Power Point for Katherine van Wormer and Diane Rae Davis,
Addiction Treatment: A Strengths Perspective, 2003,Wadsworth
Part I: Introduction
• Addiction affects us all. Strengths
perspective—strengths of clients and
strengths of the contemporary models:harm
reduction and 12 Step approach.
• Rift in field.
• Book in 3 parts: bio-psycho-social
Chapter I. Nature of Addiction:
• Examples of addiction---smoker dying of
emphysema, crack addict arrested, mother
and FAS and use of meth to lose weight
• Economic cost—health, war on drugs, over
1 million in prison for drug involvement.
Big business—gambling, Phillip Morris,
What is addiction?
• (Latin) addictus---attached to something,
positive. Today alcoholism called a ―brain
disease‖or bad habit or sin. Addiction is the
key, not the substance or behavior
• Substance dependence: requires 3 of following.
• tolerance inability to stop
• withdrawal problems excessive spending or effort
• use more than intended obtain
• reduced involvement continued use
• Rigid dichotomy here between abuse and dependence.
Addiction is a continuum. People move in and out of addiction.
Abuse—not these criteria: tolerance, withdrawal,
pattern of compulsive use.
Addiction—pattern of compulsive use.
•Has physical, psychological, social aspects.
•Emphasis on process rather than outcome.
Box 1.1 social work major working in a casino
The Disease Concept
• Disease - as metaphor by Jellinek: ―alcoholism is like a
• Random House Dictionary, disease is a condition of the
body in which this is incorrect function.
• Oxford University Dictionary– disease is absence of ease
(in treatment – disease as: primary, progressive, chronic,
and possibly fatal).
• Illness – term preferred here, less controversial.
• Alcoholism as disease: pro and con
• Addiction – is a brain disease because the addicted brain is
• Debate against: habit, behavior, responsibility, mature out
• Why (bio), what (psycho), where (social)
• Interactionism and cycle of pain: pain and
suffering loss pain, stress and drinking
• Family as a system, roles
• Why need to know about addiction? 80% behind
bars, child welfare, alcoholics at work.
-―Hooked on the net‖
-―Girl died at poker Binge‖
• Relevant movies: 28 days, Traffic
• Strengths perspective
Charles Rapp: 6 critical elements: person is not the illness, choice, hope,
purpose, achievement, presence of one key person to help.
• Project MATCH
Directed by NIAAA – 2,000 clients over 8 yrs.
What works? 12 step facilitation, cognitive, motivational enhancement.
• Stanton Peele: Resisting 12 Step Coercion
• Research from California: 1$ spent saves 7 across states.
• Harm reduction: to save lives, belief that punitive laws cause harm..69% of
Americans favor treatment over jail.
• Restorative Justice: Victim-offender programming to promote healing.
• Alcohol back to 5000 BC Iran
• Unknown to world’s indigenous people
• Koran --- condemned wine. Alcohol from Arabic
• Arabian dr. discovered evaporated distilled spirits.
Technology exceeded its grasp
• 1575 --- distilling used–gin. Booze from Dutch
• Great devastation from England, 1700-1750.
• Infant mortality, crime
• North America
• More beer than water on Mayflower.
• Slaves taught bingeing.
• 18th – Quakers and Methodists disapproved
of hard liquor.
• Male drinking cult 1725-1825 notorious.
• 1825-1919: Against hard liquor.
• Cocaine in Coke.
• 1914 Harrison Act --- restricted opioids with
(associated with Chinese) prescription for cocaine.
• Marijuana (associated with Mexicans) State laws
in southwest criminalized.
• Teetotaler T =total abstinence, from Ireland.
• Temperance woman and suffrage movement.
• U.S. Prohibition 1920-1933
• Glamorized crime. Mafia/ Hollywood/Wash. DC
link. Homicide rates increased.
• Great Depression created need for jobs.
• AA Getting Better by Nan Robertson tells of
Bill W. and Dr. Bob. Oxford Groups. Big Book. 1
million members today
• Jellinek (The Disease Concept, 1960) – 5 types of
alcoholism based on world travels:
• Alpha, Beta, Gamma , Delta, Epsilon.
• 1966 AMA declared alcoholism a disease.
• Harold Hughes –NIAAA.
• Themes of Chapter 2: dangers of potent alcohol,
role of ethnic prejudice in shaping drug
legislation, unintended consequences of
History of Treatment:
• Willam White, Slaying the Dragon.
Mistreatment of mentally ill and alcoholics
• Hazelden adapted 12 Step approach.
• Box 2:1—―Treatment in Norway‖—
universal health care for support.
• Peele and Fingarette: addiction as bad
habits not disease.
History of Harm Reduction:
• AIDS in Netherlands spawned new
approach, to reduce the harm.
• Britain, 1960s and later.
• Heroin prescribed. Needle exchanges-U.S.
Strengths Based Helping Strategies
Focus on possibilities, choices. Suspension
Two Approaches to Treatment
Problems mandate—one size Strengths-motivation
Identify family dysfunction Holistic family as resource
Models of Strengths-Based Approaches
1. Harm reduction: public health model, prevention,
Abstinence not precondition
Stages of Change Model: Prochaska and
2. Motivational Interviewing (MI)---William
• Asking the right questions; ―Tell me about a period
when you were doing well?‖
• Smoking: on a scale of 1-10 to give up smoking,
where are you now?
• MI Steps:
Roll with resistance
3. Solution focused therapy and narrative
• Miracle question
• The personal narrative
• Aftercare once a month
Part II BIOLOGY
Substance Misuse, Dependence, and the
• PET scans, fMRI functional magnetic
• brain damage
• Figure 4.1—alcohol involvement: 50% homicide, 30% in
child abuse, 40% in traffic, 67% in domestic violence, 37%
in rape. Does not include child neglect.
• Father Martin- -Chalk Talks
Jocose drunk, amorose, bellicose, lachrymose drunks
• Others: somnos drunk, (sleepy) clamorose, (loud),
scientose (know it all)
• Health effects—heart
• 7-10% of drinkers get addicted. Signs: tolerance,
withdrawal (tremors, nausea), heavy nicotine, caffeine use
• Tolerance reversal
• .4 B.A.C. may be comatose.
• Blackouts: common at .3 BAC, case in Tom Sawyer
• Opiates—from opium poppy…narcotics,
heroin now can smoke or snort
• Inhalants—household products, huffing, brain
• Cocaine-crack and powder, in urine 8 hrs., smoked for
• Brain blocks reuptake of dopamine… Addicted rats die…
• Amphetamines and meth—synthetic unlike cocaine—
• Powder can be snorted, injected. Stay awake for long
durations…Anhedonia---can’t feel pleasure.
• Nicotine—can both stimulate and relax. 80-95% of
alcoholics smoke, reduces alcohol effects. Over ½ of
• Malachy McCourt smoked for ad and got hooked.
• Box 4.1 ―To die for a cigarette‖
• Case of chewing tobacco—snuff
• Plants, LSD, synthetic, flashbacks, PCP
• Ecstasy and roofies—heightens sensory
• Can’t get back to original high due to brain
• 10% in high school have used Ecstasy.
• Dance Safe – harm reduction strategies.
• Roofies:--sleeping pill in Europe.
What Is Ecstasy?
Ecstasy is a drug that has
properties and is
structurally related to
amphetamines. Its short
form chemical name is
Short Term Effects of Ecstasy
• Feeling of
• Sense of arousal
• Increased heart rate
• Dry and sore
• Tension, High Body
• Muscle twitching
• Depression &
Long Term Effects of Ecstasy
• Liver damage
• Anxiety disorders
• Irregular heartbeats
• Brain damage
• Lowers blood glucose, increases appetite,
Stored in fat cells, long term use associated
COSTS to get high:
• Crack: $5-10 quick fix only lasts 30 min.
• Heroin: $100-200 day--$20 day can by
maintenance dose inject a couple of times
• Ecstasy: $10-20 may take 5 or so pills.
• Meth: $25 used in gay party scene in Seattle
• Marijuana: $25 or higher
• Liver: organ that metabolizes alcohol, alcohol
circulates in the bloodstream until metabolized.
• Men have special enzymes help. People
metabolize ½ oz. Per hour = small glass of
wine….1 BAC=1/1000 parts blood.
• Acetaldehyde and Antabuse
• Flushing in Asians
• Multiplying effect of 2 sedatives.
• Tylenol plus Alcohol—liver failure.
• Valium used to bring one down from cocaine (ex.
Brain Regions and Their Functions
The Brain and Addiction:
• Neurotransmitters affect emotions and memory
• Neurotransmitters affect emotions and memory
• Dopamine—reuptake affected by cocaine, which
blocks dopamine synapse
• Depletion following cocaine use. Nicotine affects
• Parkinson’s when too little—too much =
• Serotonin: influenced by alcohol, involved in sleep.
Decreased levels linked to depression, anxiety,
Depletion following cocaine use. Nicotine affects dopamine too.
The right scan is taken from someone who is on cocaine. The loss of
red areas in the right scan compared to the left (normal) scan
indicates that the brain is using less glucose and therefore is less
active. This reduction in activity results in disruption of many brain
• Addict never gets original high—brain has
changed. Addiction is a brain disease.
• Cues can trigger memory…picture of
alcoholic beverages activates certain areas
of the brain.
• Prozac reduces craving by regulating
Cocaine in the Brain
Slides are from the National Institute on Drug Abuse (NIDA) (www.nida.nih.gov)
The role of genes:
• Study of mental hospitals, prisons, 50% who used
chemical substances had mental disorders.
• Cloninger—Sweden..259 male adoptees with alcoholic
• Type 1: late onset..75% of alcoholics, relates to harm
avoidance, anxiety, guilt
• Type 2: risk taker, (starts about age 11) male,
hyperactive, antisocial, hereditary
• Ondansetron: works on Serotonin, little effect on type 1
• Twins: 40-60% concurrence of alcoholism. Separated at
birth monkeys drank more under stress, people with low
dopamine like stimulants
• People with ADD risk for drug abuse.
• Wernicke Korsakoff:
• Peripheral neuropathy
• Confabulation….Dr. Sachs—Awakenings
• Liver damage…removes toxins from blood, bile
circulates in blood stream
• Yellow, cirrhosis, immune system breakdown.
• Heart – nicotine, cocaine
• Fetal alcohol syndrome. See photographs in text.
Interventions Related to Biology
• Naltrexone approved, 1995.
• Schick Shadel—aversion—see box 5.1
• Changing brain chemistry
• Brain Lock (Schwartz)
• Ondansetron—decreasing craving
• Zyban and smoking, Naltrexone
• Methadone maintenance: should methadone
be prescribed by GP’s?
• Eating disorders and dopamine
• Luvox decreases binges.
• Holistic—herbal remedies and hypnosis
• Have you tried Cutting down?
• Have people Annoyed you?
• Have you felt Guilty about your ATOD
• Have you ever used ATOD as an Eye
• Early stage: when physiological stress
• Develop group norms; sets rules,
• Intervene when:
- all-or-nothing thinking
-one person monopolizes group
-it turns into a gripe session
• Exercises to help people find strengths:
-Cards: I feel happy when, scared when, etc.
-3 minute feeling level exercises
End of Chapter 5 and Part II
Psychology Of Addiction
Addiction across the life span
Erik Erikson’s Stages
Birth to old age
Stage 1: Trust vs. Mistrust
Stage 2: Autonomy vs. Shame and Doubt
Stage 3: Initiative vs. Guilt
Stage 4: Industry vs. Inferiority
Stage 5: Identity vs. Role Confusion 12-17 years old
Stage 6: Intimacy vs. Isolation
Stage 7: Generativity vs. Stagnation
Stage 8: Ego Integrity vs. Despair
Must resolve each crisis before going to next stage.
• Prefrontal cortex matures after age of 20
• Evidence of brain immaturity during the
teen years comes from MRI scans of the
Teenage Drinking Use
• Alcohol is the drug of choice by American
teens aged 12-17
• Less smoking by teens in the US then
Argentina: 16 year old exchange student found:
• No drinking age
• Wine or beer with supper
• Drinking to be social not to get drunk
• What the U.S. can learn from Argentina
• Learning moderation
• Cigarette use 15.9% with 12 to 17 year olds.
• Binge drinking 10.9% of youths engage in this
Household survey reported:
Rates of current illicit drug use for major
• Whites 6.6%
• Hispanic 6.8%
• African American 7.7%
• American Indian/Alaska Native 10.6%
• Persons reporting multiple race 11.2%
• Asian Americans 3.2%
School Surveys Reported:
• 80% of US high school seniors have
• 62% have smoked
• 49% have used marijuana
• 9% have used cocaine
• Smoking before 13 more likely to have problems with
alcohol and other drugs
• Almost all current smokers also drank alcohol
School surveys show African Americans and Latinos have
rates of illicit drug use lower than that of whites
In Europe: 16% tried marijuana, 6% another illicit drug, 37%
smoke regularly vs 26% US., alcohol used regularly 24%
Europe compared to 16% US—WHO survey.
• 40 % binged on alcohol in past two weeks
• Rivera Live: $10 billion alcohol consumed by
• Beer and liquor companies most well funded
• $1 billion White House advertising
campaign anti-drug ads.
• None for alcohol
• Proposal to include alcohol in ads,
• All bills regarding alcohol education died
• Children learn gambling on the Internet;
• Video poker, slot machines, and the lottery
• Strenuous exercise programs reduce
smoking. Smoking may be considered a
Predictions from Scandinavia:
• Girls who cry easily when teased are
anxious and shy.
• Most apt to develop problems later on.
• Male aggression at age 8 predicted
alcoholism 18 to 20 years later.
Predictions from Scandinavia
• Evaluations at ages 10 and 27 showed:
– High novelty seeking
– Low harm avoidance (dare devil behavior)
• Both traits predicted early-onset
• For both sexes, poor school success
predicted later drinking problems
• Child abuse and other traumas are serious
risk factors for later adolescence and
• Alcohol and other drug abuse are factors in 7
out of 10 cases of child abuse or neglect
• According to one study, children who are
spanked and slapped are twice as likely to
develop alcohol and other drug abuse
• Traumatized children often are unable to
cope with psychological stress later.
• Animal studies show stress and alcohol
consumption levels are highly correlated.
Girls Who Are Abused:
• Those molested as children have more than
double the depression rate of other women
• Abuse is the single strongest predictor of
alcohol dependency in girls
• Sexual abuse is correlated with earlier onset
of alcohol and illicit drug use.
• Girls who are sexually abused are three
times more likely to develop drinking
• Boys who were sexually abused more likely
to be diagnosed with conduct disorder,
dysthymia (mild depression), and ADHD
• Abused girls are more likely to be
diagnosed with post-traumatic stress
disorder and major depression.
• Daughters of alcoholics at increased risk for alcoholism.
• Women--fastest-growing segment of population infected
with HIV in U.S.
• Adolescents and young women at particularly high risk.
Teenage girls who are heavy drinkers are:
• five times more likely to engage in
• a third less likely to use condoms
• which can result in pregnancy and
contraction of sexually transmitted
diseases including HIV/AIDS
• Many whites engage in another high risk
behavior--cigarette smoking for the purpose
of weight control.
• Of African American females, only 6.9%
report past-month use of cigarettes.
• Media-generated weight obsession, a major
problem among girls of European American
• Obsession leads to major problems with
eating, such as anorexia and bulimia.
• Biggest threat to life and health for
adolescent boys is alcohol-related accidents
• Male counterpart to anorexia in females is
• Dysmorphia-- newly identified psychiatric
disorder in DSM IV.
• DSM-IV-TR discusses body dysmorphic
disorder only briefly
• Obsessive body building major problem for
• Revealed in popularity of anabolic steroids
• Steroids used by 2.7 % of all male high
• Health hazards: stunted growth, acne, and
Binge Drinking: Boys
• ―Party till you puke!‖ signs were posted on
one university campus
• 22% college students report binge drinking.
• In the 1980s, the attempt to curtail drunken
driving by youth.
• U.S. government imposed nationwide
minimum drinking age of 21.
• Prohibition on basis of age may be
associated with heavier binge drinking.
• Critics argue students are driven to partying
underground and away from faculty
• New campaigns for moderate drinking
encouraged by University of Washington
• Social norms campaign with messages of
• College newspaper slower to restrict
enticing beer ads.
• Most binge drinkers mature out of wild
drinking days of early adulthood.
• Cigarettes--abstinence probably works
better than moderation here.
• Two paths to drug use by kids;
– Striving to be cool
– Using drugs to escape
• Messages about long-term damage are apt
to have little impact.
• Need for drug courts--important for family
preservation and closely supervised
• Miller and Rollnick: motivational
interviewing strategies. List the following
traps to avoid:
• Traps for therapists to avoid are:
– Premature focus, such as on client’s
– Confrontational round between therapist
and client over denial
– Labeling trap--forcing the individual to
accept a label alcoholic or addict
– Blaming trap, fallacy that is especially
pronounced in couples’ counseling
Primary prevention interventions to
reduce primary risk factors are:
• Child abuse, early-prevention education and
• Smoking education to keep youths from ever
• Health and skill education at schools
• Reducing ads
• Advocacy for the hiring of more school
counselors and social workers
Stage of Change: Precontemplation
– Goals are to establish rapport
– Counselor reinforces discrepancies
Adolescent comment: ―My parents can’t
tell me what to do; I still use and I don’t
see the harm in it- do you?‖
Stage of change: Contemplation
• Ask: How was life better before drug use?
• Emphasize choices
• Typical questions are:
-What do you get out of drinking?
-What’s the down side?
Contemplation Stage continued:
• Typical adolescent comment:
• I’m on top of the world when I’m high, but
then when I come down, I’m really down. It
was better before I got started on these
• Setting date
• What do you think will work for you?
• Adolescent comments, ―I’m feeling good
about setting a date to quit, but who
• Adolescent comment: ―Staying clean
may be healthy, but it sure makes for
a dull life. Maybe I’ll check out one
of those groups.‖
• ―Therapist: ―Why don’t you look at what
others have done in this situation?‖
• Help locate an appropriate group.
• Adolescent comment:
―It’s been a few months; I’m not there yet but I’m
hanging out with some new friends...‖
• Miller advises roll with it
• Use reflective summarizing
Approach for Girls
• Equality does not mean sameness.
• Programs for girls do better when they
focus on relationships.
• Waterloo,Iowa --group home-- Quakerdale
specializes in care of teenage girls.
– Learning of life skills
– Gaining competency as in art
Elderly Substance Abusers
• 13% of U.S. population over age 65
• More men with alcohol problems
• Elderly consume 20-25% of all prescription
• Two types of elderly alcoholics: early and
• Early onset- - more severe levels of
depression and anxiety
• Elderly consume less alcohol than the
• Trend toward nursing homes for short-term
• Many male ex-alcoholics reside in nursing
• Many early onset suffer from Korsakoff’s
syndrome and other alcohol-related
• Medical complications:
– Hip fracture, suicide, brain damage
• Late onset…more women here, close family
• DWI and effect on self image
• Age segregated vs. mixed ages in treatment
• Guidelines for work in groups with elderly:
-Avoid strong language, rebuild support
-Keep pace slow
• Teach elderly clients to learn the warning signs
and high risk events;
• Review feelings that led to relapse so they can be
avoided (for example, depression);
• Help clients renew their commitment to sobriety;
• Find effective coping styles;
• Build support systems;
• Remember that non-confrontational approach is
Counselor Pitfalls: (Beechem, 2002)
• Anticipate feelings of guilt and shame in
elderly clients in trouble with the law;
– Denial in assessment
– Sympathy not empathy
Loss and grief in family members of addicted
• Types of Guilt
– Survivor guilt
• Spiritual healing—sense of meaning,
• Strength from 12 Steps
If there be grief, then let it be but rain,
And this but silver grief for grieving’s sake
If these green woods be dreaming here to wake
Within my heart, if I should rouse again.
But I shall sleep, for where is any death
While in these blue hills slumbrous overhead
I’m rooted like a tree? Though I be dead,
This earth that holds me fast will find me breath.
(Wilde & Borsten, 1978, p.75)
Eating Disorders and Gambling, Shopping,
and other Behavioral Addictions
• The only one in this chapter related to a substance
– food addiction. All others, for example, Internet
addiction are behavioral…often clients in
treatment for another disorder
• 90% of anorexia and bulimia in females.
• Begins in adolescence
• .5% of girls and women are anorexic, 1-3%
• Less than 89% of normal body weight and
fine body hair.
• 10% mortality rate, often by suicide,
correlated with perfectionism, ritualism
• See www.anorexicweb.com
• Related to obsessive compulsive disorder
– obsessive--recurrent and persistent thoughts;
– compulsions—ritualistic practices.
• Gay men at risk.
• Bulimia with alcohol misuse--30-70%
• 35% of bulimics experienced childhood
sexual abuse and use food as a drug
• Little information on compulsive
• Study in the British medical journal, Lancet—
findings from twin studies showed that a strong
craving for sweets predicted alcohol abuse
problems, perhaps caused by a lack of dopamine.
• Anorexia—Prozac is effective in reducing
• Men—muscle dysmorphia, antidepressants may
help here too;.
• Overeaters anonymous (OA) for compulsive
• Group treatment.. teach moderation—CBT
• Gambling, has become socially acceptable
• Criteria---preoccupation, increasing amounts, etc.
3-7% of gamblers have problems, suicide high in
• 2-4% in Gamblers Anonymous (GA) are women.
But many helpline calls.
• Women gamble to escape; men for action.
• Associated with other problems
• Box 7.1 Reflections of a Male Compulsive
– Geographical relocation helped him break his habit.
Questions for Screening (p. 229)
• Have you ever borrowed money in order to
gamble or cover lost money?
• Have you ever thought you might have a gambling
problem or been told that you might?
• Have you ever been untruthful about the extent of
your gambling or hidden it from others?
• Have you ever tried to stop or cut back on how
much or how often you gamble?
• Treatment: cognitive work and
• Irrational thinking about winning:
―I put so much money in this machine,
bound to win.‖
• High profile winners
• Lucky machine
• Typical 31 yr.old female who has overspent
for 13 years.
• DSM-IV-TR lists Kleptomania;
• Medications: Luvox
• Caught in the Net– Internet addicts:
preoccupied, excessive amounts of time
involved in chat rooms, playing games;
• Jeopardized relationships.
• Fantasy world—fictitious names, office
• Self-efficacy for empowerment
• Feedback – assessment of use
• Responsibility – choice is theirs
• Advice – set goals together
• Menus – of self-directed change options
(ex.- monitor computer use)
Harm Reductions Strategies:
-get a timer
-cut mailing lists
• Risk taker
• Cognitive therapy recommended.
• Prone to lying—one TV broadcast looked at
Clinton’s background and his sexual risk
taking: he grew up in alcoholic home,
engaged in risk taking, having out of
• Self-help group--Sex Addicts Anonymous.
• Distortions especially with these addictions
and anorexia. Tendency towards extreme
• Slogans of AA (―easy does it‖)
• Rational recovery, MET, RET more
Cognitive Therapy continued
• Teach clients to avoid black and white thinking.
• Ask about times when client successfully handled
• Use regular assessment for disease of addiction.
• Feeling work
– Positive reinforcement and reframing
• Stress management--- modify thinking, exercises
for group work: art work can reveal underlying
• Positive reframing and self talk…. Cognitive
therapy can be directed toward the past as well as
• Feeling work—Anger management. Anger as a
cover. Avoid all-or-nothing thinking.
• Stress management---- drink milk, use self talk,
• Group exercise: art, faces, grief and loss, quiz
cards, dreams, assertiveness.
Substance Misuse With A Co-Existing
Disorder Or Disability
• Double whammy—substance dependence and
mental disorder. Bipolar—feeling high can imitate
• Integrated Approach—fits with harm reduction
• Sample of people with schizophrenia—79% have
alcohol problems, 46% cocaine
• 32% marijuana, 8% opiates.
• Definition– having substance dependence with
• Alcoholism counselors often explain psychosis as
• Mental health professionals tend to see alcohol use
as self medication.
• Truth is both/and, not either/or.
• Coexisting disorders: anxiety, compulsive
gambling, eating and mood disorders.
Disorders that May Co-exist with
• Compulsive gambling
• Mood disorders
• Eating disorders
• Personality disorders
• Anti-social personality;
• Integrated treatment needed;
• Need to offer better housing, can rely on
funding by Supplemental Security
• Read ― A Day in the Life of a Mental health
Case Manager‖ (pp. 266-269)
• Case management--housing, shopping,
Social Aspects of Addictions
Family Risks and Resilience
• Addiction is a family disease…stigma.
• Box 9.1 Des Moines Register
―Families Wrecked by Meth Epidemic Loss‖—
loss of custody, prison
Classic Family Structure:
Addict as symptom of carrier.
• Faulty communication in family—anorexia
• Confusion of cause and effect
History of Family Treatment:
• Lack of insurance for family treatment;
• Claudia Black-―It will never happen to me‖
• Don’t talk, trust, feel—co-alcoholic,
• Virginia Satir: studied family adaptation to
• Wegscheider’s: codependent person, chief enabler.
• This text uses the more positive term, family
manager instead of chief enabler.
• Wegscheider’s terms for family roles: hero,
scapegoat, lost child, mascot
• Melody Beattie: Codependency No More
popularized the term. We suggest survivor instead
of codependent, a term that has taken on a life of
Figure 9.1 Family Forms
• Enmeshed family: Spouses are estranged:
one child here is enmeshed with father, one
F C M C
• Isolated family: Lack of cohesion and social
support. Each member is protected by wall
• Healthy family: All are touching, but their
boundaries are not overlapping.
Stages of change and family:
• 1. Precontemplation: Counselors describe family
• 2. Contemplation: family concerns – look for
solutions. Male partners may be hard to engage.
• 3. Preparation: Breaking point--formal
intervention (see boxed reading by Carroll
Schutey) Family members make a list of feeling
responses to addict’s actions.
4. Action stage:
Rehearsal and treatment of family without
Therapist feedback—Example of therapist response to
family argument: ―I note that as you, Steve said that
just then, you (kid) fell out of chair.‖ Purpose to reveal
how the family roles operate in a system.
• 5. Maintenance stage:
• Focus on process not content ―what to do if….‖ Transition with sobriety.
Rules of Fighting Fair
• Attack behavior, not person
• Keep issues of manageable size, don’t
• Don’t use negative labels.
• Don’t rehash the past.
3 R’s model
• Rename: No labels, shopping addiction as illness,
not fooling spending.
• Reframe: help client see things happen for a
• Reclaim: healing, we-ness, family circles to
make decisions (from Native Americans)
• Kathy and Ed: Case Study
Exercises related to family work:
• Drawing family maps, circles
• Relapse prevention plan.
• View family videotape.
Exercises related to family work:
1. Drawing family maps, circles
2. Relapse prevention plan.
3. Viewing excerpt from a movie or
• Racial, Ethnic, and Cultural Issues
• Need to have social political context of
• Treatment must take into account
• Importance of class—bell hooks-
• Class affects adolescents access to drugs
• Cambodians - war trauma.
• Asian Americans - highest income, filial
• Emotional sharing may lead to loss of face.
• Native Americans are less than 1% of
population: highest rate of drug use--20%,
• High alcohol abuse rate, youth inhalant use
• Factors—boarding schools and poverty.
• Use of Medicine Wheel for holistic
framework, talking circles.
• 13% of population (California: 1/3 of population)
• 58% of Hispanics in the U.S. are Mexicans.
• Substance abuse higher among Mexicans and
Puerto Ricans than Cubans.
• In U.S. 30% of Latinos smoke. Less among
women but increasing.
• AIDS, the 2nd leading cause of death.
• Group has the highest high school drop-out rate.
• Male/female role differentiation.
• Work with family should support family strengths.
• About 24% of treatment population but drug use is
not much more.
• Women tend to abstain..52% of all new HIV
cases. Higher social class a protective factor.
• Twice as many are in poverty as whites.
• Almost half of advertising budget targets blacks.
• Recovery relates to spirituality and family support.
• David Goodson quote: ― deals with cultural pain‖
(pp.331-332). Harm reduction techniques
• Rockford, Illinois child welfare program
was highlighted in the Bill Moyers PBS
series on addiction.
• Graduation ceremony
• Remarkable outreach worker.
Gender and Sexual Orientation
• Prevalence of addiction varies by culture, low of Korean
• In American high schools, rates about the same.
• More eating disorders…Stigma
• Women in treatment tend to have made drinking partners.
• South Dakota---forces pregnant women with alcohol and
drug problems into treatment.
• 240 women in the U.S. criminally prosecuted for harming
unborn children but Supreme Court says only testing of
hospital patients with their consent.
• War on Drugs---in states 45% of female prisoners are in
need substance abuse treatment compared to 22% of men.
• Violence---3 of 4 partner murders of women.
• Women alcoholics ---47% in treatment molested as
children in study of 472 women (Down’s).
• Women smoke to control weight, males to relieve
• Escape gamblers (women)
• Biological differences—women get intoxicated quicker,
have a higher mortality rate with heavy drinking, lives are
shortened by 15 years on average with alcoholism.
• Heterosexism and homophobia: U.S. studies of
schools shows suicide is 14 times the heterosexual
• Lesbians—lowest rate of AIDS of any group, but
double the drug use of other women, 55% smoke;
28% are obese.
• Reasons for high drinking rate—gay bar, fewer are
• Gay males—high risk of sexual abuse in jail cells.
• Religious fundamentalism correlated with
suicide…alcohol problems persist across life span.
• Transgender….See Do’s and Don’ts…p.362 table
• Mutual-Help Groups
• Confusion—12 Step treatment and 12 Step
self help groups.
• AA – spiritually based fellowship is
free…Voluntary: consistent with harm
• Involuntary treatment for those who failed
• Presented in Box p. 376 . Starts with Step 1: We
admitted we were powerless over alcohol—that
our lives had become unmanageable.
• Greater involvement in AA found to effective.
• Use of narratives…stories of powerlessness over
the addiction, lives out of control…metaphor of
• Means of expanding treatment.. words in Big
Book…One day at a time…Higher Power.
• Women for sobriety
• SMART----cognitive. Moderation
management—starts at 30 days of
War on Drugs is not harm reduction, but
• SSI for alcohol/drugs disabilities has been
• Managed care, reduced inpatient coverage,
reductions in Medicare reimbursement.
• Promising developments—drug court,
mental health courts.
• Confidentiality: need consent forms signed.
• Treatment options to AA—Supreme Court ruling
related to separation of church and state.
• War on Drugs—failed policy, most agree in
survey: injustice, racial oppression, huge expense.
• Media hype about drug crime, mandatory
• 52% of men in federal prison are black.
• Mothers of crack babies given punitive treatment.
Harm Reduction Strategies
• Needle exchange serves only 15% of drug
• Methadone maintenance---too low a level of
• This text argues not legalization but for
middle of the road policies to reduce harm.