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Roush, S., Monica, C., Carpenter-Song, E., & Drake, R. E. (2015). First-Person Perspectives on Dual Diagnosis Anonymous (DDA): a qualitative study. Journal of Dual Diagnosis, 11(2), 136–141.

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The first step will be helping Rue identify and challenge automatic thought and images. After identifying these emotions and cognitive distortions, she will identify past and current stressors that may have led to the development of these beliefs. We will then use different techniques to practice new behaviors. I will provide evidence contradicting the old core belief, and help Rue to reframe it.

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Concurrently, I will recommend harm reduction is recommended for Rue. Harm reduction is an umbrella term for interventions aiming to reduce the problematic effects of behaviors (Logan & Marlatt, 2010) In this case, I will refer Rue to a physician who can prescribe her the proper medication for safe opioid use reduction. Community-based programs that distribute naloxone dramatically reduce fatal opioid overdose. (Walley AY, Xuan Z, Hackman HH, et al ., 2013)

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Due to the multiple diagnoses as a very young child, I would work with Rue’s mother to find a new psychiatrist to get a proper diagnosis.

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The next step will be to assist her in learning skills to stop focusing on the past, improve existing relationships with family and friends, understand what emotions are and how they function, and how to endure emotional pain without resorting to self destructive behaviors.

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“a fellowship of persons who share their experiences, strengths, weaknesses, feelings, fears, and hopes with one another to resolve our dual diagnosis and/or learn to live at peace with unresolved problems.”

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Along with the 12 steps associated with Alcoholics and Narcotics Anonymous, Monica et al. (2010) describes Dual Diagnosis Anonymous’ additional steps: acknowledging both illnesses, accepting help for both conditions, understanding the importance of a variety of interventions, combining illness self-management with peer supports and spirituality, and working the program by helping others.

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This group emphasizes the importance of involving a support system during recovery. You will be paired with a sponsor who can help guide you through the process and provide emotional support when needed.

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Roush et al. (2015) found that this group “provides a helpful alternative for individuals who do not feel comfortable at traditional 12-step groups due to their mental illness”.

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Though this group has shown to be helpful for participants, it is not available in-person in every state. Online meetings are available, but Rue may have a difficult time staying engaged.

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Overall, as a counselor, maintaining unconditional positive regard, especially during possible instances of relapse, will be very important. Making sure to recognize and work through any biases or judgments  will help develop a positive therapeutic relationship

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Counselors should also watch for any instances of countertransference. At times, I have felt this while watching the show, both equally due to my own family history and her young age. I have found myself feeling strangely protective of her, while also understanding her grief. I recognize that I will have client's in the future that are similar to this character, and will work though any personal feelings I have when it arises.

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Miller, W. R., Forcehimes, A. A., & Zweben, A. (2011). Treating Addiction: A Guide for professionals. https://openlibrary.org/books/OL25066671M/Treating_addiction

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Walley, A. Y., Xuan, Z., Hackman, H. H., Quinn, E., Doe-Simkins, M., Sorensen-Alawad, A., Ruiz, S., & Ozonoff, A. (2013). Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ, 346(jan30 5), f174. https://doi.org/10.1136/bmj.f174

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17 Year Old Biracial Female

Queer

Diagnosed with generalized anxiety disorder, obsessive compulsive disorder, and possible bipolar disorder at the age of 6.

Prescribed psychiatric medications at the age of 8 years old to treat these disorders.

Lost her father due to cancer when she was 13 years old

Also began sneaking his pain medication at this age. Rue has escalated to using other opiates, including heroin and fentanyl, and recently relapsed.

Rue has expressed having recurring thoughts of her father and how she thinks he would view her today.

After finding out about Rue’s relapse, her mother Lisa suggested sending her back to rehab. This caused Rue to go into a violent rage and lash out at her mother before running away from the home.

She has expressed feelings of worthlessness and unlovability, and believes that her mother and sister will never truly forgive her

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Logan, D. E., & Marlatt, G. A. (2010). Harm reduction therapy: a practice‐friendly review of research. Journal of Clinical Psychology, 66(2), 201–214. https://doi.org/10.1002/jclp.20669

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“One of the hardest things was learning that I was worth recovery.”

- Benjamin Alire Sáenz

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“Remember that just because you hit bottom doesn’t mean you have to stay there.” – Robert Downey Jr.

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According to SAHMSA, As of 2023, "The percentage of people aged 12 or older in 2023 who used illicit drugs in the past year was higher among Multiracial people (36.2%) than among White (26.1%), Hispanic (21.6%), or Asian people (12.4%). Multiracial people were also more likely than White or Black people (17.6%) to have had a past year SUD"

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Multiracial youth have some of the highest substance use rates compared to same aged youth from different ethnic groups (Choi et al., 2006)

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There are very few studies on substance use, particularly opioid use for Biracial youth.

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This type of program requires social involvement. Some people get nervous or uncomfortable in groups.

It also requires a specific religious belief. A higher power must be acknowledged. Six of the twelve steps refer to God or Higher Power.

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12-Step programs are designed to provide emotional support and spiritual guidance rather than extensive medical or clinical treatment. This means that individuals who need more intensive intervention may find it difficult to get the help they need within this program.

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A.4.b. Personal Values Counselors are aware of—and avoid imposing—their own values, attitudes, beliefs, and behaviors.

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A.1.c. Counseling Plans Counselors and their clients work jointly in devising counseling plans that offer reasonable promise of success and are consistent with the abilities, temperament, developmental level, and circumstances of clients.

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B.5.a. Responsibility to Clients When counseling minor clients or adult clients who lack the capacity to give voluntary, informed consent, counselors protect the confidentiality of information received—in any medium—in the counseling relationship as specified by federal and state laws, written policies, and applicable ethical standards.

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B.5.b. Responsibility to Parents and Legal Guardians Counselors inform parents and legal guardians about the role of counselors and the confidential nature of the counseling relationship. Counselors work to establish, as appropriate, collaborative relationships with parents/guardians to best serve clients.

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E.5.c. Historical and Social Prejudices in the Diagnosis of Pathology Counselors recognize historical and social prejudices in the misdiagnosis and pathologizing of certain individuals and groups and strive to become aware of and address such biases in themselves or others.

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"fostering areas of self-care, including awareness, balance, flexibility, physical health, social support, and spirituality, can help prevent the downward spiral of stress, burnout, and professional impairment, and promote an upward spiral of well-being for mental health professionals." (Posluns & Gall, 2019)

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"Counselors must pay close attention to their own feelings to protect their clients and to learn more about them." (Substance Abuse and Mental Health Services Administration, 2000)

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Bagot, K. S., & Kaminer, Y. (2018). Harm reduction for youth in treatment for substance use disorders: One size does not fit all. Current Addiction Reports, 5(3), 379–385. https://doi.org/10.1007/s40429-018-0217-8

Choi, Y., Harachi, T. W., Gillmore, M. R., & Catalano, R. F. (2006). Are multiracial adolescents at greater risk? Comparisons of rates, patterns, and correlates of substance use and violence between monoracial and multiracial adolescents. American Journal of Orthopsychiatry, 76(1), 86–97. https://doi.org/10.1037/0002-9432.76.1.86

Jarlais, D. C. D. (2017). Harm reduction in the USA: the research perspective and an archive to David Purchase. Harm Reduction Journal, 14(1). https://doi.org/10.1186/s12954-017-0178-6

Posluns, K., & Gall, T. L. (2019). Dear Mental Health Practitioners, Take Care of Yourselves: a Literature Review on Self-Care. International Journal for the Advancement of Counselling, 42(1), 1–20. https://doi.org/10.1007/s10447-019-09382-w

Substance Abuse and Mental Health Services Administration. (2024). Highlights by Race/Ethnicity for the 2023 National Survey on Drug Use and Health. In 2023 National Survey on Drug Use and Health. https://www.samhsa.gov/data/sites/default/files/NSDUH%202023%20Annual%20Release/2023-nsduh-race-eth-highlights.pdf

Treatment, C. F. S. A. (2000). Chapter 4—Therapeutic Issues for Counselors. Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK64902/

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Harm Reduction and Pragmatism

"The two basic components of harm reduction are pragmatism—providing policies and services that are effective—and respect for the human rights of persons who use drugs." (Jarlais, 2017)

According to Bagot and Kaminer (2018), clinicians may be able to support healthy maturational processes in adolescents in the context of exercising their autonomy, while strengthening deficient areas such as social competence, coping skills, and emotion regulation.

Focus on minimizing the negative consequences of substance use rather than insisting on abstinence as the only goal.

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It is important to not assume your client’s sexual orientation and work with them to understand how they identify.