KNP3511 – PSYCHO-SPIRITUAL

ASSESSMENT AND THERAPY

RABBI GEOFFREY HABER, BA, BA, MA, DMIN, DD (HON.)

BCC (NAJC), CSCP (CASC), CSE (CASC), CE (ACPE), RP (CRPO)
DIRECTOR, SPIRITUAL CARE, BAYCREST
CERTIFIED SUPERVISOR-EDUCATOR, CLINICAL PASTORAL EDUCATION
ADJUNCT LECTURER, KNOX COLLEGE, TORONTO SCHOOL OF THEOLOGY,
UNIVERSITY OF TORONTO

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ASSESSMENTS AND TREATMENTS OF
ADDICTIVE AND SEXUAL DISORDERS

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 CONTENTS

 Assessment techniques for clients with addictions

 Treatment approaches to addictions from Twelve Step
approaches to Harm Reduction
 Sexual dysfunctions and gender variations
 Motivational interviewing (OARS and RULE)
 References

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ASSESSMENT TECHNIQUES FOR CLIENTS
WITH ADDICTIONS

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 ASSESSMENT TECHNIQUES
FOR ADDICTIONS

Causes of Substance Use Disorders

 Sociocultural: those living under stressful
socioeconomic conditions or those whose
families value or tolerate drug use.
 Psychodynamic: those who have excessive
dependency needs traceable to the early
stages of life.
 certain people have a substance abuse
personality that makes them prone to drug use.
 cognitive-behavioral: use is reinforced
initially because it reduces tensions, and such
reductions lead to an expectancy that drugs
will be comforting and helpful. 5
 ASSESSMENT TECHNIQUES
FOR ADDICTIONS

Causes of Substance Use Disorders

 Biological: people may inherit a
predisposition to the disorders.
 drug tolerance and withdrawal symptoms may
be caused by cutbacks in the brain’s production
of particular neurotransmitters during excessive
and chronic drug use.
 drugs may ultimately lead to increased
dopamine activity in the brain’s reward circuit.
 Developmental psychopathology: genetically
inherited biological predisposition and
temperamental predisposition may interact
with life stressors, problematic parenting,
and/or other environmental factors to bring 6

about a substance use disorder.

 ASSESSMENT TECHNIQUES
FOR ADDICTIONS

Substance Use Disorders Treatments

 Psychodynamic Therapies:

1. Guide clients to uncover and work through the

underlying needs and conflicts that they
believe have led to the substance use disorder.
2. Help the clients change their substance-related
styles of living.
 Although this approach is often used, it has not
been found to be particularly effective (Dodes
& Khantzian, 2016; McCrady et al., 2014)
 Psychodynamic therapy tends to be of more
help when it is combined with other
approaches in a multidimensional treatment 7

program.
 ASSESSMENT TECHNIQUES
FOR ADDICTIONS

Substance Use Disorders Treatments

 Cognitive-Behavioral Therapies:
 Help clients identify and change the
behaviors and cognitions that keep
contributing to their patterns of substance
misuse (Kampman, 2018; Aronson, 2017).
 Aversion Therapy

1. Clients are repeatedly presented with an

unpleasant stimulus (for example, an electric
shock) at the very moment that they are
taking a drug.
2. After repeated pairings, they are expected to
react negatively to the substance itself and to 8

lose their craving for it.

 ASSESSMENT TECHNIQUES
FOR ADDICTIONS
Substance Use Disorders Treatments
 Cognitive-Behavioral Therapies:

2. Contingency Management
 Based on the behavioral principles of operant
conditioning, contingency management
programs offer clients incentives (such as
vouchers, prizes, cash, or privileges) that are
contingent on the submission of drug-free urine
specimens (Rash et al., 2017; Stitzer,
Cunningham, & Sweeney, 2017).
 Usually lasting 8 to 16 week rewards clients for
abstaining from the use of the substances upon
which they are dependent.
 Major limitation is that the approach can be 9
effective only when people are motivated to
continue despite its unpleasantness or demands.
 ASSESSMENT TECHNIQUES
FOR ADDICTIONS

Substance Use Disorders Treatments

 Cognitive-Behavioral Therapies:

3. Relapse-Prevention Training
 Several strategies typically are included in
relapse-prevention training for alcohol use
disorder:
a. Clients keep track of their drinking by
writing down the times, locations, emotions,
bodily changes, and other circumstances of
their drinking, and become more aware of
the situations that place them at risk for
excessive drinking. 10
 ASSESSMENT TECHNIQUES
FOR ADDICTIONS

Substance Use Disorders Treatments

 Cognitive-Behavioral Therapies:

3. Relapse-Prevention Training
b. Therapists teach clients coping strategies to
use when such situations arise:
i. to recognize when they are approaching their
drinking limits;
ii. to control their rate of drinking (perhaps by
spacing their drinks or by sipping them rather
than gulping);
iii. to practice relaxation techniques, assertiveness
skills, and other coping behaviors in situations
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in which they would otherwise be drinking.
 ASSESSMENT TECHNIQUES
FOR ADDICTIONS
Substance Use Disorders Treatments
 Cognitive-Behavioral Therapies:

3. Relapse-Prevention Training
c. Therapists teach clients to plan ahead of
time. Clients may, for example, determine
beforehand how many drinks are appropriate,
what to drink, and under which
circumstances to drink.
 Lowers some people’s frequency of
intoxication and of binge drinking (Menon &
Kandasamy, 2018; Hart & Ksir, 2017).
 People who are young and do not have the
tolerance and withdrawal features of chronic 12
alcohol use seem to do best with this
approach.
 ASSESSMENT TECHNIQUES
FOR ADDICTIONS
Substance Use Disorders Treatments
 Cognitive-Behavioral Therapies:

4. Acceptance and Commitment Therapy

 Use mindfulness to increase awareness and
acceptance of drug cravings, worries, and
depressive thoughts.
 By accepting such thoughts rather than trying
to eliminate them, the clients are expected to
be less upset by them and less likely to act on
them by seeking out drugs.
 ACT is as effective as other cognitive-
behavioral treatments for substance use
disorders, and sometimes more effective 13
(Narayanan & Naaz, 2018; Smallwood et al.,
2016).
SUBSTANCE USE DISORDER TREATMENTS

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SUBSTANCE USE DISORDER
TREATMENTS

Biological Treatments
 Biological treatments:

1. Help people withdraw from substances

2. Abstain from them
3. Simply maintain their level of use
without increasing it further.
 Biological approaches alone rarely
bring long-term improvement, but
they can be helpful when combined
with other approaches.
SUBSTANCE USE DISORDER
TREATMENTS

Biological Treatments
1. Detoxification: systematic and
medically supervised withdrawal
from a drug.
2. Antagonist drugs: block or change
the effects of the addictive drug.
3. Drug Maintenance Therapy:
clients are given legally and
medically supervised doses of a
substitute drug.
SUBSTANCE USE DISORDER
TREATMENTS

Sociocultural Therapies
1. Self-Help and Residential Treatment Programs:
peer support along with moral and spiritual
guidelines to help people overcome addiction.
2. Culture- and Gender-Sensitive Programs: sensitive
to the special sociocultural pressures and problems
faced by drug abusers who are poor, homeless, or
members of minority groups
3. Community Prevention Programs: Programs may
also differ in whether they offer drug education, teach
alternatives to drug use, try to change the
psychological state of the potential user, help people
change their peer relationships, or combine these
techniques.
SUBSTANCE USE DISORDER
TREATMENTS

DISCUSSION—KNEE PAIN
1. What is/are the diagnosis/es
2. Spiritual Assessment using FICA
3. Intervention and plan

 F. Faith, Belief, Meaning: Determine whether or not the patient identifies with a
particular belief system or spirituality at all.
 I. Importance and Influence: Understand the importance of spirituality in the
patient’s life and the influence on health care decisions.
 C. Community: Find out if the patient is part of a religious or spiritual community,
or if they rely on their community for support.
 A. Address/Action in Care: Learn how to address spiritual issues with regards to
caring for the patient.
SUBSTANCE USE DISORDER
TREATMENTS

DISCUSSION—LIVING IT UP
1. What is/are the diagnosis/es
2. Spiritual Assessment using HOPE
3. Intervention and plan

H: Sources of hope, meaning, comfort, strength,

peace, love, and connection.
O: Organized religion.
P: Personal spirituality and practices.
E: Effects on medical care and end-of-life issues.
SEXUAL DISORDERS & GENDER VARIATIONS
SEXUAL DISORDERS & GENDER
VARIATIONS

 Two general categories of sexual disorders:

1. Sexual dysfunctions: problems with sexual

responses.
2. Paraphilic disorders: repeated and intense sexual
urges or fantasies in response to objects or
situations that society deems inappropriate, and
they may behave inappropriately as well.
 Sexual dysfunctions are typically very distressing,
and they often lead to sexual frustration, guilt, loss
of self-esteem, and interpersonal problems.
 The human sexual response can be described as a
cycle with four phases: desire, excitement,
orgasm, and resolution (Shifren, 2018)
SEXUAL DISORDERS & GENDER
VARIATIONS

Disorders of Desire
 The desire phase of the sexual response
cycle consists of:
1. an interest in or urge to have sex,
2. sexual attraction to others,
3. sexual fantasies.
 Two dysfunctions affect the desire phase

1. male hypoactive sexual desire disorder

2. female sexual interest/arousal disorder.
SEXUAL DISORDERS & GENDER
VARIATIONS

Disorders of Desire
 The desire phase of the sexual response cycle consists
of:
1. an interest in or urge to have sex,
2. sexual attraction to others,
3. sexual fantasies.
 Two dysfunctions affect the desire phase

1. male hypoactive sexual desire disorder

2. female sexual interest/arousal disorder.
 A person’s sex drive is determined by a combination of
biological, psychological, and sociocultural factors, any
of which may reduce sexual desire (Roslan et al., 2017).
SEXUAL DISORDERS & GENDER
VARIATIONS

Disorders of Excitement
1. male erectile disorder.
2. female sexual interest/arousal disorder.
 A person’s sex drive is determined by a combination of
biological, psychological, and sociocultural factors, any
of which may reduce sexual desire (Roslan et al., 2017).
Disorders of Orgasm
 Dysfunctions of this phase of the sexual response cycle
are:
1. early ejaculation and delayed ejaculation in men
2. female orgasmic disorder in women.
3. Disorders of Sexual Pain
4. Certain sexual dysfunctions are characterized by
enormous physical discomfort during intercourse
SEXUAL DISORDERS & GENDER
VARIATIONS

Treatments for Sexual Dysfunctions

 Sex therapy combines a variety of cognitive,
behavioral, couple, and family systems
therapies.
 Includes features such as:

1. Careful assessment,
2. Education,
3. Acceptance of mutual responsibility,
4. Attitude changes,
5. Sensate-focus exercises,
6. Improvements in communication, and
7. Couple therapy.
SEXUAL DISORDERS & GENDER
VARIATIONS

Paraphilic Disorders
 Paraphilias are patterns in which people
repeatedly have intense sexual urges or
fantasies or display sexual behaviors that
involve objects or situations outside the usual
sexual norms.
 Definitions of these are strongly influenced by
the norms of the particular society in which
they occur (Fuss, Briken, & Klein, 2018).
 Some clinicians argue that except when other
people are hurt by them, at least some
paraphilic behaviors should not be considered
disorders at all (Joyal, 2017, 2015; Giami,
2015).
SEXUAL DISORDERS & GENDER
VARIATIONS

Paraphilic Disorders
 Begins in adolescence
 Predominantly male
 To stimulate arousal

1. Fetishistic Disorder
2. Transvestic Disorder
3. Exhibitionistic Disorder
4. Voyeuristic Disorder
5. Frotteuristic Disorder (from French frotter, “to rub”)
6. Pedophilic Disorder
7. Sexual Masochism Disorder
8. Sexual Sadism Disorder
SEXUAL DISORDERS & GENDER
VARIATIONS
SEXUAL DISORDERS & GENDER
VARIATIONS

GENDER VARIATIONS
 Most people feel like and identify themselves as
males or females—a feeling and identity that is
consistent with their assigned gender (or birth
anatomy), the gender to which they are born.
 Many people do not experience such gender
clarity. These people are transgender, individuals
who have a sense that their gender identity (one’s
personal experience of one’s gender) is different
from their assigned gender.
 Transgender women (that is, people who identify
as female but were assigned male at birth)
outnumber transgender men (people who identify
as male but were assigned female at birth) by
around 2 to 1.
SEXUAL DISORDERS & GENDER
VARIATIONS

GENDER VARIATIONS
 DSM-5 does not consider transgender
functioning to be a psychological disorder, but it
does still categorize gender dysphoria—a pattern
of significant distress or impairment due to one’s
transgender feelings and thoughts—as a disorder.
 Transgender feelings and thoughts in children
often disappear by adolescence or adulthood, but
in some cases, children with such feelings
develop into transgender adults.
 Hormone treatments have been used to help some
people adopt the gender role they believe to be
right for them. Gender reassignment surgery has
also been performed.
MOTIVATIONAL INTERVIEWING: OARS AND
RULE

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 MOTIVATIONAL
INTERVIEWING

Stages of Change
 Motivational interviewing (MI) is an effective
counselling method that enhances motivation
through the resolution of ambivalence.
 Three critical components of motivation:

1. the importance of change for the patient

(willingness)
2. the confidence to change (ability)
3. whether change is an immediate priority
(readiness).
 Using MI techniques, the practitioner can
tailor motivational strategies to the 32
individual's stage of change
 MOTIVATIONAL
INTERVIEWING

Strengthening commitment to change

 The simplest and most direct way is to elicit a
patient's intention to change by asking a series
of targeted questions from the following four
categories:
1. disadvantages of the status quo
2. advantages of change
3. optimism for change
4. intention to change
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 MOTIVATIONAL
INTERVIEWING

Strengthening commitment to change

 Alternatively, if a practitioner is time poor, a
quick method of drawing out 'change talk' is to
use an 'importance ruler'.
 Example:

1. 'If you can think of a scale from zero to 10 of

how important it is for you to lose weight.
2. On this scale, zero is not important at all and
10 is extremely important.
3. Where would you be on this scale? Why are
you at ____ and not zero?
4. What would it take for you to go from ___ to 34
(a higher number)?'
 MOTIVATIONAL
INTERVIEWING

Strengthening commitment to change

 Decide on a 'change plan' together.
 This involves:

1. Standard goal setting techniques,

2. Using the spirit of MI as the guiding principle
3. Eliciting from the patient what he/she plans to
do (rather than instructing or advising).
 If a practitioner feels that the patient needs
advice at this point in order to set appropriate
goals, it is customary to ask permission before
giving advice as this honors the patient's
autonomy. 35
 MOTIVATIONAL
INTERVIEWING

Strengthening commitment to change

 Examples of key questions to build a 'change
plan' include:
1. It sounds like things can't stay the same as
they are. What do you think you might do?
2. What changes were you thinking about
making?
3. Where do we go from here?
4. What do you want to do at this point?
5. How would you like things to turn out?
6. After reviewing all of this, what's the next
36
step for you?
 MOTIVATIONAL
INTERVIEWING
 Motivational Interviewing is an empathic,
person-centered counselling approach that
prepares people for change by:
1. helping them resolve ambivalence,
2. enhance intrinsic motivation,
3. build confidence to change. (Kraybill and
Morrison, 2007)
 OARS are the basic interaction techniques
and skills that are used “early and often” in
the motivational interviewing approach.
1. Open questions,
2. Affirmation,
3. Reflective listening, 37

4. Summary reflections
 MOTIVATIONAL
INTERVIEWING
OARS: Open Questions
 Open questions:

1. Invite others to “tell their story” in their own

words without leading them in a specific
direction.
2. Should be used often in conversation but not
exclusively.
3. Of course, when asking open questions, you
must be willing to listen to the person’s
response.
 Open questions are the opposite of closed
questions.
 Closed questions typically elicit a limited 38

response such as “yes” or “no.”

 MOTIVATIONAL
INTERVIEWING
OARS: Open Questions
 The following examples contrast open vs. closed
questions. Note how the topic is the same, but the
responses will be very different:
 Did you have a good relationship with your parents? vs.
What can you tell me about your relationship with your
parents?
1. Examples of open questions:
2. How can I help you with ___?
3. Help me understand ___?
4. How would you like things to be different?
5. What are the good things about ___ and what are the less
good things about it?
6. When would you be most likely to___?
7. What do you think you will lose if you give up ___? 39
8. What have you tried before to make a change?
9. What do you want to do next?
 MOTIVATIONAL
INTERVIEWING
OARS: Affirmations
 Affirmations are statements and gestures that:

1. Recognize client strengths and acknowledge behaviors that

lead in the direction of positive change, no matter how big
or small.
2. Build confidence in one’s ability to change. To be
effective, affirmations must be genuine and congruent.
 Examples of affirming responses:

1. I appreciate that you are willing to meet with me today.

2. You are clearly a very resourceful person.
3. You handled yourself really well in that situation.
4. That’s a good suggestion.
5. If I were in your shoes, I don’t know if I could have
40
managed nearly so well.
6. I’ve enjoyed talking with you today.
 MOTIVATIONAL
INTERVIEWING
OARS: Affirmations
 Affirmations are statements and gestures that:

1. Recognize client strengths and acknowledge behaviors that

lead in the direction of positive change, no matter how big
or small.
2. Build confidence in one’s ability to change. To be
effective, affirmations must be genuine and congruent.
 Examples of affirming responses:

1. I appreciate that you are willing to meet with me today.

2. You are clearly a very resourceful person.
3. You handled yourself really well in that situation.
4. That’s a good suggestion.
5. If I were in your shoes, I don’t know if I could have
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managed nearly so well.
6. I’ve enjoyed talking with you today.
 MOTIVATIONAL
INTERVIEWING

OARS: Reflective Listening

 Reflective listening is a primary skill in outreach.
 It is the pathway for engaging others in relationships,
building trust, and fostering motivation to change.
 Reflective listening appears easy, but it takes hard
work and skill to do well.
 Sometimes the “skills” we use in working with
clients do not exemplify reflective listening but
instead serve as roadblocks to effective
communication.
 Examples are misinterpreting what is said or
assuming what a person needs. 42
 MOTIVATIONAL
INTERVIEWING

OARS: Reflective Listening

 Thinking reflectively accompanies good reflective
listening.
 It includes:
1. Interest in what the person has to say
2. Respect for the person’s inner wisdom.

 Listening breakdowns occur in any of three places:

1. Speaker does not say what is meant
2. Listener does not hear correctly
3. Listener gives a different interpretation to what the
words mean
 Reflective listening is meant to close the loop in
43
communication to ensure breakdowns don’t occur.
 MOTIVATIONAL
INTERVIEWING

OARS: Reflective Listening

 Some people find it helpful to use some
standard phrases:
1. So you feel…
2. It sounds like you…
3. You’re wondering if…

 There are three basic levels of reflective

listening that may deepen or increase the
intimacy and thereby change the affective
tone of an interaction.
 In general, the depth should match the
44
situation.
 MOTIVATIONAL
INTERVIEWING

OARS: Reflective Listening

 Examples of the three levels include:
1. Repeating or rephrasing: Listener repeats or
substitutes synonyms or phrases, and stays
close to what the speaker has said

2. Paraphrasing: Listener makes a restatement

in which the speaker’s meaning is inferred

3. Reflection of feeling: Listener emphasizes

emotional aspects of communication
through feeling statements. This is the 45
deepest form of listening.
 MOTIVATIONAL
INTERVIEWING

OARS: Reflective Listening

 Varying the levels of reflection is effective
in listening.

 At times there are benefits to over-stating or

under-stating a reflection.

 An overstated reflection may cause a person

to back away from their position or belief.

 An understated reflection may help a person

to explore a deeper commitment to the 46
position or belief.
 MOTIVATIONAL
INTERVIEWING
OARS: Summaries
 Summaries are special applications of
reflective listening.
 They can be used throughout a conversation
but are particularly helpful at transition
points.
 For example, after the person has spoken
about a particular topic, has recounted a
personal experience, or when the encounter is
nearing an end.
 Summarizing helps to ensure that there is
clear communication between the speaker
and listener.
47
 Summarizing can provide a stepping stone
towards change.
 MOTIVATIONAL
INTERVIEWING
OARS: Summaries
Structure of Summaries
1. Begin with a statement indicating you are making a summary.
a. For example: Let me see if I understand so far...
b. Here is what I’ve heard. Tell me if I’ve missed anything.

2. Give special attention to Change Statements.

a. These are statements made by the client that point towards a
willingness to change.
b. Miller and Rollnick (2002) identified four types of change
statements, all of which overlap significantly:
c. Problem recognition: “My use has gotten a little out of hand at
times.”
d. Concern: “If I don’t stop, something bad is going to happen.”
e. Intent to change: “I’m going to do something, I’m just not sure
48
what it is yet.”
f. Optimism: “I know I can get a handle on this problem.”
 MOTIVATIONAL
INTERVIEWING
OARS: Summaries
Structure of Summaries
3. If the person expresses ambivalence, it is
useful to include both sides in the
summary statement.
a. For example: “On the one hand…, on the
other hand…”

4. It can be useful to include information in

summary statements from other sources.
a. For example, your own clinical
knowledge, research, courts, or family.
49

5. Be concise.
 MOTIVATIONAL
INTERVIEWING

OARS: Summaries
Structure of Summaries
6. End with an invitation. For example:
a. Did I miss anything?
b. If that’s accurate, what other points are there to
consider?
c. Anything you want to add or correct?
7. Depending on the response of the client to
your summary statement, it may lead
naturally to planning for or taking concrete
steps towards the change goal.
50
 MOTIVATIONAL
INTERVIEWING

RULE
 Motivational interviewing is a counselling
method that involves enhancing a patient’s
motivation to change
 Four guiding principles, represented by the
acronym RULE:
1. Resist the righting reflex;
2. Understand the patient’s own motivations;
3. Listen with empathy;
4. Empower the patient.
51
 MOTIVATIONAL
INTERVIEWING
RULE
Resist the righting reflex
 The righting reflex describes the tendency of
health professionals to advise patients about the
right path for good health.
 This can often have a paradoxical effect in
practice, inadvertently reinforcing the argument
to maintain the status quo.
 Essentially, most people resist persuasion when
they are ambivalent about change and will
respond by recalling their reasons for
maintaining the behavior.
 Motivational interviewing in practice requires
52
clinicians to suppress the initial righting reflex
so that they can explore the patient's motivations
 MOTIVATIONAL
INTERVIEWING

RULE
Understand your patient's motivations
 It is the patient's own reasons for change,
rather than the practitioner's, that will
ultimately result in behavior change.
 By approaching a patient's interests, concerns
and values with curiosity and openly exploring
the patient's motivations for change, the
practitioner will begin to get a better
understanding of the patient's motivations and
potential barriers to change.
53
 MOTIVATIONAL
INTERVIEWING

RULE
Listen with empathy
 Effective listening skills are essential to
understand what will motivate the patient, as
well as the pros and cons of their situation.
 A general rule-of-thumb in MI is that equal
amounts of time in a consultation should be
spent listening and talking.

54
 MOTIVATIONAL
INTERVIEWING
RULE
Empower your patient
 Patient outcomes improve when they are an
active collaborator in their treatment.
 Empowering patients involves exploring their
own ideas about how they can make changes
to improve their health and drawing on the
patient's personal knowledge about what has
succeeded in the past.
 A truly collaborative therapeutic relationship
is a powerful motivator.
 Patients benefit from this relationship the most
when the practitioner also embodies hope that 55

change is possible.
REFERENCES

56
 REFERENCES

 It’s Pronounced Metro Sexual. (2017). Genderbread Person v3.3. Retrieved: https://
www.genderbread.org/resource/genderbread-person-v3-3
 Lubman, D., Hall, K., Gibbie T. (2012). Motivational interviewing techniques
Facilitating behaviour change in the general practice setting. Autralian Family
Physician 14(9). Retrieved:
https://www.racgp.org.au/afp/2012/september/motivational-interviewing-techniques
#:~:text=Motivational%20interviewing%20is%20a%20counselling,empathy%3B%2
0and%20Empower%20the%20patient
.
 Miller W.R., Rollnick S. Motivational Interviewing. Preparing people for change.
2nd edn. New York: The Guilford Press, 2002.
 Rosengren, D. (2007). Motivational interviewing: open questions, affirmation,
reflective listening, and summary reflections (OARS). SAMHSA. Rockville, MD: 57
Homelessness Resource Center (HRC). Retrieved: https://
www.homelesshub.ca/resource/motivational-interviewing-open-questions-affirmatio
REFERENCES

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