Title: Case & Scenario-based Learning in Higher Education for Addiction Counseling
Author Name: Lauren Flynn
1. Introduction
This e-Book chapter will explore the use of case and scenario-based learning to address addiction biases in mental health counseling students in higher education. The chapter first contextualizes the issue of addiction bias within addiction as a national health concern that requires appropriately trained counselors in order to treat populations impacted by addiction. The chapter introduces the need to address addiction bias in counselor training for counselors to be adequately trained and prevent negative treatment outcomes associated with addiction bias. This chapter proposes the use of case and scenario-based learning as a tool for addressing addiction bias in higher education, specifically in addictions-related courses within Mental Health Counseling Master’s Programs.
With over 40 million Americans considered diagnosable with a Substance Use Disorder (SUD) in 2020, the mental health treatment of persons suffering from addiction remains a critical focus for the counseling profession (SAMHSA, 2020). Annual drug-related fatalities of more than 100,000 reached record highs during COVID and constitute a significant national healthcare concern (Centers for Disease Control and Prevention, 2021). In addition to substance-related concerns, the prevalence and impact of process-related addictions, including but not limited to sex (Karila et al., 2014), gaming (Paulus et al., 2018), gambling (Abbott, 2020), and food (Oliveira et al., 2020), are also increasing national concerns. Furthermore, the co-occurrence of process addictions with substance use disorders is common (Grant et al., 2010), resulting in more complex treatment and other clinical challenges. With nearly 14.5% of individuals in the United States age 12 and older meeting criteria for a SUD and only 2.4% of the population obtaining substance use treatment in the past year, it is clear that addiction is a persistent concern in our society that remains largely untreated (SAMHSA, 2020).
Given the alarming prevalence of addiction and deficiency of treatment services, now more than ever, there is a need for counselors to be well-trained in order to provide effective clinical services to individuals with addictions and members of their social support systems. Counselor Education programs are tasked with adequately preparing future counselors to address such issues through addictions-related counseling coursework. The addiction counseling competencies established by the Substance Use and Mental Health Services Administration in 2017 (SAMHSA) highlighted the need to encourage self-awareness of the counselors’ attitudes towards clients and the treatment process as they shape the therapeutic relationship (2017). The SAMHSA competencies recommend that negative attitudes held by counselors be considered through the framework of stigma, and the potentially harmful consequences of stigma on the counselor, client, and the field (2017).
Stigma toward persons with addictions is both pervasive and deeply embedded in American culture (National Academies of Sciences, Engineering, and Medicine et al., 2016; Crapanzano, Vath, and Fisher , 2014). A national survey of public attitudes toward substance-related addiction found that the American public held significantly more negative views toward persons with drug addiction than persons with mental health disorders (Barry et al., 2014). In a separate investigation, the medical community was found to have worse attitudes toward individuals with substance use disorders than toward individuals with other mental health or medical conditions (Avery et al., 2019). A systematic review of health professionals’ attitudes towards individuals with substance use disorders found that health professionals generally had negative attitudes toward patients with substance use disorders (Van Boekel et al., 2013).
Literature related to health care provider attitudes towards persons with substance abuse histories identified a common perception that addicted clients were more difficult with whom to work, potentially violent, manipulative, and irresponsible (Van Boekel et al., 2013, Ford, 2011). Such perceptions have led to feelings of frustration, disappointment, resentment, and powerlessness among some health care professionals (Van Boekel et al., 2013, McGillion et al., 2000). Negative attitudes held by health care providers can impact client self-esteem in the counseling relationship and influence treatment outcomes (Van Boekel et al., 2013). Negative attitudes held by health care providers can significantly impact the well-being of those seeking substance use treatment and can be detrimental to those trying to access the services and support they need (Chasek et al., 2012; Van Boekel et al., 2013; Livingston et al., 2011). Stigma among healthcare providers can also block access to recovery services, subsequently widening already existing treatment inequities surrounding substance addiction (Earnshaw, 2020).
An addiction counseling course may serve as the only opportunity for students’ potentially harmful biases and stigmas toward addiction and persons with addiction to be challenged. Challenging negative attitudes enables students to obtain accurate information and form new attitudes (2007). For this reason, it is essential that the potentially harmful attitudes toward addiction and clients with addictions be addressed within masters-level addiction counseling curricula. Counselor educators should support students in identifying potential biases and aid in the development of non-stigmatizing perceptions of people with addictions.
2. Overview of the Case
As outlined in the introduction, the chosen setting is higher education. Specifically, this case is situated in an addictions counseling course within a masters-level mental health counseling program. The issue addressed by this case pertains to the need to facilitate student self-awareness of their biases and attitudes toward addictions and persons with addiction. The issue of awareness is captured by the human dimension of the Significant Learning Model of higher education that encourages student learning about themselves and others (Reiser & Dempsey, 2017). The proposed solution attempts to integrate the human dimension into an addictions counseling course in order to help students reflect on their attitudes and beliefs related to the subject area.
3. Solutions Implemented
In order to address student addiction-related biases within an addiction counseling course and facilitate self-awareness of addiction-related attitudes, the use of case and scenario-based learning is proposed as a potential solution. A case study would present a potential vignette of a client with characteristics that practitioners would typically encounter in the field. The purpose of the case vignette is to expose students to the complexity and multifaceted story that a client entering therapy with them might possess. The elements of the client’s situation and backstory are used to prompt students to reflect on their assumptions and biases related to substance addiction. The instructor of an addictions counseling class would provide the case or scenario to students and instruct them to read it through independently then cluster in pairs or small groups in order to process their initial reactions, thoughts regarding the case, and how their personal experiences or individual beliefs systems relate to the case. Consider the following case scenario crafted for this purpose:
Case study
Jodi is a 23-year-old Hispanic female who has been addicted to heroin for five years. While on a binge three years ago, Jodi was raped and became pregnant. She gave birth to her daughter Andrea three months prematurely. Andrea is 2 years old and is currently involved in the foster care system because she was born addicted to heroin and there were no family members available to care for her. She lives with her foster family and Jodi is able to visit her weekly, however, Jodi has only visited three times during the past year since she has been active in her addiction. Jodi uses heroin approximately five times a day intravenously. She has attempted to obtain sobriety twice, but she left both treatment programs prematurely. Following her most recent attempt to obtain sobriety, Jodi returned to using heroin and has been actively using for the past four months. She is currently homeless and has been engaged in illegal sex work to supply her habit. Jodi has no contact with her parents; she states that her mother is currently in active addiction using crack cocaine and is unable to care for Jodi’s 16-year-old sister. Jodi states that her dad lives in another city but has had problems with addiction and is sober now. She reported that her father went to a halfway house and never returned home when she was 15 and has not had contact since. Jodi stated that her substance use started when her father left as a means to cope with her sadness. She began using marijuana daily at age 15, then progressed to alcohol, and was later introduced to heroin by a friend when she was 17. Jodi had been diagnosed with post-traumatic stress disorder (PTSD) due to her rape three years ago but has never received mental health treatment. Jodi expresses feeling depressed all of the time because she misses her daughter and her younger sister. When she is not using heroine, she misses the drug. Jodi’s support system consists only of her friends who are also active in addiction. She states that she would like to begin a relationship with her daughter, to develop better coping strategies, and to have a sober life.
4. Outcomes
The case of Jodi presents a complex scenario of a potential client like one student might encounter in their future work as counselors in an addiction treatment setting. The use of this case or scenario-based learning activities would prompt students to reflect on various potential areas of biases that they may hold, which are common areas of social stigma. Specifically, engagement in this activity might prompt the following questions: What do I believe about heroine and people who use heroine? What do I believe about parents with addictions? What are my reactions to the client using heroine while she was pregnant? Do I have particular attitudes regarding the client’s relationship with her daughter? What do I believe about the client’s illegal sex work and ongoing homelessness? How do I feel regarding the client using heroine intravenously multiple times a day? These questions will often reveal potential areas of bias, judgement, and even aversion towards working with this client.
The case will also prompt the learners to develop a greater understanding of a person’s addiction by encouraging students to reflect on the intricacies of the client’s backstory such as their diagnosis of PTSD related to their sexual trauma, their tumultuous family history, the client’s desire to obtain sobriety, her introduction to substances at a young age, and her longing for a relationship with her sister and daughter. Reflection on these elements of the client’s story may disrupt feelings of bias and stigma towards the client and promote empathetic understanding of the client’s experience. In collaboratively processing and reflecting on the case, students may also propose suggestions for treatment and how they would work with this client. The performance improvements that would be achieved through this learning task would be the students’ increased self-awareness of their attitudes toward a client with addiction, using Jodi as an example. Additional performance improvements that are anticipated to be achieved through this case/scenario-based learning is heightened empathy toward clients with addiction and increased understanding of the complexity of addiction.
5. Implications
As a future educator of mental health counseling students, it is important for me to be intentional about integrating classroom learning activities into my curriculum that will both resemble real-world counseling practice and challenge students’ potential stigmatizing beliefs regarding their future clients. Through researching the topic, I know that challenging student addiction-related biases will be especially important in order to prepare them for their future work with clients who may experience addiction. I plan to utilize the client vignette that I crafted for this assignment in the next addiction counseling course that I teach in order to utilize case and scenario-based learning with my students. I plan to pair this activity with small group discussions about their prior understandings of and experiences with addiction in order to further promote the human dimension of the Significant Learning Model.
6. References
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