Addiction Treatment Parts 1_2_3.ppt

Document Sample
Addiction Treatment Parts 1_2_3.ppt Powered By Docstoc
					  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
          Biopsychosocial Model
• Why (bio), what (psycho), where (social)
• Interactionism and cycle of pain: pain and
  suffering  loss  pain, stress and drinking
  more pain
• Family as a system, roles
• Why need to know about addiction? 80% behind
  bars, child welfare, alcoholics at work.
• Headlines:
    -―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.
    Chapter 2

Historical Perspectives
• 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.
       Temperance movement

• 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
  in asylums.
• 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.
           Chapter 3

Strengths Based Helping Strategies
   Focus on possibilities, choices. Suspension
               of disbelief.
      Two Approaches to Treatment
      Traditional                Strengths-based
           Bio                        Bio
        Dichotomy                  Continuum
         Psycho                      Psycho
Problems mandate—one size       Strengths-motivation
        fits all
          Social                       Social
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:
     Enhance Motivation
     Express empathy
     Develop discrepancy
     Avoid argumentation
     Roll with resistance
     Support self-efficacy
  3. Solution focused therapy and narrative

• Miracle question
• The personal narrative
           Traditional Treatment:

•   Detox
•   Outpatient
•   Inpatient
•   Aftercare once a month
         Part II BIOLOGY

            Chapter 4

Substance Misuse, Dependence, and the
• PET scans, fMRI functional magnetic
  resonance imaging—
• craving
• brain damage
      Depressants: Alcohol
• 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
  damage, coma
• Cocaine-crack and powder, in urine 8 hrs., smoked for
  faster high.
• Brain blocks reuptake of dopamine… Addicted rats die…
  heart attack.
• Amphetamines and meth—synthetic unlike cocaine—
  suppresses appetite.
• 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
  schizophrenics smoke.
• 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
             some hallucinogenic
             properties and is
             structurally related to
             amphetamines. Its short
             form chemical name is
             MDMA (3,4-
Split        phetamine).
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
                •   Depression
                •   Confusion
                •   Paranoia

• Marijuana.
• Lowers blood glucose, increases appetite,
  Stored in fat cells, long term use associated
  with apathy.
           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.
  Robert Downey).
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
  dopamine too.
• Parkinson’s when too little—too much =
• Serotonin: influenced by alcohol, involved in sleep.
  Decreased levels linked to depression, anxiety,
  impulsiveness suicide.
     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
  serotonin levels.
            Cocaine in the Brain

Slides are from the National Institute on Drug Abuse (NIDA) (
                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.
          Medical Consequences:
• 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.
          Chapter 5

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
•   Bulimics—depression/anorexia—anxiety
•   Luvox decreases binges.
•   Holistic—herbal remedies and hypnosis
         Screening: CAGE

• Have you tried Cutting down?
• Have people Annoyed you?
• Have you felt Guilty about your ATOD
• Have you ever used ATOD as an Eye
    Group Work:
•   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
          Part III

  Psychology Of Addiction

        Chapter 6
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.
          Adolescent Brain:
• Prefrontal cortex matures after age of 20
• Evidence of brain immaturity during the
  teen years comes from MRI scans of the
  adolescent brain
        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
  social/ethnic groups:
• 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
     used alcohol
• 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.
            College Students
• 40 % binged on alcohol in past two weeks
• Rivera Live: $10 billion alcohol consumed by
  under 21
• 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,
   measures failed.
• All bills regarding alcohol education died
in Congress.
• Children learn gambling on the Internet;
• Video poker, slot machines, and the lottery
• Strenuous exercise programs reduce
  smoking. Smoking may be considered a
  gateway drug.
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
• Child abuse and other traumas are serious
  risk factors for later adolescence and
  adulthood drinking
• 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
  problems later
• 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
  sexual intercourse.
• 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
  muscle dysmorphia.
• Dysmorphia-- newly identified psychiatric
  disorder in DSM IV.
• DSM-IV-TR discusses body dysmorphic
  disorder only briefly
• Obsessive body building major problem for
  young males
• Revealed in popularity of anabolic steroids
• Steroids used by 2.7 % of all male high
  school students.
• Health hazards: stunted growth, acne, and
   shrinking testicles.
         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.
            Harm Reduction:

• 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
  addictive behavior
  – 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
  treatment programs
• 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-Specific Motivational
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?‖
    Motivational Enhancement
 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
         Preparation Stage:
• Setting date
• What do you think will work for you?
• Adolescent comments, ―I’m feeling good
  about setting a date to quit, but who
             Action Stage:
  • 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.
         Maintenance Stage:
• Adolescent comment:
  ―It’s been a few months; I’m not there yet but I’m
    hanging out with some new friends...‖
• Inevitable
• Miller advises roll with it
• Use reflective summarizing
             Gender Specific
            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
  late onset
• Early onset- - more severe levels of
  depression and anxiety
• Elderly consume less alcohol than the
• Trend toward nursing homes for short-term
  alcoholism rehabilitation
• Many male ex-alcoholics reside in nursing
• Many early onset suffer from Korsakoff’s
  syndrome and other alcohol-related
  neurological problems.
• 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
          Relapse Prevention:
• 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;
• Ageism
  – Countertransference
  – Denial in assessment
  – Sympathy not empathy
Loss and grief in family members of addicted

• Types of Guilt
   – Survivor guilt
   – Helplessness
   – Ambivalence
• Spiritual healing—sense of meaning,
• Strength from 12 Steps
               William Faulkner
• Poem:
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)
             Chapter 7

Eating Disorders and Gambling, Shopping,
      and other Behavioral Addictions
             Eating Disorders
• 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
• 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.
• Bulimia
• Anorexia—Prozac is effective in reducing
  compulsive behavior;
• 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
  motivational therapy.
• Irrational thinking about winning:
  ―I put so much money in this machine,
  bound to win.‖
• High profile winners
• Lucky machine
         Shopping Addiction
• Typical 31 yr.old female who has overspent
  for 13 years.
• DSM-IV-TR lists Kleptomania;
• Medications: Luvox
           Cyber Addiction
• 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)
• Empathy
• Self-efficacy
Harm Reductions Strategies:

      -get a timer
       -cut mailing lists
       -no detours
            Sex Addiction
• 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
  bounds sex
• Self-help group--Sex Addicts Anonymous.
           Cognitive Therapy

• 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
  a problem.
• 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
  the present.
• Feeling work—Anger management. Anger as a
  cover. Avoid all-or-nothing thinking.
• Stress management---- drink milk, use self talk,
  get exercise.
• Group exercise: art, faces, grief and loss, quiz
  cards, dreams, assertiveness.
              Chapter 8
Substance Misuse With A Co-Existing
  Disorder Or Disability
               Dual Diagnosis:

• Double whammy—substance dependence and
  mental disorder. Bipolar—feeling high can imitate
  drug use;
• Integrated Approach—fits with harm reduction
• Sample of people with schizophrenia—79% have
  alcohol problems, 46% cocaine
• 32% marijuana, 8% opiates.
               Dual Diagnosis
• Definition– having substance dependence with
  mental disorder
• Alcoholism counselors often explain psychosis as
  drug induced.
• 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
           Substance Abuse:

•   Anxiety
•   Compulsive gambling
•   Mood disorders
•   Eating disorders
•   Personality disorders
•   Psychosis
          Personality Disorders:

•   Borderline;
•   Anti-social personality;
•   Integrated treatment needed;
•   Need to offer better housing, can rely on
    funding by Supplemental Security
    Insurance (SSI).
           Case Management:

• Read ― A Day in the Life of a Mental health
  Case Manager‖ (pp. 266-269)
• Case management--housing, shopping,
        Part IV:
Social Aspects of Addictions

         Chapter 9
     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,
• Al-Anon—1950s
• Virginia Satir: studied family adaptation to
  person’s illness.
                 Role Theory:

• 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
  its own.
      Figure 9.1 Family Forms
• Enmeshed family: Spouses are estranged:
  one child here is enmeshed with father, one
  with mother

          F    C            M    C
• Isolated family: Lack of cohesion and social
  support. Each member is protected by wall
  of defenses.


            C                     C

• Healthy family: All are touching, but their
  boundaries are not overlapping.


                C         C

     Stages of change and family:

• 1. Precontemplation: Counselors describe family
  communication patterns.
• 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
    addicted member.

    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
           Chapter 10
• Racial, Ethnic, and Cultural Issues
• Need to have social political context of
  being minority.

• Treatment must take into account
  ethnoculture norms.
• Importance of class—bell hooks-
• Class affects adolescents access to drugs
            Asian Americans:
• Cambodians - war trauma.
• Asian Americans - highest income, filial
• Emotional sharing may lead to loss of face.
           American Indians:

• Native Americans are less than 1% of
  population: highest rate of drug use--20%,
  cigarettes--53% use.
• 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.
            African Americans:
• 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
               Project Safe

• Rockford, Illinois child welfare program
  was highlighted in the Bill Moyers PBS
  series on addiction.
• Graduation ceremony
• Remarkable outreach worker.
            Chapter 11

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.
            Sexual Orientation
• 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
  mothers….G/L AA.
• 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
    Chapter 12

• 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
  at moderation.
               Twelve Steps
• 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.
             Other Self-Help
•   GA
•   NA
•   Women for sobriety
•   SMART----cognitive. Moderation
    management—starts at 30 days of
 Chapter 13

Public Policy
  War on Drugs is not harm reduction, but
  harm maximization.
• SSI for alcohol/drugs disabilities has been
• Managed care, reduced inpatient coverage,
  reductions in Medicare reimbursement.
• Promising developments—drug court,
  mental health courts.
               Federal Laws
• 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
  minimum sentencing.
• 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
  the drug.
• This text argues not legalization but for
  middle of the road policies to reduce harm.
The End

Shared By:
suchufp suchufp http://