Transcript Uppers, Downers and All Arounders

Uppers, Downers and All
Arounders
Chapter 9
TREATMENT
OVERVIEW
• Chemical dependency and addiction are one of
the most prevalent of brain diseases
• Has a greater impact on society than any other
brain diseases
• Chemical Dependency # 1 public physical health
problem
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16.4 anxiety disorders
1.3% schizophrenia
7.1% mood disorders
11 million on alcohol
3 million on illicit drugs
2 million on both alcohol and other drugs
25% on nicotine addiction
2-6% on gambling addiction
Current Treatment Issues
• Expanding use of medications to treat
withdrawal, reduce craving and promote
abstinence
• In creasing use of technology to diagnose and
visualize physiological effects of addiction on
brain
• Lack of resources to provide treatment: States
spend only 13% on treatment and only 4% used
on prevention
– For every $1spent, $4-$20 saved on prison costs, lost
of time on jobs, health problems and extra social
services.
Current Treatment Issues
• Coercive treatment works in promoting positive
outcomes
– 33% re-arrests
– 45% reduction of reconviction
– 87% reduction in return to prison
• Conflict between abstinence recovery and harm
reduction
• Large segment of society moving towards
abstinence, that promotes prohibition
• Treatment personnel do not see Harm reduction
as an option or transition to abstinence
Treatment Effectiveness
• California Drug and Alcohol Treatment Assessment
Study of 1,850 persons over 3-5 years:
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Continual abstinence of 50%
74% reduction in crime
State saved $7 for every $1 spent
TX most effective when patients treated continuously for a period
of 6 -8 months
– Group therapy more effective
– Clients with alcohol issues had better outcomes
– Better outcomes linked to culturally appropriate programs
• Drug Abuse Treatment Outcome Study (DATOS)
– 50-70% reduction in drug use
– Short and long term residential programs work best
Treatment and Prisons
• 1,962,220 Americans in federal and state prisons for
drug offenses
• 40-65% committed crimes while under the influence of
alcohol and/or other drugs
– 57% of federal prisoners and 21% of state prisoners serving a
sentence for drug offenses
• 5 million were on probation or parole
– 24%drug law violation
– 17% DUI of Alcohol
• Only 10% with serious addictions had treatment in
prisons, even though 94% of federal and 56% of state
prisons and 33% of jails had some substance abuse
treatment services
• Studies showed that Treatment reduced recidivism
• $25,000 -$45,000 a year spent on keeping an offender in
jail
Principles and Goals of Treatment
• Principles
– No single treatment is appropriate for all
– Treatment needs to be readily available
– Effective treatment attends to all needs of
individual, not just the drug use
– Assessment needs to be continuous
– Remaining in treatment for adequate time is
critical for effectiveness
– Counseling and other behavioral therapies is
critical
Principles and Goals of Treatment
• Principles
– Medications are important, especially combined with
treatment
– Persons with co-occurring disorders should have
integrated treatment to address both drug and mental
health issues
– Treatment does not have to be voluntary to be
effective
– Possible drug use during treatment must be
monitored continuously
– Treatment programs should provide assessment for
HIV/AIDS, Hepatitis A, B, and C, Tuberculosis and
other infectious diseases
– Recovery is a long-term process and may require
multiple treatment episodes
Principles and Goals of Treatment
• Goals
– Motivate clients towards abstinence
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Education
Counseling
12 Step Groups or Self-help Groups
Harm Reduction (methadone, medication)
Relapse Prevention
– Reconstructing their lives: Creating a drug-free
lifestyle
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Address social and economic issues
Homelessness
Relationships
Jobs
Drug-free activities
Life skills
Education
Principles and Goals of Treatment
• Supporting Goals
– Enriching Job or Career Functions
– Vocational services
– Personal Finances
– Medical functioning
• Checking for undiagnosed illnesses
– Optimizing Psychiatric and Emotional
Functioning
• Over 50% of persons have coexisting mental
illness
– Spiritual Issues
• Include spiritual options for clients
Selection of a Program
• Diagnosis
– American Psychiatric Association’s Diagnostic
and Statistical Manual of Mental Disorders
(DSM-IV-TR)
• Pattern of use, negative impact on the social or
occupational functioning of the user, pathological
effects (tolerance or withdrawal symptoms)
– Addiction Severity Index (ASI)
• Comprehensive and lengthy criteria for the
diagnosis of chemical dependency
• 180 items covering six items: medical,
employment, drug/alcohol, legal, family/social, and
psychiatric history
Selection of a Program
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Michigan Alcoholism Screening Test
(MAST): Long (25 ?’s) Short (13 ?s)
– Directed at negative life effects of alcohol
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CAGE
– Simplest assessment tool of 4 questions
1. Have you ever felt the need to Cut down on your
drinking?
2. Do you feel Annoyed by people complaining
about your drinking?
3. Do you ever feel guilty about your drinking?
4. Do you ever drink an Eye-opener in the morning
to relieve the shakes?
Treatment Options
• No treatment has been found to be universally
effective for everyone
• Wide-range of Treatment Options
– Cold-turkey/white knuckles dry-out to medically
detoxification
– Expensive medical or residential approaches, free
peer groups, 12 step, Social Model Group Therapy
– Outpatient treatment, half-way houses, residential
programs
– Long-term residential (2 or more years) and 7-day
hospital Detox with aftercare
– Methadone maintenance or harm reduction
• Acupuncture, aversion therapies, etc.
– Addicts drop-out from TX centers that they feel
uncomfortable in or not relevant to their problems
Treatment Options
• Medical Model Detoxification Programs
– Supervised and managed by medical professionals:
hospital inpatient, residential or outpatient
• Office-based medical detoxification and
maintenance treatment for opiate abuse
– Qualified private medical practitioners
• Social model detox programs
– Nonmedical programs: in or out patient
• Social Model Recovery Programs
– Uses a variety of approaches to move a client
towards recovery
Treatment Options
• Therapeutic Communities
– Generally long-term (1-3 years)
– Self contained residential programs that provide full
rehabilitation and social services
• Halfway Houses
– Permits addicts to keep their jobs and outside
contacts while being involved with residential
treatment program
• Sober Living or Transitional-living Programs
– Consists of apartments or cooperative living groups of
recovering addicts who have completed a long-term
residential program
Treatment Options
• Partial Hospitalization and Day Hospitals
– Medical outpatient programs that involve patients in
therapeutic activities for 4-6 hours per day while living
at home
• Intensive Outpatient
– 6-8 hours per week
• Harm Reduction programs
– Mainly pharmacotherapy maintenance
• Admissions in 2000
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1.6 million treated in various facilities
Estimates that 2 million need treatment
3.5 million need some care
12,000 on Big Island in need of treatment
Only 56 CSACs on Big Island
Treatment Options
• Hitting Bottom
– Necessary since addiction is progressive
disease
– If early detection is recognized, then chances
of recovery is better
• Denial
– Refusal to acknowledge the negative impact
on life
• Breaking Through Denial Intervention
– Difficult but necessary since self-diagnosis is
needed for treatment to be effective
Treatment Options
• Intervention
– Strategy to confront denial in drug abusers
– Consists of members (family, friends, coworks, etc.)
– Facilitator prepares members to expect
defense mechanisms like denial,
rationalization, minimization, anger,
accusations
– Timing, location and surprise is crucial
– Successful or not, it is essential that group
members continue to meet
Treatment Options
• Detoxification
– Helps to normalize client’s thinking processes
so they can full participate in Treatment
– Takes about a week to excrete cocaine
– Takes about 4 weeks to 10 months until the
body chemistry settles down
– Medically or chemically assisted detox is
aimed at minimizing life-threatening
withdrawal symptoms
– Assessment of severity is important to
determine if detox is necessary
Treatment Options
• Medication therapy for detox for cocaine,
methamphetamine and other stimulants
include:
– Phenobarbital
– Clonidine
– Buprnorphine
– Naltreone
– Antipsychotic and antidepressants
• Anabuse for prevention of alcohol relapse
• Psychotherapy is also important during the
detox phase
Treatment Options
• Initial Abstinence
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Environmental triggers can trigger relapse
HALT (hungry, angry, lonely, tired)
RID (restless, irritable, discontent)
Addicts and alcoholics must learn about their triggers
and what precipitates a relapse
– Cue (Triggers) Extinction Therapy
• Addicts/alcoholics learn about cues and drug using situations
that increase cravings then desensitize them through
education, biofeedback or talk down
– Psychosocial support
• Clients Build a sober support network that will give them
continuing advice
– Acupuncture; relief withdrawal symptoms by
stimulating the peripheral nerves that send messages
to release endorphins that promote wellbeing
Treatment Options
• Long-term Abstinence
– Succeeds through continued participation in
group, family, and 12 Step meetings
– Addict must accept that addiction is:
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Chronic
Progressive
Incurable
Potentially fatal
Relapse is always possible
Compulsive addicts that switch drugs always find
that the same symptoms resurface in the new drug
Treatment Options
• Recovery
– Recovering addicts need to reconstruct their
lives and find things they enjoy doing that give
them satisfaction & natural highs
• Outcomes and follow-up
– Evaluations of outcomes are important to
determine treatment success or failure and
adjustments made
– Aftercare is most important part of treatment.
Individual Therapy
• Individual Therapy
– Effective because counselors work one-on-one
– Allows the counselor and client to evaluate treatment
progress
– Allows counselor and client to develop short and long
term goals
– Allows counselor and client to identify other issues
client needs to work on
– Provides a written documentary of counselor and
client interaction
– Less Threatening
Individual Therapy
• Individual Therapy
– Cognitive behavioral therapy (CBT)
• Looking at belief systems and changing them
• Internal dialogue
• Examining faulty assumptions and misconceptions and
replacing these with effective beliefs
– Cognitive Restructuring (REBT)
• A, B, C, D, & F Theory of Personality (Albert Ellis)
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Activating event
Belief of this event
Emotional and behavioral consequence
Disputing the event
Effect
New Feeling
Individual Therapy
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Cognitive Restructuring
1. Fully acknowledging that we are responsible for
creating our emotional problems
2. Accepting the notion that we have the ability to
change these disturbances
3. Recognizing that our emotional problems stem from
irrational beliefs
4. Clearly perceiving these beliefs
5. Seeing the value of disrupting faulty thinking
6. Accepting that if we expect to change we need to
work hard on changing beliefs and faulty thinking
7. Continuing to practice REBT methods is essential to
recovery
Individual Therapy
• Reality Therapy
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People have the capacity to make healthy choices
Each person creates their lifestyle
Active and Directive Therapy
Debating irrational beliefs
Homework assignments
Keeping records of activities
Learning new coping skills
Changing one’s language and thinking patterns
Role play & imagery
Confronting faulty beliefs
Aversion Therapy
Assertiveness Training
Social Skills Training Motivational Interviewing
Individual Therapy
• Motivational Interviewing
– Counselor Skills
• Express empathy
– See the world through the client’s eyes
– Reflective listening
• Roll with the Resistance
– Resistance is not challenged
– Help the client explore the client’s ideas
• Develop discrepancy
– Help the client recognize where they are and where they want
to be
– See how their current actions will not lead them to their goals
• Support self-efficacy
– Empower clients to chose their own options
– Counselor encourages them to change
Individual Therapy
• Motivational Interviewing
– Pre-contemplation
• Client will not admit they have a problem although others see they
do
• Counselor’s task is to raise doubt in client
– Contemplation
• Client begins to think he/she may have a problem
• Counselor can evoke reasons to change by showing risks of not
changing
• Strengthen the reasons to change
– Determination
• The client decides to do something to change
• Counselor helps the client choose options
– Action
• The client chooses a strategy to change and pursues it
• Counselor helps the client take those steps
– Maintenance
– Client works on and maintaining change strategies
Group Therapy
• Major Focus is to have clients help each other to
break the isolation of chemical dependency
• The group is the catalysis for change
• Facilitated Groups
– 6 or more clients who meet with one or more
therapists daily, weekly or monthly basis
• Peer Groups
– Therapist plays less of an active role, usually
observing the process. Do not direct or lead group
– Self-help Groups
• 12 Step Groups: Solving problems through personal spiritual
change
– Educational Groups
• Counselors provide psychoeducational groups that teach skill
building
Group Therapy
• Targeted Groups
– Directed at a specific population of users
• women's, men's, adolescents, gay and lesbians,
dual diagnosis, etc
• Topic Specific Groups
– Different Issues: relapse prevention, AIDS,
recovery maintenance, relationships, etc.
• Group Therapy promotes better outcomes
and sustain abstinence more than
individual counseling
10 Common Errors Made by Beginning
Counselors
1. Failure to have realistic view of group
treatment
2. Self-disclosure issues and failure to drop
the “mask” of professionalism
3. Agency culture issues and personal style
4. Failure to understand the stages of
therapy
5. Failure to recognize counter-transference
6. Failure to clarify group rules
10 Common Errors Made by Beginning
Counselors
7. Failure to do Group Therapy by Focusing
on Individual Problem
8. Failure to Plan in Advance
9. Failure to integrate new members
10. Failure to understand interactions in the
group as a metaphor for drug-related
issues occurring in the group member’s
family of origin
Family Therapy
• Addiction is a family disease, and drugs and
alcohol affect the client’s family
• Family is often ignored
• Goals of Family Treatment
– Acceptance by all family members that addiction is a
treatable disease not a sign of moral weakness
– Establishing and maintaining a drug-free family
– Developing a system for family communication
– Processing the family’s readjustment
• Tough Love
– Family learns to establish limits for their interaction
with addict
Children of Addicts and Adults Children of
Addicts
• Model Child
• High achievers: represents family
• Problem Child or scrape goat:
– has multiple personal problems
• Lost Child
• Disconnected from family: avoids emotional
confronting issues
• Mascot Child or Family Clown
• Uses avoidance to make everything trivial
• Well liked
Children of Addicts and Adults Children of
Addicts
• Most children of alcoholics and addicts
also are:
– Isolated and afraid
– Approval seekers
– Frightened by angry people
– Become or marry alcoholics
– Feel guilty when standing up for themselves
– Become addicted to excitement or stimulation
– Confuse pity and love
– Repress feelings from traumatic childhoods
– Judge themselves harshly
Target Populations
• Women
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Women tend to progress faster to addiction
Die younger
Less likely to ask for help
Internalize blame
Has less support from family members
Lacks childcare to enter treatment
Difficulty recognizing need for treatment
• Men
– More likely to enter treatment from criminal justice
system
– Tend to blame things on external events
Target Populations
• Older People
– Less likely to seek treatment or ask for help
– Addiction is seen as aging process or reaction
to medicine
– Few treatment programs aimed toward older
people
• Ethnic Groups
– Treatment geared to specific ethnic groups
tends to promote continued abstinence
– Cultural competence important
Target Populations
• African Americans
– 24% of admissions to publicly funded facilities
– Have higher threshold for pain
– Greater tolerance for delays for treatment
– In some urban areas, high rate African
American babies are born tox positive for
drugs
– Teenagers have a greater risk of dying from
crack cocaine
– More in jail for drugs than in college
Target Populations
• Asian & Pacific Islanders
– Respond better to credentialed professionals
than peers
– Prefer individual counseling
– Rely more on their own responsibility to
handle their addiction rather than higher
power
– Have strong gender rules, so separate male
and female groups are better
– Family shame often keeps the family enabling
and rescuing the addict
Target Populations
• Bicultural and bilingual treatment personal
greatly increase the chances of successful
treatment
• Incorporates cultural traditions
– Healing
– Talking circles
– Purification ceremonies
– Meditative practices
– Sweat lodges
– Shamanistic ceremonies
– Community Singing Ceremonies
Target Populations
• Physical disabilities
– Much-neglected population
– Counselor may focus too much on the
disability and miss the signs and symptoms of
relapse
– Not take into account the extra stress from the
disability
• Gay and Lesbian
– 20-25% are heavy alcohol users
– High incidence of HIV/AIDS in gay male
community
Treatment Obstacles
• Denial and lack of financial resources
• Use of psychoactive drugs can delay
user’s emotional development
• Keep them from learning how to deal with
life problems
• Poor follow through or monitoring
– Drop out or lack of compliance
– Conflicting goals
• Lack of Treatment Resources