which case the counseling psychologist concludes with a report to the referring physician and recommendations to the client. In other settings, the assessment informs treatment planning to be carried out by the psychologist or by other health care providers. In assessment, three spheres of function must be considered: the client, her family and other role contexts, and culture. We reviewed key aspects of each of these spheres.

Specific interventions for various diseases are presented in more detail elsewhere in this volume. We reviewed a variety of basic interventions that will likely be present in most health counseling treatments. It should be noted that each of the interventions we discussed would be tailored to the client and to her treatment setting. Assessment information should inform the specifics of intervention, especially information on the impact of the disease and its treatment and of the cultural context.

Compliance remains the ultimate challenge for psychologists. We can develop assessment plans and treatment goals, but without the client’s firm commitment and follow-through, the promise of the plans and goals will not be reached. Thus, each psychologist must consider compliance within both assessment and intervention phases

Chapter 6: Alcohol Problems Causes, Definitions, and Treatments

What causes alcoholism? Or, put another way, why is it that although so many people consume alcohol on a regular basis, only a small minority become dependent? This seemingly straightforward question has bewitched clinicians and researchers for centuries. Only recently, with generous help from the disciplines of molecular genetics and neuroscience, have behavioral scientists begun to piece together this age-old puzzle. Part of the problem lies in the way in which alcohol dependence is defined and conceptualized. Another concern is that we have yet to identify the proverbial “switch”–that functional entity (biological, psychological, or otherwise) that “transforms” a nondependent consumer of alcohol into one who is alcoholic. But perhaps most critically, the parallel paths of behavioral scientists, molecular geneticists, and neuroscientists have until recently severely limited the transdisciplinary idea sharing and collaborations that are essential to gaining a complete and balanced understanding of the etiology of this classic biobehavioral phenomenon. This chapter attempts to provide some unifying themes that appear to be common to all etiologic models of addiction and to review what is known about some of the more common genetic, constitutional, and learned/ environmental factors that have been implicated in the pathogenesis of alcohol dependence. A rapprochement of these diverse factors may result in a clinically useful working model of understanding the risk for alcoholism.

Definitions and Description of Alcoholism

A nosologic consensus is the outcome of clarifying an etiologic disease pathway. Unfortunately, the classification of alcoholism, like many other multisymptomatic behavioral disorders, has been a matter of some debate. The classic medical approach employs the categorical disease model in which alcoholism is conceptualized as being qualitatively distinct relative to normal “social” drinking (Meyer, 2001). Theorists espousing a categorical point of view would consider abstinence/nonuse, use, abuse, and dependence as conceptually distinct states. Also consistent with this approach is Cloninger and colleagues’ (1988) classic description of “types” of alcoholics, an approach that has received only mixed empirical support (Sannibale & Hall, 1998). Concerns regarding the limited nature of such categorical approaches have led many to adopt a quantitative approach, which stresses that alcohol use lies on a continuum from nonuse to dependence (Meyer, 2001). Factors such as quantity of alcohol consumed, frequency of consumption, and variability (i.e., regularity with which drinking occurs) move people along this continuum, the extreme of which is alcohol dependence (Streissguth, Martin, & Buffington, 1976). Recent discussions about the existence of a “switch” that is responsible for transforming a “normal drinker” into an “alcoholic” (e.g., Tsuang, Bar, Harley, & Lyons, 2001), as well as data suggesting that there is great individual variability within the subset of alcoholics, have led to a blending of the two approaches. By the prevailing view, alcoholism is seen as a qualitatively distinct state, but there is a continuum of symptom severity within the subgroup of alcoholics (Meyer, 2001). In addition, quantitative drinking factors (e.g., quantity, frequency, variability) are necessary predictors of the development of alcoholism. That being said, it must also be acknowledged that the putative switch has not yet been identified, and as such, most researchers have relied on studying quantitative drinking factors as a reasonable surrogate. Therefore, the preponderance of theoretical grist has aimed at understanding why some would drink more than others rather than at directly addressing why some people become alcoholics. For now, the proverbial lamppost shines down on the quantitative approach.

Alcohol Dependence

The DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) (American Psychiatric Association, 1994) defines drug dependence as a collection of any three of seven symptoms. All must create meaningful distress and occur within the same year. The diagnosis requires judgment on the clinician’s part, but the symptoms tend to be obvious. Each symptom reflects the idea that a person requires the drug to function and makes maladaptive sacrifices to use it. The current diagnosis focuses on consequences rather than on the amount or frequency of consumption. These consequences are (a) tolerance and (b) withdrawal, which were once considered the hallmarks of dependence. The additional symptoms are (c) use that exceeds initial intention, (d) persistent desire for the drug or failed, attempts to decrease consumption, (e) loss of time related to use, (f) reduced activities because of consumption, and (g) continued, use despite problems.

Tolerance serves as a hallmark of physiological dependence. It occurs when repeated use of the same dose no longer produces the same effect. This symptom often indicates extensive drinking and may motivate continued consumption. People do not grow tolerant to a drug; rather, they grow tolerant to its effects. After repeated use, some of the effects of a drug may decrease, whereas others may not. Tolerance to the desired effects of alcohol may encourage people to drink more, and increased use may coincide with a greater chance for problems.

The second symptom of dependence, withdrawal, refers to the discomfort associated with an absence of the drug. No two people experience withdrawal in the same way. Hallmark signs can range from mild irritability to full-blown hallucinations. Alcohol withdrawal frequently includes tremor, anxiety, craving, and troubled sleep. A severe, palsy-like tremor with frequent perceptual aberrations, known as delirium tremens, often accompanies severe withdrawal.

The DSM-IV distinguishes between dependence with physiological aspects and dependence without physiological aspects. If tolerance or withdrawal appears among the three required symptoms, a diagnosis of physiological dependence is appropriate. Nevertheless, even without the presentation of tolerance or withdrawal, individuals may still receive a diagnosis of alcohol dependence without the specifier “with physiological dependence.” This change in procedure has made the diagnosis of alcohol dependence potentially more common.

The third symptom of dependence involves use that exceeds initial intention. This symptom suggests that individuals may plan to have only a couple of drinks but then drink markedly more once they become intoxicated. Use that exceeds intention was once known as “loss of control.” Many people misinterpreted the idea of loss of control, suggesting that it referred to an unstoppable compulsion to drink everything available. Based on this interpretation, people who drank to the point of blackout but still had liquor in the house the next morning might have claimed that they did not show loss of control. Today, use that exceeds intention does not imply this dramatic unconscious consumption. This symptom simply suggests that dependent users may have trouble drinking only a small amount if that is what they intend to do. Ironically, people who never intend to drink a small amount might not get the opportunity to qualify for this symptom.

Dependence also includes failed attempts to decrease use, or a constant desire for the drug, as the fourth symptom. An inability to reduce drinking despite a wish to do so certainly suggests that the drug has altered behavior meaningfully. Yet people with no motivation to quit would likely never qualify for failed attempts. Thus, people who have not attempted to quit may still qualify for this symptom if they show a persistent continuous craving. An inability to stop drinking or a constant desire to consume alcohol suggests dependence.

The fifth symptom of dependence involves loss of time related to use. The time lost can be devoted to experiencing intoxication, recovering from it, or seeking the drug. Because alcohol is legal, users might not spend considerable time in search of it. Hence, the number of hours required to qualify for a meaningful loss of time remains unclear, making this symptom quite subjective. A clear-cut case would be anyone whose day is devoted to obtaining alcohol, drinking to the point of intoxication, and recovering from the effects of alcohol. An individual who spends even a portion of the day (e.g., a few hours) on these activities would also qualify. In contrast, an individual who consumes several drinks an hour before going to bed each night might argue that he or she has lost little time and should not qualify for this symptom. Thus, subjective assessment of a meaningful amount of time may contribute to problems with the diagnosis of dependence.

The sixth symptom of dependence is reduced activities because of drinking. This symptom focuses on work, relationships, and leisure. The presence of this symptom suggests that alcohol has taken over so much of one’s daily life that the user would, qualify as dependent. Any impairment in job performance because of intoxication, hangover, or devoting work hours to obtaining alcohol would qualify for this symptom. Individuals missing work every Monday to recover from weekend, binges might also qualify. Sufficient functioning at work, however, does not indicate that one is not dependent. Even with phenomenal job performance, impaired social functioning may be indicative of problems. If a drinker’s only friends are drinking buddies and they only socialize while intoxicated, the substance has obviously had a marked impact on friendships. Recreational functioning is also important to the diagnosis. A decrease in leisure activities suggests impaired recreation. A drinker who formerly enjoyed hiking, reading, and theater but who now spends all of his or her free time intoxicated in front of the television would qualify for this symptom. This approach to the diagnosis implies that drinkers who are not experiencing multifaceted lives can improve the way in which they function by drinking less. The final symptom of dependence requires continued use despite problems. People who persist in using the drug despite obvious negative consequences would, qualify for this symptom. Recurrent use regardless of continued occupational, social, interpersonal, psychological, and/or health problems obviously shows dependence. Many of these difficulties involve meaningful others in the drinker’s life. Continued consumption despite conflicts with loved ones, employers, and/or family members might qualify for this symptom. This situation supports the idea that anyone who continues to use despite negative consequences (e.g., stomach ulcers, feelings of guilt, loss of self-respect) must have a strong commitment to alcohol.

Alcohol Abuse

A subset of individuals may experience negative consequences from alcohol that do not qualify for a diagnosis of dependence but that meet criteria for a diagnosis of abuse. This diagnosis requires significant impairment or distress directly related to drinking. A diagnosis of alcohol abuse requires only one of the four symptoms that appear in the DSM-IV: (a) interference with major obligations, (b) intoxication in unsafe settings, (c) legal problems, and (d) continued use in the face of problems. Each of these signs requires some interpretation on the part of the individual making a diagnosis; however, most experienced diagnosticians agree on who meets criteria for substance abuse and who does not (Üstün et al., 1997). Abuse remains distinctly separate from dependence, which requires different symptoms and more of them. Although a diagnosis of abuse clearly serves as a sign of genuine troubles, many clinicians consider dependence to be more severe. Thus, those who qualify for dependence would not receive the diagnosis of abuse.

The first symptom of abuse, interference with major obligations, requires impaired performance at work, home, and/or school. Impairments may arise due to intoxication, recovery from intoxication, and/or time devoted to searching for liquor. The definition is necessarily broad so as to include people with a variety of responsibilities. Specifically, this symptom applies to employees who miss work because they have hangovers, students who fail tests because they attend classes intoxicated, and parents who neglect their children so that they can spend time in bars.

The second symptom requires intoxication in unsafe settings. The DSM-IV specifically lists driving a car and operating machinery as hazardous situations in which intoxication could create dangerous negative consequences. Many experienced drinkers claim that their intoxicated driving differs little from their sober driving. Such statements may reflect poorly on their driving abilities in general, but people who tremble as a result of withdrawal might actually drive better after a couple of drinks. Despite this fact, driving a car while drunk, even for only a few blocks, qualifies as alcohol abuse.

The intoxicated performance of any task can lead to a diagnosis of abuse if impairment may lead to negative consequences. This action need not be as elaborate as scaling a skyscraper or handling a firearm. Driving a forklift or using power tools might qualify. Note that no negative consequences actually need to occur; their increased likelihood alone can qualify for abuse. Thus, those who drive drunk but never receive tickets or have accidents would still qualify for abuse due to the fact that they increase their likelihood, of experiencing negative consequences.

The third symptom included in the diagnosis of alcohol abuse concerns legal problems. This symptom may say as much about society’s values as it does about an individual’s behavior (Brecher, 1972; Grilly, 1998). Any legal troubles related to public intoxication, driving while intoxicated, drunk and disorderly behavior, alcohol-related aggression, or underage drinking would qualify.Finally, the fourth symptom of alcohol abuse concerns consistent use despite problems. Note that recurrent use in the face of occupational, social, interpersonal, psychological, and/or health problems qualifies as abuse.

Alcohol Problems

Describing alcohol-related difficulties as addiction, abuse, or dependence creates certain misunderstandings. All three words may sound deprecating (Eddy, Halbach, Isbell, & Seevers, 1965; Miller, Gold, & Smith, 1997), and each lacks clarity; however, addiction has no accepted definition. As noted previously, abuse and dependence have formal definitions, but the specific diagnosis does not reveal an individual’s actual problems. Anyone who qualifies for abuse may have one or more of the four symptoms required, meaning that an individual with such a diagnosis could be experiencing any one of more than a dozen combinations of symptoms. Likewise, dependence requires three of seven symptoms, providing more than 30 potential combinations of symptoms. These terms may also encourage the minimization of problems that do not qualify for a diagnosis, and this can interfere with treatment.

People experiencing negative consequences from alcohol may prove to be unwilling to limit consumption if they do not qualify for addiction, abuse, or dependence. This limitation has inspired an approach that emphasizes problems rather than diagnoses or diseases. Thus, instead of worrying about whether a specific user qualifies for a disorder, time might be better spent identifying individual problems related to drinking. For example, a client may report frequent stomach pains. A survey of this person’s drinking may reveal that the pain often follows a binge. Although this problem might not interfere enough to qualify for abuse, the client may benefit from drinking less or quitting. This emphasis on problems may allow the clinician to avoid pointless arguments about whether or not someone is an addict. Instead, the clinician and the client can focus on reducing the harm that alcohol may cause.

Models of Alcoholism

As with many other topics in psychology, there are nearly as many theories of the development of alcohol problems as there are theorists. By and large, however, there is agreement that people drink alcohol because it makes them feel good. Principles of operant conditioning suggest that either positive reinforcement, negative reinforcement, or a combination of the two play a role in drinking behavior. Some data support the role of positive reinforcement in alcohol consumption. For example, Newlin and Thomson (1990) argued that individuals with a positive family history for alcoholism may be more sensitive to the positive/stimulant effects of alcohol, and several studies support this supposition (e.g., Erblich, Earleywine, Erblich, & Bovbjerg, in press). Research in this area has also underscored the importance of negative reinforcement in understanding alcohol consumption. Nearly a half century ago, Conger (1956) advanced the now classic “tension reduction hypothesis,” which speaks broadly to alcohol’s negatively reinforcing properties. More recent modifications to the tension reduction hypothesis have focused on alcohol’s ability to dampen the human stress response (Levenson, Sher, Grossman, Newman, & Newlin, 1980), and further modifications have demonstrated that stress response dampening may be mediated by alcohol’s impairment of cognitive processes (Erblich & Earleywine, 1995; Josephs & Steele, 1990). Regardless of the mechanism, reinforcement appears to play a central role in the initiation and maintenance of drinking behavior.

Over the past two decades, Schuckit and colleagues (e.g., Schuckit, 1994; Schuckit, Tsuang, Anthenelli, Tipp, & Nurnberger, 1996) have presented considerable empirical evidence (both cross-sectional and longitudinal) indicating that drinkers who experience lower levels of response to alcohol consumption are more likely to experience problem drinking. They have suggested that such individuals may need to drink more than others to achieve a desirable level of reinforcement or that such individuals’ lower interoceptive responses to the substance make it more difficult for them to regulate intake appropriately. Conversely, others have suggested that those who experience higher levels of response to alcohol consumption are more likely to develop problem drinking (e.g., Nagoshi & Wilson, 1987). These theorists have proposed that the more reinforcing the effects of alcohol, the more likely one is to consume. Newlin and Thomson (1990) proposed that both may be the case; that is, lower levels of response to the aversive effects of alcohol, coupled with higher levels of response to its positive effects, create a “double whammy” risk factor for problem drinking. Subsequent empirical studies have provided some support for their model (e.g., Erblich et al., in press). The prevailing view remains that the reinforcement value of alcohol figures prominently in understanding problem drinking. A critical question, by extension, would, be the following: What factors contribute to differential levels of alcohol’s reinforcement value?

Specific Genetic Factors

Quantitative genetic studies have demonstrated in a compelling fashion that alcoholism has a substantial, but not an exhaustive, heritable component. Cadoret, Troughton, O’Gorman, and Heywood (1986) estimated that up to 60% of the population’s variability in alcoholism is attributable to genetic factors. Other epidemiological studies have established that individuals who have an alcoholic parent are three to four times more likely to develop alcoholism themselves. Although exogenous (i.e., nongenetic) factors may account for some of the observed intergenerational transmissibility of alcoholism, the confluence of these epidemiological and quantitative genetic studies suggests a preeminent role of genetics in conferring vulnerability to problem drinking.

In 1990, Blum and colleagues became the first to discover a relationship between a specific genotype and alcoholism. A long tradition of research in neuroscience has implicated dopamine as the central nervous system (CNS) neurotransmitter of reward, and studies have demonstrated that drug use is associated with increased CNS dopamine release. Based on this research, Blum and colleagues (1990) tested the possibility that polymorphisms (i.e., genotypic variants) in the dopamine D2 receptor gene (DRD2) would be related to alcoholism. Indeed, they found that severe alcoholics were significantly more likely to carry the DRD2 “Al” allele compared with controls. They suggested that this locus may be related to a lower number of D2 receptors, resulting in hypodopaminergic function that could be alleviated by, among other things, alcohol consumption. This suggestion may be consistent with the overall reinforcement model of risk for alcoholism, such that carriers of this polymorphism may find consuming alcohol more rewarding than do noncarriers. Whether or not this is the case remains to be seen. Strikingly, studies of genetics have typically not included assessments of perceived levels of reinforcement, so that intuitive relations between genotype and reinforcement remain largely speculative. Another concern is that molecular biology has, to date, procured only sketchy evidence that the DRD2 polymorphism is functional; that is, carrying the A1 allele does not necessarily translate to fewer D2 receptors. Therefore, the mechanism through which DRD2-A1 confers increased risk for alcoholism remains unclear.

Nevertheless, Blum and colleagues’ (1990) initial findings have spurred an intensive search for other candidate genotypes that may predict problem drinking. Blum and colleagues (2000) have since tested other dopamine-related genotypes, including polymorphic loci on DRD4 and SLC6A3, a gene that generates the protein responsible for regulating presynaptic dopamine reuptake. Other candidate genes (e.g., SLC6A4, 5HT-1B, GABA-A, muOR, PENK) include those related to serotonin function, GABA function, and opioid release (for a review, see Blum et al., 2000). Studies have provided mixed results, and even the positive studies account for only a small proportion of variance in alcoholism or drinking, with substantial heterogeneity. Findings underscore the importance of polygenic or gene-environment interactions in better understanding this complex behavioral disorder. Indeed, early biochemical research (Davis & Walsh, 1970) has suggested that by-products of alcohol’s metabolism (i.e., tetrahydroisoquinolines) may cause a cascade that directly impinges on opioid receptors but that also indirectly affects the breakdown and availability of synaptic dopamine. Although not yet tested, work by Berridge and Robinson (1998) raised the possibility that genes related to dopamine function may operate by increasing the motivational salience of the substance (e.g., craving or “wanting”), whereas relevant polymorphisms in opioid genes may operate by increasing the hedonic value of consumption (e.g., actual reward or “liking”). Although perhaps a way off, possession of these genotypes may suggest distinct loci of intervention (i.e., craving management therapy for carriers of dopamine-related high-risk genotypes vs. opiate antagonist therapy or counterconditioning for carriers of opioid-related high-risk genotypes).

Along similar lines, recent studies characterizing the dysregulation of CNS functional systems through chronic alcohol use have demonstrated striking down-regulation of both the D1 and D2 receptor systems (Self & Nestler, 1998). To the extent that genetics may play a role in receptor density, a potential gene-environment interaction may exist that renders some drinkers particularly susceptible to chronic hypodopaminergic states. This possibility is particularly intriguing as data emerge suggesting that, within the dopamine system, the D1 subsystem is associated with liking, whereas D2 is more associated with wanting (Berridge & Robinson, 1998; Self, 1998). The convergence of these data may suggest that psychopharmacological agents with differential affinities to D1 and D2 may prove to be selectively efficacious depending on the particular need, of the drinker (e.g., a D2 genetically “vulnerable” person may need more craving management).

A final set of candidate genotypes that has been examined include those genes responsible for generating alcohol metabolic enzymes (e.g., alcohol dehydrogenase, acetaldehyde dehydrogenase, P450 liver enzymes in the cytochrome system) (Higuchi, Muramatsu, Matsushita, Murayama, & Hayashida, 1996). Polymorphic loci on these genes (e.g., ALDH2, ADH2, ADH3, CYP2E1) are subjects of continued scrutiny and may also relate to the magnitude of the hedonic response to alcohol consumption. Because stress is a potent antecedent of alcohol consumption, examination of genetic factors that relate to the stress response (e.g., cortisol regulation) may be a promising avenue in the future. Clearly, the preliminary search for candidate genotypes has yielded only modest results. Genome-wide microarray technology may prove to be highly useful in elucidating the roles of multiple genes in animal models of alcoholism.

Cognitive Factors

There is currently a large body of research demonstrating that individuals with a genetic predisposition to alcoholism display substantial cognitive and neuropsychological deficits. Giancola and Moss (1998) argued that cognitive and neuropsychological deficits, especially those related to executive functioning that predate drinking experiences (e.g., attention, planning, cognitive flexibility, appropriate inhibition), may somehow be related to the development of alcoholism. For example, Alterman, Gerstley, Goldstein, and Tarter (1987) reported, that “children of alcoholics” perform more poorly on tasks that putatively assess frontal lobe functioning such as the Stroop task, the Trail Making task, and the Wisconsin Card Sort task. Studies of stimulus-evoked potentials, especially the P300 component (Rodriguez, Porjesz, Chorlian, Polich, & Begleiter, 1999), have provided converging biological support for the notion that children of alcoholics display poorer attentional capacities than do other children. In contrast to the predictors mentioned previously, these cognitive predictors do not necessarily directly operate through differential reinforcement. A likely explanation is that although drinkers with cognitive deficits experience comparable levels of reinforcement from alcohol to those of drinkers without such deficits, the former lack the cognitive resources to regulate their intake or to say “no” when offered a drink. This problem may become particularly pronounced when high-risk drinkers, who are already mildly cognitively deficient, become intoxicated, further undermining their ability to process information or to attend to internal or external intake regulation cues. The possibility also exists that cognitive deficits are epiphenomenal to a broader relation between chronic hypofrontality (which may, in fact, be related to the reinforcement value of alcohol) and future drinking behavior. Alternatively, Erblich and Earleywine (1999) suggested that such deficits may also stem from the more general effects of growing up with an alcoholic parent. Poorer nutrition, educational opportunities, and physical abuse have been reported among children of alcoholics (Rao, Begum, Venkataramana, & Gangadharappa, 2001). One could speculate that growing up in such an environment may lead to the observed cognitive deficits and, as indicated previously, may be an important mechanism through which problem drinking develops. Speculation aside, the precise mechanism through which cognitive and neuropsychological deficits lead to alcoholism remains unclear. In addition, whether these deficits are genetic or environmental in origin is also unclear. Nevertheless, these factors are important to consider when developing an etiologic model of alcoholism.

Characterologic Factors

It is now well established that specific personality factors are strongly predictive of drinking behavior. Nearly four decades ago, MacAndrew (1967) identified clusters of items on the Minnesota Multiphasic Personality Inventory (MMPI), primarily related to deviance proneness, that significantly differentiated alcoholics from nonalcoholics. This early research was one of the first systematic investigations of the potential role of personality characteristics in problem drinking. Since then, the MacAndrew Alcoholism Scale and the Holmes Alcoholism Scale have become mainstays of risk assessment for alcoholism. Recent modifications have found that shorter versions of these scales (7 to 13 items) may be even more strongly related to alcoholism (Conley & Kammeier, 1980; Hoffman, Lumry, Harrison, & Lessard, 1984). Problem drinking has been related to other measures of deviance proneness as well. For example, several studies have found that problem drinkers, alcoholics, and children of alcoholics score significantly more pathologically on the Socialization scale of the California Personality Inventory (e.g., Finn, Sharkansky, Brandt, & Turcotte, 2000). In addition, symptoms of antisocial and borderline personality disorders are common among problem drinkers, alcoholics, and children of alcoholics. Indeed, Sher and Trull (2002) reviewed the literature on personality disorders and concluded that although substance abuse is related to many personality symptoms, including those of paranoid and avoidant personality disorder, the largest consistent set of findings is in antisocial and borderline symptoms.

Problem drinking appears to be related to other personality constructs as well. Studies have demonstrated repeatedly that high scores on Zuckerman’s Sensation Seeking Scale (and other similar scales) predict drinking behavior (e.g., Finn, Earleywine, & Pihl, 1992). Other studies of novelty seeking using similar instruments provide additional support for such a relation (Hesselbrock & Hesselbrock, 1992). A longitudinal study of children’s novelty seeking found that those who scored highly were more likely to become alcoholics as adults (Cloninger et al., 1988). Interestingly, one of the relatively few transdisciplinary studies performed (Laine, Ahonen, Rasanen, & Tiihonen, 2001) revealed that individuals high in novelty-seeking personality traits also have higher densities of CNS dopamine transporter (DAT). This finding is consistent with genetic hypotheses that high levels of DAT (which clears dopamine from the synapse) would relate to problem drinking.

Still other studies have examined the role of traits such as disinhibition, reward dependence, external locus of control, and negative self-concept and have found significant relations with drinking behavior (e.g., Hesselbrock & Hesselbrock, 1992). Interestingly, neurophysiological studies have linked many of these personality traits, especially sensation seeking, disinhibition, and deviance, to chronic hypo-perfusion of the orbitofrontal cortex (Friedman, Cycowicz, & Gaeta, 2001). Theorists have suggested that these personality traits may represent part of a broader syndrome related to cortical underarousal (Brennan & Raine, 1997). The localization of these traits in the CNS is particularly intriguing because the orbitofrontal cortex is precisely the area involved in the cognitive deficits mentioned previously. Furthermore, this region of the brain is highly dopaminergic. The physiological convergence of these biogenetic, cognitive, and personality factors speaks to the preeminent role of a “hungry” brain in dramatically increasing the incentive salience and reward value of alcohol consumption.

Exogenous Factors

Stress is the most consistently reported antecedent to drinking behavior. Naturalistic studies of stress have found strong relations between a number of stressors (e.g., social, medical, trauma) and drinking behaviors. As one example, Seeman and Seeman (1992) found that chronic stress associated with work predicted later alcoholism. Indeed, anecdotal clinical reports consistently support the contention that acute stress is a powerful proximal determinant of drinking episodes. To ascertain a causal relation between stress and drinking, investigators have employed laboratory-based studies of experimental stressors (Stewart, 2000). Findings have demonstrated that social, cognitive, and physical stressors can induce alcohol craving, potentiate the hedonic impact of consumption, and increase the amount of alcohol consumed post-stressor (Stewart, 2000). Interestingly, the magnitudes of stress reactions also predict drinking behavior, such that the previously mentioned drinking parameters are more severe for those who have stronger stress reactions (Sinha & O’Malley, 1999). This finding is important because it suggests not only that stress is a predictor of drinking but also that some who are predisposed to more powerful stress reactions (through some genetic factor or otherwise) are at a particularly high risk for problem drinking. The classic stress vulnerability model may be particularly appropriate for understanding alcoholism. Specifically, constitutional factors, such as genetics, personality characteristics, neuropsychological dysfunction, and stress reactivity, may render some individuals particularly vulnerable to the effects of stress and place them at high risk for dependence.

If stress predicts drinking behavior, coping skills should moderate the degree to which stress has an impact. Indeed, studies have demonstrated that coping skills can buffer the effects of stress on drinking behavior (“Wills, Sandy, & Yaeger, 2002). Darwin, Freud, and (most recently) Bandura have underscored the importance of coping in adapting to stressful situations. The Darwinian model of homeostatic maintenance would predict that an organism would consume alcohol to return to a baseline “pre-stress state” (Darwin, 1859/1998). Indeed, ethologists have speculated that animals may take laborious detours from traditional migratory paths to find psychoactive substances. It is thought that this may serve to maintain homeostasis during the stressful process of migration. Freud (1901) formulated the role of coping in terms of “defense mechanisms.” He argued that those who are “orally fixated” (i.e., those who experienced some sort of developmental arrest in early life when oral pleasure dominated) might use alcohol to cope with stressors in favor of other healthier coping mechanisms. Finally, Bandura (1969) argued in his social learning theory that use of alcohol as a coping mechanism may stem from imitative learning processes. Drinkers may have observed their parents use alcohol as a method of “unwinding” after a long day, or they may have observed similar media representations of alcohol (e.g., “Miller time”). All of these theorists share the notion that management of stress is a critical moderator of drinking behavior and must be considered when trying to understand the effects of stress on the development of alcoholism.

Another major predictor of drinking behavior is one’s expectations of the consequences of drinking (e.g., Keane, Lisman, & Kreutzer, 1980). The more one expects alcohol consumption to lead to positive outcomes (e.g., better social performance, better sexual performance, more tension reduction, euphoria), the more one will drink. Similarly, the less one expects alcohol consumption to lead to negative consequences (e.g., hangover; excessive sedation; sluggishness; trouble with family, friends, work, and the law), the more one will drink. Studies have shown repeatedly that the Alcohol Expectancy Questionnaire, a classic instrument used to assess positive expectancies, predicts drinking behavior (e.g., Williams & Ricciardelli, 1996). Similarly, the more recently developed Negative Alcohol Expectancy Questionnaire has been found to negatively correlate with drinking variables (McMahon & Jones, 1994). Recent innovations have identified powerful ingrained cognitive schemata that underlie these expectations (Rather, Goldman, Roehrich, & Brannick, 1992), and these are especially strong among those at risk for alcoholism (Erblich, Earleywine, & Erblich, 2001). In an intriguing study, Smith (1994) found that expectations of favorable drinking consequences predated drinking experiences, suggesting that such expectancies may be learned relatively early in life and are not simply a readout of people’s actual experiences with alcohol.

Modeling is another critical component in the development of drinking behavior, according to Bandura’s social learning theory. Children and teens often rely on role models when developing behavioral repertoires, especially regarding health behaviors (Yancey, Siegel, & McDaniel, 2002). Observing parents, siblings, and other peers consume alcohol may play a powerful role in shaping future behavior (Roski et al., 1997). Other role models, including those seen in advertisements, television programs, and movies, can have a profound influence as well. Thompson and Yokota (2001) found that although the trend has been decreasing, a substantial number of G-rated movies depict alcohol and/or drug use.

Social support is yet another factor found to be involved in the development of problem drinking. Individuals who report low levels of social support are more likely to report problem drinking than are others (Green, Freeborn, & Polen, 2001). In a longitudinal study, Schuckit and Smith (2001) found that even among individuals at high risk for alcoholism, high levels of social support protected against developing alcoholism 15 years later. Marlatt (1996) discussed numerous “proximal determinants” or factors that contribute to the decision to consume alcohol “in the moment.” He suggested, that those individuals with poor social skills, especially those who are uncomfortable with saying “no,” are more likely to consume alcohol (see also Smith & McCrady, 1991). In addition, those who have lower levels of self-efficacy, especially regarding the willpower to abstain or moderate drinking behavior, are more likely to consume alcohol. Taken together, stress, coping, expectancies, modeling, social support, social skills, and self-efficacy can be conceptualized as necessary, but not sufficient, moderators of risk for developing alcoholism, such that the presence of these factors may determine whether or not someone who is vulnerable (by virtue of genetics, personality, or cognitive functioning) will develop alcoholism. It should, be noted, that although these concepts are being presented independently, there is a sizable literature suggesting complex interrelationships between factors that is beyond the scope of this chapter. An illustration of this point is that coping, social skills, and self-efficacy all may be related and may be affected by expectancies (Marlatt & Gordon, 1985). Nevertheless, we believe that the current body of literature on predictors of drinking behavior points to a classic stress vulnerability model, whereby constitutional factors such as genetics, personality, and cognitive capacities can render an individual vulnerable to the effects of numerous exogenous factors. In sum, the available data suggest that the stress vulnerability approach provides a clinically useful working model of the pathogenesis of alcoholism.

Psychological Treatments for Alcohol Problems

At least three different approaches have shown considerable promise in minimizing the negative consequences of alcohol: cognitive-behavioral therapy (CBT), motivational interviewing, and 12-step facilitation. CBT focuses on changing the thoughts and situations that previously led to the use of alcohol. Motivational interviewing uses assessments and interpersonal interactions to enhance decisions to alter problem behaviors. Finally, 12-step facilitation employs specific techniques to help people make good use of 12-step treatment.

Each treatment has its strengths. An enormous project that contrasted the outcomes of these three treatments for alcohol-dependent individuals found that all three were comparably effective (Project MATCH Research Group, 1998). The treatments share several factors, and this may help to explain their similar outcomes. Each emphasizes the client’s responsibility for change, each treats alcohol use as a phenomenon independent of the individual’s value as a person, and each stresses regular attendance and active participation in treatment.

Descriptions of these therapies do not reveal all of their nuances, and even the best attempt to reduce a treatment to a few pages of text invariably fails. Academic descriptions of psychotherapy often miss its potential for intimate and curative interactions, whereas stereotypical depictions of the process often emphasize education, empathy, encouragement, and occasional insights. Ideally, these descriptions combine to alter actions, diminish problems, and increase happiness. The techniques and rationales of each of the treatments discussed, in what follows provide only a limited picture of the ways in which they actually proceed.

Although treatments differ in their methods and strategies, most require a meaningful relationship with a therapist. Therapists often believe that techniques create change, but the relationship may serve as an equally important contributor (Strupp, 1989). The idea that the relationship is more important than specific strategies may help to explain some of the similar outcomes created by different therapies (Wampold et al., 1997). Manualized treatments, which clearly delineate specific material for each session, can lead to different outcomes with different therapists. Although the therapeutic relationship may account for these differences, it does not mimic the friendship and coaching common outside of therapy. Data clearly support psychotherapy’s efficacy, but the mechanisms that lead to success remain unclear (Dawes, 1994).

Space limitations preclude a lengthy description of all available treatments for alcohol-related problems. Given the widespread. familiarity and availability of 12-step programs, this chapter focuses on CBT and motivational interviewing. The reader who is interested in facilitating participation in 12-step programs is encouraged to read the work of Nowinski and Baker (1992).

Cognitive-Behavioral Therapy

CBT for alcohol problems focuses on altering environments, thoughts, and actions associated with drinking. Different environments may trigger undesired problematic consumption. These triggers involve both external and internal factors. External factors include any person, location, or object associated with alcohol. A beer mug, a rock song, or a swizzle stick may easily trigger a desire to drink. Internal factors include thoughts and feelings linked to alcohol. Some triggers are direct and some are indirect. Direct factors, such as craving and urges, are close to drinking. Indirect factors also increase the chance of drinking, but their import is less obvious. These include frustration, anger, and even delight. CBT suggests that problem drinkers learn to use alcohol in reaction to these triggers in much the same way as people learn any behavior. Therefore, they can learn to engage in new behaviors instead of problematic drinking by altering environments, thoughts, and actions (Beck, Wright, Newman, & Liese, 1993).

The situations that precede drinking often appear to be diverse. For example, an assessment might reveal dramatic drinking at a sporting event, after conflict at home, and every Friday night. The commonalities among these situations are obscure. The cognitive-behavioral model suggests that thoughts about the situations may contribute more to drinking than do the circumstances themselves. Thus, each environment may elicit specific thoughts. A common thought in all of these situations might be that “alcohol is the only way in which to enhance this experience.” These types of thoughts are probably easier to alter than are the situations, so the thought rather than the environment becomes the focus of CBT.

The cognitive-behavioral model suggests that people carry a set of underlying beliefs into each situation. Certain situations activate these beliefs, eliciting specific thoughts that subsequently lead to action. For example, a problem drinker might believe that alcohol provides the only way in which to relax. The drinker may interpret a situation as stressful, leading to the activation of the belief that he or she needs alcohol to relax. This belief would likely lead to thoughts of drinking, which might inspire all of the actions required to get a drink. In CBT, the client would learn to challenge his or her beliefs in an effort to minimize or eliminate drinking. Thus, the client may develop skills enabling him or her to see the situation as less stressful, thereby altering the belief that drinking is the only effective way in which to relax (Beck et al., 1993). Instead of drinking, the client might listen to music, meditate, or exercise.

Therapists have developed many techniques for altering these beliefs. Most require identifying the underlying belief and then looking for evidence to support or dispute it. A common strategy that cognitive-behavioral therapists employ includes Socratic questioning, a method by which therapists guide clients through a series of questions so that they might arrive at their own answers. Instead of providing information, this strategy teaches a process for discovery. Eventually, clients can learn to ask these sorts of questions of themselves so that they can maintain sobriety without therapists.

This process also elicits the thoughts and feelings most important to clients. For example, those who believe that alcohol provides the only way in which to relax might respond particularly well to questions about alternative ways in which to unwind. Questions about restful recreation in general may prove helpful. Queries about favorite activities before clients began drinking may also work. As clients generate their own list of preferred ways in which to soothe themselves without alcohol, the belief that alcohol is the sole source of relaxation weakens. It is important to note that clients find their own examples more compelling than any list of relaxation techniques that therapists might generate. This approach also respects clients’ ability to present evidence to alter their beliefs (Overholser, 1987). In sum, changing the thoughts about situations that previously led. to drinking can help to decrease problematic consumption.

CBT relies on other techniques that are too numerous to list here, but one key set of strategies concerns relapse prevention. Many people can quit drinking briefly but cannot maintain abstinence. Thus, many cognitive-behavioral techniques focus not only on quitting but also on avoiding relapse to alcohol. Thoughts and beliefs remain important in preventing relapse given their relevance to a phenomenon known as the abstinence violation effect. The abstinence violation effect concerns the way in which people cope with backsliding once they have committed to altering their alcohol consumption.

Most people who decide to eliminate or decrease their use of alcohol subsequently make mistakes. They use alcohol when they intended to quit, or they use more than their established limits. The abstinence violation effect may occur when a small thoughtless sip of beer turns into a full weekend binge. It is as if people say, “Well, I wrecked my abstinence, so I might as well drink the whole bottle.” Minimizing the impact of small slips is essential to relapse prevention. Although many believe that the pharmacology of alcohol makes a single dose inevitably turn into a relapse, changes in thinking can actually prevent these slips from creating further problems. In fact, it has been shown that the interpretation of the slip appears to contribute more to relapse than does the actual occurrence of the slip itself (Marlatt & Gordon, 1985).

There is no doubt that intoxicated individuals can make poor decisions about continued drinking and that the pharmacological effects of alcohol contribute to these decisions. Nevertheless, many individuals who relapse report abstinence violation effects that occurred at extremely low doses. A single sip of liquor or smell of wine often lead to the decision to binge. Pharmacology might not play a particularly strong role in these relapses. Marlatt, Demming, and Reid (1973) revealed that alcoholics who drank alcohol but were not aware of doing so did not show the abstinence violation effect and did not continue drinking after the initial dose. In contrast, alcoholics given a placebo believed to be alcohol did show the abstinence violation effect and did consume considerably more alcohol after the placebo. These findings indicate that thoughts also play an important role in relapse prevention.

In sum, CBT relies on the principles of learning theory to treat alcohol-related problems. The treatment may work by altering beliefs about alcohol use and its consequences. It also focuses on the prevention of relapse by identifying situations that may increase the risk of drinking and then teaching alternative ways in which to act under those conditions.

Motivational Interviewing

Motivational interviewing involves brief interactions with a therapist to help the client decrease alcohol-related problems. The treatment enhances motivation before attempting any changes in behavior because in the absence of motivation, any efforts to teach techniques for limiting alcohol consumption are typically an inefficient use of time for both the client and the therapist. Motivational interviewing focuses on identifying clients’ own reasons to quit. Once these reasons help to increase desire, clients often develop their own strategies for eliminating alcohol from their lives. Many people stop drinking on their own, and motivational interviewing essentially enhances the chances that a client will join this group. (For a more detailed discussion of motivational interviewing, see Chapter 4.)

Motivational interviewing relies on principles designed to help the client decrease alcohol problems. First, the therapist behaves in a manner that will increase the likelihood of change such as listening attentively without judgment or blame. Second, the therapist employs the “stages of change” model, which views change as a fluid process that requires a different intervention for each stage of the client’s willingness to act. In motivational interviewing, the behaviors employed by the therapist that are most likely to induce behavior change on the part of the client (e.g., empathy, nonpossessive warmth, genuineness) were originally emphasized in client-centered therapy (Rogers, 1950).

The Stages of Change Model

As mentioned in the previous section, empathy, warmth, and genuineness lay the foundation for any productive therapeutic interaction. Many therapies rely on these aspects of the therapeutic relationship to help support growth. Motivational interviewing combines these qualities with the stages of change model to decrease problem drinking. The stages of change model describes specific steps that individuals appear to take when they alter problem behaviors (Prochaska & DiClemente, 1983). The researchers proposed six stages: (a) precontemplation, (b) contemplation, (c) determination, (d) action, (e) maintenance, and (f) relapse (Prochaska, Norcross, & DiClemente, 1994).

Precontemplation describes the period before individuals consider altering behavior. Drinkers in precontemplation have never considered cutting down or quitting. An adept therapist would not waste time attempting to teach these individuals how to quit because they currently lack the motivation to do so. Instead, the therapist assesses clients’ quantity and frequency of drinking in an effort to get them to contemplate change. The best approach for this assessment is the time line “followback” (Sobell & Sobell, 1995), a calendar technique that asks drinkers to go through each day for the previous 3 months and list the number of drinks consumed. The therapist would also ask about any associated consequences such as negative emotions, fatigue, hangovers, accidents, and liver troubles. This assessment often leads clients to make the connection between their drinking and the consequences of their drinking. If these connections are made and they lead clients to consider change in any way, clients have entered the contemplation stage.

Contemplation includes the weighing of the pros and cons of altering actions or continuing the same behavior. The motivational interviewer encourages drinkers in this stage to candidly report all of the positive and negative experiences they attribute to their use of alcohol. Initial assessments of pros and cons often reveal ambivalence, that is, strong desires to continue drinking as well as equally strong desires to stop. Ambivalence serves as a common important component of contemplation. Other approaches to treatment may see ambivalence as denial. The stages of change model emphasizes ambivalence as an inherent part of change. During further discussion, the therapist respectfully reflects drinkers’ concerns back to them, emphasizing the negative consequences that they generated earlier. This process often leads problem drinkers to a decision to change. A firm decision to change qualifies as a step toward determination.

Determination begins with a clearly stated desire to alter actions. This stage serves as the appropriate time for drinkers to formulate a plan for limiting alcohol consumption. The plan often stems from brainstorming between the interviewer and the drinkers and may include any options that look promising. For example, the strategy for change may rely on techniques from CBT such as altering beliefs and preventing relapse. In addition, drinkers may decide that membership in a 12-step program sounds appropriate.

Once clients regularly limit their drinking or abstain, they have entered the action stage. They no longer merely consider change; they actually make the desired change. This stage proves to be particularly informative as the genuine experience of new habits and actions reveal valuable information unanticipated during the contemplation and determination stages. Clients may find some situations to be easier or more difficult than they expected. The motivational interviewer will offer reassurance about the process becoming less difficult with the passing of time and more practice. The interviewer helps clients to solve problems related, to their alcohol use and listens attentively to clients’ detailed descriptions of their difficulties and successes.

After a steady period of action, clients may report increased confidence in their skills. This sense of efficacy, an optimism in their own ability to continue the new behaviors, serves as a hallmark of the maintenance stage. Self-efficacy and sustained change are the keys to maintenance. The therapist and the clients will now work together to prevent relapse. They identify situations that put the drinkers at high risk for relapse, and they plan ways in which to avoid problematic alcohol use in these circumstances. For example, clients may decide to avoid parties where alcohol is present. They may role-play refusing drinks if they are offered them. They may practice relaxation techniques if tension often precedes their drinking. They may call a hotline or a friend during times of temptation. It is important to note that these techniques for preventing relapse are consistent with 12-step and CBT approaches.

Occasional backsliding occurs in many efforts to alter maladaptive drinking behavior. The stages of change model considers lapses and relapses as another category of change. Discussing this fact with clients may help to normalize the occasional slip. Considering lapses as a part of the change process may decrease the chances of an abstinence violation effect transforming a slip into a full-blown relapse. The key to the lapse stage parallels the key to the maintenance stage–preventing relapse. Lapses require immediate action. Lapsing drinkers can prevent relapse by rapidly exiting the situation and removing the chance of continued drinking. Many who lapse berate themselves, but their time and energy may be better spent in identifying the precursors to the slips. A frank examination may reveal a new high-risk situation, providing the opportunity to formulate a plan for how to handle this predicament in the future. For example, a former drinker may find himself or herself lapsing after a fight with a family member. This situation might not be one that the drinker had identified as high risk before. Now the drinker knows that he or she needs to plan new ways in which to deal with conflict. The drinker can turn this lapse into a learning experience to prevent future drinking. Thus, lapses remain a part of the change process, and planning for them may minimize problems.

Conclusions

Alcohol can create numerous problems in the lives of drinkers. Different genetic and environmental factors interact in the creation of alcohol abuse, dependence, and problems. A family history of alcoholism, a combination of personality traits, and a set of cognitive factors all can combine with various life stressors to lead people to turn to alcohol for relief of stress. Consistent use of large quantities may lead to alcohol abuse. It can further lead to alcohol dependence or to other life problems. Three imperfect but useful treatments have proved to be effective in alleviating alcohol problems for many individuals: CBT, motivational interviewing, and 12-step facilitation. These therapies have many overlapping characteristics but also employ techniques specific to each approach that are designed to decrease alcohol-related problems. Although the road to sobriety is fraught with difficulties, many people have changed their lives by eliminating the problems related to their continued alcohol use. Putting an end to problem drinking can have a dramatic impact on health and happiness.

NORMAN A. SPRINTHALL SANDRA DEANGELIS PEACE PATRICIA ANNE DAVIS KENNINGTON

In presenting our rationale for cognitive-developmental stage theories for counseling in this chapter, we discuss the failure of prior models for counseling and the need for a preventive-developmental framework. The cognitive-developmental paradigm, as opposed to previous models, is linked directly to comprehensive theory and major longitudinal and cross-cultural research. Ultimately, any effective counseling practice must reside on the broadest set of theoretical and empirical validations. It is insufficient, in our view, to base practice on perhaps interesting and speculative eclectic and/or “pop” psychology ideas. Instead, we present the assumptions linked to empirical cross-validation that outline a sequence of cognitive-developmental stages that humans employ when faced with difficult and problematic issues of development. We integrate theories of Loevinger, Kohlberg, Piaget, and others to describe the different preferred modes of cognitions that humans employ depending on their cognitive capacity to make meaning from experience. This is followed by a series of case studies to illustrate the crucial importance of selecting a counseling technique that matches the client’s needs and then gradually mismatches within a zone of manageable dissonance. We also complement individual counseling with examples of social role-taking activities designed to shift the emphasis to primary prevention. We close the chapter with a discussion of implications for both counseling and counselor education. The cognitive-developmental model encompasses nearly all common techniques. As we note, the effective counselor employs systematic techniques such as behavior modification, rational emotive techniques, person-centered methods, and cognitive-behavioral methods selected and keyed to the current cognitive-developmental stage of the client.

Background: The Need for a Preventive and Developmental Approach

During the 1970s, applied psychology was confronted with a professional dilemma. Research had shown that traditional approaches of counseling and psychotherapy had, at best, achieved only very modest positive effects (Smith & Glass, 1977). In fact, much earlier research had shown no effect whatsoever (Bergin, 1963). Partly as a result of these findings, some leaders within the psychological establishment called for what then was viewed as a radical change. Miller (1969), in his American Psychological Association presidential address, urged that psychologists concentrate on giving their skills away to the lay public. He said that we should select principles and practices from the armamentarium of applied psychology and teach the public how to employ such knowledge and skills on its own behalf. At the same time, Kohlberg and his associates had completed a major review of child, adolescent, and adult development and reached a stark conclusion: “Put bluntly, there is now research evidence indicating that clinical treatment of emotional symptoms during childhood leads to predictions of adult adjustment” (Kohlberg, 1974, p. 251). Kohlberg further noted, “The best predictors of the absence of adult mental illness and maladjustment are the presence of various forms of competence and ego maturity in childhood and adolescence rather than the absence of problems and symptoms” (p. 251).

This same theme was echoed by Albee’s (1982) comments on the need for a primary preventive approach for applied psychology rather than after-the-fact treatment on an individual basis from the intrapsychic paradigm. The way in which to avoid mental illness was to promote psychological development; prevention always is more effective than a curative approach. Allport (1968) had consistently pointed out that most psychological theories of the day essentially conceptualized humans as reactive rather than proactive. And within counseling, there were a series of special journal issues devoted to a rationale for primary prevention such as those in the Personnel and Guidance Journal (Barclay, 1984) and, more recently, in Elementary School Guidance and Counseling (Paisley & Peace, 1995). Baker (2000) also has written extensively about the need for school counselors to achieve a balance of primary prevention and intervention programs with the same goalhealthy development for all students. The goal is applicable to other client settings as well.

Although all of these efforts are important as significant reasons for a preventive and developmental approach, it is instructive to examine just briefly the failures of many of the precursors. For example, Super (1955) attempted to create such a model with his concept of
“hygiology,” presumably a variant of the mental hygiene movement or Alschuler’s (1970) concept of a “Eupsychian psychology” or even van Kaam’s (1965) model of a “positive existentialism.” These attempts were no more successful than parallel ventures to revise psychoanalytic models to include a positive and proactive conflict-free sphere for ego development as a target for counseling (Hartmann, 1958).

It might be somewhat of an overgeneralization, but nearly all of these prior attempts to form an adequate model for development and primary prevention were unable to resolve the theory-research-practice gap. For example, psychoanalytic ego theory and van Kaam’s (1965) positive existentialism were brilliant theoretical discourses, yet they lacked a research base and had only very broad guidelines for practice. Similarly, other models for prevention may display an opposite set of problems, namely, a major focus on practice and perhaps research without adequate conceptual frameworks. From one of our allied fields, in teacher education, Katz and Raths (1985) referred to this as the “Goldilocks problem,” with the slender Goldilocks slipping and sliding in the overly spacious beds of the papa and mama bear. Theory is too broad to fit practice. At the other extreme, we could denote the problem as the “Procustean” difficulty. That mythical Greek robber would simply stretch a short victim or lop off the limbs of a tall victim to force a fit between the person and his or her bed, for example, a theory too narrow bereft of research as a framework for practice.

The Retreat to Eclecticism

The result of all these well-meaning but misguided attempts created the conditions for an eclectic model for counseling, and quite unfortunately, that has merely replaced one set of problems with an equal set of new problems for prevention. As documented by program analyses of Hollis (1997), no single theory with a research base provides an adequate basis for practice. The solution at this point in the phases of intellectual history is to reject ideological purity and adopt eclecticism. Counselor education programs, for example, now are apt to provide a variety of deliberately different theories and practices. These form a broad repertoire of counseling models. The counselor then is expected either to develop the ability to pick and choose from among these competing alternatives and find one that fits or to use different methods with equal competencesometimes referred to in the literature as “happy eclecticism.” Even recent integrative models (Ivey, 1986; Lazarus, 1981; Meichenbaum, 1991) lack a central theoretical rationale for selecting techniques in a meaningful fashion. The assumption is that somehow the counselor will be able to make these choices prudently and that clients will benefit. Does this mean that we have reached the end point in the journey of intellectual development for counseling practice?

One of the most glaring problems is that eclecticism actually creates more and varied practices rather than providing a disciplined focus for the practitioner. New “therapies” emerge almost overnight and perhaps even faster than a small group of proponents can gather, form themselves into a group, and seek legal certification. Creating new counseling “guilds” through such proliferation avoids requisite theory and research and promotes what Barclay (1984) referred to as an “endless flow of gimmicky techniques” (p. 476). Without theory and research, eclecticism expands randomly using the anecdotal and the idiosyncratic (Brabeck & Weifel, 1985). Practice is simply a series of fads, fables, and folklore wandering in a zone between the trivial and the cosmic without distinguishing one from the other. Thus, it is with a sense of urgency that we turn toward an elaboration of a cognitive-developmental model for counseling as a careful synthesis of theory, research, and practice, resting equally on all three components.

The Cognitive-Developmental Model

The cognitive-developmental model rests on a series of assumptions that themselves have been tested out through extensive research. The most important of these are as follows:

1. Humans create meaning from experiencea cognitive process. “Meaning is not given to us but by us” (Duckworth, 1996, p. i). These cognitive structures form into a stage of development.

2. Cognitive stages form a hierarchical and invariant sequence of meaning making from the less complex to increasingly greater levels of complexity of thinking (Kohlberg, 1984).

3. Stage growth is determined by interaction between the person and the environment including cultural, ethnic, and racial backgrounds (Lewis, Lewis, Daniels, & D’Andrea, 1998). It is neither unilateral nor automatic and is a lifelong process.

Since at least the 1960s, there have been literally thousands of studies documenting these aspects of the developmental model in a variety of domains including cognitive, moral reasoning, and ego development. Stages of cognitions have been studied in the classic work of Piaget (1964, 1972) and confirmed many times over by the recent work of Case (1992) and King and Kitchener (1994) and cross-culturally by Ginsburg and Opper (1988). Stages of moral judgment were validated first on males by Kohlberg (1975) and then longitudinally on both males and females by Kohlberg (1984) and Rest (1986) and cross-culturally by Gielen (1996) and Snarey (1985). Stages of ego development were documented by Loevinger and Wessler (1970), confirming in many ways the theoretical propositions of Erikson (1959) and cross-culturally and within cultures by Hy and Loevinger (1996) and Faubert, Locke, Sprinthall, and Howland (1996). The Loevinger measure of ego stages has been translated into at least 11 languages for other cultures and demonstrates similar growth patterns across the stages in these cultures.

We should add that there are some developmental theories that do not agree with these basic assumptions. For example, both Ivey (1986) and Noam (1988) suggested that developmental stages are nonhierarchical. A close examination of these claims reveals a lack of significant longitudinal and cross-sectional empirical research in support of these views. Also in our view, these theorists might have confused developmental multilevelness as an indicator of a lack of age-stage growth. Current theory based on many of the studies cited previously indicates that cognitive stage growth occurs across a series of semi-independent areas, for example, cognitive, self (ego), moral, interpersonal, and affective domains. There may be systematic gaps in development across these domains according to experience and significant role-taking opportunities. This horizontal decalage (i.e., systematic gaps in development) results in patterns of uneven development that may give the appearance of a lack of a hierarchical stage and sequence (Loevinger, 1987a). In reality, however, such a decalage is an indicator of different stages within each individual. From a counseling standpoint, the usual presenting problems are systematic gaps in the personal and interpersonal domains when compared to stage functioning in academic/intellectual areas. The current state of the art along with a robust research base, then, supports the stage sequence framework as well as the problems presented by uneven development across different domains.

Also, the most recent evidence indicates that none of these cognitive-developmental frameworks by Piaget, Kohlberg, Rest, and other developmentalists is biased against women. In fact, the most current outcome from a large number of studies by Rest and Narvaez (1994) documented a recent trend in stages of moral development indicating that women consistently score higher on justice issues than do men. These findings also were confirmed by Lind (1993) in Germany; by Stewart, Sprinthall, and Siemienska (1997) in Poland; and by Daniels, D’Andrea, and Heck (1995) in Hawaii. Loevinger (1987b) originally normed her stage theory on an exclusively female population and subsequently cross-validated the scheme with male samples. Morrow (1993) examined the Loevinger system in a sample of lesbian women and found no bias by sexual orientation. The distribution by stage from Morrow’s sample was exactly parallel to that from Loevinger’s normative female and male samples. From all of this, and in spite of the commentary by critics such as Gilligan (1982), we can document the lack of bias across these developmental stage theories.

As a result of this extremely large set of basic research studies, it can be concluded that humans do exhibit the characteristics of cognitive-developmental growth as they confront problems of living in a complex and diverse society.

Cognitive-Developmental Stage and Behavior: Is There a Link?

From a counseling standpoint, of course, the question of stage theory does not end with the theoretical and cross-cultural validations noted earlier. Far more important is the stage-behavior connection. Namely, do humans behave differently and in accordance with these stages? The results here are not as clear-cut, yet the trends are highly consistent. Humans who process experience at higher stages of development are more likely to act in humane and altruistic modes than are cohorts who function at less complex stages. These results were summarized by Sprinthall, Sprinthall, and Oja (1998) in studies of resisting cheating, whistle-blowing situations, resisting obedience to arbitrary authority, aiding a bystander in distress, and returning an important questionnaire. Studies reviewed by Rest and Narvaez (1994) documented the relationship between higher stages and fraud detection by certified public accountants; between higher stages and skilled professional performance by physicians, veterinarians, dentists, and nurses; and the opposite by those professionals functioning at lower stages. Goleman (1998) documented similar findings for business executives. Peace (1995), in her review, showed clear relationships between stage of development and professional performance in areas such as teaching and counseling.

In summary, we can conclude that as each stage of development is transcended, individuals increase their competence in a wide variety of domains (Heath, 1991). These include greater effectiveness in problem solving and
even problem finding, interpersonal sensitivity, recognition of individual differences, valuing cultural diversity, decision making in accord with democratic principles of equity and fairness, ego strength to withstand unjust criticism, and self-knowledge and awareness.

Cognitive-Developmental Stage: Counseling Goals and Strategies

The overall process of counseling, either through primary prevention or by individual and small group work, starts with the current stage level of functioning of the client. Then, the counselor creates a slightly more challenging interaction that results in a constructive mismatch so as to promote developmental growth (Hunt, 1974). All developmentalists agree that growth is not automatic, unilateral, or without some pain. The accommodation-as-similation disequilibrium is inevitable given that growth toward greater effectiveness requires the person to give up his or her “old” and ineffective methods of problem solving. Thus, with any developmental strategy, there needs to be a careful balance between support and challenge. Each stage, then, is not fixed or permanent as a special education label; rather, the stage represents the current preferred mode of problem solving. The goal is to aid the growth process, step by step, to a system that is toward more complex functioning at both the cognitive and affective levels. This is based on Vygotsky’s (1962) theory of the zone of proximal development. It is important to remember that no one is completely “in” one stage; rather, there are elements of both higher and lower cognitive process. The counseling dictum is to connect with the current mode and then facilitate development to the slightly higher and more complex mode. Our case studies in subsequent sections illustrate this “plus one” concept given that effective growth always is a gradual and graduated process.

Having established the research and theory base for stage as a predictor of different levels of behavior (e.g., lower stages produce less complex problem-solving strategies and vice versa), we now can outline a general synthesis of stage level and strategies to promote client growth. Early work on this model first was suggested by D’Andrea (1984), Ivey (1986), Loevenger and Wessler (1970), Swensen (1980), and Young-Eisendrath (1988). Paisley and Hubbard (1994) and Vernon (1999) also incorporated developmental theories into counseling strategies for children and adolescents. The current model, described in the following paragraphs, is a further elaboration of those initial efforts. Also, we have expanded and integrated the stage definitions of Loevinger, Kohlberg, and others as a means of providing broad definitions of human functioning across domains of cognitive, affective, and interpersonal functioning. For background purposes, a brief overview of Loevinger’s and Kohlberg’s stages is outlined in Table 7.1.

We now provide a few sample strategies at each level of functioning in two modes: (a) individual/group counseling and (b) primary prevention role-taking strategies. First, given the importance of primary prevention, we do wish to emphasize the need for the role-taking mode as a genuine complement to the more traditional methods. This idea of incorporating both counseling strategies and preventive social role-taking methods originated with a colleague, Jean Williams (personal communication, April1993). A key element in using a cognitive-developmental framework to create person-environment interactions to promote growth is social role-taking, first suggested by Mead (1934). Assuming a complex new role such as peer mentoring, tutoring, counseling, teaching, child care, or companions to older persons can facilitate the ability to take another’s perspective, comprehend a wider worldview, and tolerate ambiguity (Sprinthall, 1994). Significant role-taking experiences in a person’s contextual setting combined with guided reflection has been shown to promote more complex levels of thinking and reasoning (Boss, 1994; Sprinthall, Reiman, & Thies-Sprinthall, 1993). More details on the conditions needed for designing successful role-taking activities are discussed in a subsequent section.

Sample Strategies for Each Level of Functioning

Delta/Delta Three Level

Table 7.2 outlines the client characteristics common at a highly concrete and low level of psychological integration along with the corresponding counseling techniques. For example, Loevinger’s stage definitions, unfortunately, somewhat mix the numerical and the conceptual. Thus, her lower stages of functioning, the equivalent of Stages 1 and 2, are denoted as Delta/Delta Three levels. The individual does not differentiate ideas and feelings and exhibits impulse control problems, sees the world in a narrow-minded dichotomy of right and wrong, and focuses on materialistic gain for self. This

ometimes is referred to as the impulsive/self-protective stage.

Counseling strategies initially would focus very directly on the concrete, for example, a behavior modification system set up and managed by the counselor. The individual at that level is not capable of consistent self-management. This also means that the counselor needs to employ high structure with minimal ambiguity using immediate, concrete, and meaningful rewards through positive reinforcement. At the same time, the counselor stresses the concrete connection between the individual’s current maladaptive behavior and consequences (means connected to ends). This also indicates that the counselor would be very active in the processto set up, maintain, and comment on the reinforcement schedules. Because client self-understanding is very limited, there will be only a rudimentary consciousness of level of emotions in self and others. This would mean a very limited discussion of feelings, perhaps only an acknowledgment and naming of a few. Use of expressive arts, such as drawing, photography, music, and drama (Gladding, 1998), could be effective when strictly verbal modes fail.

Social role-taking through a peer helping model would be highly concrete and highly structured. For example, at the school level, high school students could be taught to use almost a paint-by-the-numbers approach to transmit a health education curriculum to elementary school students, complete with easy-to-follow transparencies and worksheets. Also, the counselor then would facilitate short and structured discussions with the helpers after each session. The counselor would present a few words describing feelings that the helpers might have experienced and would ask them to pick out one or two and write them down in a journal. This will gradually expand the ability to process experiences of the helpers and then later to begin to process the feelings of the elementary school students. A similar format could be used with adults working out of a community setting (e.g., women’s center, church outreach program, sheltered workshop, retirement home). For example, the client could be taught how to teach retirement home residents simple skills such as crafts and exercise.

Stage Three Level

Table 7.3 presents characteristics of clients functioning at the Stage Three level of integration. The main problem at this level is the lack of individuation and autonomy. The person is largely “other directed” and caught in constant need for social conformity, with abundant use of clichs and a ready acceptance of stereotypes concerning race and gender. An appropriate counseling mode needs to emphasize assertiveness training, complete with cognitive-behavioral “self-talk.” This should occur in a sequence of modest steps to ensure success. After a period of initial successes, it also might be possible to employ a few of Ellis’s (1994) rational emotive behavior therapy techniques, particularly the “worst-case scenario” approach. Group counseling could employ a moral dilemma discussion method to increase clients’ perspectives (Claypoole, Moody, & Peace, in press; Powell, Locke, & Sprinthall, 1991).

The social role-taking method could focus directly on one aspect of excessive social conformity: Have the individuals larn how to use

“I-messages” and then teach either peers or others how to use the techniques, a small yet significant step out of

social conformity and a lack of individuation. We have found that this Stage Three level is very common with adolescents and with a rather large number of both young and middle-aged adults (Sprinthall, 1993). The content of the conformity may be different, but the structural process is highly similar. A survey of our community counseling center at North Carolina State University indicated that at least 50% of the adults seeking help still functioned at that level. Quite unfortunately, most were women who had been “treated” previously only with drugs to handle their depressive feelings (Sprinthall, 1993).

Stage Four Level

Table 7.4 describes the characteristics at Stage Four as well as the problem areas most associated with that level. McClelland (1980) identified this as a level with a high need for achievementa rational problem solver and a moderate risk takeras opposed to the previous Stage Three, where the strong need is for affiliation and relationship. Thus, at Stage Four, there is an important developmental gain, namely, individuation and self-directed decision making. However, such individuality carries with it an identifiable set of concerns such as overachievement, a lack of mutuality in relationships, a narrow rationalism, and perhaps an aloofness to anyone less fortunate. As a result, concerns for others might be low. Objectivity might be so high that there is no room for subjectivity.

Counseling, then, would focus on expanding emotional awareness. Goleman (1998) referred to this as “emotional intelligence.” Because individuals here are self-directed, self-managed behavioral contracts could be negotiated, keeping track of how the person and cohorts feel in everyday situations. Similarly, self-managed systematic relaxation modes could be followed to further expand the range and complexity of human emotions. These procedures would help the person to loosen up and not worry quite so much about linking self-esteem to his or her most recent grade point average or some other criterion. Written reflection, through journals or poetry writing, also could prompt emotional expression and fresh insights. The counselor could enhance client development by guiding the reflection process through asking questions, reflecting feelings, and using positive reinforcement (Sprinthall et al., 1993).

Role-taking here would focus on leading groups in peer helping, teaching active listening and accurate empathy. Learning empathy by teaching it to others, such as peers (e.g., mentors, tutors, residence hall advisers in schools and colleges) or paraprofessional helpers in community centers, would be the most obvious choice of role-taking (Delworth & Aulepp, 1976). Keeping journals on self and discussing how the “helpee” felt would expand interpersonal and intrapersonal perspective taking. These leadership role-taking experiences could be graduated in levels of complexity according to how quickly the person learns from the helping experiences (Sprinthall, 1994).

Stage Four/Five to Five Level

Table 7.5 presents the characteristics of a very high stage of development, Stage Four/Five to Five. Of course, the first question that always is asked is why anyone who functions at that level would need help. Swensen (1980)

quipped something to the effect that if a counselor runs into anyone at that level, then one should reverse roles and request help. However, Loevinger (1987b) made it clear that higher stages are not necessarily happier ones. In fact, the real problems at this level are those that appear as endemic to our societythe twin evils of racism and sexism. How can a person relax and experience joy when there are so many societal problems at the doorstep? How,

n an existential sense, can a person accept his or her limits and avoid what often is called a “messianic complex”?

Probably the counselor with such a client needs to facilitate an examination of the client’s strengths and emotional investment that are aligned with pressing societal concerns. The counselor may help the client prioritize how time will be spent in altruistic actions. Also, the counselor can continue to help the client reframe the problems and concerns in a careful balance of seriousness and humor. Readings, particularly Frankel’s (1939) compelling discussion on meaning and purpose under horrendous conditions or other such accounts, would promote perspectives for a balance between one’s obligation to society at large and one’s obligation to self and private life. Quite obviously, the counseling interactions would become much more of a peer dialogue at this level. Helping the client to integrate a spiritual dimension could help with questions about life’s purpose and meaning (Burke & Miranti, 1992).

The social role-taking component likely would involve creating a support system, that is, a common concerns and (interests-based) dialogue group with others in the community. This would reduce the isolation and increase the resources for each individual as he or she struggles with these central life issues. The personal, work, and societal dilemmas could be the context for a searching examination toward actualizing a holistic approach to life including physical, psychological, spiritual, and emotional aspects. As Loevinger and Wessler (1970) noted, at this level, all the complexities of life are evident, and seemingly irreconcilable issues are confronted (e.g., rational passion, commitment, relativism). This is one of the tasks of the generativity stage described by Erikson (1959) or, in the words of Allport (1968), becoming “whole hearted yet half sure” (p. 320).

Conditions for Social Role-Taking Activities

In addition to using traditional individual and group counseling strategies, the counselor needs to be intentional about incorporating social role-taking activities as part of the counseling process. For optimal success in promoting client development, the following conditions for designing and implementing role-taking activities are necessary.

Significant role-taking experiences. These are complex situations in which the client feels fully involved with others, requiring the client to construct new ways of thinking and behaving in response to the new demands of the role. As opposed to role-playing in a counseling session, a significant new helping role triggers empathy as the client actively cares for another and perspectives increase. The counselor matches client characteristics of developmental stage with an appropriate level of social role-taking such as the examples described earlier.

Guided reflection. It is important to provide ongoing opportunities to examine the new role-taking experiences through journal writing and discussions. These forms of reflection help the client to process his or her thoughts and feelings and to understand experiences from different perspectives. The counselor can monitor client progress and guide the growth process by responding to the client’s written reflections with systematic feedback, differentiated based on developmental level (Sprinthall et al., 1993).

Balance between reflection and experience. Programs must be carefully planned to allow for sequences of experiential activities balanced with regular cycles of reflection and self-analysis. This interplay of action and reflection ideally should occur on a weekly basis so that there is an ongoing examination of one’s adjustment to the new role.

Support and challenge. Complex new roles create a challenge for people. Psychological support is needed when clients enter a state of disequilibrium as they give up old cognitions for newer and more complex methods of problem solving and understanding. The goal is to manage an appropriate ratio of support and challenge, which varies for each individual.

Continuity. For cognitive structural change to take place, the role-taking experience and the other conditions described previously have to be continuouspreferably weeklyand span 6 to 12 months.

Age and Stage Issues

On an overall basis, then, the framework becomes a guiding format for the counselor. Each stage represents a consistent cognitive problem-solving system. The stage structures how we as individuals derive meaning from experience. It is important to note the qualitative differences between the less complex and more complex stages. This also means that the stage system can be more significant than age. For example, a 30-year-old who employs a Stage Three social conformity mode finds a parallel in a 17-year-old who also solves problems at Stage Three. The same would hold for a 45-year-old and a 25-year-old Stage Four conscientious achiever. No one, however, is ever completely “in” a single stage. There always is overlap across the earlier and later stages juxtaposed with the current modal system. Figure 7.1 depicts very crudely some of the age-stage relationships across the life span. Note that as age increases, the modal stages also increase. This represents primarily an integration of longitudinal studies from Loevinger (1987a) and Kohlberg (1984) and other developmental researchers.

Transitions

From a counseling viewpoint, the age-stage question is more complicated than depicted in Figure 7.1. Transitions from stage to stage usually are created by a crisis in problem solving and interaction with the environmental press Ivey & Bradford Ivey, 1998). The current system is literally jammed, and anxiety follows as the person begins to confront the reality that the current mode is inadequate to the new task. An obvious example occurs at the Stage Three level when one struggles with how to please everybody or the crisis created when a concrete dualistic thinker confronts an essay exam requiring symbolic interpretation. One of us still remembers hearing a college student bitterly complaining about why a professor kept talking about Herman Melville’s symbolism. After all, he said, “Why spoil a good sea story with Melville’s complexes?” Kegan (1982) reminded us that a modal stage is only a temporary “evolutionary truce” (p. 108) that may shatter when confronted with a more complex task. During such periods, of course, the individual may be most inclined to seek counseling assistance given that a common response to a more complex task involves feelings of despair, retreat, and withdrawal or the opposite (e.g., anger, acting out). Thus, it is during these periods of transition that the emotional agenda will be most apparent and most accessible to an alert counselor.

Assessment Issues

Certainly, one of the keys to the developmental approach concerns assessment. It is clear that the choice of individual treatment and the complementary social role-taking activity is guided by an assessment of the current level of functioning. There has been some advocacy for using formal developmental testing methods to guide counseling strategies to promote growth (D’Andrea & Daniels, 1992). We have found that a less formal method of using the counselor’s listening skills represents the starting point. The counselor bears in mind the problem-solving strategies common to each stage (as noted in Tables 7.2 to 7.5 on client characteristics and problem areas) and listens and questions during an initial interview or two. This generally will provide at least an initial approximation of stage level. The counselor needs to remain open to adjustments to this initial view if further discussion yields important new insight. It is good to remember that we need to know what the modal level is during difficult situations. Metaphorically, it is similar to assessing the competence of a sailor during a storm versus being safely at anchor in a peaceful harbor. An appropriate level of support through accurate empathy is particularly important during the emotionally charged transition periods. Consequently, assessment is an ongoing process of listening and revising when necessary to gradually get an accurate fix on present cognitive stage process.

Case Studies

As a means of illustrating the assessment intervention strategies, we present a few examples of a person’s seeking counseling assistance and then present some sample strategies for short-term counseling and social role-taking suggestions.

Case 1. The client is a 34-year-old male with a history of underachievement in school and career. His characteristics include the inability to see long-term consequences and the desire to solve problems exclusively from an intuitive perspective. He seems easily swayed by popular opinion. All of this results in a low planning orientation toward problem solving. Despite an attractive personality and strong social skills, he has failed to get promoted and remains an assistant sales manager. He switches companies, but the career pattern repeats itself. During counseling, the client says that it might be time to figure out what is getting in the way of being successful. He talks about himself in a very clich manner.

The chief characteristics of this client are the following: low planning, low rationality, high social skills, and reliance on stereotypes and clichs. This would lead to an initial assessment of a Stage Three system. From this, the counselor would choose some assertiveness training and decision making, emphasizing contracting and similar activities to promote self-direction and self-management. Social role-taking could involve volunteer work as a school mentor to middle school students using one of the career decision-making curricula.

Case 2. The teenager, a 15-year-old, has a record of being a real “cut-up” in school and has had multiple minor scrapes with the police. She shows a very short attention span in counseling and class discussions. The student seems to understand self and ideas at a concrete level. She is easily distracted, with grades heading toward a dropout level. There is little in-depth insight. She indicates a desire to do better in school but does not know where to start.

The characteristics of this client are obvious: impulsive behavior, acting up, concrete thinking, and low on self-awareness/insight. These fit closely with the Delta/Delta Three level and will require high levels of counselor directedness. Behavioral contracts directed by the counselor focused in rudimentary study skills represent the starting point. After an initial period with positive reinforcement for small successes, the counselor could arrange for the teenager to “help” some elementary school students in Grades 1 and 2 to improve their reading skills as an appropriate role-taking activity.

Case 3. The client, a 60-year-old at the community counseling center, has just learned that his company has folded as a result of a heavily leveraged buy-out. He has 30 years experience with the company as an accountant but has heard that the new firm might not fully honor his retirement plan. He has been a “company man” all his life and says, “I always figured that I’d work there til retirement at [age] 70.” At this point, he appears confused and depressed as he reflects, “It’s something I never thought I’d have to confront.” He concludes, “I always thought good work and loyalty was enough.”

In this situation, the client actually exhibits segments of two stages. There are characteristics of Stage Four, including conscientious achievement. Stage Three is represented by his loyalty to the company and his assumption that “they” would take care of him together with a lack of self-direction and assertiveness. The counselor could well choose to build on the Stage Four elements, for example, a planning orientation along with supporting exploration for career options. Simultaneously, the counselor needs to expand the client’s emotional repertoire because this apparently is his first major crisis.

Journal writing assignments can encourage expression of feelings and thoughts. The counselor can guide the written reflection by providing feedback and reflecting feelings. Social role-taking eventually could include volunteer work at a senior center in setting up a tax advising service.

These cases are necessarily brief to simply illustrate aspects of the process of assessment and strategies for both counseling and social role-taking. Also, we need to point out that research supporting these approaches does vary. Because the counseling model is relatively new, positive esults have been reported in the form of case studies by Ivey (1986) and Kegan (1982) and from our practice in supervising graduate students in a community-based counseling center. However, the research base for the social role-taking procedures has been widely researched over the past 25 years across age groups (children, adolescents, young adults, and older adults) and different geographical, social, and racial groupings (Sprinthall, 1994; Sprinthall et al., 1993). The meta-analysis shows a consistent positive effect size (circa +1.0) in promoting developmental stage growth for those helpers who participated in the peer programs. Also, such studies have shown the importance of varying the amount of responsibility and structure in relation to different developmental stages. Hedin’s research (as reported by Sprinthall, 1994), in particular, demonstrated how to employ three different role-taking strategies for adolescents who themselves presented three different levels from Delta/Delta Three to Stage Four. Each group then improved within its own stage as a result of the helping activity.

Implications

For Counseling Practice

We have outlined the importance of creating a counseling system based on the developmental stage characteristics of individuals. The following are a few of the major implications for counselors:

Learn to tune in and listen for the structure of the problem-solving strategies and successively review the client’s current mode of stage cognitions, an ongoing process.

Select strategies that are most apt to match and slightly mismatch the current mode of stage cognitions.

Be particularly alert to transition periods in modes because of heightened anxiety and stress. Monitor level of support and challenge.

Remember that a stage is not fixed or permanent but rather the current mode with abilities both slightly higher and slightly lower than the current stage.

Keep a balance between counseling strategies and preventive social role-taking activities because the latter has so clearly achieved a solid research base for developmental growth.

Remember that an extremely broad research base has clearly demonstrated that there is no bias toward women, a person’s sexual orientation, or ethnically diverse persons. The scheme is fair by gender, culture, and sexual orientation.

The use of a cognitive-developmental framework through social role-taking represents a comprehensive model for differing sociopolitical, cultural, ethnic, and racial contexts.

For Counselor Education

Traditionally, counselor education programs have placed great emphasis on remedial and individual therapeutic paradigms of how change takes place (Lewis et al., 1998). This limits many counselors’ understanding of primary prevention and developmental interventions. Training in an expanded developmental model should aim to do the following:

Provide a base in theory and research as a basis for practice, avoiding atheoretical eclectic modes

Outline a framework that broadly encompasses strategies such as those of Rogers and Ellis and cognitive-behavioral, behavioral contracting, and preventive modes that avoid singularity

of intervention (Peace & Sprinthall, 1998)

Become rooted in development in a manner that allows us as a profession to regain our distinctiveness and separation from clinically oriented therapy including replacing the non-researched base of the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders [American Psychiatric Association, 1994]) with a developmental understanding of persons (Ivey & Bradford-Ivey, 1998)

In fact, those of us who made dire predictions (Sprinthall, 1990) as to the difficulties of forsaking a developmental model for clinical private practice have, perhaps unfortunately, seen these predictions borne out. The gold of third-party reimbursement has turned out to be fool’s gold as headlines in the National Psychologist announced, “Average Income of Psychologists Has Dropped Notably” (1998) and “Psychology Told to Put House in Order Before Seeking Prescription Privileges” (1998).
Perspectives on the Future
The demands and expectations placed on counselors continue to grow in complexity and degree (Lewis et al., 1998). Factors such as continuing demographic changes, new immigrants, economic discrepancies, disenfranchised adolescents, and managed care require counselors to broaden their ideas about helping. The developmental framework described in this chapter can guide counselors’ work to respond to future client and societal issues. By meeting clients where they are and gradually applying challenging conditions, not only are their presenting issues addressed, but there also is potential for clients to be transformed to a new way of being. Counselors can play an important role in promoting the development of people to increasing levels of empathy, to be better citizens, and to negotiate the intricacies of interacting with diverse populations. In this sense, counselors also can contribute to addressing societal problems.
Likewise, future challenges provide a rationale for restructuring counselor education programs to focus as much attention on enhancing counselors’ cognitive development as on acquiring skills (Peace & Sprinthall, 1998). The need for counselors to develop higher levels of thinking, problem solving, and ethical actions is greater than ever. Competent counselors have to be described as those with the ability to see the social and political implications of their actions and to use their skills to promote greater equality, justice, and humane conditions inside and beyond their work settings. Counselors can use their training to help clients manage and alter their environments and to assist others in viewing situations from multiple lenses and from an ethical perspective. There are many opportunities for counselors to provide a compassionate voice and to serve as advocates on behalf of clients and policy reform (Kennington, 1999).