Advice to Behavioral Health Clinicians: Screening and Assessment for Co-Occurring Disorders in Men

Posttraumatic stress disorder

In the general population, men are exposed to trauma more often than women, although women experience higher rates of PTSD(Breslau 2002; Kessler et al. 1995). Between 5and 6 percent of men have had PTSD sometime in their lives (Breslau et al. 1998; Kessleret al. 1995). However, in certain male populations exposed to greater amounts of trauma,rates of PTSD are likely to be higher. Studies have found rates of trauma exposure between 42 and 95 percent in men seeking treatment for substance use disorders (Farley et al. 2004)and equally high rates in populations of men with serious mental illness (Goodman et al. 2001) and men who are homeless with co-occurring disorders (Christensen et al. 2004).Men involved in the criminal justice system (Swartz and Lurigio 1999) and men who are combat veterans (Kulka et al. 1990) are 2 to 3 times more likely to experience PTSD than men in the general population.

Prior trauma exposure may also contribute to the development of PTSD following a subsequent trauma. Smith and colleagues (2008)report that individuals who had been the victim of an assault prior to being deployed in Operation Iraqi Freedom (OIF) were twice as likely to develop new-onset PTSD during or after deployment than were service members with no history of assault. Kessler and colleagues (1995) found that men with PTSD are more likely to have a co-occurring substance use disorder (51.9 percent) than men without PTSD (34.5 percent) and are also more likely to have a co-occurring substance use disorder than women with PTSD (27.9 versus 26.9 percent, respectively). These data suggest that men in substance abuse treatment are at particularly high risk for having both PTSD and a substance use disorder.

Men and women are typically exposed to different types of trauma and appear to be affected differently by traumatic events. The most common traumas for men are exposure to combat; being physically assaulted, shot, or stabbed; and witnessing killings or serious injuries. Women, however, are most often exposed to sexual assault and rape (Breslau 2002;Kessler et al. 1995). Men are also more likely than women to be victims of violent crime (Catalano 2004). In a sample of men with substance use disorders (both in and out of treatment), 45 percent had witnessed a killing or injury, 33 percent had been physically assaulted, 16 percent had been threatened, and 16 percent had experienced a sudden injury or accident; women were 14 times more likely to have been raped than men but 3 times less likely to have been physically assaulted(Cottler et al. 2001).

Among men, rape and combat are the two types of trauma most likely to lead to PTSD.In a general population sample of men, rape (a relatively rare event for adult men) resulted in PTSD approximately 65 percent of the time; combat exposure resulted in PTSD 38.8 percent of the time (Kessler et al. 1995).

[Question #56. Among men, rape and combat are the two types of trauma most likely to lead to :]

Men are expected to be tough, so their trauma histories may not be explored in treatment as often as those of women, nor are they as likely to self-identify as trauma survivors. The problem is complicated by men’s greater tendency to externalize their experiences of trauma; thus,men are more likely than women to react to their own traumatization by victimizing others.Men are also more likely to report symptoms of increased alcohol use and irritability as a result of traumatic experiences (Green 2003).

Case example: Tim

Tim is a 30-year-old veteran of OIF. While on active duty, he was exposed to several life-threatening events, including being in a convoy vehicle that hit an improvised explosive device (IED) on the roadside. The passenger in the vehicle’s front seat was killed, and Tim was thrown from the back, resulting in abrasions and bruises across his body, a broken arm and knee cap, and wounds from shrapnel. At the time of this traumatic event, Tim was screened for trauma symptoms but was approved to return to combat; as soon as his wounds healed, he returned to his unit for another 7 months of active duty.

Following his discharge from the Army, Tim entered college and majored in criminal justice. Although he had exhibited some trauma symptoms prior to starting college (sleep disturbances, nightmares, anxiety when he saw objects on the side of the road), the symptoms were not disabling until he began an internship at a local prison. Within the first month of the internship, Tim began experiencing disabling PTSD symptoms that were exacerbated by the noises, sights, and smells in the prison.The yelling among inmates and the clanging of metal doors were particularly stressful. He began smoking marijuana after work and on weekends to quell his symptoms, and he tested positive for marijuana on a routine drug screen.He was referred to the prison’s employee assistance program, which referred him to a substance abuse treatment program for evaluation.

The substance abuse program staff identified Tim’s co-occurring PTSD and substance abuse and enrolled him in a 2-month assessment group for his substance use. To address his PTSD symptoms, the program also arranged regularly scheduled appointments at the local U.S. Department of Veterans Affairs (VA) clinic with a behavioral health counselor who had been trained in PTSD treatment.

The planned TIP, Trauma-Informed Care in Behavioral Health Services (SAMHSA planned g), provides more information on trauma and PTSD among men and women with substance use disorders and on treating trauma concurrently with substance use disorders. It offers more detail regarding all trauma-related subjects touched on in the following sections of this chapter.

Treating men for PTSD

Many interventions to address both PTSD and substance use disorders, even if developed for both male and female clients, have been evaluated primarily with women or with men who have experienced combat-related trauma.Behavioral health clinicians may need to consider how to adapt these interventions for other populations. In some cases, models created specifically for women have been adapted for men; one such example is the Men’s Trauma Recovery and Empowerment Model (MTREM). This model appears promising in its ability to engage male clients and improve their coping skills, and it is a useful example of how trauma treatment can be adapted for a male population (personal communication with R. D. Fallot, June 10, 2005). However,research on M-TREM’s effectiveness is ongoing; no recent study reports are available to provide empirical evidence of its potential success.

[Question #58. The trauma treatment model to engage male clients and improve their coping skills is:]

The developers who adapted TREM for male clients formulated eight basic assumptions about how trauma treatment for men should differ from that provided to women. These assumptions are shown, along with the developers’ responses to them, in Exhibit 4-1.

Other researchers and behavioral health clinicians have suggested ways in which treatment for men with PTSD may need to differ from that provided for women with the disorder.For example, Lisak (2001b) notes that the ideology of masculinity limits the resources available to men to respond to trauma. Therefore,any treatment for men with trauma must address how men internalize masculine ideology concurrently with their trauma histories. Otherwise, the legacies of masculine socialization can impede the process of healing from trauma by keeping men from connecting with the painful feelings that result from it.

Ruzek (2003) describes several interventions for treating veterans with co-occurring PTSD and substance use disorders; most of this population is male, and the research Ruzek draws upon is primarily with male clients. Specifically, he notes that members of this population often have anger control problems that need to be addressed in the context of their trauma treatment.

The Seeking Safety model for treating co-occurring trauma and substance use disorders effectively reduced PTSD symptoms and substance use in a small (n=5) study of men with co-occurring substance use disorders and PTSD (Najavits et al. 2005).

Emotionally directed, cognitively oriented counseling can help men connect with their feelings and the feelings and experiences of others (Hardy 2004). Treatment for trauma and trauma-related disorders typically involves the active processing of painful feelings that expose the individual as vulnerable—an exploration that runs counter to the masculine norms of our culture, thus making this process potentially more difficult with male clients than with female clients. Because of this added impediment, behavioral health clinicians treating men with trauma histories must explore with them the social processes of masculinization and the ways in which masculine norms hinder recovery from trauma (Lisak 2001b). Treatment for men with histories of trauma, whether or not they have PTSD, is discussed later in this chapter. Specific information on treating men exposed to combat trauma is presented in the following section.

Combat stress reaction

CSR is an acute anxiety reaction similar to an acute stress disorder but only occurring among combatants (and noncombatants exposed to combat events) in an armed combat situation.Although the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,Text Revision (DSM-IV-TR; APA 2000) does not list CSR as a diagnosis, CSR (also called combat trauma) affects a significant number of male veterans. Substance use and mental disorders are strongly associated with trauma from combat exposure (Hoge et al.2006; Ruzek 2003).

[Question #59. An acute anxiety reaction similar to an acute stress disorder but only occurring among combatants is:]

Common causes of CSR often relate to direct attacks, as with insurgent small arms fire or IEDs, and can also result from being near combat, handling the bodies of wounded or dead individuals, being repeatedly exposed to events with a high risk of death or injury, or making frequent on-the-spot decisions under ambiguous conditions—especially when the result is death or injury to others.

CSR can be transient and nondebilitating, orit can result in major psychological disorganization. Normally, with support and treatment,symptoms diminish in a relatively brief period of time (1 to 2 months). If symptoms persist beyond that time, the person may be diagnosed with PTSD. Typical CSR symptoms include hyper vigilance, sleeplessness, irritability, anger, and difficulty concentrating. More severe symptoms may include freezing up,feelings of impending doom, significant but unreasonable guilt, unpredictable responses in ordinary situations, and impaired memory.

Significant strides have been made in recent years in addressing CSR in combat zones.Military personnel are briefed prior to entering a war theater about stressors and coping strategies. Personnel with combat stress symptoms are more rapidly and efficiently identified, and onsite treatment in the combat zone has been remarkably improved. Most treatment for service members is provided in their assigned camp by members of combat stress control teams composed of behavioral health professionals who use brief and targeted individual, group, and psychoeducational methods.If service members do not respond to these services, they are evacuated from the combat zone whenever possible to access more specialized resources. A more detailed deblockedion of this process is described in the planned TIP, Trauma-Informed Care in Behavioral Health Services (SAMHSA planned g). Reintegration efforts for veterans returning to the United States have been significantly enhanced as well. Programs for families, ongoing medical care, and civilian life have been developed and implemented throughout all service branches.

Behavioral health clinicians should know that veterans are eligible for a variety of services offered by regional VA centers, including readjustment counseling, referral for benefits assistance, marital and family counseling, substance abuse information and treatment referral, job counseling and vocational assistance referral, and sexual trauma counseling and treatment referral.
The Iraq War Clinician Guide (National Center for PTSD and Walter Reed Army Medical Center 2004) is a treatment reference for mental health issues among veterans of OIF. This document is available for free on VA’s National Center for PTSD Web site (http://www.ptsd.va.gov/professional/manuals/manual-pdf/iwcg/iraq_clinician_guide_v2.pdf). Military One Source also offers veterans and their families useful resources relating to mental health and substance abuse issues (http://www.militaryonesource.mil; 1–800–342–9647).

Social phobia

Social phobia, also called social anxiety disorder, is one of the most common anxiety disorders. It affects women more than men, with a lifetime occurrence of 15.5 percent for women and 11.1 percent for men (APA 2000; Kessler1998). It entails a “marked and persistent fear of social or performance situations in which embarrassment may occur” (APA 2000, p.450). Men with social phobia seek treatment more often than women, which is opposite the norm for most mental disorders (Weinstock 1999). Men may be more likely to seek treatment for this disorder because it has a greater impact on them due to the gender role expectation that they be more proactive in social relations.

[Question #61. Women with social phobia seek treatment more often than men.true/false?]

Men are particularly susceptible to using alcohol to combat the symptoms of social phobia.Some men describe how they drink to be able to leave the house, interact with others, or work in front of others (e.g., when making presentations). Men with social phobia may use alcohol at work when confronted with stressors that involve interpersonal interaction.They may drink heavily at unavoidable social events and then experience the negative effects of heavy use. Social phobia also makes it difficult for men to enter substance abuse treatment, where they fear being overwhelmed with anxiety. They may be especially fearful of group sessions or 12-Step participation and will feign illness or other crises to avoid attending. It can be easy for counselors to equate this behavior with clients being resistant or less motivated.

Many clients with social phobia have anticipatory anxiety: imagining a worst case scenario about an upcoming event at which they might be the center of attention, interrogated by others, or exposed as a fraud; they then react emotionally as if that event has occurred.Anticipatory anxiety emotionally validates that the upcoming event is, indeed, dangerous and needs to be avoided. Some people cope with anticipatory anxiety by using drugs or alcohol to quell their symptoms.

[Question #62. Clients imagining a worst case scenario about an upcoming event at which they might be the center of attention have:]

Screen clients with social phobia symptoms (see DSM-IV-TR for symptoms; APA 2000) for the disorder and refer, if necessary, to qualified behavioral health professionals who specialize in the treatment of anxiety disorders for assessment and discussion of treatment options, including counseling (especially cognitive–behavioral therapy) and medication.Along with confronting limiting beliefs and perceptions, counseling should build skills in social interaction, anxiety self-monitoring, and positive coping options for use during anxiety-producing social situations.

Obsessive–compulsive disorder

Although not highly prevalent in the general population, OCD almost always co-occurs with other mental disorders and often with substance use disorders (Mancebo et al. 2009;Pinto et al. 2006). A study of people in treatment for OCD found that 27 percent of the sample met criteria for a lifetime diagnosis ofa substance use disorder; men were more likely than women to have a co-occurring substance use disorder.

For a man with OCD and a co-occurring substance use disorder, the substance use disorder may have originated in an attempt to cope with overwhelming and disabling anxiety.However, as substance use progresses, it actually worsens anxiety symptoms. Substance abuse treatment can be complicated by men’s resistance to giving up a drug that they believe necessary to their emotional survival, by anxiety that arises from the emotional intensity of treatment, and sometimes, by deficits in social skills important for recovery from substance abuse. As with other anxiety disorders, a licensed behavioral health service provider with specific training in the treatment of anxiety disorders should diagnose and treat OCD, which should be treated concurrently with the substance use disorder. In addition to counseling, treatment may include medication.

Generalized anxiety disorder

GAD is sometimes associated with substance use disorders. In cases of GAD, the origins of the substance use disorder may lie in attempts to cope with overwhelming and disabling anxiety. However, as substance use progresses, it actually worsens anxiety symptoms. Substance abuse treatment can be complicated by men’s resistance to giving up a drug that they believe necessary to their emotional survival, by anxiety that arises from the emotional intensity of treatment, and sometimes, by deficits in social skills important for recovery from substance abuse. As with other anxiety disorders, a licensed behavioral health service provider who specializes in the treatment of anxiety disorders should conduct diagnosis and treatment;the anxiety disorder needs to be treated concurrently with the substance use disorder.

Dysthymia and major depressive disorder

According to a number of studies, women are from 1.5 to 3 times as likely as men to have a depressive disorder, and this finding holds true in many settings around the world (Chuick etal. 2009; Kessler 2000a; Levin and Sanacora2007). However, approximately 12.7 percent of all men will experience an episode of major depression at least once during their lives (Kessler et al. 1994).

Different explanations have been proposed for the large difference in rates of depression between genders. Depression seems to manifest differently in men than in women.This may contribute to the higher incidence of substance use disorders and antisocial personality disorder(ASPD) in men than women (NationalInstitute of Mental Health [NIMH] 2003; Pollack 1998c; Real 1997). Others have suggested that the apparent difference may exist because men are less likely to seek help for depression, present with different symptoms of depression than women, and may be diagnosed by behavioral health clinicians and diagnostic instruments that are influenced by gender bias. Men tend to be underdiagnosed with depression, whereas women are overdiagnosed (Levin and Sanacora 2007). However,conclusive evidence supporting a single explanation is still lacking (Winkler et al. 2004).

The fact that men are less often diagnosed with depression than women may also result from cultural factors that define permissible masculine behavior—so that the same gender roles that shield men from their emotions in other areas may keep them from showing symptoms of depression, alter their symptoms,or make them less likely to report symptoms. Studies also show that rates of depression are nearly the same among some subgroups of men and women, such as the elderly (Bebbington et al. 2003) or certain cultural/ethnic groups (e.g., the Amish, HassidicJews), in which men are less likely than men in the general population to have substance use disorders, ASPD, or other problems that may be manifestations of underlying issues thatalso cause depression (Cochran 2001).

A study of patients at a German hospital found gender differences in the presentation of symptoms, but not the severity, of depression—with men who were depressed more likely to show emotional rigidity, blunted affect, and decreased libido (Winkler et al.2004). Men who are depressed may be more likely to focus on somatic or physical complaints than women, and depression in men may manifest in interpersonal difficulties andconflicts. Notably, men with depression are more likely to have a substance use disorder than women who are depressed (Cochran2001; Pollack 1998c).

Depressed mood, whether attributable to aspecific disorder or not, can significantly affect substance abuse treatment and recovery. For example, among a group of men who had relapsed during the 12 months following treatment, the most reported reason for relapse—reported by 26.9 percent of participants—was depressed mood (Strowig 2000). Such feelings as boredom and anger can cause relapse to substance use and may also result from underlying depression. TIP 48 (CSAT 2008b) discusses how to address subclinical depressive symptoms (for men and women) in substance abuse treatment settings.

Treatment for depressive disorders can be concurrent with substance abuse treatment. It usually includes a combination of counseling and antidepressant medication, which only behavioral health clinicians specifically trained in the treatment of mood disorders should provide.

The term “depressive symptoms” is generally applied to a state of sadness, depressed mood, the blues, or related feelings and behaviors that do not meet diagnostic criteria for a DSM-IV-TR (APA 2000) mood disorder. People with such symptoms may experience considerable emotional pain and significantly impaired functioning in some areas.

Symptoms of depression exist on a continuum ranging from sadness and other depressive symptoms occurring at appropriate times and for short periods, during which the individual successfully uses coping strategies, to clinical (or major) depression as described in the DSM-IV-TR (APA 2000). The line between depressive symptoms and full-blown depressive disorders is a question of degree. Having depressive symptoms differs from having a major depressive disorder in terms of the number or severity, but not the type, of symptoms experienced by a client. Only behavioral health professionals credentialed to diagnose mental illness can determine whether a client has a serious disorder, such as major depression, dysthymia, bipolar disorder, or substance-induced mood disorder. Counselors who suspect that a client has a depressive illness should refer him to a behavioral health professional for assessment, diagnosis, and treatment.

Depressive symptoms may become more or less intense over time due to the client’s physiology, stressful events in the client’s life, or the client’s stopping or starting substance use. For example, someone who drinks heavily may have intense depressive symptoms that seemingly meet criteria for depressive illness but lessen dramatically in the weeks after initial abstinence from alcohol. Similarly, someone with major depression or dysthymia who has taken antidepressant medication for several weeks may show few or no currently debilitating depressive symptoms. Conversely, a client may demonstrate only mild depressive symptoms at intake but may be headed toward a significant depressive episode.

As with substance abuse, although a person may be in remission from his depressive symptoms, the depressive disorder may remain. Treatment must address prevention of and early intervention in recurrences, especially during early recovery from substance use disorders. Many depressive disorders cycle and recur. If a client has a history of a mood disorder, he and his counselor should be on the lookout for a recurrence of symptoms.

Source: CSAT 2008b, page 5. Adapted from material in the public domain.

Bipolar disorder

Men and women appear to be affected differently by bipolar disorder.The disorder has an earlier age of onset in men than in women;men with the disorder also seem to have more frequent manic episodes and require a greater number of weeks of hospitalization for these episodes than women with the disorder,whereas women have more depressive episodes than men (Arnold 2003). Men with bipolar disorder appear more likely than women with the disorder to have a co-occurring substance use disorder, according to a number of studies reviewed by Arnold (2003); see also Albanese and colleagues (2006).

Many clients in substance abuse recovery who have been diagnosed with bipolar disorder describe trying to regulate their manic and depressive cycles with substances. For instance, in a manic episode, clients may use alcohol or sedatives to sleep and/or stimulant drugs to increase the high of the episode (i.e., emotional expansiveness and sense of well-being). In a depressive cycle, clients may use alcohol (even though it is a depressive drug) to dull the pain of their depression and/or stimulants to counteract the effects of the depression.

[Question #63. In a depressive cycle, clients may use alcohol as a depressive drug to dull the pain of their depression and/or stimulants to counteract the effects of the depression true/false?]

depression. Manic symptoms can often be confused with symptoms of substance abuse, making diagnosis simply by observation difficult. Generally,bipolar disorder has to be diagnosed by a thorough examination of the client’s mental health history, which should be conducted by a licensed behavioral health professional trained in making such diagnoses. Treatment for the substance use and bipolar disorders needs to be integrated or at least concurrent, as symptoms for one can trigger onset or relapse of the other. In addition to counseling, psychotropic medication is usually prescribed to regulate the bipolar disorder; the use of medication to regulate the illness must be considered in the client’s total treatment plan.

Antisocial personality disorder

The National Comorbidity Study found that 5.8 percent of men (compared with 1.2 percent of women) had sufficient symptoms to warrant a diagnosis of ASPD at some point during their lifetimes (Kessler et al. 1994).NESARC found similar rates of 5.5 percentfor men and 1.9 percent for women (Grant etal. 2004b). In a study by Klonsky and colleagues (2002), ASPD was associated with both self-endorsement of masculine attributes and peer reports of masculine attributes among a sample of male and female college students. In large-scale studies, 80 percent of ASPD cases in the general population are men; this may relate to impulsive aggression,which characterizes ASPD, being a trait more common to men than women (Paris 2004).Most ASPD symptoms are described in terms of male behavior, so women may be underdiagnosed if they have ASPD symptoms less likely to appear in diagnostic criteria, such as stealing from an employer or engaging in prostitution.

Studies of people in substance abuse treatment(Compton et al. 2000) and people with substance use disorders who are not in treatment (Falck et al. 2004) have found much higher rates of ASPD for both men and women. Moreover, rates of ASPD in treatment settings tend to be closer between genders than rates found in the general population (Millery and Kleinman 2001), and some researchers have even found slightly higher rates among women in treatment than among their male counterparts (Galen et al. 2000). NESARC’s survey of the noninstitutionalized population showed a stronger association between ASPD and substance use disorders in women than in men;however, this may be, in part, because men are overrepresented in criminal justice populations left out of the sample (Grant et al. 2004b).

Assessment of possible ASPD in substance abuse treatment clients can be confounding.Many clients have exhibited antisocial behavior during their drug use that does not justify an ASPD diagnosis. People may display antisocial symptoms in one context, such as prison, but not another. Diagnosis for ASPD is generally based on the client’s history as well as his current behavior. Forrest (1994) describes some of the difficulties of and alternative approaches to differential diagnosis in his book, Chemical Dependency and Antisocial Personality Disorder.

Treatment of men with ASPD in substance abuse treatment settings can be difficult. In fact, certain elements of usual substance abuse treatment can make people with ASPD anxious and prone to act out in treatment. Often,substance abuse treatment emphasizes emotional sharing, personal disclosure, honesty,and confronting shame—all of which may feel provocative and overwhelming to men with ASPD. Clients who are antisocial may manipulate staff members and other clients, violate or flout program rules, be intentionally deceptive, shame or abuse others, attempt to control the treatment environment and, as a last resort, leave treatment early. As a result, people with ASPD may require special treatment that provides a safe and contained environment in which to manage their anxiety. In early treatment, counselors may need to emphasize controlling negative behavior and compliance with rules while downplaying emotional expression and interpersonal sharing, and they should establish clear consequences for violating program rules (though these might seem draconian in other treatment settings). Treatment programs for co-occurring ASPD and substance abuse are often found in prison settings, but many clients who could benefit from such programs are not in prison. A community alternative is the establishment of long-term residential therapeutic communities (TCs), although not all TCs are appropriate for people with ASPD.

Suicidality

A variety of mental and substance use disorders can increase a man’s risk for committing suicide; therefore, although it is not a disorder per se, suicidality must be addressed. Women are three times more likely to attempt suicide than men, but men are more than four times as likely to die from suicide (NIMH 2001). Infact, researchers have found this to be true across cultures, with a few notable exceptions,such as mainland China (Arsenault-Lapierreet al. 2004). The highest rate of completed suicide among any demographic group occurs inWhite American men ages 65 and older (U.S.Public Health Service 1999). Higher rates of suicide completion among men may result, in part, from the deadlier methods men typically choose for suicide. For example, 79 percent of all suicides using fire arms are committed by White men, and fire arms are involved in most(58 percent) completed suicides (Antai-Otong2003). Additionally, men tend to perform fewer suicidal acts but exhibit a higher intent to die (Nock and Kessler 2006).

Substance use and abuse are major risk factors for suicide; men with substance use disorders have high rates of death by suicide (Wilcox etal. 2004). Approximately 30 to 40 percent of suicide attempts and completed suicides involve acute alcohol intoxication (Cherpitel etal. 2004). Substance-related problems appear to be more often associated with suicide in men than in women, suggesting an even greater need to screen for suicidality among men intreatment (Arsenault-Lapierre et al. 2004).

[Question #66. Substance use and abuse are major risk factors for:]

Co-occurring mental disorders increase the likelihood of suicide even more than substance abuse alone: depression, schizophrenia, bipolar disorder, and personality disorders all increase the chances that someone will both attempt and complete suicide (Arsenault-Lapierre etal. 2004; Blumenthal 1988). Other factors,such as certain physical ailments (e.g., epilepsy,cancer, Huntington’s chorea) and a family history of suicide, also appear to increase the likelihood of suicide (Blumenthal 1988). Rates of death by suicide vary by race and ethnicity. Exhibit 4-3 depicts age-adjusted rates of suicide per 100,000 individuals in the year 2006 according to the Centers for Disease Control and Prevention’s (CDC’s) National Center for Injury Prevention and Control(NCIPC; 2009).

Appendix D of TIP 42 (CSAT 2005c) recommends that all substance abuse treatment clients receive at least a basic screening for suicidality and notes a particularly high risk among clients who have relapsed to substance use after an extended period of abstinence.TIP 42 (Chapter 8 and Appendix D) also listskey questions for evaluating suicide risk and provides other information on this topic.

TIP 50, Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment (CSAT 2009a), provides more data on suicide by men and women with substance use disorders as well as information on and case studies relating to addressing this issue in substance abuse treatment.TIP 50 proposes that counselors use a four-step screening and intervention process with clients who may be suicidal: (1) Gather information, (2) Access supervision, (3) Take responsible action, and (4) Extend the action.These steps, known by the acronym GATE, are described in the text box on the next page. [Question #67. The steps for GATE process with clients who may be suicidal are:]

Men With Physical Health Problems

Men with substance use disorders are at increased risk for a wide range of medical conditions either caused or exacerbated by their substance use, including various cancers, cardiovascular and pulmonary conditions, neurological problems, gastrointestinal disorders,endocrine syndromes, and hepatic disorders (Mannelli and Pae 2007; Ries et al. 2009;Saitz 2009). They are also at increased risk for infectious diseases, including viral hepatitis (see TIP 53, Addressing Viral Hepatitis in People With Substance Use Disorders [SAMHSA 2011a]) and HIV/AIDS (see the “Men With HIV/AIDS” section on p. 84 of this TIP; see also TIP 37, Substance Abuse Treatment for Persons With HIV/AIDS [CSAT 2000c]). Some such illnesses (e.g., liver cirrhosis) may result directly from the substances used, whereas others (e.g., HIV/AIDS) may result from the method of drug administration or the lifestyle that accompanies substance abuse. [Question #68. Diseases resulting from the method of drug administration or the lifestyle that accompanies substance abuse is: ]

The consensus panel recommends that all clients entering substance abuse treatment programs have a thorough physical examination with appropriate laboratory studies. Programs should also provide medical services or link to such services; doing so can improve recovery outcomes for clients (Friedmann et al. 2003,2009). Integrated medical care results in better abstinence outcomes than independent but linked services (Weisner et al. 2001), and onsite services result in better use of medical care than offsite services (Friedmann et al. 2001).

• Modify psychoeducational and cognitive–behavioral counseling approaches to be sure that clients with TBI are able to incorporate the information.
• Adapt treatment to accommodate the shorter attention span of clients with TBI.
• Help clients develop and implement coping strategies to manage everyday functioning, such as making lists, managing stress, and asking for the support of others.
• Note that inappropriate affective responses (e.g., anger disproportional to stimulus) may be symptoms of TBI.
• Educate the client about TBI, its symptoms, and its effects.
• Work with families to assist clients in their recovery from both TBI and substance use disorders.

• ITIP 29, available at the SAMHSA Store (http://store.samhsa.gov)
• National Institute of Neurological Disorders and Stroke
  (http://www.ninds.nih.gov/disorders/tbi/tbi.htm)
• Brain Injury Association of America (http://www.biausa.org)
• Brainline.org (http://www.brainline.org)
• NCIPC’s Traumatic Brain Injury Web site
  (http://www.cdc.gov/TraumaticBrainInjury/index.html)
• Defense and Veterans Brain Injury Center (http://www.dvbic.org)
• The National Institute of Neurological Disorders and Strokes’ Traumatic Brain Injury
  Information Web site (http://www.ninds.nih.gov/disorders/tbi/tbi.htm)
• Anger Management for Substance Abuse and Mental Health Clients:
  A Cognitive Behavioral Therapy Manual (also available in Spanish), available at the SAMHSA Store (http://store.samhsa.gov)
• Anger Management for Substance Abuse and Mental Health Clients: Participant Workbook
  (also available in Spanish), available at the SAMHSA Store (http://store.samhsa.gov)

Source: CSAT, 2010b. Adapted from material in the public domain.

Specific Needs of Younger Men Entering Treatment

Young adult men, typically defined as men ages 18 to 24 (Park et al. 2006), have issues related to masculinity and substance abuse that distinguish them from men in other age groups. Drug and tobacco use, binge drinking,and recent illicit drug use are most common in this age group and are more common for men in this age group than for women (Park et al.2006). In this age group, men are three times more likely than women to die, and high rates of death by automobile crashes, homicide, and suicide account for much of the difference (Park et al. 2006; Pollack 2010). Among young men in certain cultural/ethnic groups (notably Native American and African American men),rates of violent death are considerably higher.Frequent or binge alcohol use and frequent drug use have been associated, in diverse samples of young men, with increased risk for being the victims of violence; these behaviors appear to increase young men’s likelihood of being perpetrators of violence as well (Cooperet al. 2000; Friedman et al. 1996; Richardsonand Budd 2003). For both younger and older adults, binge drinking has been associated with significant alcohol-related problems, and men (15 percent) are more likely than women (4.7 percent) to binge drink (Blazer and Wo 2009a). In one study, younger men were five times as likely to be involved in fighting or violent crime and seven times as likely to break or damage something as their counterparts who drank less frequently and did not binge drink (Richardson and Budd 2003).

High rates of substance use/abuse and violence may reflect the fact that young men are often less secure about their masculinity than older men and therefore may feel a greater need to engage in behaviors that supposedly prove their masculinity to others. Take, for example, the elevated death rate by automobile collision among men in this age group. This results largely from the fact that young men are the least likely of men in any age group to use seat belts and the most likely of men in any age group to be in a crash in which at least one driver is alcohol impaired (Park et al. 2006).Young men also engage in a variety of other high risk behaviors. For example, young men who inject drugs are more likely to engage in practices that put them at high risk for contracting HIV (Rondinelli et al. 2009).

[Question #70. High rates of substance use/abuse and violence in the young male population reflect:]

Heavy drinking and illicit drug use can be seen as high risk behaviors that young men engage in, in part, to demonstrate their masculinity. Research by Peralta (2007) found that most undergraduate students (both male and female) agreed that drinking was generally perceived as an activity that expressed masculinity. More White American (76 percent) than African American (53 percent) students held this belief, suggesting that cultural background influences attitudes about masculinity and drinking. Students interviewed for the study spoke of the beliefs that being able to hold your liquor was a sign of masculinity and that bouts of heavy drinking were rites of passage for men (but not women).

Other types of substance use may also be perceived, in certain cultural contexts, as ways of expressing masculinity. Brown (2010) evaluated methamphetamine use among young Native American and White American men in Appalachia and found that use of the drug was linked with a strong masculine identity, but admitting that one had a problem with the drug (e.g., by entering treatment) was considered a sign of weakness. In other contexts, success in the drug trade is also considered an expression of a strong masculine identity (Bourgois 2003).

Young men may have some unique substance abuse treatment needs, although these vary according to cultural and sociodemographic factors. For example, young men who have made a living from the drug trade or other criminal activity may need vocational training and help finding a job, whereas college students in recovery value alcohol-free housing (i.e.,dorms) and social activities (Bell et al. 2009).

Young men often enter treatment under coercion (by family, the criminal justice system,schools, and/or employers), and thus more effort may be needed to help them move from an early stage of readiness for change (precontemplation) toward embracing and accepting abstinence. The largest single source of treatment referrals for individuals (both male and female) in this age group is the criminal justice system, which accounted for 52 percent of first-time admissions and 46 percent of return admissions in 2006; the percentages for men alone are likely higher (SAMHSA, OAS2008a). In comparing young adults to those ages 26 to 45 in a largely (85 percent) male,probation-referred treatment population,Sinha and colleagues (2003) found that young adults were significantly more likely to be in precontemplation but significantly less likely to be in contemplation, determination, or maintenance stages than adults ages 26 to 45.Young adult male clients may also be more resistant to involvement in mutual-help groups, especially when groups specifically for younger people are unavailable. Transference-related issues can arise for younger clients who have older counselors. Some transference may be positive and useful for treatment, but much may be negative, causing clients to rebel against the advice and support of older counselors.

[Question #71.The largest single source of substance abuse treatment referrals for individuals in younger age groups is the criminal justice system. True/False? ]

Data on substance abuse treatment programs specifically geared toward young adult men are limited, but various program models have been tried with this population (including gender-specific programming), particularly in criminal justice settings. Research into TCs (see Chapter 5) shows that young adult men are less likely than other clients to be involved with or integrated into the TC (Chan et al. 2004),perhaps because they have a greater need to rebel against the high degree of structure offered by TCs. Even so, this should not disqualify the TC approach, which has been found useful for young men (more so than older men) in prison settings (Messina et al. 2006).

Data suggest that adults who begin using substances at a younger age are more likely to be classified as substance dependent when they get older than those who start using substances later in life. Some boys start using alcohol or tobacco in the fifth or sixth grade or even earlier (SAMHSA 2005; Vega et al. 1993).Boys may start to use substances at an especially early age because of factors in their school environments, such as availability of drugs on or near the school campus (National Institute on Drug Abuse 1999), or because of substance abuse in their homes.

Specific Needs of Older Men Entering Treatment

Men 55 years of age and older often decrease or end their alcohol and drug use, and their rates of substance use disorders decline as well. A number of factors contribute to these changes, including early mortality among individuals who drink heavily and/or use illicit drugs, negative effects of substances on medical problems, additional medical problems caused by substance use, decreased desire to use, potential financial strain, and less participation in social events and activities focused on substance use (Menninger 2002). However,other factors, such as loneliness and depression, may cause some older adults to increase their drinking (Capraro 2000; Strowig 2000).Some of these factors may affect men and women differently. For example, older men seem less concerned than older women about the effects of alcohol on their health (Satreand Knight 2001), which may help explain why older age is associated with greater decreases in alcohol consumption for women than for men (Satre and Aren 2005).

In SAMHSA’s 2007 National Survey of Drug Use and Health (NSDUH), a survey of the general U.S. population ages 12 and older, 2.6 percent of men ages 65 and older met criteria for a past-year alcohol use disorder (U.S.Department of Health and Human Services [HHS], SAMHSA, OAS 2008a). Other studies have found higher rates (see review in Satre and Aren 2005). Also in the 2007 NSDUH,a greater percentage of men than of women over the age of 65 reported drinking more than the amount recommended by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), which is no more than one drink per day for older men (NIAAA 2005). Among those ages 65 and older who reported drinking at least one drink in the prior month, 48.7 percent of men reported more than one drink per day compared with 28.7 percent of women; 17.7 percent of men reported more than two drinks per day (HHS, SAMHSA, OAS 2008a). Although rates of alcohol abuse/dependence declined with age for both men and women, the extent of that decline was greater for women than for men.In the 2007 NSDUH, men ages 65 and older were 37.5 times more likely to not have a past-year alcohol problem than to have one; women in the same age group were 249 times more likely (HHS, SAMHSA, OAS 2008a).

Data from SAMHSA’s 2005 and 2006 NSDUH surveys (Blazer and Wu 2009a)show that men ages 65 and older were more likely to engage in binge drinking if they had higher incomes; were separated, widowed, or divorced; smoked; and/or used illicit drugs. As with younger men, men ages 65 and older were significantly more likely to binge drink (14 percent) than were women (3 percent).Research with older adults who have completed treatment also shows that older men have greater difficulty than older women maintaining abstinence after substance abuse treatment(Satre et al. 2004a; Satre et al. 2004b).

Although published data on the abuse of substances other than alcohol by adults older than 55 is limited, many researchers have raised concern about the misuse and abuse of preblockedion drugs by this population (Blazer and Wu 2009b; Simoni-Wastila and Yang 2006).Some studies describe preblockedion drug abuse as less common among older men than older women (Simoni-Wastila and Yang 2006); others conclude the inverse specifically for pain medication (Blazer and Wu 2009b). For more information, see SAMHSA’s Get Connected! Linking Older Adults With Medication, Alcohol,and Mental Health Resources toolkit (2003). Also see TIP 26, Substance Abuse Among Older Adults (CSAT 1998d), which recommends that substance abuse treatment programs for both male and female older adults:

• Make use of age-specific groups that are supportive and nonconfrontational and work to build or rebuild the client’s self-esteem.
• Focus on coping with depression, loneliness, and loss.
• Help older clients rebuild social support networks.
• Have pacing and content that reflect the needs of older people.
• Use staff members interested and experienced in working with older people.
• Integrate/link to medical services, older adult services, and other services used by older adults.

Men With Systems-Related Needs

Men enter treatment with multiple needs, as their substance abuse has likely affected every aspect of their lives. Often, a man’s behavior involves him with a system (e.g., the criminal justice system) that may require his treatment providers to interact with that system. In othercases, other systems may be required to provide for a man’s specific needs (e.g., housing).Some such systems (medical services, VA services, and vocational rehabilitation) have already been covered in this TIP; two more that involve many men in treatment (housing and homelessness services and the criminal justice system) are discussed in the following sections.

[Question #75. Casa Los Arboles, an intensive inpatient program that provides services specifically for homeless men, use staff members recovering from substance abuse. True/ False?]

Men From Diverse Cultural and Geographic Groups

Rates and patterns of substance use/abuse vary among men according to cultural group. Researchers generally investigate cultural differences using broad racial/ethnic categories;those categories are thus used here. However,each broad category encapsulates a diverse set of cultures, and intragroup differences may be greater than intergroup differences in many cases. Behavioral health service providers are encouraged to investigate the specific cultures of their clients and discuss those cultures with their clients.

SAMHSA’s NSDUH showed that among men in 2007, American Indians/Alaska Natives had the highest rates of past-year substance use disorders (17.6 percent) of any single group, and Asians had the lowest rates (7 percent). The same survey showed past-year rates of substance use disorders of 13.0 percent for non-Hispanic White men, 12.1 percent for African American men, and 12.2 percent for Hispanic/Latino men (HHS, SAMHSA,OAS 2008a).

SAMHSA’s TEDS surveys individuals when they enter treatment and thus excludes the many men who need but do not receive treatment. Exhibit 4-4 presents data on substance preferences for men entering treatment by ethnic or racial group. Percentages are derived from State and jurisdiction reports of treatment admissions to programs that received public funds (directly or indirectly) in the year2005. With the exception of alcohol plus another substance, only the primary substance of abuse is indicated (SAMHSA, OAS 2008b). These data indicate, to some extent, how culture affects patterns of substance use/abuse.

Information about substance use by diverse cultural groups of men is given in the following sections, as is information on specific substances and the populations that use them.Because of the gender rather than cultural focus of this TIP, this discussion of cultural issues is limited. More information can be found in the planned TIP, Improving Cultural Competence (SAMHSA planned c), which explores cultural and ethnic differences in substance abuse and discusses various culturally and ethnically based treatment issues.

[Question #69.Young African-American men are less likely to use drugs than young White-American men, older African-American men are more likely to do so—this is referred to as:]