A stockbroker in New York with a cocaine habit, a ranch hand in Montana with a drinking problem, a West Coast teen coming down from a methamphetamine high--psychologists are successfully treating clients like these every day.

The number of psychologists doing so, however, is regrettably small.

While people with substance abuse disorders collectively represent the most frequently occurring mental health problems in the country, psychologists often hesitate to treat them, believing they need specialized treatment.

But many psychologists who have ventured into addiction treatment say this population represents a burgeoning growth opportunity. On top of the enormous numbers of people addicted to drugs, alcohol or nicotine, many who are in need of treatment aren't receiving it. As one example, 63 percent of people addicted to illicit drugs did not receive treatment in 1997, according to the most recent data from the Substance Abuse and Mental Health Services Administration.

Psychologists are well-prepared to fill in the gap, however, those specializing in the addictions say. Well-trained psychologists already possess the essential therapeutic ingredients for delivering treatment to substance-abusing clients, they say, including empathy, good listening skills and training in modalities shown to curb addictive behaviors.

The challenge, these experts maintain, is for practitioners to adapt, modify and refine these skills to enhance their effectiveness with these clients.

"Psychologists have vastly underestimated what we can do in this area," says William R. Miller, PhD, distinguished professor of psychology and psychiatry at the University of New Mexico and a well-known treatment researcher. "We have this funny notion that we should send people off to specialized treatment centers, even though research shows psychological treatments to be highly effective with this population."

Indeed, says private practitioner and addictions expert Arnold Washton, PhD, psychologists who can deal competently with substance abuse issues can "seize practice opportunities and take advantage of the dramatic shift from inpatient to outpatient treatment for people with substance abuse problems."

Treating substance abuse patients is also a public health opportunity, notes Washton, who heads the Center for Addiction Psychology, a treatment center with offices in New York and Princeton, N.J. If left untreated, he says, substance abuse disorders can exact heavy tolls in the form of suicides, homicides, HIV infection and other major health problems, and ruined relationships. Indeed, a February report issued by the Robert Wood Johnson Foundation calls substance abuse the nation's number one health problem.

Conversely, he says, clients given the right kind of help can thrive.

"Once these clients are off of alcohol or drugs, you can see concrete improvements in their health, family relationships and all other areas of their life," Washton says. "These patients get better, and they get better quickly."

Expanding the scope of private practice

Many psychology practitioners say that individual therapy is the setting of choice for treating substance abuse problems. While it's true that psychologists may need extra training to understand the unique nature of addictions, in other ways, they're already well-equipped to help, says Tom Horvath, PhD, who heads a San Diego practice specializing in addictions called Practical Recovery Services.

In his practice, for example, Horvath uses a "harm reduction" approach--drawn from the work of University of Washington psychologist G. Alan Marlatt, PhD--that does not require abstinence and puts the client in the driver's seat.

Clients are guided through six steps, including establishing and maintaining motivation to change; coping with cravings; developing basic problem-solving skills; achieving a balanced lifestyle; improving relationships; and finding a higher meaning in life. The first five steps are based on empirically proven psychological theories and treatments; the last is an effort to include a spiritual component, albeit an open-ended one that leaves spiritual meaning up to the client.

Psychologists who work in this way can offer an important alternative to 12-step approaches. "Regardless of how effective 12-step programs are for some people, they're not for everyone," Marlatt says. Often, says Washton, the 12-step program is designed for people who have already come to terms with their problem and are ready to take action. But many people with substance abuse problems are nowhere near that point and benefit more from the gentler, more empathic approach that typifies psychologists' training and style.

Other ways psychologists can include substance abuse services in their treatment include:

  • Screening every client who walks in the door for substance abuse problems. Many who need substance abuse treatment fall through the cracks because practitioners don't ask them about such problems, Washton says. He recommends psychologists conduct "cost-benefit analyses" with clients who admit to a substance use problem--a technique that gently helps the client acknowledge the reality of how such use affects his or her life. "The most important question you can ask anyone is, 'What do you like about this behavior?'" Horvath says. Then, he says, spend about six sessions elaborating on it. "This technique can really get the ball rolling and help you see which direction to take with a client."

  • Examining cause-and-effect in dually diagnosed patients. Many clients who suffer substance abuse problems also have other mental health conditions such as depression, anxiety or more serious disorders. Routinely screening mental health patients for substance abuse problems can help practitioners better understand whether a client is self-medicating to treat his depression, for example, or whether alcohol or some other substance is fueling the depression.

Tackling rural substance abuse

Another way psychologists can weave substance use into their practices is to forge relations with primary-care physicians. This point is particularly relevant in rural areas, where health practitioners of any stripe are at a minimum, and substance abuse problems are at a maximum. And today, the need for effective substance abuse treatments is greater than ever. While alcohol overuse has always been a part of rural culture and tends to be an unadmitted problem, now there's a host of new problems involving harder drugs, including the prescription painkiller Oxycontin in Appalachia and designer drugs in rural ski towns, those involved say.

A study in this month's Professional Psychology (Vol. 32, No. 3), by Idaho State University psychologists Tony Cellucci, PhD, and Peter Vik, PhD, underscores this problem. Of the 144 licensed Idaho psychologists surveyed, practitioners in rural areas reported the highest numbers of substance-abusing clients compared with their counterparts in cities, towns and greater metropolitan areas. Indeed, only 11 percent of those in this mostly rural state said they'd had no contact with alcohol- or other drug-abusing clients.

Striking up partnerships with family or general practitioners accomplishes several goals, emphasizes Michael Enright, PhD, who co-owns Family Practice Associates. His work with a team of family physicians in Jackson Hole, Wyo.:

  • Allows sharing of knowledge in an area of enormous need.

  • Fosters respectful, egalitarian relationships between psychologists and the medical community.

  • Brings psychology into the health-care mainstream.

The latter point is especially important in parts of the country where mental health treatment is still viewed with suspicion, says Douglas Wear, PhD, chair of APA's Committee on Rural Health.

"Unlike in urban areas where seeing a therapist may be a badge of pride, in these settings, getting mental health treatment is considered an embarrassment, something you don't want others to know about," says Wear, who owns the consulting firm Wear & Associates in Seattle. "On the other hand, there's no anonymity in these settings--everyone knows your car, and they know what's inside every building a person goes into, including the mental health center or the psychologist's office."

Psychologists should consider buying buildings and practices with physicians as well, Enright says. "If you want to build up your practice, own and share your offices with family physicians," he advises.

Other practice avenues

Training in substance abuse opens up many other avenues for psychologists. For example, addictions experts are perfect candidates for heading public or private treatment clinics and training and supervising staff, Washton says. Because they often possess more advanced training than traditional addictions counselors, they can offer these programs a strong empirical focus, good management skills and a host of other benefits. Washton is a role model for some of these alternate routes. In addition to heading up a large private outpatient addiction treatment center for 12 years, he has also directed publicly funded treatment centers and directed a medical school clinic for cocaine and heroin addiction.

Another venue for those with specialized training is to write books or manuals, suggests Washton, who himself has written several books on addiction, including "Psychotherapy and Substance Abuse: A Practitioner's Handbook" (Guilford, 1995).

"The field needs more high-quality information written by experts who are good clinicians and good writers," he says.

Tori DeAngelis is a writer in Syracuse, N.Y.