Psychology 2185 Abnormal Psychology

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Psychology 2185 Abnormal Psychology Powered By Docstoc
					Substance-Related Disorders
Substance Abuse

   A substance is any natural or synthesized product
    that has psychoactive effects—it changes
    perceptions, thoughts, emotions, and behaviors.
    –   Need not be a medicine or illegal
    –   E.g., alcohol, tobacco, caffeine

   Drug vs. psychoactive drugs
    –   Drug - any chemical substance that can alter a biological
        system.
    –   Psychoactive drugs - affect brain function, mood, and
        behavior.
Potency

   Potency is the amount of a drug that must be
    given in order to obtain a particular response.
   Influenced by:
    –   Route of administration
    –   Ability of the drug to enter the brain
    –   How well a drug interacts with receptors in the
        brain
    –   How quickly the body and brain adapt to the drug.
Route of Administration

    For a drug to affect brain function, it must first reach
    the brain.
    –   For all drugs, they do so through the blood supply to the
        brain.


   Routes
    –   Orally
    –   Direct injection into a vein
    –   Intranasal and intraoral (e.g., chewing tobacco) delivery
    –   Smoking
Reaching the Brain

   Blood-brain barrier.
    –   Specialized cells that prevent particular
        compounds in the circulatory system (blood
        supply) from entering the brain.
    –   Allows certain drugs to pass through and affect
        brain cells and excludes others, depending on the
        size and chemical characteristics of the drug
        molecule.
Drug-Receptor Neurotransmitter
Interactions

   All psychoactive drugs have various effects on
    neurotransmitter systems.
   Psychoactive drugs often mimic neurotransmitters
    and interact with neurotransmitter receptors.
   Receptors & neurotransmitters (lock & key system)
   Drugs can influence neurotransmission by
    –   interfering with the synthesis of a neurotransmitter
    –   interfering with the release of the neurotransmitter
    –   blocking the receptors of the postsynaptic neuron
Neuroadaptation

   Neuroadaptation: complex biological
    changes that occur in the brain with repeated
    or chronic exposure to a drug.
    –   Drug -> effect
    –   Repeated exposure -> the body and brain to
        adapt to the presence of the drug.
    –   Homeostatic or ―self-corrective‖ mechanism to
        compensate for the effects of the drug.
Tolerance

   Tolerance
    –   One form of adaptation
    –   A state of decreased response to a drug following
        prior or repeated exposure to that drug.
    –   Progressively more drug is needed in order to
        obtain the same effect.
Types of Tolerance

   Metabolic tolerance develops when repeated exposure to a drug
    causes the person’s liver to produce more enzymes that are used to
    metabolize the drug.

   Pharmacodynamic tolerance (neuroadaptation) occurs when
    receptors in the brain adapt to continued presence of the drug by
    downregulation.

   The third process involved in drug tolerance involves behavioral
    conditioning mechanisms through cues that are regularly associated
    with the administration of a drug.
     –   This association functions as conditioned stimuli to elicit a conditioned
         response that is opposite in direction to the natural effect of the drug.
Tolerance & Dependence

   Tolerance
    –   One form of adaptation
    –   A state of decreased response to a drug following prior or
        repeated exposure to that drug.
    –   Progressively more drug is needed in order to obtain the same
        effect.

   Physical Dependence
    –   The need for the presence of the drug in order to function
        normally.
    –   Experience of a withdrawal syndrome upon cessation of the
        drug.
Withdrawal syndrome

   Characterized by observable, physical signs such
    as:
    –   Marked changes in body temperature
    –   Marked changes in heart rate
    –   Seizures
    –   Tremors
    –   Vomiting


May also be less observable:
    –   Depression
    –   Irritability
    –   craving
Substance-Related Conditions Recognized
by the DSM-IV-TR

   Substance intoxication: Experience of significant
    maladaptive behavioral and psychological symptoms
    due to the effect of a substance on the central
    nervous system.

   Substance withdrawal: Experience of clinical
    significant distress in social, occupational, or other
    areas of functioning due to the cessation or
    reduction of substance use.
Substance-Related Conditions Recognized
by the DSM-IV-TR, continued

   Substance abuse: Diagnosis given when recurrent substance
    use leads to significant harmful consequences.
     – interference with the person’s ability to fulfill major role obligations
       at work or at home, the recurrent use of a drug in dangerous
       situations, and repeated legal difficulties associated with drug use.

   Substance dependence: Diagnosis given when substance
    use leads to physiological dependence or significant
    impairment or distress.
DSM
Criteria


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Substance-Related Disorders

   About 10% of all adults in the U.S. display substance
    abuse or dependence
    –   Only 26% receive treatment

   Many drugs are available in our society
    –   Some are naturally occurring; others are produced in a
        laboratory
    –   Some require a physician’s prescription for legal use;
        others, like alcohol and nicotine, are legally available to
        adults
            Still others, like heroin, are illegal under all circumstances
Substance-Related Disorders

   Recent statistics suggest that drug use is a
    significant social problem
    –   Over 28 million people in the U.S. have used an
        illegal substance within the past year
    –   Over 19 million are using one of them currently
    –   Almost 25% of all high school seniors have used
        an illegal drug within the past month
Easy to
get


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Depressants
Depressants

   Depressants slow the activity of the central nervous
    system (CNS)
    –   Reduce tension and inhibitions
    –   May affect judgment, motor activity, and concentration


   Two widely used depressants:
    –   Alcohol
    –   Sedative-hypnotic drugs (e.g., benzodiazepines)
Depressants: Alcohol

   About 2/3 of the U.S. population drinks
    alcohol
    –   Nearly 7% of people over age 11 are heavy
        drinkers, having 5 drinks on at least 5 occasions
        per month
            Among heavy drinkers, the ratio of men to women is 3:1
             (around 9% to 3%)
Depressants: Alcohol

   The extent of the effect of ethyl alcohol is determined
    by its concentration (proportion) in the blood
    –   A given amount of alcohol has a lesser effect on a large
        person than on a small one

   Gender also affects blood alcohol concentration
    –   Women have less alcohol dehydrogenase, an enzyme in
        the stomach that metabolizes alcohol before it enters the
        blood
    –   Women become more intoxicated than men on equal doses
        of alcohol
Depressants: Alcohol

   Levels of impairment are closely tied to the
    concentration of ethyl alcohol in the blood:
    –   BAC = 0.06: Relaxation and comfort
    –   BAC = 0.09: Intoxication
    –   BAC > 0.55: Death
            Most people lose consciousness before they can drink
             this much
Depressants: Alcohol

   The effects of alcohol subside only after
    alcohol is metabolized by the liver
    –   The average rate of this metabolism is 13% of an
        ounce per hour
    –   You can’t increase the speed of this process!
Depressants: Alcohol

   Alcohol abuse and dependence
    –   Its effects can extend across the lifespan
            Alcohol use is a major problem in high school, college, and
             adulthood
            About 8% of U.S. adults meet the criteria for alcohol abuse or
             dependence (―alcoholism‖) each year
               – In their lifetime, between 9% and 18% of adults will
                 display one of these patterns, with men outnumbering
                 women 2:1
Substance Abuse/Dependency
by Ethnicity




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Depressants: Alcohol

   Alcohol dependence
    –   For many people, the pattern of alcohol misuse includes
        dependence
            They build up a physiological tolerance and need to drink
             greater amounts to feel its effect
            They may experience withdrawal, including nausea and
             vomiting, when they stop drinking
            A small percentage of alcohol-dependent people experience a
             dramatic and dangerous withdrawal syndrome known as
             delirium tremens (―the DTs‖)
               – Can be fatal!
Problems Experienced by People Who Are
Diagnosed with Alcohol Abuse or Dependence


      Continued to drink with serious illness

                Was arrested while drinking

       Wanted to stop drinking but couldn't

 Engaged in daily or weekly heavily drinking

       Consumed a fifth of liquor in one day

Thought him- or herself an excessive drinker

                              Family objects

                                                0   10   20   30     40    50   60      70   80   90

                                                                   Percent saying yes
Depressants: Alcohol

   What is the personal and social impact of
    alcoholism?
    –   Alcoholism destroys families, social relationships,
        and careers
            Losses to society total almost $200 billion annually
            Plays a role in suicides, homicides, assaults, and
             accidents
            Seriously affects the children (some 30 million) of
             alcoholic parents
Depressants: Alcohol

   What is the personal and social impact of
    alcoholism?
    –   Long-term excessive drinking can seriously damage
        physical health
            Especially damaged is the liver (cirrhosis)
    –   Long-term excessive drinking can cause major nutritional
        problems
            Example: Korsakoff’s syndrome (psychosis)
    –   Long-term excessive drinking can cause cognitive problems
            Alcohol-induced dementia or persisting amnesic disorder
    –   Women who drink alcohol during pregnancy place their
        fetuses at risk from fetal alcohol syndrome (FAS)
Depressants:
Barbiturates & Benzodiazepines

   Barbiturates, such as phenobarbital (Nembutal) and
    amobarbital (Amytal), were used for a variety of purposes,
    including the treatment of chronic anxiety.

   Benzodiazepines, which include diazepam (Valium) and
    alprazolam (Xanax), have replaced the barbiturates in the
    treatment of anxiety disorders, in large part because of their
    lower potential for producing a lethal overdose.
Depressants:
Barbiturates & Benzodiazepines

   These substances can lead to a state of intoxication
    that is identical to alcohol intoxication.

   Repeated administration leads to tolerance and
    abrupt stoppage leads to a significant withdrawal
    symptom. Drug seeking behavior also develops.
Stimulants
Stimulants

   Cocaine, Amphetamine, Methamphetamine produce their
    effects by simulating the actions of certain
    neurotransmitters, specifically epinephrine, norepinephrine,
    dopamine, and serotonin.

   The stimulants can be taken orally, injected, or inhaled.

   They are called stimulants because they activate the
    sympathetic nervous system.
Effects of Stimulant Use

   Many people use and abuse stimulants because they induce a
    positive mood state.
   Tolerance develops quickly to the euphoric effects of
    stimulant drugs.
   The feelings of exhilaration and well-being are typically
    followed, several hours later, by the onset of lethargy and a
    mildly depressed or irritable mood.
   Acute overdoses of stimulant drugs can result in irregular
    heartbeat, convulsions, coma, and death.
   High doses and repeated administration of stimulants can
    lead to the onset of psychosis.
Meth Mouth

Meth mouth is an
informal name for
advanced tooth decay attributed to heavy
methamphetamine use. According to the American Dental
Association, meth mouth "is probably caused by a
combination of:
   –    drug-induced psychological and physiological changes resulting
       in xerostomia (dry mouth)
   –   extended periods of poor oral hygiene
   –   frequent consumption of high calorie, carbonated beverages
   –   tooth grinding and clenching.
Opiates
Opiates

   The opiates (sometimes called opioids) are drugs that have
    properties similar to those of opium.
   The main active ingredients in opium are morphine and
    codeine, both of which are widely used in medicine,
    particularly to relieve pain.
   When morphine is used as a painkiller, it is taken orally so
    that it is absorbed slowly through the digestive system.
   The opiates can induce a state of dreamlike euphoria, which
    may be accompanied by increased sensitivity in hearing and
    vision.
Abuse and Dependence

   Laboratory studies of mood indicate that the positive,
    emotional effects of opiates do not last.
   They are soon replaced by long-term negative changes in
    mood and emotion.
   The opiates can induce nausea and vomiting among novice
    users, constrict the pupils of the eye, and disrupt the
    coordination of the digestive system.
   Continued use of opiates decreases the level of sex hormones
    in both women and men, resulting in reduced sex drive and
    impaired fertility.
Long Term Use

   High doses of opiates can lead to a comatose state, severely
    depressed breathing, and convulsions.
   At high doses, people who are addicted to opiates become
    chronically lethargic and lose their motivation to remain
    productive.
   People who are addicted to opiates become preoccupied with
    finding and using the drug, in order to experience the rush
    and to avoid withdrawal symptoms.
   Tolerance develops rather quickly, and the person’s daily dose
    increases regularly until it eventually levels off and remains
    steady.
Before and After
Cannabis
Cannabis

   Marijuana and hashish are derived from the hemp
    plant, Cannabis sativa.
   The most common active ingredient in cannabis is a
    compound called delta-9-tetrahydro-cannabinol
    (THC).
   The subjective effects of marijuana are almost
    always pleasant.
Abuse

   Cannabis intoxication is often accompanied by temporal
    disintegration, a condition in which people have trouble
    retaining and organizing information, even over relatively
    short periods of time.

   Some people get paranoid after marijuana abuse
Dependence

   Most evidence suggests that people do not develop
    tolerance to THC unless they are exposed to high doses
    over an extended period of time.

   Prolonged heavy use of marijuana may lead to certain types
    of performance deficits on neuropsychological tests,
    especially those involving sustained attention, learning, and
    decision making.
Hallucinogens
Hallucinogens

   Cause people to experience hallucinations and, although
    many other types of drugs can lead to hallucinations at toxic
    levels, hallucinogens cause hallucinations at relatively low
    doses.

   The molecular structure of many hallucinogens is similar to
    the molecular structure of various neurotransmitters, such as
    serotonin and norepinephrine.
Hallucinogens

   LSD, psilocybin (mushrooms), mescaline,
    MDMA (ecstasy), and PCP
   The effects of hallucinogenic drugs are difficult to
    study empirically because they are based primarily
    in subjective experience.
   They typically induce vivid, and occasionally
    spectacular, visual images.
Abuse & Dependence

   Most hallucinogens are not particularly toxic.

   The use of hallucinogens follows a different pattern than
    that associated with most other drugs. Hallucinogens, with
    the possible exception of PCP, are used sporadically and on
    special occasions rather than continuously.

   There is no evidence of dependence, tolerance, or
    withdrawal
Causes
What Causes Substance-Related
Disorders?

   Clinical theorists have developed
    sociocultural, psychological, and biological
    explanations for substance abuse and
    dependence
    –   No single explanation has gained broad support
    –   Best explanation: a COMBINATION of factors
Causes of Substance-Related
Disorders: The Sociocultural View

   A number of theorists propose that people
    are more likely to develop patterns of
    substance abuse or dependence when living
    in stressful socioeconomic conditions
    –   Example: higher rates of unemployment correlate
        with higher rates of alcohol use
    –   Example: people of lower SES have higher rates
        of substance use in general
Causes of Substance-Related
Disorders: The Sociocultural View

   Other theorists propose that substance
    abuse and dependence are more likely to
    appear in societies where substance use is
    valued or accepted
    –   Example: rates of alcohol use varies between
        cultures (also, alcohol use more accepted in
        males)
            The Georgian drinking culture.
Causes of Substance-Related
Disorders: The Psychodynamic View

   Psychodynamic theorists believe that people who
    abuse substances have powerful dependency needs
    that can be traced to their early years
    –   Caused by a lack of parental nurturing
            Some people may develop a ―substance abuse personality‖ as
             a result
    –   Psychodynamic theory posits that the person with a
        substance related disorder will have a "tremendously
        impoverished and impaired capacity to experience‖
    –   Drug use is seen as part of the individual’s attempt to deal with
        needs and conflicts, relations with others, and the social
        environment in which he or she lives.
    –   No good research support for the psychodynamic view
Causes of Substance-Related Disorders: The
Behavioral and Cognitive Views


   According to behaviorists, operant conditioning may
    play a key role in the development and maintenance
    of substance abuse
    –   They argue that the temporary reduction of tension
        produced by a drug has a rewarding effect, thus increasing
        the likelihood that the user will seek this reaction again
    –   Similarly, the rewarding effects may also lead users to try
        higher doses or more powerful methods of ingestion
Causes of Substance-Related Disorders: The
Behavioral and Cognitive Views


   Cognitive theorists further argue that such
    rewards eventually produce an expectancy
    that substances will be rewarding, and this
    expectation is sufficient to motivate
    individuals to increase drug use at times of
    tension
Causes of Substance-Related Disorders: The
Behavioral and Cognitive Views


   In support of these views, studies have found that
    many subjects do in fact drink more alcohol or seek
    heroin when they feel tense
   This model is arguing a ―self-medication‖ hypothesis
    –   If true, one would expect higher rates of substance use
        among people with psychological symptoms
            Studies have found higher rates of substance use among
             people with mood disorders, PTSD, eating disorders, and
             schizophrenia
Causes of Substance-Related
Disorders: The Biological View

   In recent years, researchers have come to
    suspect that drug misuse may have
    biological causes

   Studies on genetic predisposition and
    specific biochemical processes have
    provided some for this model
Causes of Substance-Related
Disorders: The Biological View

   Genetic predisposition
    –   Research with ―alcohol-preferring‖ rats has
        demonstrated that their offspring have similar
        alcohol preferences
    –   Similarly, research with human twins has
        suggested that people may inherit a
        predisposition to abuse substances
            Concordance rates in identical (MZ) twins: 54%
            Concordance rates in fraternal (DZ) twins: 28%
Causes of Substance-Related
Disorders: The Biological View

   Genetic predisposition
    –   Stronger support for a genetic model may come
        from adoption studies
            Studies compared adoptees whose biological parents
             were dependent on alcohol with adoptees whose
             biological parents were not dependent
              –   By adulthood, those whose biological parents were
                  dependent showed higher rates of alcohol use themselves
Causes of Substance-Related
Disorders: The Biological View

   Genetic predisposition
    –   Genetic linkage strategies and molecular biology
        techniques have also provided direct evidence in
        support of this hypothesis
            An abnormal form of the dopamine-2 (D2) receptor gene
             was found in the majority of subjects with alcohol
             dependence but in less than 20% of nondependent
             subjects
Causes of Substance-Related
Disorders: The Biological View

   Biochemical factors
    –   Over the past few decades, investigators have pieced
        together a general biological understanding of drug
        tolerance and withdrawal
            Based on NT functioning in the brain
               – The specific NTs affected depend on which drug is used
    –   Recent brain imaging studies have suggested that many
        (perhaps all) drugs eventually activate a single ―reward
        center‖ or ―pleasure pathway‖ in the brain
Causes of Substance-Related
Disorders: The Biological View

   Biochemical factors
    –   The reward center extends from the brain area called the
        ventral tegmental area to the nucleus accumbens and on to the
        frontal cortex
    –   The key NT appears to be dopamine
            When dopamine is activated at this center, a person experiences
             pleasure
    –   Certain drugs stimulate the reward center directly
            Examples: cocaine and amphetamines
    –   Other drugs stimulate the reward center indirectly
            Examples: alcohol, opioids, and cannabis
Causes of Substance-Related
Disorders: The Biological View

   Biochemical factors
    –   Theorists suspect that people who abuse
        substances suffer from a reward-deficiency
        syndrome
            Their reward center is not readily activated by ―normal‖
             life events so they turn to drugs to stimulate this
             pleasure pathway, especially in times of stress
            Dopamine may be the key to this syndrome
Hypodopaminergic Functioning

   Reduced activity in the reward pathway can
    trigger drug seeking behavior
   Reduced activity can come about through 3
    primary pathways:
    –   Genetics
    –   Drug Use
    –   Cessation of Drug Use
         Genetic Causes of
    Hypodopaminergic Functioning

   Polymorphisms have been shown to cause
    dopamine reduced receptor density
   Polymorphisms have been shown to cause
    dopamine receptor insensitivity
   Polymorphisms have been shown to cause
    faster clearance of dopamine from the
    synapse
Drug Induced Hypodopaminergic
          Functioning

   Tolerance occurs through down regulation
    –   As a person uses more drugs the dopamine
        system becomes insensitive to typical amounts of
        dopamine so more dopamine is needed
    –   When a person stops using drugs there is an
        imbalance in the dopamine system while the
        person tries to reestablish homeostasis
Biological Causes are IT

   Research focuses now almost primarily on
    biological causes
   It is possible to identify biological processes
    that explain the behavioral and cognitive
    explanations
   No known biological processes of the
    psychodynamic explanations
Treatments
How Are Substance-Related
Disorders Treated?

   Many approaches have been used to treat substance-
    related disorders, including psychodynamic, behavioral,
    cognitive-behavioral, biological, and sociocultural
    therapies
   Although these treatments sometimes meet with great
    success, more often they are only moderately helpful
   Today treatments are typically used in combination
    on both an outpatient and inpatient basis
Psychodynamic Therapies

   Psychodynamic therapists try to help those
    with substance-related disorders become
    aware of and correct underlying
    psychological problems

   Research has not found this model to be
    very effective
    –   Tends to be of greater help when combined with
        other approaches in a multidimensional treatment
        program
Behavioral Therapies

   A widely used behavioral treatment is
    aversion therapy, an approach based on
    classical conditioning principles
    –   Individuals are repeatedly presented with an
        unpleasant stimulus at the very moment they are
        taking a drug
    –   After repeated pairings, they are expected to
        react negatively to the substance itself and to lose
        their craving for it
Behavioral Therapies

   Aversion therapy is most commonly applied
    to alcohol abuse/dependence
   Covert sensitization is another version of this
    approach
    –   Requires people with alcoholism to imagine
        extremely upsetting, repulsive, or frightening
        scenes while they are drinking
    –   The pairing is expected to produce negative
        responses to liquor itself
Behavioral Therapies

   Another behavioral approach focuses on
    teaching alternative behaviors to drug taking
    –   This approach, too, has been applied to alcohol
        abuse and dependence more than to other
        substance-related disorders
   Contingency management is a behavioral
    approach that has been successful in short-
    term treatment
Behavioral Therapies

   Behavioral interventions are of limited
    success when used alone
    –   They are best when used in combination with
        either biological or cognitive approaches
Cognitive-Behavioral Therapies

   Two popular combined approaches, both applied
    particularly to alcohol use:

    –   Behavioral self-control training (BSCT)
            Clients keep track of their own use and triggers
            Learn coping strategies for such events
            Learn to set limits on drinking
            Learn skills (relaxation, coping, problem-solving)
    –   Relapse-prevention training
            Clients are taught to plan ahead for drinking situations
            Used particularly to treat alcohol use; also used to treat
             cocaine and marijuana abuse
Biological Treatments

   Biological treatments may be used to help
    people withdraw from substances, abstain
    from them, or simply maintain their level of
    use without further increases
    –   These approaches are of limited success long-
        term when used alone but can be helpful when
        combined with other approaches
Biological Treatments

   Detoxification
    –   Systematic and medically supervised withdrawal
        from a drug
            Can be outpatient or inpatient
    –   Two strategies:
            Gradual withdrawal by tapering doses of the substance
            Induce withdrawal but give additional medication to
             block symptoms
Detox

   Methadone - morphine is replaced with methadone
    and then slowly withdrawn.
   Clonidine: reduces the release of norepinephrine
    (the most toxic consequence of withdrawal).
    Suppresses cardiovascular and autonomic
    symptoms of withdrawal.
   Clonidine and naltrexone: ―rapid detox‖ shortens the
    time of withdrawal to 5 days or less.
   ―One day detox‖: general anesthesia or heavy
    sedation and IV naloxone or oral naltrexone.
   Buprenorphine: administered once a day to relieve
    withdrawal symptoms.
Biological Treatments

   Detoxification
    –   Detoxification programs seem to help motivated
        people withdraw from drugs
            For people who fail to receive psychotherapy after
             withdrawal, however, relapse rates tend to be high
Biological Treatments

   Antagonist drugs
    –   An aid to resist falling back into a pattern of
        substance abuse or dependence, antagonist
        drugs block or change the effects of the addictive
        substance
            Example: disulfiram (Antabuse) for alcohol
            Example: naltrexone for narcotics, alcohol
Biological Treatments

   Drug maintenance therapy
    –   A drug-related lifestyle may be a greater problem than the
        drug’s direct effects
            Example: heroin addiction
    –   Thus, methadone maintenance programs are designed to
        provide a safe substitute for heroin
            Methadone is a laboratory opioid with a long half-life, taken
             orally once a day
            Programs were roundly criticized as ―substituting addictions‖
             but are regaining popularity, partly because of the spread of
             HIV/AIDS
Sociocultural Therapies

   Three main sociocultural approaches to
    substance-related disorders:
    –   Self-help and residential treatment programs
    –   Culture- and gender-sensitive programs
    –   Community prevention programs


   Important to consider the social cues for
    substance use in its treatment.
Sociocultural Therapies

   Self-help and residential treatment programs
    –   Most common: Alcoholics Anonymous (AA)
            Offers peer support along with moral and spiritual
             guidelines to help people overcome alcoholism
    –   Many self-help programs have expanded into
        residential treatment centers or therapeutic
        communities
            People formerly dependent on drugs live, work, and
             socialize in a drug-free environment while undergoing
             individual, group, and family therapies
Sociocultural Therapies

   Culture- and gender-sensitive programs
    –   A growing number of treatment programs try to be
        sensitive to the special sociocultural pressures
        and problems faced by drug abusers who are
        poor, homeless, or members of ethnic minority
        groups
    –   Similarly, therapists have begun to focus on the
        unique issues facing female substance users
Sociocultural Therapies

   Community prevention programs
    –   Perhaps the most effective approach to
        substance-related disorders is to prevent them
    –   Prevention programs may focus on the individual,
        the family, the peer group, the school, or the
        community at large
            The most effective of these prevention efforts focus on
             multiple areas to provide a consistent message about
             drug use in all areas of life
Overcoming his addiction

				
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