This document discusses the challenges human service workers face in helping clients with alcohol and drug abuse issues. It notes that substance abuse affects people of all backgrounds and is a widespread problem. As generalists working with many specialists, human service workers must achieve early detection of substance abuse issues to enable prevention or appropriate care. The key challenge is accurately identifying how substance abuse contributes to and results from a client's other problems in areas like health, legal issues, finances, family, etc. Failure to correctly identify these connections would undermine efforts to effectively help the client.

1. CHAPTER 13 WORKING WITH PEOPLE WHO LIVE WITH
HIV AND AIDS: THE PROBLEM AND HUMAN SERVICES
WM. LYNN MCKINNEY
As a human service worker, you are almost certain to have
clients who are people living with human immunodeficiency
virus (HIV) and persons living with AIDS (PWAs). This is true
because AIDS affects people of all ages, sexual orientations,
and ethnic and minority groups and because the needs of PWAs
and people living with HIV are numerous and span virtually all
human service programs. Because AIDS is an illness, there are
medical needs. Since most PWAs eventually must stop working,
they have income needs. The number of children who have HIV
is growing, and these young people may have educational needs.
For several reasons, there are likely to be psychological and
social needs.
First of all, AIDS occurs primarily in people younger than fifty,
which means that PWAs must deal with a fatal illness at an
early age. Second, AIDS is found mainly in marginalized people
such as homosexual men, injection drug users, and racial and
ethnic minorities. Still another reason that PWAs may have
psychological needs is that many of them will have many
friends who are seriously ill or who have died. The effects of
such losses are potentially enormous. Thus, the entire human
service system is involved in working with people living with
AIDS and HIV. So, as you enter the field, it is important that
you know about HIV and AIDS and society’s reactions to the
disease.
Working with people with AIDS and HIV presents particular
challenges. Many people with this illness will not have close
ties with their families who may have turned their backs on
what is perceived to be a social embarrassment. Most will be
poor, some because they were poor when they became sick and
others because the disease is impoverishing. Death from AIDS-

2. related causes can be horrible; the diseases and infections that
affect a PWA can leave people thin and weak and seemingly
defenseless for long periods of time. Unlike those with other
illnesses, PWAs may be very sick and close to death for a while
and then go through long periods of good health when they can
lead happy, productive lives. As more cases of AIDS are
diagnosed among drug users, more clients may be difficult to
work with. Finally, with more women contracting the virus and
dying, there are orphaned children who are not infected as well
as children who were born with the virus. Many of these
children are not or cannot be cared for by their mothers or other
relatives.
However, working in the HIV field can be rewarding. As you
must know, as you are planning to enter the human service
field, all work with people is rewarding. If your interest is in
research, you can become involved with learning more about the
virus, thus increasing the probability of a cure, a vaccine, or
better care for people who are HIV positive. If you work with
individual clients, you will no doubt develop intense, deep
relationships with many of them; some of these will be
enormously enriching, revealing to you some of the best aspects
of humanity. Work with HIV will probably stretch you
professionally, broadening your knowledge and experience so
that, should you decide to change jobs, you will present an
attractive array of qualifications to prospective employers.
Finally, you can gain satisfaction knowing that you are working
with people, many of whom live on society’s margins, and
doing what you can in response to a pandemic—a worldwide
outbreak of a disease affecting an extraordinarily large
percentage of the population.
You probably knew some things about HIV by the time you
entered college. But because it is a politically charged issue, the
quantity and quality of HIV education varies greatly. Although
we may review in this chapter some material that you already
know, there will also be material that is new to you. The
objectives of this chapter are (1) to solidify your basic medical

3. understanding of HIV and AIDS, (2) to help you understand
some of the social ramifications of HIV, and (3) to acquaint you
with current issues. This chapter is only an introduction to the
topic. Reading about HIV and AIDS in books, newspapers, and
professional journals should be a part of your professional
growth. We urge you to become involved in AIDS service
organizations (ASOs) as well. Practical experience is an
excellent means to expand your knowledge.
HIV AND AIDS AS MEDICAL ISSUES
In 1985 the specific virus that is believed to cause AIDS was
identified. It is human immunodeficiency virus (HIV). Today
there are two strains of HIV active in the United States. The
most prevalent strain is HIV-1, which has been with us since the
early 1980s. The virus is constantly mutating as new
medications are developed. We still know much less about HIV
and AIDS than we wish we did. Fortunately, research is
revealing new information to us regularly.
Acquired immune deficiency syndrome (AIDS) was first noted
in the United States very early in 1981, but it was not until
three or four years later that it was identified as a syndrome and
given a name. Doctors in San Francisco and New York began to
notice that they were treating a new group of patients, primarily
gay and bisexual men in their twenties and thirties, for a series
of diseases that were highly unusual among healthy young
people. Initially what doctors were seeing was called gay-
related immune deficiency (GRID) because it was noted
exclusively in gay men. Eventually the medical profession
developed the description Acquired Immune Deficiency
Syndrome (AIDS). The words that make up the acronym AIDS
provide specific meaning. (For an incisive account of the early
years of the disease in the United States and for insight into the
politics of this illness, read And the Band Played On by Randy
Shilts.)
The A in AIDS, which stands for “Acquired,” indicates how a
person gets the disease. AIDS is a communicable disease; a
person must get it from someone else. In this sense, it is like

4. hepatitis, a cold, or measles. AIDS is not inherited like some
diseases such as sickle cell anemia and Tay-Sachs disease.
Unlike some other diseases, (e.g., cancer), it does not just begin
inside an individual, in many cases for unknown reasons. People
have to get AIDS from someone else, and it is not easy to get
(we emphasize this fact and explain what it means later in this
chapter).
The I and the D stand for “immune deficiency,” which refers to
the characteristics of this disease that make it unlike any other
disease. Instead of making you sick directly, HIV attacks the
helper T cells in the human body. These helper T cells are
important for us to be able to fight off infections. When they
become weakened, our bodies become vulnerable to other
diseases, virtually all of which we ordinarily are resistant to.
This literally causes a deficiency of the body’s immune system,
leaving the infected individual susceptible to a wide variety of
infections that ordinarily would not affect noninfected
individuals.
Finally, the S stands for “syndrome.” A syndrome is a
collection of symptoms and effects of other diseases. AIDS is
considered to be a syndrome because a person with AIDS does
not die of AIDS but rather of other diseases, most of which
were rarely seen in the United States until the advent of AIDS.
These diseases, commonly called “opportunistic infections,” can
occur because T cells are destroyed and can no longer ward off
infections.
People with HIV may continue to be asymptomatic for many
years, but eventually symptoms will appear and a diagnosis of
AIDS can be made. For two reasons it is important to have a
clear diagnosis. First, there is a psychological impact on the
infected individual of having AIDS versus having HIV.
Different sorts of supportive services may be necessary as an
individual progresses from knowing that he or she is infected
with HIV to knowing that he or she has AIDS.
Second, once someone is determined to have AIDS, he or she
may become eligible for a variety of state and federal programs.

5. Initially a person was diagnosed with AIDS if he or she had any
one of two or three diseases or opportunistic infections;
pneumocystis carinii pneumonia (PCP) and Kaposi’s sarcoma, a
rare form of skin cancer, were the most common. In early 1993,
the Centers for Disease Control (CDC) in Atlanta changed the
way in which it defined whether a person had AIDS. Now a
person is classified as having AIDS if his or her helper T
lymphocyte count falls below 200 (ordinarily the helper T count
ranges from 800 to 1,200) and if he or she also has at least one
of the specific diseases associated with AIDS.
The definition was changed because it had been much more
useful in diagnosing AIDS in men than it was in women. Since
women experience the disease differently and since more and
more women now have AIDS, it was important to change the
definition.
The two opportunistic infections that are the greatest killers of
men are PCP and toxoplasmosis. Toxoplasmosis is a chronic,
severe brain infection. Toxo is a common parasite that is found
in most everyone. As is true of all other opportunistic
infections, it is fought off by healthy immune systems.
However, in individuals whose immune systems are
compromised, toxo can become activated, resulting in blindness,
paralysis, and dementia. Fortunately there are now prophylactic
treatments for both of these diseases.
Women with HIV are more likely to develop other diseases,
particularly yeast infections, invasive cervical cancer, recurrent
bacterial pneumonias, and bloodstream infections. Recently an
increase in the number of cases of pulmonary tuberculosis has
been noted.
Unless it is your intention to enter the medical field, this is
probably enough for you to know about the medical aspects of
AIDS and HIV. As you become involved with PWAs, you may
need to increase your medical knowledge, but, as we repeat
often in this chapter, knowledge about AIDS is increasing
rapidly, and you should learn more as part of your continuing
professional development and as the need confronts you.

6. The Transmission of HIV
HIV is transmitted through bodily fluids, specifically blood,
semen, and vaginal fluid. Although the virus is present in other
bodily fluids such as tears and sweat, it is found in such slight
concentrations that these fluids are not considered dangerous.
HIV is difficult to transmit. There are very few ways in which
HIV can be transmitted from one person to another. Unprotected
sex and sharing needles are the two most common ways. A third
way is across the placenta from an infected woman to her
unborn child. Until 1985, HIV was occasionally transmitted by
blood transfusions, but since that time the U.S. blood supply has
been considered safe because of donor screening and because all
blood to be used for transfusions is tested before it is given to
someone.
HIV is not easy to catch because, for a person to be exposed to
the virus, it must enter a person’s bloodstream. This can occur
when individuals share an unsterilized needle to inject
steroids or other drugs. It can also occur during unprotected
sex, either vaginal, anal, or oral. But again, for infection to
occur, the skin must be broken. This often occurs during anal
intercourse, can occur during vaginal intercourse, and can occur
during oral sex if the person performing oral sex has skin breaks
such as canker sores or unhealthy gums. Tears in the skin need
only be microscopic in size for transmission to occur.
Sexual transmission of HIV from men to women is much more
common than from women to men. This is true because the skin
must be broken for the virus to cross from one individual to
another and because the virus is present in dangerous
concentrations in semen. It is more likely that the lining of the
vagina or anus will experience a tear during sex than it is that
the penis will suffer some sort of skin break. Infection from a
man to a woman is more likely because sex commonly results in
the ejaculation of semen. The most risky form of sex between
men is unprotected (i.e., without a condom) anal intercourse.
Infection is less likely during oral sex but can occur if semen is
ejaculated. It is possible for the person performing oral sex to

7. infect his or her partner only if infected blood somehow enters
the sexual partner’s penis such as if he or she has strep throat or
other infectious lesions in the throat. Sex between two women
and oral sex by a man on a woman rarely result in transmission,
but it is possible. Use of dental dams during such oral sex is
urged.
One quarter of babies born to infected mothers are born with the
virus, but we now know that pregnant HIV-positive women who
take AZT during the last three months of pregnancy and receive
an infusion of AZT during labor and delivery can reduce to 8
percent the probability that their babies will be born infected.
Why the virus crosses the placenta in some cases and not in
others is not known at this time. As part of your continuing
professional growth, you should regularly read newspaper and
journal articles about AIDS and HIV to stay informed. Research
is making great strides, and you, as a human service student and
professional, are responsible for keeping your knowledge
current.
CHAPTER 15 HELPING FOR ALCOHOL AND DRUG ABUSE
MARCEL A. DUCLOS MARIANNE GFROERER
The statistics describing the use and abuse of alcohol and other
mind-altering drugs ring familiar on the nightly news, find bold
print in the newspapers, and flavor everyday conversations.
General hospitals treat medical/surgical patients suffering from
medical complications due to abuse and dependency. Emergency
mental health and medical services are often faced with
management of the intoxicated person. Community mental
health centers daily confront the detrimental poly-drug use of
scores of deinstitutionalized patients, including the dually
diagnosed. School personnel, counselors, teachers, and
administrators alike witness the ebb and flow of the season’s
most preferred or most accessible substance on the school
grounds. They must additionally contend with the far-reaching
effects of substance use on students, families, and
neighborhoods. Along with community workers and social
service agency staff, law enforcement officers also struggle to

8. overcome a gnawing defeatism when children and youth sustain,
as victims, the ravages of their own or others’ use in a cycle of
destruction and even death.
No age group, no socioeconomic status, no level of education,
no geographic area—urban, suburban, or rural, mountain, plain,
or coast—no occupation or profession, and no religious
affiliation—whether church, temple, synagogue, or mosque—
protects from the insidious and infectious spread of the
problem. Our society’s cultural heritage of ambivalence reveals
itself by the earliest promotion of the use of alcohol in the
colonies and the colonial militia, combined with a primitive
“righteous” response to inebriation. No time period in U.S.
history, not even the years of Prohibition, provided a drug
abuse–free environment for the growth and development of
citizens. Nor can such an environment be anticipated for the
near future. It is a dream, an idealistic vision. Human service
practitioners must face the disillusionment of the present reality
and continue to attend hopefully in the expectation of
manageable goals realistically attainable by troubled and
afflicted clients.
At-risk behaviors due to disinhibition and impaired judgment
caused by mind-altering substances obligate human service
practitioners to consider strategies—educational, medical,
economic, political, sociological, psychological, and spiritual—
to address the problems on the contemporary scene. These
problems include the ones the nation shuns the most: the
growing AIDS epidemic, all forms of child abuse, and the
persisting plague of violence in our society. The long
multicultural history of the human services teaches that the
“cure” of human ills, including substance abuse problems,
cannot come from logic alone but requires authentic caring. For
the human service practitioner, caring in its concrete, active
form means consistent and care-filled attention to the details of
a realistic treatment plan.
CHALLENGES FACED BY HUMAN SERVICE WORKERS
The human service worker stands, as a generalist, in the middle

9. of a network of providers, ready to work cooperatively with the
many specialists assessing, developing treatment/service plans,
delivering care, evaluations, and outcomes. In the arena of
alcohol and drug abuse, the key challenge to the worker remains
the same: achieving the earliest detection for possible
prevention. Yet in the reality of the service delivery systems,
the challenge almost always involves the detection of
intoxication, the history of abuse, the possibility of dependence,
and/or risk as victim or victimizer. No accurate or appropriate
care can be designed and provided in any context without
knowledge of the effects of drugs on a client’s life. Failure to
identify the contributing and resulting connections between
substance abuse and the client’s presenting problems with
health, the law, money, work, school, society, family, and self
will spell a decisive failure in care, however well packaged the
plan and well intentioned the delivery. The old psychiatric rule
“diagnosis predicts prognosis and therefore directs treatment”
applies here as well.
The first challenge, then, is one of accuracy. However, much
client care may be a matter of heart; it must be guided by
knowledge and experience. Accurate knowledge of the
psychoactive substance use disorders and their associated
intoxication and withdrawal syndromes arms the worker with
necessary information to intervene at the earliest possible
moment. The continuum of care reaches from direct immediate
crisis intervention to consultation and referral as required.
The second challenge lies in the subjective domain, in the
human service worker’s own personal story. Few individuals
can claim never to have been touched by the effects of
substance-induced behaviors, though they might claim, for
themselves, lifelong abstinence. Whether in personal, social, or
professional experiences, the human service worker will have
accumulated learned responses to this population. The challenge
of empathic acceptance, of healthy emotional distance, or
disidentification of a client-enhancing response to
countertransference calls for clear, helpful supervision. Whether

10. the service being delivered to the client entails modest
assistance with some agency paperwork or involves the
complex, long-term work of case management, the energy at the
meeting of client and practitioner will generate the atmosphere
of change. It therefore becomes an inner challenge for the
worker to know her or his own story and to use that level of
awareness to promote the client’s good and to attempt to cause
no harm.
The third challenge pertains to the temptation of the human
service practitioner to view himself or herself as competent to
function as a substance abuse counselor despite a lack of
specialized academic training and clinical experience. The
treatment of substance abuse and dependence is a
multidisciplinary enterprise. The work of a substance abuse
counselor is defined by observable and measurable
competencies. For the human service worker who serves an
addicted population, it is an ethical imperative to know one’s
limits of competence and role within the agency and to consult
and refer as necessary.
The worker who is unfamiliar with the neurological impairments
caused by particular substances abused would be in danger of
placing the client, self, and others in physical and/or
psychological jeopardy. Depressants, stimulants, narcotics, and
hallucinogens present their own sets of impairments and their
own relative levels of danger. Confusion about the client’s
antecedent or resultant developmental and personality disorders
would make the adoption of an individualized helping style
difficult. Early trauma in combination with many years, even
decades, of substance abuse exacts heroic transformational work
on the part of the recovering person. Overestimation of the
addicted person’s ability to stop using and become sober
without sufficient time for emotional healing and behavior
change would lead to errors in the selection of strategy, in the
expectation of outcomes, and in the fundamental process of
defining the real problems. The nature of the disorder and of
rehabilitation leads to paradoxes for the recovering addict as

11. well as for the human service practitioner.
Again, the history of drug use gives us a clue about the
paradoxical nature of psychoactive substances, of the disease of
substance addiction, and of the recovery process. The ancients
and the alchemists taught that nature cured disease with either
similars or opposites, depending on the illness. Substance abuse
and dependence is such a disease. The substances themselves
produce their opposites: depressants can rebound into anxiety;
stimulants can plunge into depression; narcotics produce their
own pain; hallucinogens can lead to loss of self. That which the
user originally sought through partaking of the drug eventually
eludes the abuser. The drug exacts due payment for all
experiences—soothing, exciting, painless, or expansive. All that
was beyond the ego’s humble ability to integrate into the psyche
and beyond the body’s physiological capacity to metabolize into
vital energy returns with a vengeance.
The enslaving addiction to the drug releases the abuser to an
opposite dependence, binding her or him to a committed pursuit
of inner freedom hard won by selfless courage. In the tradition
of recovery, the paradox of the twelve-step program of
Alcoholics Anonymous (and Narcotics Anonymous) describe
that which will nurse the recovering person back to sanity with
an elixir of opposites—a bitter medicine that many will reject.
No recovery program anywhere can sidestep the necessary laws
of nature that direct bodies, minds, and souls from illness to
health.
The client’s life calls for a complete turn-around—nothing less
will do. The cleverness and cunning that characterized the
addiction must become slowness and carefulness, accepting the
wisdom of another, allowing the unshakable inner self to put
aside the false grandiose ego projected by the substance. A new
life begins only with the death of the old one. It is ultimately
the paradox of life and death because substance dependency is a
matter of life and death.HUMAN SERVICE RESPONSES TO
SUBSTANCE ABUSE
The human services respond to the problem of addiction in

12. society in three ways: education, prevention, and treatment. The
choice of response is determined by the level of addiction,
which is the target of the approach. Limiting considerations to
the individual, the human services distinguish between the
person who has never used drugs for recreation, the one who
only rarely uses chemicals for recreation, the person who uses
frequently and whose abuse leads to some personal and
professional problems, the individual who is dependent to the
point of resulting medical complications, and the small
percentage of individuals who, in their chemical dependency,
are also socially isolated and face predictable death. Because
chemical dependency is potentially life threatening, the human
services respond according to the immediacy of the danger to
self and others.Education
Successful drug education programs have incorporated in their
materials and services the knowledge, attitudes, and behavior
necessary to optimize the choice of a drug abuse–free life. Some
programs emphasize convincing the audience of the dangers of
drugs, whereas other programs underline the objective facts
about the substances, advocating neither abstinence nor
reasonable use. Other programs utilize the power of
identification with a noteworthy person in recovery to score a
point with the listeners or viewers. Still other programs,
especially those geared toward the school- and college-age
population, are even more direct in their approach, providing
training in assertively resisting encircling pressures.Prevention
Prevention does not only refer to those persuasive efforts aimed
at stopping abuse before it starts. It also involves those
interventions aimed at signaling to a user in the early stages of
abuse that continued use could result in damaging
consequences. Early diagnosis with crisis monitoring, crisis
intervention, and referral are such interventions. For those
individuals who are in the later stages of abuse that lead to
dependency, the prevention efforts address the goal of halting
the slide to that conclusion. In this instance, intervention efforts
could take the form of early treatment, monitored maintenance,

13. or social/medical detoxification. The motto “the best defense is
a good offense” applies in this domain.Treatment
Because drug abuse and drug dependence are characterized as
mental disorders in the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV), medicine, nursing, and psychology
are the disciplines that have traditionally taken responsibility
for the treatment of these illnesses. Social work and mental
health counseling have also sought to remedy the social and
societal ills related to substance addiction. The profession of
substance abuse counseling, newly emergent in the early 1970s,
has now taken on a prominent role in the treatment of
individuals suffering from substance- related disorders. Human
service providers who are certified by the International
Certification Reciprocity Consortium as alcohol and drug abuse
counselors have given evidence of specialized competence in
their assigned roles and functions as they work alongside some
of the other traditional professions. These particular individuals
have passed an objective exam and have been successful in an
oral defense of a case presentation before a member state board.
They also may choose to become a member of the National
Association of Alcoholism and Drug Abuse Counselors
(NAADAC).
All of these professionals, according to their own training and
skills, cooperate to promote the client’s achievement of physical
and psychological health, social and financial stability, and
behavioral and interpersonal satisfaction. In all of this there
still remains a key role for the generalist in the human service
field: that of case manager, as the coordinator of all those
services that promote follow-through and attainment of the
treatment goals.
Whether the goals are abstinence after detoxification,
management of disruptive behavior, stability of employment or
housing, or improved overall self-care and health, the variety of
treatment settings and assortment of approaches employed is as
diverse as the developmental needs and problems of the clients.
Depending on the severity of the addiction, the setting might be

14. an in-hospital treatment program, a residential center, or a day
program or out-patient individual, family, or group contact. The
human service worker plays a valuable role in all of these
settings as a team member with other providers.
It is important to note that treatment facilities vary, depending
on the population served and the substance treated. Though they
have commonalities worth acknowledging, treatment facilities
may, in order to focus on specific areas of need, specialize in
work with the elderly, adolescents, women’s issues, cocaine or
heroin abuse, homeless individuals, or the dually diagnosed. In
each case, the facility will function along standard guidelines of
substance abuse treatment but with its own particular focus.
With this in mind, an outline of the most commonly found
treatment facilities follows.In-Hospital Treatment Program
Used for:
· Detoxification from physical dependence
· Individuals unable to remain substance-free without
supervision
Provides:
· Medical monitoring of withdrawal
· Group psychoeducational counseling and introduction to
support groups such as AA/NA
· Possibly some social services/case management
Length of stay:
· Twelve to twenty-eight days (some may be as brief as three to
seven days, depending on insurance coverage)
· May transition into outpatient programResidential Treatment
Center
Used for:
· Long-term maintenance of sobriety/drug abstinence after
detoxification
· Individuals without financial resources in need of halfway
house/therapeutic community for recovery
Provides:
· Necessities of daily living (shelter, nutrition, life-skills
training, education)

15. · Role modeling, direct reality-based feedback in daily living
situations, and promotion of self-discipline
Length of stay:
· Three months to two years (usually funded by public or
private nonprofit agencies)
· Includes assistance for vocational, social, and emotional
transition back into community/family livingOutpatient Services
Used for:
· Transitional treatment after detoxification or residential
treatment
· Individuals with early stage or less severe problems, those not
physically addicted, those able to maintain employment during
treatment, or those living in a stable and supportive
environment
· Individuals unable to afford or not eligible for inhospital or
residential treatment programs
Provides:
· Counseling, education, support system for individual, couple,
family, or group
· …