Download Module Four - Central Texas College

DAAC 1319: Intro to AOD
Module Three Notes
Understanding Special Populations & Diversity
Module Three:
Understanding Special Populations & Diversity
Adolescents
In terms of public health, adolescent substance use disorders have far-reaching social and economic
ramifications. The numerous adverse consequences associated with teenage drug abuse include:
· fatal and nonfatal injuries from alcohol and drug related motor vehicle accidents (the number one
killer of young people today);
· homicides (the number 2 killer of young people);
· suicides (while suicide is the number 3 killer of young people, some form of drug use is involved in the
majority of suicides both committed and attempted by this age group);
· violence;
· delinquency;
· psychiatric disorders;
· and risky sexual practices (it is important to note that HIV/AIDS is the number 6 killer of young
people).
Substance use by young people is on the rise, and initiation of use is occurring at ever-younger ages. Patterns
of substance use over the past 20 years have been documented by two surveys--the National Household
Survey on Drug Abuse conducted by the Substance Abuse and Mental Health Services Administration
(SAMHSA) and the Monitoring the Future Study conducted by the National Institute on Drug Abuse (NIDA).
Data released in 1996 indicated that in the early to mid-1990s, the percentage of 8th graders who reported
using illicit drugs (i.e., drugs illegal for Americans of all ages) in the past year almost doubled, from 11.3
percent in 1991 to 21.4 percent in 1995. Drug use by high school students also has risen steadily since 1992.
The survey also indicates that 33 percent of 10th graders and 39 percent of 12th graders reported the use of
an illicit drug within the preceding 12 months. These estimates are probably low because the statistics are
gathered in schools and do not include the high-risk group of dropouts.
An estimated 15 percent of 8th graders, 24 percent of 10th graders, and 30 percent of 12th graders reported
having had five or more drinks within the preceding 2 weeks. Slightly more than half of high school students
(grades 9 through 12) reported having had at least one drink of alcohol during the past 30 days. It is further
estimated that 9 percent of adolescent girls and up to 20 percent of adolescent boys meet adult diagnostic
criteria for an alcohol use disorder. Furthermore, the proportion of daily smokers among American high school
seniors remains disturbingly high at about 20 percent.
The surveys have found that the perceived risk of harm from drug involvement has been declining while the
availability of drugs has been rising. Particularly in the case of marijuana, sharp declines in harm perception
have been observed among 8th, 10th, and 12th graders. This shift has occurred at the same time that
marijuana use has spread. Since 1991, the percentage of students who thought that regular marijuana use
carries a "great risk" of harm has dropped from 79 percent to 61 percent among 12th graders, from 82 percent
to 68 percent among 10th graders, and from 84 percent to 73 percent among 8th graders. During the same
period, reported use of marijuana within the preceding year rose for all these grades by an average of 11
percent.
Household products are abused as well as illegal drugs: The percentage of youths 12 to 17 years old who tried
inhalants rose from 1.1 percent in 1991 to 2.2 in 1994. "Heroin chic" as exemplified by rock stars and fashion
models has boosted the popularity of that drug among young people. Surveys reported that in some areas, the
adolescent use of heroin mixed with water and then inhaled has increased. Clearly, drug use trends among
young people are a major national concern. Within the context of national surveys of frequency of use, the
prevalence of those meeting criteria for a diagnosis is becoming clearer.
The Consequences
In terms of public health, adolescent substance use disorders have far-reaching social and economic
ramifications. The numerous adverse consequences associated with teenage drinking and substance use
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DAAC 1319: Intro to AOD
Module Five Notes
disorders include fatal and nonfatal injuries from alcohol- and drug-related motor vehicle accidents, suicides,
homicides, violence, delinquency, psychiatric disorders, and risky sexual practices. Longitudinal studies have
established associations between adolescent substance use disorders and (1) impulsivity, alienation, and
psychological distress, (2) delinquency and criminal behavior, (3) irresponsible sexual activity that increases
susceptibility to HIV infection, and (4) psychiatric or neurological impairments associated with drug use,
especially inhalants, and other medical complications.
Substance use disorders that begin at an early age, especially when there is no remission of the disorder,
exact substantial economic costs to society. The trend toward early onset of substance use disorders has
increasingly resulted in adolescents who enter treatment with greater developmental deficits and perhaps
much greater neurological deficits than have been previously observed. Moreover, the risks of traumatic injury,
unintended pregnancy, and sexually transmitted diseases (STDs) are high in adolescents in general. Drug
involvement that is superimposed on these already high risks has numerous potentially adverse
consequences that have not yet been the subject of in depth study beyond basic population studies.
Mortality
Alcohol-related motor vehicle accidents exact a heavy toll on society in terms of economic costs and lost
productivity. Nearly half (45.1 percent) of all traffic fatalities are alcohol-related, and it is estimated that 18
percent of drivers 16 to 20 years old--a total of 2.5 million adolescents--drive under the influence of alcohol.
According to the Youth Risk Behavior Surveillance System conducted by the CDC, which monitors health risk
behaviors among youths and young adults, unintentional injuries, including motor vehicle accidents, are by far
the leading cause of death in adolescents, causing 29 percent of all deaths. An estimated 50 percent of these
deaths are related to the consumption of alcohol.
Sexually Risky Practices
Adolescents are at higher risk than adults for acquiring STDs for a number of reasons. They are more likely to
have multiple (sequential or concurrent) sexual partners and to engage in unprotected sexual intercourse.
They are also more likely to select partners who are at higher risk for STDs. Among females, those 15 to 19
years old have the highest rates of gonorrhea, while 20- to 24-year-olds have the highest rate of primary and
secondary syphilis.
Adolescents who use alcohol and illicit drugs are more likely than others to engage in sexual intercourse and
other sexually risky behaviors. A positive correlation has been demonstrated between alcohol use and
frequency of sexual activity. In a Massachusetts survey of adolescents 16 to 19 years old, two-thirds reported
having had sexual intercourse, 64 percent reported having sex after using alcohol, and 15 percent reported
having sex after using drugs.
Providers of adolescent treatment for substance use disorders must sometimes grapple with these two
questions:
· Can the provider admit an adolescent into the treatment program without obtaining the consent of a
parent, guardian, or other legally responsible person?
· How can substance use disorder treatment programs communicate with others concerned about an
adolescent's welfare without violating the stringent Federal regulations protecting confidentiality of
information about clients?
The answers to these questions are especially complex for those who treat adolescents for substance use
disorders because a mix of Federal and State laws govern these areas; "adolescence" spans a range of ages
and competencies; and the answer to each question may require consideration of a matrix of clinical as well
as legal issues.
Consent to Treatment
Americans attach great importance to being left alone. They pride themselves on having perfected a social
and political system that limits how far government and others can control what they do. The principle of
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DAAC 1319: Intro to AOD
Module Five Notes
autonomy is enshrined in the Constitution, and U.S. courts have repeatedly confirmed Americans' right to
make decisions for themselves. This tradition is particularly strong in the area of medical decision making: An
adult with "decisional capacity" has the unquestioned right to decide which treatment he will accept or to refuse
treatment altogether, even if that refusal may result in death.
The situation is somewhat different for adolescents because they do not have the legal status of full-fledged
adults. There are certain decisions that society will not allow them to make: Below a certain age (which varies
by State and by issue), adolescents must attend school, may not marry without parental consent, may not
drive, and cannot sign binding contracts. Adolescents' right to consent to medical treatment or to refuse
treatment also differs from adults'. Whether a substance use disorder treatment program may admit an
adolescent without parental consent depends on State statutes governing consent and parental notification in
the context of substance use disorder treatment and a number of fact-based variables, including the
adolescent's age and stage of cognitive, emotional, and social development. Although it may make clinical
sense to obtain consent for treatment from an underage adolescent, it is relevant to consider the wide range of
factors that contribute to a program's decision to admit an adolescent for treatment without parental consent.
State Laws
More than half the States, by law, permit adolescents less than 18 years of age to consent to substance use
disorder treatment without parental consent. In these States, providers may admit adolescents on their own
signature. (The important question of whether the provider can or should inform the parents is discussed
below.)
In States that do require parental consent or notification, a provider may admit an adolescent when there is
parental consent or (in those States requiring notification) when the adolescent is willing to have the program
communicate with a parent. Presumably, a parent whose child seeks treatment will consent. (A parent or
guardian who refuses to consent to treatment that a health care professional believes necessary for the
adolescent's well-being may face charges of child neglect.)
The difficulty arises when the adolescent applying for admission refuses to permit communication with a
parent or guardian. As is explained more fully below, with one very limited exception, the Federal
confidentiality regulations prohibit a program from communicating with anyone in this situation, including a
parent, unless the adolescent consents. The sole exception allows a program director to communicate "facts
relevant to reducing a threat to the life or physical well-being of the applicant or any other individual to the
minor's parent, guardian, or other person authorized under State law to act in the minor's behalf," when the
program director believes that the adolescent, because of extreme youth or mental or physical condition, lacks
the capacity to decide rationally whether to consent to the notification of her parent or guardian. The program
director believes the disclosure to a parent or guardian is necessary to cope with a substantial threat to the life
or physical well-being of the adolescent applicant or someone else.
Impact of Chemical Dependency on Adolescent Development
Cognitive Development
·
Continuation of personal fable thinking.
· Distorted cognition as a result of the adolescent delusional system.
· Interferes with maturation of abstract thinking.
· Limited life experiences prevent opportunity to develop or refine reasoning and thinking skills.
· Drug induced states perpetuates adolescents illusion of accomplishment.
Language Skills
· Language skills may be impeded by problems with recall, retrieval, and short term memory.
· Remain stuck in early adolescent phase in which they are more likely to use acting out behavior or
avoidance as opposed to language to deal with conflict.
· Language skills may be impacted because of decline of academic performance.
· Lack of adequate language skills present barriers in academic and interpersonal functioning and may
present limitation for adolescent, in engaging in and benefiting from treatment.
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DAAC 1319: Intro to AOD
Module Five Notes
Physical Development
· Adolescent avoids uncomfortable feelings about sexual development as apposed to mastering them
· Heavy use of marijuana at an early age interferes with the development of secondary sex
characteristics.
· Adolescents frequently engage in sexual activity for which they are emotionally unprepared.
· Adolescents do not obtain accurate sexual information.
· Adolescents do not develop appropriate outlets for sexual energy or control over sexual impulses.
· Adolescents are confused by sex roles and often experience guilt and shame regarding sexual
activity.
Role of The Family
· Adolescents avoid true separation task. They pretend to be declaring independence from family by
drug use, but continue to display behavior which will ensure parental over involvement in their lives.
· Adolescent ensures that no one will expect competency or independence from them.
· Adolescent avoids tasks of moving into young adulthood; thereby, ensuring continued and prolonged
dependency on their family.
· Adolescent is incompetent to meet their own needs.
· Emotional rifts caused by substance abuse may prevent peace making at the appropriate times.
Social Development
· Adolescent relies on drugs as primary relationship, drugs provide the experience that people should.
· Adolescent depends on chemicals to ease discomfort in social situations thereby not developing basic
social skills such as starting a conversation, dancing at parties, feeling that others like and accept
you.
· Adolescent may become involved in a peer group that remains narcissistic, lacks empathy for others,
and is based on drug using values.
· Adolescent remains stuck in developmental phase in which the most pathological peer has the most
power.
· Adolescent is not developing a self image, but rather works hard to develop a “druggie” facade.
· Adolescent avoids social realities such as rules, mores and values.
· Adolescent does not take the social risks necessary to grow and mature.
· Adolescent perceptions of others are distorted.
· Socialization is seriously impeded due to drug using peer group which sets standards and dictates
roles to the adolescent.
· Adolescent does not develop past egocentric state of early adolescence.
· Drug use provides a false sense of achievement.
Emotional Development
· Adolescent medicates emotions and does not learn emotional impulse control.
· Adolescent does not learn that they can manage emotions instead they continue to be afraid of their
feelings.
· Adolescent protects self from fear, feelings of isolation, anxiety, vulnerability, shame and quilt by
projecting blame and grandiose attitudes.
· Adolescent remains emotionally immature.
Academic Development
· Academic underachievement.
· Low energy level in regards to school or job performance.
· Ability to function impaired by use.
· Maintain false sense of accomplishment at school.
· Never matures past the "life has limitless possibilities" phase into the realization that the future
depends on one making responsible choices; or maintains an external locus of control that attributes
blame to the system for failing to meet their needs.
· Maintains immature attitude that they should not have to do this because it is boring.
· Remains suck in the critical thinking phase.
· Is exposed to easier ways to make money than working (i.e., selling drugs).
· Does not appreciate need to set goals and choose a vocation/career.
· May realize that they are not academically or vocationally equipped to move into adulthood, which in
turn contributes to low self-esteem.
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DAAC 1319: Intro to AOD
Module Five Notes
It is useful to characterize adolescent substance use behavior on a continuum of severity ranging from:
· abstinence;
· use: minimal or experimental use with minimal consequences;
· abuse: regular use or abuse with several and more sever consequences;
· abuse/dependence: regular use over an extended period with continued severe consequences;
· recovery: return to abstinence, with a relapse phase in which some adolescents cycle through the
stages again; and
· secondary abstinence.
Any response to an adolescent who is using substances should be consistent with the severity of drug
involvement. Youth treatment providers should be sensitive to the developmental differences among
adolescents and make necessary adjustments to accommodate such differences. The treatment needs and
techniques in working with a 13 year old should be different than those used in working with a 17 year old.
One of the factors that contribute to adolescents not being screened and diagnosed for substance use
disorders is that many health service providers, juvenile justice workers, educators and others who work with
at-risk youth have little or no training in these techniques and instruments. The juvenile justice systems should
screen all adolescents at the time of arrest or detention, to include status offenders. In addition all
adolescents receiving mental health assessments should be screened. Adolescents entering the child welfare
system; school dropouts in vocational, or alternative school programs; and runaway youth in emergency
shelters should be screened. Adolescents who present with substantial behavioral changes or needing
emergency medical services for trauma, or who suddenly begin to experience medical problems such as
accidents, injury, or gastrointestinal disturbances should be screened. In addition, schools should screen
youth who show increased oppositional behavior, significant changes in grade point average, and a great
number of unexcused school absences (TIP 31). Early identification and intervention is critical to prevent the
long term ramifications of a full blown substance use problem.
Women’s Issues
“Today we know that when a woman abuses alcohol or other drugs, the risk to her health is much greater than
it is for a man. Yet there is not enough prevention, intervention, and treatment targeting women. It is still
much harder for women to get help. That needs to change.”
Former First Lady Betty Ford, April 1995
Alcohol, tobacco, and other drug abuse can have devastating consequences on women’s health. Lung cancer
rates among females, for example, have increased six fold in the past 40 years. Lung cancer now has passed
breast cancer as the leading fatal cancer for women. Women who abuse alcohol and/or drugs are at
particular risk for: sexual assault; unprotected sex; unwanted pregnancies; sexually transmitted diseases,
including HIV/AIDS. The incidence of AIDS is increasing more rapidly among women than men, with
heterosexual contact rather than intravenous drug use fast becoming the primary method of transmission to
women. Some women use alcohol and drugs as a way of coping with past abuse. For example, childhood
sexual abuse is a strong predictor of later problem drinking. Alcohol is associated with domestic violence.
Over half of the defendants accused of murdering their spouses and almost half of the victims of spousal
murders were drinking alcohol at the time of the offense. Women become more intoxicated than men when
drinking identical amounts of alcohol. With lower water and higher fat contents in their bodies, the alcohol is
less diluted and therefore has a greater impact. Enzymes that help metabolize alcohol in the body are less
efficient in women than in men. Cirrhosis of the liver, a result of chronic alcohol consumption, occurs in
women after a shorter period of consumption than in men.
Adolescent girls are at particular risk for alcohol, tobacco, and other drug abuse:
· Adult males drink more than adult females, but young males and females consume similar amounts
of alcohol. Some surveys show more alcohol consumption among females 12-17 years old than
among males in the same age group.
· Among 12 to 17 year olds, females surpass males in the use of cigarettes, cocaine, crack, and
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DAAC 1319: Intro to AOD
Module Five Notes
·
·
prescription drugs for non-medical reasons.
Alcohol use by preteen girls can delay the onset of puberty, interfering with adolescent maturation.
Alcohol, cocaine, and/or opiates in high doses disrupt the menstrual cycle in women of child bearing
age, inhibiting ovulation and aversely affecting fertility and sometimes leading to early menopause.
Women are more likely than men to combine alcohol with prescription drugs. Dangerous alcohol-drug or
drug-drug interaction occurs more frequently in older than younger women for a number of reasons, including
declining health leading to more prescribed medications and inadequate communication among various
prescribing doctors.
Pregnancy provides a strong motivation for alcohol, tobacco, and drug using women to seek help. However,
fear of reprisals, legal interventions, and loss of child custody prevents many women from getting help. The
often punitive actions taken against women who seek treatment has served to deter many women of color and
poverty from treatment.
Short and Long Term Effects of Prenatal AOD Exposure:
The chart below shows possible consequences from the use of commonly abused substances by the mother
during pregnancy (CWLA, 1993).
Chemical
Effects on Newborn
Long-term Effects on Child
Alcohol and
other CNS
Depressants
·
·
·
·
·
·
·
·
low birth rate
respiratory difficulties
feeding problems
serious infections
sleep disturbances
Fetal Alcohol Syndrome (FAS)
Alcohol withdrawal
Fetal Alcohol Effects (FAE)
Range of problems from gross retardation
to subtle CNS deficits.
· Developmental problems may include:
- hyperactivity
- attention deficit
- language difficulties
- delayed maturation
· FAS children may have:
- poor muscle tone
- body control problems
- delayed mental development
- mental retardation
below
average
physical
growth
Marijuana
·
·
·
·
increased tremulousness
altered visual response
some withdrawal-like crying
sedation
·
Cocaine and
other CNS
Stimulants
·
increased risk of IUGR including
reduced head circumference and
prematurity
withdrawal symptoms
- tremors, crying shrilly, startling
- abnormal sleep/wake cycles
- feeding difficulties
- increased/decreased muscle tone
in rare cases, structural birth defects
of
the
genitourinary
tract,
cardiovascular
system,
central
nervous system and extremities,
Research has not had time to evaluate
long term impacts. Effects may carry over
into childhood with CNS organization
challenges including:
· behavior and attention deficits
· impulsivity
· tantrum behaviors
·
·
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Symptoms disappear shortly after
birth with no known long term effects.
DAAC 1319: Intro to AOD
Module Five Notes
seizures
Narcotics
·
·
·
·
·
IUGR
prematurity
SIDS
Strabisms (visual disorder mainly
related to methadone)
dramatic withdrawal symptoms:
- restlessness/disturbed sleep
- tremors
- poor feeding, vomiting, diarrhea
- fever, irregular breathing,
- seizures, hiccups, irritability
Severely affected children experience:
· uneven motor coordination
· hyperactivity
· attention disorders
· impulse control difficulties
· slowed psychomotor development
· speech problems
· 5 to 10 % increase in the rate of SIDS
· increased rate in infant HIV
Barriers to Treatment For Women
There are a number of barriers that prevent women access to treatment services. These include but are not
limited to: stigma associated with addiction within certain cultural groups; shame associated with sexual abuse
issues; child care issues; financial resources; lack of programs designed to address the unique issues faced
by women; appropriate aftercare services; links by treatment providers to resources serving women; and lack
of effective case management services. In addition to these barriers, women who often need these services
are unaware that they exist. Non-profit organizations historically have had difficulty in creating appropriate
marketing strategies to reach the populations they serve.
Two critical issues often faced by women seeking treatment include domestic violence, and sexual abuse.
Treatment Improvement Protocol (TIP) Series 25, Substance Abuse Treatment and Domestic Violence looks
at the impact of domestic violence on women and its implication for substance abuse treatment providers.
This TIP is an excellent source of information. Specific recommendations can be found on screening, referral
and treatment of survivors of domestic violence.
Domestic violence
In the United States, a woman is beaten every 15 seconds. At least 30 percent of female trauma patients
(excluding traffic accident victims) have been victims of domestic violence, and medical costs associated with
injuries done to women by their partners total more than $44 million annually. Much like patterns of substance
abuse, violence between intimate partners tends to escalate in frequency and severity over time. "Severe
physical assaults of women occur in 8 percent to 13 percent of all marriages; in two-thirds of these
relationships, the assaults reoccur". In 1992, an estimated 1,414 females were killed by "intimates," a finding
that underscores the importance of identifying and intervening in domestic violence situations as early as
possible.
An estimated three million children witness acts of violence against their mothers every year, and many come
to believe that violent behavior is an acceptable way to express anger, frustration, or a will to control. Some
researchers believe, in fact, that "violence in the family of origin [is] consistently correlated with abuse or
victimization as an adult". Other researchers, however, dispute this claim. The rate at which violence is
transmitted across generations in the general population has been estimated at 30 percent and at 40 percent.
Although these figures represent probabilities, not absolutes, and are open to considerable interpretation, they
suggest to some that 3 or 4 of every 10 children who observe or experience violence in their families are at
increased risk for becoming involved in a violent relationship in adulthood.
Identifying the Connections
Researchers have found that one fourth to one half of men who commit acts of domestic violence also have
substance abuse problems. A recent survey of public child welfare agencies conducted by the National
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DAAC 1319: Intro to AOD
Module Five Notes
Committee to Prevent Child Abuse found that as many as 80 percent of child abuse cases are associated with
the use of alcohol and other drugs, and the link between child abuse and other forms of domestic violence is
well established. Research also indicates that women who abuse alcohol and other drugs are more likely to
become victims of domestic violence and that victims of domestic violence are more likely to receive
prescriptions for and become dependent on tranquilizers, sedatives, stimulants, and painkillers and are more
likely to abuse alcohol. Other evidence of the connection between substance abuse and family violence
includes the following data:
·
About 40 percent of children from violent homes believe that their fathers had a drinking problem and
that they were more abusive when drinking.
·
Childhood physical abuse is associated with later substance abuse by youth.
·
Fifty percent of batterers are believed to have had "addiction" problems.
·
Substance abuse by one parent increases the likelihood that the substance-abusing parent will be
unable to protect children if the other parent is violent.
·
A study conducted by the Department of Justice of murder in families found that more than half of
defendants accused of murdering their spouses as well as almost half of the victims had been
drinking alcohol at the time of the incident.
·
Teachers have reported a need for protective services three times more often for children who are
being raised by someone with an addiction than for other children.
·
Alcoholic women are more likely to report a history of childhood physical and emotional abuse than
are nonalcoholic women.
·
Women in recovery are likely to have a history of violent trauma and are at high risk of being
diagnosed with posttraumatic stress disorder.
No less troubling is the impact of sexual abuse on female clients. It is not unusual for 40 % or more of the
women clients in a treatment program to have unresolved incest issues. Statistics show that one in every
three women in the general population will be assaulted sexually before the age of 18. Assessment
procedures must include questions to evaluate if either domestic violence or sexual abuse are issues for each
woman. If uncovered, the program must be prepared to make appropriate referrals to other community
providers who specialize in these areas. LCDC’s are not qualified to address sexual abuse issues, in fact any
counselor who has not had significant specialized training in this area can cause more harm than good.
Lesbian, Gay & Bisexual Youth/Adults (LGBT)
Research has found that gay, lesbian, and bisexual Americans are at increased risk for alcohol and other drug
problems. This population remains misunderstood and undeserved. Few prevention or treatment programs
address risk factors for this group. These factors include:
·
history of family alcohol and other drug problems
·
physical, sexual or psychological abuse and victimization
·
school drop-out
·
attempted suicide
·
low self-esteem/self-efficacy
·
inadequate social services
·
homelessness
·
pro-use norms within their group
·
lack of role models
It is not enough to assume that gay, lesbian, and bisexual youth and adults are included in other high-risk
category prevention and treatment programs. Their vulnerability to alcohol and other drug use is unique and
exacerbated by feelings of rejection by their environment and self. They often feel rejected because of their
sexual orientation, over which they have no control.
The Connection Between Substance Use Among LGBT Populations
A tremendous controversy exists over the exact rates of substance use within lesbian, gay, bisexual, and
transgender populations (LGBT). It is frequently reported that people who are LGBT experience increased
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Module Five Notes
risk for substance use and abuse. Many sources report that one out of every three gay men and lesbians, or
over 8 million LGBT men and women, struggle with alcohol and drug-related problems. But, this data is not
universally accepted. Other research studies have found that moderate alcohol use rates in the LGBT
communities are similar to those of the mainstream populations, but that the LGBT population is
over-represented on both ends of the spectrum (those who abstain and those who are heavy drinkers). More
research is needed in order for prevention and treatment efforts to target these communities effectively!
Three main factors have made it difficult to determine the extent of the substance use and abuse in LGBT
populations.
·
No one can say with certainty the number of individuals who are LGBT.
·
Alcoholism, drug abuse, and addiction have only recently been highlighted as significant social
problems.
·
Denial and secrecy commonly characterize alcoholism and drug abuse in all populations.
Why is it Important to Develop and Implement Specific LGBT Programs? According to health professionals, it
is crucial for outreach and prevention programs to reach people where they are. Counselors and service
providers need to be sensitive to the issues faced by the LGBT population, and treatment facilities need to
accept them without discrimination, without denying their sexuality, and without attempts to "cure" their sexual
preference. LGBT-specific programs also lend assistance in establishing new social and emotional networks
to maintain recovery and provide support from members of their community in maintaining a sober, drug-free
life.
In addition to issues of social and family rejection, reality is that many counselors are unprepared to serve
these clients. Homophobia is not limited to the general population. It is critical that you examine your values
and biases on this subject. The reality that you will work with clients whose sexual orientation may be different
than your own can not be avoided. Only through self-awareness will you be able to prepare yourself to serve
these clients fairly and effectively. Having a general understanding of heterosexism and homophobia is
important in working with LGBT individuals. Heterosexism and homophobia describe the forms of bigotry
against LGBT people. Heterosexism resembles racism or sexism and denies, ignores, denigrates, or
stigmatizes non-heterosexual forms of emotional and affectional expression, sexual behavior, or community.
Homophobia is defined as the irrational fear of, aversion to or discrimination against LGBT behavior or
persons. Internalized homophobia describes the self-loathing or resistance to accepting an LGBT sexual
orientation and is an important concept in understanding LGBT clients.
Legal Issues
Although Federal and a number of State statutes protect recovering substance abusers from many forms of
discrimination, LGBT individuals are not afforded the same protections in many areas of the country.
Disclosure of one’s sexual orientation can lead to employment problems or the denial of housing and social
services. LGBT individuals may lose custody of their children if their sexual orientation becomes known during
a custody dispute. Even in those States that have enacted statutes prohibiting discrimination on the basis of
sexual orientation, LGBT individuals have sometimes been denied protection. LGBT individuals regard
protecting information about their sexual orientation and substance abuse histories as critically important.
Programs that treat this population must be particularly sensitive about maintaining clients’ confidentiality,
because the consequences of an inappropriate disclosure can be devastating.
Treatment Issues
The term “coming out” refers to the experiences of some, but not all, gay men and lesbian women as they
explore their sexual identity. There is no correct process or single way to come out, and some LGBT
individuals do not come out. This process is unique for each individual, and it is the choice of the individual. A
counselor may do harm if he or she forces openness by questioning a client’s sexuality before the client is
ready.
Providing support for LGBT clients and their families is a significant element of substance abuse treatment.
Like other clients, LGBT individuals in treatment are involved in multidimensional situations and come from
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DAAC 1319: Intro to AOD
Module Five Notes
diverse family backgrounds. A family history and a review of the dynamics of the family of origin are part of a
thorough biopsychosocial assessment. Counselors need an understanding of the dynamics of LGBT
interpersonal relationships. This understanding includes awareness of the internal and external problems of
same-sex couples and the diversity and variety of relationships in the LGBT community. Although many
individuals have a life partner, others are single or in non-traditional arrangements. Counselors need to be
aware of their own biases when working with individuals who find themselves outside the cultural norm of a
heterosexual, monogamous, and legally sanctioned marriage.
LGBT individuals may be victims of anti-gay violence and hate crimes such as verbal and physical attacks.
Some victims may turn to alcohol or drugs as a coping method. It is important that substance abuse
counselors obtain training and education about interpersonal violence and stigmatized client populations.
Lesbians resemble other women in that their patterns of substance use vary. However, fewer lesbians than
heterosexual woman abstain from alcohol; rates of reported alcohol problems are higher fro lesbians than for
heterosexual women; and drinking, heavy drinking and problem drinking show less decline with age among
lesbians than among heterosexual women. Risk factors for abusing alcohol include relying on women’s bars
for socializing and peer support; the negative effects of sexism and heterosexism; additional stressors related
to coming out or “passing” as heterosexual; and the effects of trauma from violence or abuse. The trauma
experienced by some lesbians may affect their behavior and emotional state. One study reported that 21 % of
lesbians were sexually abused as children and 15 % were abused as adults.
In spite of growing acceptance of gay people, social outlets for gay men still tend to be limited. The “gay
ghetto,” the section of town where gay people feel comfrotable, usually is identified by the presence of gay
bars. The number of gay coffee shops, bookstores, and activities that involve alcohol and drug use is
increasing, but gay bars and parties that focus on alcohol and drug use are still very visible elements of gay
social life.
HIV/AIDS continues to be a major factor in gay male fie. The percentage of HIV-infected people in the United
States who are gay has steadily dropped, but many gay men in treatment may be HIV sero-positive, have
AIDS, or have a sense of loss from losing friends. For some gay men, sex and intimacy may be disconnected.
Substance use allows them to act on suppressed or denied feelings but makes it harder to integrate intimacy
and sex.
Bisexual identity is not necessarily defined by sexual behavior. An assessment of a self identified bisexual
client includes sexual behavior and identity issues and the range of psychosocial issues that may complicate
substance abuse treatment. The current conceptualization of bisexuality is that it is a sexual orientation.
Counselors may have biases about bisexuals, believing that they are psychologically or emotionally damaged,
are developmentally immature, or have a borderline personality disorder, with changing poor impulse control
or acting-out behavior. Bisexuals may feel alienated not just form the heterosexual majority but also from the
lesbian and gay community. Internalized Biphobia may result in a struggle toward self-acceptance.
The psychiatric model views trans-sexualism as psychopathological and classifies it as a gender identity
disorder. Many in the transgender community disagree with this classification. Issues in substance abuse
treatment for transgender clients include societal and internalized trans-phobia, violence, discrimination, family
problems, isolation, lack of educational and job opportunities, lack of access to health care, and clients’ low
self-esteem. Many transgender people have had negative experience sight providers of health care, and they
may be distrustful of providers.
Hormone therapy is often overlooked as a clinical issue. Hormone treatment is a standard medical practice
for transsexuals, and clients may need assistance in maintaining regular legally prescribed hormone therapy
while in treatment for substance abuse. It is important that both the counselor and the client understand that
hormone therapies can affect mood, especially when taken improperly. Transgender clients may face and
additional risk from using “street” or “black market” hormones. Because testosterone must be injected,
obtaining or using needles may be relapse triggers for clients in early recovery. Logistics such as rest room
use and sleeping arrangements need to be sensitive to both transgender clients and other clients. Evidence
suggests that transgender individuals have a higher rate of exposure to violence and discrimination than
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lesbians and gay men, and such experiences can influence a transgender client’s ability to complete and
maintain successful recovery form substance abuse. Some transgender clients have been prostitutes or sex
workers, resulting in clinical issues that can also block recovery if they are not adequately addressed.
It is important that the counselor respect the client and his or her frame of reference; recognize the importance
of cooperation and collaboration with the client; maintain professional objectivity; recognize the need for
flexibility and be willing to adjust strategies in accordance with client characteristics; appreciate the role and
power of a counselor as a group facilitator; appreciate the appropriate use of content and process therapeutic
interventions; and be non-judgmental and respectfully accepting of the client’s cultural, behavioral, and value
differences.
Elderly
Alcohol and other drug abuse by the elderly is a largely hidden problem. While the rate of misuse and abuse
of prescription and other drugs is much higher for this age group than for younger adults, these problems are
less likely to be detected or treated. Relatively few chemically dependent elderly are treated in substance
abuse treatment programs.
Researchers are only beginning to realize the pervasiveness of substance abuse among people age 60 and
older; until relatively recently, alcohol and prescription drug misuse, which affects as many as 17 percent of
older adults, was not discussed in either the substance abuse or the gerontological literature.
The reasons for this silence are varied: health care providers tend to overlook substance abuse and misuse
among older people, mistaking the symptoms for those of dementia, depression, or other problems common
to older adults. In addition, older adults are more likely to hide their substance abuse and less likely to seek
professional help. Many relatives of older individuals with substance use disorders, particularly their adult
children, are ashamed of the problem and choose not to address it. The result is thousands of older adults
who need treatment and do not receive it.
Alcohol Abuse
Alcohol problems among the elderly are typically categorized into early and late onset alcoholism. Early onset
alcoholism is used to describe individuals who experienced chemical dependency problems in early and
middle adulthood that carried over into late adulthood. Late onset alcoholism refers to those who developed
chemical dependency problems later in life, in reaction to the stresses of aging.
Physiological changes, as well as changes in the kinds of responsibilities and activities pursued by older
adults, make established criteria for classifying alcohol problems often inadequate for this population. One
widely used model for understanding alcohol problems is the medical diagnostic model as defined in the
American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
(DSM-IV). The DSM-IV criteria for substance dependence include some that do not apply to many older adults
and may lead to under identification of drinking problems.
Some experts use the model of at-risk, heavy, and problem drinking in place of the DSM-IV model of alcohol
abuse and dependence because it allows for more flexibility in characterizing drinking patterns. In this
classification scheme, an at-risk drinker is one whose patterns of alcohol use, although not yet causing
problems, may bring about adverse consequences, either to the drinker or to others. As their names imply,
the terms heavy and problem drinking signify more hazardous levels of consumption. Although the distinction
between the terms heavy and problem is meaningful to alcohol treatment specialists interested in
differentiating severity of problems among younger alcohol abusers, it is less relevant to older adults. To
differentiate older drinkers it is recommended that the terms at-risk and problem drinkers be used.
Abuse of Prescription Drugs
Prescription medication misuse is the most common form of drug abuse among the elderly. Prescription
drugs are used by older people at much greater rates than other age groups. The elderly make up 11 % or
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the U.S. population, yet they account for 25 to 33 % of the prescription drugs used each year.
Estimates of chemical dependency problems among U.S. elderly rage from 2 to 10 %, or between 500,000
and 2.5 million people over the age of 55. Many life changing events place the elderly at risk for subs4+
nmnmnntance abuse problems. They retire and begin to outlive spouses, friends and family members. Not
only do they lose these significant others, but the life roles that these relationships represent. Limited financial
resources and physical ailments take their toll as well.
People 65 and older consume more prescribed and over-the-counter medications than any other age group in
the United States. Prescription drug misuse and abuse is prevalent among older adults not only because more
drugs are prescribed to them but also because, as with alcohol, aging makes the body more vulnerable to
drugs' effects.
Any use of drugs in combination with alcohol carries risk; abuse of these substances raises that risk, and
multiple drug abuse raises it even further. For example, chronic alcoholics who use even therapeutic doses of
acetaminophen may experience severe heap-toxicity. Alcohol can increase lithium toxicity and enhance
central nervous system depression in persons taking tricyclic antidepressants.
High doses of
benzodiazepines used in conjunction with alcohol or barbiturates can be lethal.
Benzodiazepines
Benzodiazepine use for longer than 4 months is not recommended for geriatric patients. Furthermore, among
the different benzodiazepines, longer acting drugs such as flurazepam (Dalmane) have very long half-lives
and are more likely to accumulate than the shorter acting ones. They are also more likely to produce residual
sedation and such other adverse effects as decreased attention, memory, cognitive function, and motor
coordination, and increased falls or motor vehicle crashes. By contrast, some shorter acting benzodiazepines
such as oxazepam (Serax) and lorazepam (Ativan) have very simple metabolic pathways and are not as likely
to produce toxic or dependence-inducing effects with chronic dosing.
Sedative/Hypnotics
Aging changes sleep architecture, decreasing the amount of time spent in the deeper levels of sleep (stages
three and four) and increasing the number and duration of awakenings during the night. However, these new
sleep patterns do not appear to bother most medically healthy older adults who recognize and accept that their
sleep will not be as sound or as regular as when they were young. Although benzodiazepines and other
sedative/hypnotics can be useful for short-term amelioration of temporary sleep problems, no studies
demonstrate their long-term effectiveness beyond 30 continuous nights, and tolerance and dependence
develop rapidly. It is recommended that symptomatic treatment of insomnia with medications be limited to 7 to
10 days with frequent monitoring and reevaluation if the prescribed drug will be used for more than 2 to 3
weeks. Intermittent dosing at the smallest possible dose is preferred, and no more than a 30-day supply of
hypnotics should be prescribed.
Identification of elderly in need of treatment is difficult because they are often retired, live away from their
families, do little or no driving, and participate in few social activities. This lack of coercive forces can make it
difficult to determine if a cd problem exists. Physicians and counselors also find it hard to differentiate between
cd problems and what would be normal physical and mental ailments for this age group. The elderly are often
viewed as poor treatment risks because society sees them as physically, mentally and economically unstable.
However, successful treatment and recovery are highly possible for this population if intervention and
treatment are designed to meet their needs.
Substance Abuse Among Older Adults, TIP 26 provides information on identification , screening, assessment
and treatment strategies for working with this population.
People with Disabilities
The burdens that alcohol, tobacco, and other drug problems pose are compounded when the individual is one
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of the estimated 43 million Americans who have one or more physical or mental disabilities. For these
individuals, the process of recovery is made more difficult by barriers that do not exist for others.
In 1990, Congress passed the Americans with Disability Act (ADA), which describes people with disabilities as
“a discrete and insular minority who have been subjected to a history of purposeful, unequal treatment and
relegated to an inferior status in our society.” Congress noted that people with disabilities face discrimination
in employment, housing, public accommodations, education, transportation, communication, recreation,
institutionalization, health services, voting, and access to public service.
Congress passed the ADA to eliminate major forms of discrimination against people with disabilities including
·
overprotective rules and policies;
·
segregation or relegation to lesser services or programs;
·
outright intentional exclusion;
·
exclusionary standards, and
·
architectural, transportation, and communication barriers.
Alcohol and drug problems are significantly more prevalent among people with disabilities. One possible
reason for increased problems is that regular use of prescription medication, both non-psychoactive and
psychoactive, may serve to potentiate the effects of drugs such as alcohol. Another reason may be that
alcohol, tobacco, and other drug problems that existed prior to the disability tend to continue and worsen.
In 1990, it was estimated that 36.1 million people in America (14.5 percent of the population) had a disability
that limited their functioning in some manner. A great number of people with disabilities have struggled for
years with barriers to employment, inaccurate and hurtful stereotypes, and inaccessible community services.
In order to redress these barriers that affect millions of Americans, President Bush in 1990 signed into law the
Americans With Disabilities Act (ADA), the most significant civil rights legislation in two decades. The
legislation prohibits discrimination on the basis of disability, including substance use disorders, and guarantees
full participation in American society, including access to community services and facilities, for all people with
disabilities. It makes provision for many accommodations that may be necessary in substance use disorder
treatment, such as the use of large print materials, reading services, attended care, adaptive equipment such
as listening devices, and flexible schedules to accommodate different physical needs. Because of this
legislation, many people today are more aware of the problems faced by people with physical and cognitive
disabilities.
Though the ADA is correcting the situation, many people with disabilities remain stigmatized and shut out.
They are also at much higher risk than the rest of the population for substance abuse or dependence. A study
of adult males receiving treatment for alcoholism, for instance, revealed that 40 percent had a history
indicative of learning disabilities. Another study indicated that at least one half of persons with a substance
use disorder and a coexisting disability are not being identified as such by the systems providing them
services.
New York State maintains within their Office of Alcoholism and Substance Abuse Services (OASAS) some of
the most comprehensive records in the country on substance use disorder services for persons with
disabilities. The OASAS client services statistics for 1997 showed that of 248,679 clients served by licensed
facilities in New York, a total of 55,719 (or 22.4 percent of the total clientele) were recorded as having a
coexisting physical or mental disability. Of these clients, 58.9 percent had a disability not related to mental
illness (e.g., mobility impaired, visually impaired, deaf). These records were generated by treatment staff
personnel who were not necessarily trained in disability assessment or by client self-reports, which suggests
that some disabilities (e.g., traumatic brain injury [TBI], learning disability, attention deficit/hyperactivity
disorder [AD/HD]) may be greatly under-reported. Given that these "hidden" conditions affect more than half of
all special education students, coexisting disabilities may actually affect up to 40 percent of all clients served
by substance use disorder treatment programs.
Yet despite the prevalence of substance use disorders among people with disabilities, these individuals are
less likely to enter or complete treatment. This is because physical, attitudinal, or communication barriers often
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limit their treatment options or else render their treatment experiences unsatisfactory.
Fortunately today, substance use disorder treatment providers are better able to face the challenges of
accommodating people with coexisting disabilities because they have already had the experience of making
treatment modifications for other constituencies. Over the past decades, the substance use disorder treatment
field has matured through the challenges of treating populations with specific needs, such as women,
adolescents, people from various racial and ethnic minority groups, and gay men and lesbians. The
effectiveness of treatment has improved as a result--it has become more developmentally and culturally
specific, flexible, and holistic. Rather than placing a person in an established treatment "slot," treatment
providers are learning the importance of modifying and adapting services to meet an individual client's needs.
Thus, the knowledge and skills necessary to adapt a treatment program to meet the needs of people with
coexisting disabilities are a logical extension of existing principles.
Disabilities: Diseases, disorders, and injuries, whether congenital or acquired, can have various effects on
organs and body systems. Conditions (and diseases) such as multiple sclerosis, TBI, spinal cord injury,
diabetes, and cerebral palsy can lead to impairments, such as impaired cognitive ability, paralysis, blindness,
or muscular dysfunction. These impairments in turn cause disabilities, which limit an individual's ability to
function in various areas of life, such as learning, reading, and mobility. While diseases, impairments, and
disabilities are distinct categories, they are often used interchangeably; to ensure clarity.
The field of disability services has developed its own terminology to discuss physical and cognitive disabilities,
and many substance use disorder treatment providers will not be familiar with these terms.
The World Health Organization (WHO) has devised a method for the classification of impairments and
disabilities. This complex system has been simplified here into four main categories:
·
Physical impairments are caused by congenital or acquired diseases and disorders or by injury or
trauma. For example, spinal cord injury is a disorder that can cause paralysis, an impairment.
·
Sensory impairments include blindness and deafness, which may be caused by congenital disorders,
diseases such as encephalopathy or meningitis, or trauma to the sensory organs or the brain.
·
Cognitive impairments are disruptions of thinking skills, such as inattention, memory problems,
perceptual problems, disruptions in communication, spatial disorientation, problems with sequencing
(the ability to follow a set of steps in order to accomplish a task), misperception of time, and
perseveration (constant repetition of meaningless or inappropriate words or phrases).
·
Affective impairments are disruptions in the way emotions are processed and expressed. For the
purposes of this discussion, affective impairments are considered to include problems caused by both
affective and mood disorders, such as major depression and mania. These impairments include the
symptoms of mental disorders, such as disorganized speech and behavior, markedly depressed
mood, and anhedonia (joylessness).
What Is the ADA?
The Americans With Disabilities Act of 1990 is the first federal law initiated and championed by persons with
disabilities. Unlike prior laws and regulations, the ADA puts the onus of accommodation on society rather than
the individual with a disability. The ADA guarantees equal opportunity for individuals with disabilities in public
and private sector services and in employment. It is a comprehensive anti-discrimination law which extends to
virtually all sectors of society and every aspect of daily living. The ADA is a federal civil rights act which
provides the same basic civil rights protections to persons with disabilities as afforded all other Americans.
The ADA is organized into five titles.
·
Title I: Employment--Employers with 15 or more employees must ensure that their employment
practices do not discriminate against qualified people with disabilities. (In California, this applies to
employers who have 5 or more employees.) Title I provides protection for job applicants and
employees during all phases of employment, including the application process, interviewing, hiring,
employment itself, and discharge from employment. Employers must also reasonably accommodate
the disabilities of qualified applicants and employees, unless an undue hardship would result.
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·
·
·
·
Title II: State and local government services--Requires that public programs and services be made
accessible to persons with disabilities. Mandates nondiscrimination on the basis of disability in policy,
practice and procedure. Prescribes a self-evaluation process, and requires that architectural and
communications barriers be removed to the extent required to provide full access to program
services.
Title III: Public accommodations--Title III requires places of public accommodation to be accessible
to, and usable by, people with disabilities. Places of public accommodation are all private businesses
and privately owned and operated programs that offer goods and services to the general public. Title
III entities must not discriminate by excluding people with disabilities, treating them separately, or
requiring them to participate in separate programs. Reasonable modifications must be made to
policies, practices, and procedures so that people with disabilities may participate. Auxiliary aids and
services that ensure effective communication with people with disabilities must also be provided so
long as they do not create an undue burden or fundamentally alter the services that the program
offers. New construction must be barrier free. In existing buildings, architectural barriers to disability
access must be removed when it is readily achievable. "Readily achievable" means "easily
accomplishable and able to be carried out without much difficulty or expense." Programs must review
possible readily achievable barrier removal on an ongoing basis, typically annually or with each new
program budget.
Title IV: Telecommunications--Title IV has mandated the establishment of a national network of
telecommunication relay services that is accessible to people who have hearing and speech
disabilities. It also requires captioning of all federally funded television public service announcements.
Title V: Non-retaliation, and other provisions--Title V explicitly prohibits retaliation against people
exercising their rights under the ADA. It sets forth specific responsibilities for the adoption of
enforcement regulations by federal agencies. It also includes a number of miscellaneous provisions.
The ADA includes a set of architectural standards called the Americans With Disabilities Act Accessibility
Guidelines (ADAAG). All Title II and Title III entities must comply with ADAAG requirements for new
construction and alteration building projects. In California, public and private building projects must also
comply with state accessibility regulations (Title 24). Title 24 has recently been revised to incorporate
specifications found in the ADAAG. The Equal Employment
Opportunity Commission and the U.S. Department of Justice have been designated as the lead ADA
enforcement agencies. The Architectural and Transportation Barriers Compliance Board develops
accessibility guidelines (architectural standards) for enforcement of the Act.
Clients in the Criminal Justice System
Another category of special needs clients are those who are involved in the criminal justice system. On any
given day, some 1.7 million men and women are incarcerated in Federal and State prisons and local jails in
the United States. Recent studies suggest that more than 80 % of them are involved in substance use.
Substance use disorders disproportionately affect incarcerated Americans. Although prison substance use
disorder programs annually treat more than 51,000 inmates, this figure represents less than 13 % of the
offender population identified as needing treatment. Studies also indicate that with the exception of
detoxification most offenders have never received treatment in the community. Offenders with substance use
disorders not only crowd the nation’s prisons, they are also responsible for a disproportionate amount of crime
and for relatively violent crime. Compared to offenders who do not use drugs, drug-using “violent predators”
commit many more robberies, burglaries, and other thefts (TIP 30) @ www.health.org/survey/30.htm .
On any given day, some 1.7 million men and women are incarcerated in Federal and State prisons and local
jails in the United States, and a recent study suggests that more than 80 percent of them are involved in
substance use. In 1996 alone, taxpayers spent over $30 billion to incarcerate these individuals -- who are the
parents of 2.4 million children. Put another way, one of every 144 American adults is behind bars for a crime in
which substances are involved.
By a variety of measures, it is clear that substance use disorders disproportionately affect incarcerated
Americans. Yet this population is significantly under treated: Although prison substance use disorder programs
annually treat more than 51,000 inmates, this figure represents less than 13 percent of the offender population
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identified as needing treatment. Studies also indicate that (with the exception of detoxification) most offenders
have never received treatment in the community. Clearly, the majority of individuals in the criminal justice
system in need of substance use disorder treatment are not receiving services either while they are
incarcerated or after release to the community.
Providing substance use disorder treatment to offenders is good public policy. Recent research shows that
punishment is unlikely to change criminal behavior, but substance use disorder treatment that also addresses
criminal behavior can reduce recidivism. Inmates with substance use disorders are the most likely to be
re-incarcerated again and again and the length of their sentences continually increases. The more prior
convictions an individual has, the more likely he has a substance use disorder. In State prisons, 41 percent of
first offenders have used drugs, compared to 63 percent of inmates with two prior convictions and 81 percent
of inmates with five or more prior convictions. Half of State parole and probation violators were under the
influence of drugs, alcohol, or both when they committed their new offense. State prison inmates with five or
more prior convictions are three times more likely than first-time offenders to be regular crack cocaine users.
Offenders with substance use disorders not only crowd the nation's prisons, they are also responsible for a
disproportionate amount of crime and for relatively violent crime. Compared to offenders who do not use
drugs, drug-using "violent predators" commit many more robberies, burglaries, and other thefts.
However, offenders who have completed substance use disorder treatment during incarceration are still at
great risk for relapse and recidivism when released. They need a variety of services to maintain sobriety
during their transition from the institution to the community. This chapter provides an overview of the benefits
of those transitional services. It also discusses obstacles to implementing such services and provides
strategies for overcoming these obstacles. Finally, models for transitional
services are described.
Some incarcerated offenders enter treatment for the same reasons as those "on the outside": They want to
stop using substances and need help. Others, however, may have different motivations: boredom, the desire
to improve their chances for parole, a wish to escape the violent culture of general population, or some
combination of the above. Others may be mandated to treatment by the courts. Surprisingly, research shows
that once an offender begins treatment, outcomes are not affected by the reasons for entering treatment. A
certain proportion of those who undergo treatment within the institution will succeed if supervised closely.
Other key findings on the effectiveness of substance use disorder treatment within correctional institutions
include the following:
·
Pre-release therapeutic communities have shown high rates of success among inmates studied.
·
Involvement in substance use disorder treatment is associated with decreased criminal recidivism.
Improvements have been seen in rates of re-arrest, conviction, re-incarceration, and time to
recidivate.
·
Involvement in substance use disorder treatment is associated with decreased substance use and
relapse and other health-related outcomes.
·
Duration of correctional substance use disorder treatment is associated with positive treatment
outcomes. Research has shown that, up to a point, longer lengths of treatment are more effective
than shorter lengths of treatment for substance-using offenders.
·
Involvement in substance use disorder treatment, such as prison-based therapeutic communities, is
associated with successful parole outcomes (including reductions in parole revocations).
·
Inmates involved in substance use disorder treatment had reduced rates of re-arrest and relapse
when compared with inmates who did not participate.
Treatment During Transition To the Community
Service systems should provide offenders with appropriate treatment, since no treatment is likely to lead to
continued drug use and crime. Treatment that stops when the offender is released, however, may not be
enough. Release presents offenders with a difficult transition from the structured environment of the prison or
jail: Despite the hardships endured "inside," they at least knew what to expect. Many offenders are released
with no place to live, no job, and without family or social supports. They often lack the knowledge and skills to
access available resources for adjustment to life on the outside, all factors that significantly increase the risk of
relapse and recidivism. The positive effects of substance use disorder treatment within correctional institutions
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may diminish once the offender moves out of the institutional environment unless follow-up care is provided in
the community.
The benefits of treatment during the transition from incarceration to the community are substantiated in
several recent studies. In a study of drug offenders in Delaware, offenders who participated in 12 to 15
months of treatment in prison and another 6 months of treatment in the community were more than twice as
likely to be drug-free 18 months after release as those who had only the prison treatment. Those offenders
were also arrested much less in the year and a half following release. A similar study in California had
comparable results. Continuity of care from the institution to the community is associated with positive
outcomes for prevention of relapse and criminal recidivism in other research as well.
It is well documented that the most effective substance use disorder treatment is multifaceted and addresses
many aspects of the substance user's life. This is particularly true for criminal justice populations, yet
treatment providers generally do not match offenders with substance use disorders to services tailored to their
needs. Effective care for those with mental and physical health problems, for example, must incorporate the
care of these illnesses into the plan for treatment of substance use disorders and criminality. Assessment and
treatment efforts must also acknowledge and incorporate the offenders' differences in culture, gender, age,
and type of criminal offense.
People with mental and physical health problems constitute a major category of special needs populations.
Society's failure to provide appropriate options for them contributes to disproportionately high numbers of
these individuals who eventually find themselves under criminal justice supervision and many of these
offenders, particularly the mentally ill, cycle through the criminal justice and social services systems repeatedly
because their problems are not fully addressed in any system. For example, once individuals with mental
illness are incarcerated, short-term goals of controlling undesirable behavior and a reliance on medication
often take precedence over more comprehensive approaches to treatment.
Upon release, offenders with multiple problems suffer from an additional stigma and may be denied services
because community providers lack training to deal with their problems. For example, providers who do not
understand the issues for those with mental illness or mental retardation may believe that these individuals
cannot benefit from treatment and are dangerous. Part of the case manager's job is to add to the transition
team those specialists who can correct such misinformation.
However a population is defined (e.g., by a health problem or cultural background), it is important to know the
substances of choice, types of crime, and other life patterns. Elderly people, for example, abuse prescription
drugs and alcohol, but rarely use illicit drugs. People with mental retardation are often arrested for nuisance
offenses and may be manipulated into criminal activities. Women's substance use is often woven into their
intimate relationships; many are incarcerated for possession of a drug that their significant others are selling.
These substance use patterns have significant implications for treatment.
Cultural sensitivity and cultural competency, important in all treatment, are particularly essential with offender
populations, because minorities are notoriously over represented in incarcerated settings. For example, 40.5
percent of the prison population is African-American, even though African Americans make up only 12.7
percent of the general U.S. population according to September 1998 census data. For some offenders, such
as those of African-American and Latino heritage, the family and extended family should be specifically
included in the transition plan because of the importance those cultures place on family relationships. Self-help
models of treatment may need adaptation for different cultures and for women.
Ideally, staffing patterns at all levels of the treatment system should reflect the population served, from clerical
staff through executive management. Specific efforts should be made to recruit and maintain such staff
members. Licensing, certification, and credentialing should support the use of culturally competent staff, and
support continuing education in the knowledge and skills relevant to the population. Staff members should be
able to communicate in local languages and dialects, and published materials and consent forms should be
available in these languages as well. If this is not possible, staff members should find creative means to
compensate for this deficit, although family members, especially children, should never be used as
interpreters. Incentives that encourage culturally sensitive client interactions should be woven into the
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Module Five Notes
employee performance evaluation system.
Whether the differences are cultural, medical, age-, or gender-related, it is important to remember that
offenders are not a homogenous population. This chapter will help community treatment providers and
correctional workers deliver effective transitional services to groups with special needs.
Women
In 1997, slightly less than 8 percent of those incarcerated were women 6.4 percent of the prison population
and 10.6 percent of the jail population, but that percentage is rising. Women are substantially more likely than
men to serve time for a drug offense rather than a violent crime. Compared to men, women are more heavily
drug-involved, and are often polydrug and intravenous drug users, though they use less alcohol than men.
Women in prisons in 1996 were most likely to be black (46 percent), ages 25-34 (50 percent), unemployed at
the time of arrest (53 percent), and never married (45 percent). In State prisons in 1991 more than 75 percent
of the women had children; two-thirds had children under the age of 18.
Incarcerated women and women with substance use disorders are more likely to have suffered physical and
sexual abuse. Incarcerated women's physical health profiles include a high incidence of HIV/AIDS and other
STDs, pregnancy, and certain types of coexisting mental disorders. The most common mental health disorder
among female offenders is depression. At the Turning Point Alcohol and Drug Program for women in Oregon,
approximately 50 percent were diagnosed with depression. Another commonly found disorder is post
traumatic stress disorder, not uncommon in victims of physical and sexual abuse. The importance of
addressing women's health care in correctional settings is spelled out by the National Commission on
Correctional Health Care's (NCCHC) position statement on Women's Health Care in Correctional Settings. In
it, NCCHC recommends, among
other things, intake procedures that include gynecologic history and nutritional intake, pregnancy tests, tests
for STDs, and available counseling for depression, substance use disorders, and other disorders common to
incarcerated women.
Until recent years, substance use disorder treatment programs for women have been slow to emerge in
correctional institutions and in the community, and many institutions still have no women-specific treatment
services. Those services that are available often evolved from models developed for men.
Incarceration disrupts relationships with children, as well as with a spouse or partner. If a woman is a single
parent involved in drugs and criminal behavior, a child protective service agency generally steps in after the
arrest to take control and custody of dependent children. A high percentage of mothers have their children
permanently removed from their custody as a result of
their incarceration. Parental rights for mothers (perceived as chief caretakers) are scrutinized closely by social
services and foster care workers. In some jurisdictions, women have been increasingly criminalized for using
drugs when pregnant.
To work effectively with this special population, counselors need to have training on criminal thinking errors
and how they are used to keep the criminal from taking responsibility for their own actions. To date the most
successful treatment programs for working with criminals are Therapeutic Communities (TCs). Techniques
utilized by these programs will be discussed in other modules.
As you can see from both the information presented in the text and in this module, effective counseling does
not just happen. Counselors must take responsibility for learning about special population categories and
needs. They must take a long hard look at themselves to identify prejudices and biases which may affect their
ability to work with certain client populations. Without this self-knowledge, counselors end up doing harm,
intentionally or unintentionally to their clients. The process of becoming a culturally competent counselor is a
life long journey.
Overview of Dual Disorders
The information provided below on dual disorders/diagnoses; has been taken from Treatment Improvement
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Protocol 9: Assessment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse, by the
Center for Substance Abuse Treatment unless other wise noted.
The Relationships Between AOD Use and Psychiatric Symptoms and Disorders
Establishing an accurate diagnosis for patients in addiction and mental health settings is an important and
multifaceted aspect of the treatment process. Clinicians must discriminate between acute primary psychiatric
disorders and psychiatric symptoms caused by alcohol and other drugs (AODs). To do so, clinicians must
obtain a thorough history of AOD use and psychiatric symptoms and disorders.
There are several possible relationships between AOD use and psychiatric symptoms and disorders. AODs
may induce, worsen, or diminish psychiatric symptoms, complicating the diagnostic process. All of these
possible relationships must be considered during the screening and assessment process.
Mood Disorders
The term mood describes a pervasive and sustained emotional state that may affect all aspects of an
individual's life and perceptions. Mood disorders are pathologically elevated or depressed disturbances of
mood, and include full or partial episodes of depression or mania. A mood episode (for example, major
depression) is a cluster of symptoms that occur together for a discrete period of time.
A major depressive episode involves a depression in mood with an accompanying loss of pleasure or
indifference to most activities, most of the time for at least 2 weeks. These deviations from normal mood may
include significant changes in energy, sleep patterns, concentration, and weight. Symptoms may include
psychomotor agitation or retardation, persistent feelings of worthlessness or inappropriate guilt, or recurrent
thoughts of death or suicide. The diagnosis of major depression requires evidence of one or more major
depressive episodes occurring without clearly being related to another psychiatric, AOD use, or medical
disorder. Major depression is sub-classified as major depressive disorder, single episode and recurrent.
There are nine symptoms of a major depressive episode listed in the DSM-IV draft, and diagnosis of this
disorder requires at least five of them to be present for 2 weeks.
Dysthymia is a chronic mood disturbance characterized by a loss of interest or pleasure in most activities of
daily life but not meeting the full criteria for a major depressive episode. The diagnosis of dysthymia requires
mild to moderate mood depression most of the time for a duration of at least 2 years.
A manic episode is a discrete period (at least 1 week) of persistently elevated, euphoric, irritable, or
expansive mood. Symptoms may include hyperactivity, grandiosity, flight of ideas, talkativeness, a decreased
need for sleep, and distractibility. Manic episodes, often having a rapid onset and symptom progression over a
few days, generally impair occupational or social functioning, and may require hospitalization to prevent harm
to self or others. In an extreme form, people with mania frequently have psychotic hallucinations or delusions.
This form of mania may be difficult to differentiate from schizophrenia or stimulant intoxication.
A hypomanic episode is a period (weeks or months) of pathologically elevated mood that resembles but is
less severe than a manic episode. Hypomanic episodes are not severe enough to cause marked impairment
in social or occupational functioning or to require hospitalization.
A bipolar disorder is diagnosed upon evidence of one or more manic episodes, often in an individual with a
history of one or more major depressive episodes. Bipolar disorder is sub-classified as manic, depressed, or
mixed, depending upon the clinical features of the current or most recent episodes. Major depressive or manic
episodes may be followed by a brief episode of the other.
Cyclothymia can be described as a mild form of bipolar disorder, but with more frequent and chronic mood
variability. Cyclothymia includes multiple hypomanic episodes and periods of depressed mood insufficient to
meet the criteria for either a manic or a major depressive episode. The revised third edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-IV) states that for a diagnosis of cyclothymia to be made,
there must be a 2-year period during which the patient is never without hypomanic or dysthymic symptoms for
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more than 2 months.
Substance-induced mood disorder is described in the DSM-IV according to the following criteria:
A A prominent and persistent disturbance in mood characterized by either (or both) of the following:
1) depressed mood or markedly diminished interest or pleasure in all, or almost all, activities,
2) elevated, expansive, or irritable mood.
B. There is evidence from the history, physical examination, or laboratory findings of substance
intoxication or withdrawal, and the symptoms in criterion A developed during, or within a month of,
significant substance intoxication or withdrawal.
C. The disturbance is not better accounted for by a mood disorder that is not substance induced.
Evidence that the symptoms are better accounted for by a mood disorder that is not substance
induced might include: the symptoms precede the onset of the substance abuse or dependence; they
persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or
severe intoxication; they are substantially in excess of what would be expected given the character,
duration, or amount of the substance used; or there is other evidence suggesting the existence of an
independent non-substance-induced mood disorder (e.g., a history of recurrent non-substance-related
major depressive episodes) .
D. The symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
E. The disturbance does not occur exclusively during the course of delirium.
Substance-induced mood disorder can be specified as having 1) manic features, 2) depressive features, or 3)
mixed features. Also, it can be described as having an onset during intoxication or withdrawal. For most of the
major mental illnesses, the DSM-IV includes the alternative of a substance-induced disorder within that
diagnosis.
Prevalence
The most common psychiatric diagnoses among patients with an AOD disorder are anxiety and mood
disorders. Among those with a mood disorder, a significant proportion has major depression. Mood disorders
may be more prevalent among patients using methadone and heroin than among other drug users. In an
addiction treatment setting, the proportion of patients diagnosed with major depression is lower than in a
mental health setting.
During the first months of sobriety, many AOD abusers may exhibit symptoms of depression that fade over
time and that are related to acute withdrawal. Thus, depressive symptoms during withdrawal and early
recovery may result from AOD disorders, not an underlying depression. A period of time should elapse before
depression is diagnosed.
Anxiety Disorders
The anxiety disorders are the most common group of psychiatric disorders. The term anxiety refers to the
sensations of nervousness, tension, apprehension, and fear that emanate from the anticipation of danger,
which may be internal or external. Anxiety disorders describe different clusters of signs and symptoms of
anxiety, panic, and phobias.
A panic attack is a distinct period of intense fear or discomfort that develops abruptly, usually reaching a
crescendo within a few minutes or less. Physical symptoms may include hyperventilation, palpitations,
trembling, sweating, dizziness, hot flashes or chills, numbness or tingling, and the sensation or fear of nausea
or choking. Psychologic symptoms may include depersonalization and derealization and fear of fainting, dying,
doing something uncontrolled, or losing one's mind. A panic disorder consists of episodes of panic attacks
followed by a period of persistent fear of the recurrence of more panic attacks.
When the focus of anxiety is an activity, person, or situation that is dreaded, feared, and probably avoided, the
anxiety disorder is called a phobia. Phobia-inspired avoidance behavior as well as travel and activity
restrictions may become intense and incapacitating. The phobias include agoraphobia, social phobia, and
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simple or specific phobia; panic attacks and panic disorders are often but not necessarily involved.
Specific phobia, also called single or simple phobia, describes the onset of intense, excessive, or
unreasonable fear, stimulated by the presence or anticipation of a specific object or situation. The causes may
be naturally occurring (for example, animals, insects, thunder, water), situational (such as heights or riding in
elevators), or related to receiving injections or giving blood. Social phobia describes the persistent and
recognizably irrational fear of embarrassment and humiliation in social situations. The social phobia may be
quite specific (for example, public speaking) or may become generalized to all social situations. Agoraphobia
is the fear of being caught in a situation from which a graceful and speedy escape would be impossible,
difficult, or embarrassing. Examples of feared situations include attendance in an auditorium, being stuck in
traffic, and being outside the house.
In generalized anxiety disorder, there is no specific focus to the anxiety; symptoms are free-floating.
Generalized anxiety disorder involves excessive anxiety, worry, and apprehensive expectations focused on
many life circumstances, more days than not, for a period of at least 6 months. The intensity, duration, and
frequency of symptoms are out of proportion to the probability or consequences of the feared event. Somatic
symptom clusters often involve:
1) motor tension (such as trembling, restlessness, and fatigue),
2) autonomic hyperactivity (for example, shortness of breath, palpitations, sweating, dry mouth,
dizziness, and abdominal distress), and
3) hyperarousal (such as exaggerated startle response, irritability, insomnia, and poor concentration).
Obsessive-compulsive disorder (OCD) is an anxiety disorder involving obsessions or compulsive rituals or
both. Obsessions are repetitive and intrusive thoughts, impulses, or images that cause marked anxiety. They
often involve transgressing social norms, harming others, and becoming contaminated, but they are more
intense than excessive worries about real problems. Compulsions are repetitive rituals and acts that people
are driven to perform and which they perform reluctantly to prevent or reduce distress. The frequency and
duration of their repetition make them inconvenient and often incapacitating. Examples include ritualistic
behaviors (such as hand-washing and rechecking) and mental acts (for example, counting and repeating
words silently); they are time-consuming and interfere significantly with daily functioning.
Post-traumatic stress disorder (PTSD) involves an individual's experiencing a psychologically traumatic
stressor such as witnessing death, being threatened with death or injury, or being sexually abused. At the time
of the stressor event, the individual experiences intense fear, helplessness, or horror. PTSD entails a
persistent re-experiencing of the trauma in the form of recurrent and intrusive images and thoughts, or
recurrent dreams, or experiencing episodes during which the trauma is relived (perhaps with hallucinations).
People with PTSD experience persistent symptoms of increased arousal such as insomnia, irritability,
hypervigilance, and exaggerated startle response. They persistently avoid stimuli related to the trauma such
as activities, feelings, and thoughts associated with the traumatic event.
Interest in the role of sexual abuse and incest in PTSD and other psychiatric and AOD disorders has
increased. Clinicians note that long-term responses to childhood and adult sexual abuse often include
symptoms associated with PTSD and other psychiatric problems, including an increased risk for AOD
disorders. Many such problems are addressed in treatment efforts popular in adult children of alcoholic
(ACOA) programs, some of which are controversial and unsubstantiated by research or long-term observation.
Such treatment approaches may exacerbate AOD use and psychiatric disorders and should be cautiously
undertaken. Amnesic periods have to be carefully evaluated both as blackout phenomena and as possible
dissociated states. Such differentiation can be extremely complicated. While a clinician's immediate response
may be to identify these patients as being intoxicated, they may be experiencing independent psychiatric
phenomena.
Personality Disorders
The word personality describes deeply ingrained patterns of behavior and the manner in which individuals
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perceive, relate to, and think about themselves and their world. Personality traits are conspicuous features of
personality and are not necessarily pathological, although certain styles of personality traits may cause
interpersonal problems. Personality disorders are rigid, inflexible, and maladaptive behavior patterns of
sufficient severity to cause significant impairment in functioning or internal distress. Personality disorders are
enduring and persistent styles of behavior and thought, not atypical episodes.
Several alcohol and other drug (AOD)-induced states can mimic personality disorders. If a personality disorder
coexists with AOD use, only the personality disorder will remain during abstinence. AOD use may trigger or
worsen personality disorders. The course and severity of personality disorders can be worsened by the
presence of other psychiatric problems such as mood, anxiety, and psychotic disorders.
Antisocial personality disorder involves a history of chronic antisocial behavior that begins before the age of
15 and continues into adulthood. The disorder is manifested by a pattern of irresponsible and antisocial
behavior as indicated by academic failure, poor job performance, illegal activities, recklessness, and impulsive
behavior. Symptoms may include dysphoria, an inability to tolerate boredom, feeling victimized, and a
diminished capacity for intimacy.
Borderline personality disorder is characterized by unstable mood and self-image, and unstable, intense,
interpersonal relationships. These people often display extremes of over-idealization and devaluation, marked
shifts from baseline to an extreme mood or anxiety state, and impulsiveness.
Narcissistic personality disorder describes a pervasive pattern of grandiosity, lack of empathy, and
hypersensitivity to evaluation by others.
Passive-aggressive personality disorder involves covertly hostile but dependent relationships. People with
this disorder commonly lack adaptive or assertive social skills, especially with regard to authority figures. They
often display a passive resistance to demands for adequate social and occupational performance. They
generally fail to connect their passive-resistant behavior with their feelings of resentfulness and hostility toward
others.
Avoidant personality disorder includes social discomfort, hypersensitivity to both criticism and rejection, and
timidity, with accompanying depression, anxiety, and anger for failing to develop social relations.
Obsessive-compulsive personality disorder describes a disorder of perfectionism and inflexibility.
Symptoms may include distress associated with indecisiveness and difficulty in expressing tender feelings,
feelings of depression, and anger about being controlled by others. Hypersensitive to criticism, these people
may be excessively conscientious, moralistic, scrupulous, and judgmental.
Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and
attention seeking. Behavior may include constant seeking of approval or attention, striking self-centeredness,
or sexual seductiveness in inappropriate situations.
Paranoid personality disorder is characterized by a pervasive and unjustified proclivity to interpret the
actions of others as intentionally threatening, demeaning, and untrustworthy.
Dependent personality disorder is characterized by a pervasive pattern of dependent and submissive
behavior and an intense preoccupation with possible abandonment. Persons with this disorder often feel
anxious and depressed, and may experience intense discomfort when alone for more than a brief time.
Schizoid personality disorder involves a pervasive pattern of indifference to social relationships and a
restricted range of emotional experience and expression.
Schizotypal personality disorder entails deficits in interpersonal relatedness and peculiarities of ideation,
appearance, and behavior and dysphoric states such as anxiety and depression.
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Self-defeating personality disorder is characterized by a pattern of self-defeating behavior in work and
personal relationships, often with complaints of exploitation by others; these persons are often unaware of
their contributions to the outcomes of their behavior.
Personality disorders not otherwise specified (NOS) include disorders of personality functioning that are not
classifiable as specific personality disorders. Instead, individuals do not meet the full criteria for any one
personality disorder; yet their symptoms cause significant impairment in social or occupational functioning, or
cause subjective distress. Personality disorders NOS include impulsive, immature, and sadistic personality
disorders.
Diagnoses should be clinically based, and not influenced by professional, personal, cultural, or ethnic biases.
For example, in the past some African Americans were stereotyped as having paranoid personality disorders;
women have been diagnosed too frequently as being histrionic, but they are seldom diagnosed as antisocial or
psychopathic; Native Americans with spiritual visions have been misdiagnosed as delusional or having
borderline or schizotypal personality disorders.
People with a personality disorder often use AODs for purposes that relate to the personality disorder: to
diminish symptoms of the disorder, to enhance low self-esteem, to decrease feelings of guilt, and to amplify
feelings of diminished individuality.
People with borderline personality disorder often use AODs in chaotic and unpredictable patterns and in
polydrug patterns involving alcohol and other sedative-hypnotics taken for self-medication. People with
personality disorders often develop problems with benzodiazepines that have been prescribed for complaints
such as anxiety, which may lead to relapse to the primary drug of choice.
Many people with antisocial personality disorder use AODs in a polydrug pattern involving alcohol, marijuana,
heroin, cocaine, and methamphetamine. The illegal drug culture corresponds with their view of the world as
fast-paced and dramatic, which supports their need for a heightened self-image. Consequently, they may be
involved in crime and other sensation-seeking, high-risk behavior. Some may have extreme antisocial
symptoms. They tend to prefer stimulants such as cocaine and the amphetamines. Rapists with severe
antisocial personality disorder may use alcohol to justify conquests. People with less severe antisocial
personality disorder may use heroin and alcohol to diminish feelings of depression and rage.
Psychotic Disorders
All too often, AOD use disorders are undetected in patients with psychotic disorders, and traditional treatment
approaches are often inadequate. For example, attempts have been made to treat psychotic and AOD use
disorders in a sequential manner, treating one disorder first and then the other. While a single-focus approach
is helpful for differential diagnosis, and is effective in treating some patients, it is frequently unsuccessful for
patients with AOD problems who have severe and recurrent psychotic episodes. This information provides an
overview of a dual-focus approach to the assessment and treatment of patients with these dual disorders. A
single-focus approach emphasizes the importance of developing a diagnosis and subsequent treatment plan
-- such as is done when treating patients who have a single disorder. In a dual-focus approach, the emphasis
is not on making a diagnosis, but rather on 1) the severity of presenting symptoms, 2) crisis intervention and
crisis management, 3) stabilization, and 4) diagnostic efforts within the context of multiple-contact, longitudinal
treatment. By concentrating on symptoms, crisis management, and stabilization, clinicians can simultaneously
focus on patients' treatment needs that are caused by both the psychotic disorder and the substance use
disorder. It is important to focus on the following:
· Initial focus on severity of presenting symptoms, not on diagnosis of one disorder or another
· Acute crisis intervention and crisis management
· Acute, sub-acute, and long-term stabilization of patient
· Ongoing diagnostic efforts
· Multiple-contact longitudinal treatment.
The term psychosis describes a disintegration of the thinking process, involving the inability to distinguish
external reality from internal fantasy. The characteristic deficit in psychosis is the inability to differentiate
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between information that originates from the external world and information that originates from the inner
world of the mind (such as distortions of normal thinking processes) or the brain (such as abnormal sensations
and hallucinations).
Psychosis is a common feature of schizophrenia. Psychotic symptoms are often a feature of organic mental
disorders, mood disorders, schizophreniform disorder, schizoaffective disorder, delusional (paranoid) disorder,
brief reactive psychosis, induced psychotic disorder, and atypical psychosis.
Schizophrenia is best understood as a group of disorders with similar clinical profiles, invariably including
thought disturbances in a clear sensorium and often with characteristic symptoms such as hallucinations,
delusions, bizarre behavior, and deterioration in the general level of functioning.
Severe disturbances occur with relation to language and communication, content of thought, perceptions,
affect, sense of self, volition, relationship to the external world, and motor behavior. Symptoms may include
bizarre delusions, prominent hallucinations, incoherence, flat affect, avolition, and anhedonia. Functioning is
impaired in interpersonal, academic, or occupational relations and self-care.
Schizophrenia can be divided into subtypes:
1) in the paranoid type, delusions or hallucinations predominate;
2) in the disorganized type, speech and behavior problems predominate;
3) in the catatonic type, catalepsy or stupor, extreme agitation, extreme negativism or autism,
peculiarities of voluntary movement or stereotyped movements predominate;
4) in the undifferentiated type, no single clinical presentation predominates; and
5) in the residual type, prominent psychotic symptoms no longer predominate. The diagnosis of
schizophrenia requires a minimum of 6 months' duration of symptoms, with active psychotic
symptoms for 1 week (unless successfully treated).
Clinicians generally divide the symptoms of schizophrenia into two types: positive and negative symptoms.
Acute course schizophrenia is characterized by positive symptoms, such as hallucinations, delusions,
excitement, and disorganized speech; motor manifestations such as agitated behavior or catatonia; relatively
minor thought disturbances; and a positive response to neuroleptic medication.
Chronic course schizophrenia is characterized by negative symptoms, such as anhedonia, apathy, flat affect,
social isolation, and socially deviant behavior; conspicuous thought disturbances; evidence of cerebral
atrophy; and generally poor response to neuroleptics. In general, acute substance-induced psychotic
symptoms tend to be positive symptoms.
Schizophreniform disorder is a condition exhibiting the same symptoms of schizophrenia but marked by a
sudden onset with resolution in 2 weeks to 6 months. Some patients exhibit a single psychotic episode only;
others may have repeated episodes separated by varying durations of time.
Schizoaffective disorder is a condition that includes persistent delusions, auditory hallucinations, or formal
thought disorder consistent with the acute phase of schizophrenia, but the condition is also frequently
accompanied by prominent manic or depressive symptoms. Schizoaffective disorder is further divided into
bipolar (history of mania) and unipolar (depression only) types.
Delusional disorders are characterized by prominent well-organized delusions and by the relative absence of
hallucinations; disorganized thought and behavior; and abnormal affect. The delusional disorders are divided
into six types: persecutory, grandiose, erotomanic, jealous, somatic, and unspecified.
Brief reactive psychosis describes a condition in which an individual develops psychotic symptoms after
being confronted by overwhelming stress. The onset of symptoms is abrupt, without the gradual symptom
development often seen in schizophrenia or schizophreniform disorder, and the duration is brief (no longer
than 1 month).
Induced psychotic disorder describes a disorder characterized by the uncritical acceptance by one person
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of the delusional beliefs of another. In other words, a dominant partner has a delusional psychosis that is
believed and accepted by a passive partner.
AOD-induced psychotic disorders are conditions characterized by prominent delusions or hallucinations
that develop during or following psychoactive drug use and cause significant distress or impairment in social or
occupational functioning. This disorder does not include hallucinations caused by hallucinogens in the context
of intact reality testing.
Although there can be great variability in individual susceptibility to AOD-induced psychotic symptoms, it is
important for the clinician to determine if the presenting symptoms could plausibly be induced by the type and
amount of drug apparently consumed. For example, vivid auditory, visual, and tactile hallucinations are
plausible side effects of a 5-day, high-dose cocaine binge. However, should these symptoms emerge during a
brief episode of mild alcohol intoxication, it is likely that the symptoms represent an underlying psychotic
process that has been exacerbated by the use of alcohol.
Pharmacologic Management
Addiction is not a fixed and rigid event. Like psychiatric disorders, addiction is a dynamic process, with
fluctuations in severity, rate of progression, and symptom manifestation and with differences in the speed of
onset. Both disorders are greatly influenced by several factors, including genetic susceptibility, environment,
and pharmacologic influences. Certain people have a high risk for these disorders (genetic risk); some
situations can evoke or help to sustain these disorders (environmental risk); and some drugs are more likely
than others to cause psychiatric or AOD use disorder problems (pharmacologic risk).
Pharmacologic effects can be therapeutic or detrimental. Medication often produces both effects. Therapeutic
pharmacologic effects include the indicated purposes and desired outcomes of taking prescribed medications,
such as a decrease in the frequency and severity of episodes of depression produced by antidepressants.
Detrimental pharmacologic effects include unwanted side effects, such as dry mouth or constipation resulting
from antidepressant use. Side effects perceived as noxious by patients may decrease their compliance with
taking the medications as directed.
Some detrimental pharmacologic effects relate to abuse and addiction potential. For example, some
medications may be stimulating, sedating, or euphorigenic and may promote physical dependence and
tolerance. These effects can promote the use of medication for longer periods and at higher doses than
prescribed.
Prescribing medication involves striking a balance between therapeutic and detrimental pharmacologic effects.
For instance, therapeutic anti-anxiety effects of the benzodiazepines are balanced against detrimental
pharmacologic effects of sedation and physical dependency. Similarly, the desired therapeutic effect of
abstinence from alcohol is balanced by the possibility of damage to the liver from prescribed disulfiram
(Antabuse).
Side effects of prescription medications vary greatly and include detrimental pharmacologic effects that may
promote abuse or addiction. With regard to patients with dual disorders, special attention should be given to
detrimental effects, in terms of 1) medication compliance, 2) abuse and addiction potential, 3) AOD use
disorder relapse, and 4) psychiatric disorder relapse.
Not all psychiatric medications are psychoactive. The term psychoactive describes the ability of certain
medications, drugs, and other substances to cause acute psychomotor effects and a relatively rapid change in
mood or thought. Changes in mood include stimulation, sedation, and euphoria. Thought changes can include
a disordering of thought such as delusions, hallucinations, and illusions. Behavioral changes can include an
acceleration or retardation of motor activity. All drugs of abuse are by definition psychoactive.
In contrast, certain non-psychoactive medications such as lithium can, over time, normalize the abnormal
mood and behavior of patients with bipolar disorder. Because these effects take several days or weeks to
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occur, and do not involve acute mood alteration, it is not accurate to describe these drugs as psychoactive,
euphorigenic, or mood altering. Rather, they might be described as mood regulators. Similarly, some drugs,
such as anti-psychotic medications, cause normalization of thinking processes but do not cause acute mood
alteration or euphoria.
However, some antidepressant and anti-psychotic medications have pharmacologic side effects such as mild
sedation or mild stimulation. Indeed, the side effects of these medications can be used clinically. Physicians
can use a mildly sedating antidepressant medication for patients with depression and insomnia, or a mildly
stimulating anti-psychotic medication for patients with psychosis and hypersomnia or lethargy. While the side
effects of these drugs include a mild effect on mood, they are not euphorigenic. Nevertheless, case reports of
misuse of non-psychoactive medications have been noted, and use should be monitored carefully in patients
with dual disorders.
While psychoactive drugs are generally considered to have high risk for abuse and addiction, mood- regulating
drugs are not. A few other medications exert a mild psychoactive effect without having addiction potential. For
example, the older antihistamines such as doxylamine (Unisom) exert mild sedative effects, but not euphoric
effects.
Some drugs promote reinforcement, or the increased likelihood of repeated use. Reinforcement can occur by
either the removal of negative symptoms or conditions or the amplification of positive symptoms or states. For
example, self-medication that delays or prevents an unpleasant event (such as withdrawal) from occurring
becomes reinforcing. Thus, using a benzodiazepine to avoid alcohol withdrawal can increase the likelihood of
continued use. Positive reinforcement involves strengthening the possibility that a certain behavior will be
repeated through reward and satisfaction, as with drug-induced euphoria or drug-induced feelings of
well-being. A classic example is the pleasure derived from moderate to high doses of opiates or stimulants.
Drugs that are immediately reinforcing are more likely to lead to psychiatric or AOD use problems.
Long-term or chronic use of certain medications can cause tolerance to the subjective and therapeutic effects
and prompt dosage increases to recreate the desired effects. In addition, many drugs cause a well-defined
withdrawal phenomenon after the cessation of chronic use. Patients' attempts to avoid withdrawal syndromes
often lead them to additional drug use. Drugs that promote tolerance and withdrawal generally have higher
risks for abuse and addiction.
Eating Disorders
Anorexia nervosa
Anorexia nervosa is a life-threatening eating disorder defined by a refusal to maintain body weight within 15
percent of an individual's minimal normal weight. Other essential features of this disorder include an intense
fear of gaining weight, a distorted body image, and amenorrhea (absence of at least three consecutive
menstrual cycles when otherwise expected to occur) in women. Sometimes people starve and binge-purge,
depending on the extent of weight loss. This can be physically very dangerous. People who present an
on-going preoccupation with food and weight even at lesser weight reductions would benefit from exploring
their cognitive and relationship skills.
The term anorexia literally means loss of appetite, but this isn't a true symptom of the disorder. In fact, people
with anorexia are usually hungry, but they control their eating. This is frequently sublimated through cooking
for others or hiding food in their personal space which they will not eat.
Who develops anorexia?
Like all eating disorders, it tends to occur in pre or post puberty, but can develop at any life change. Anorexia
nervosa predominately affects adolescent girls, although it can also occur in men and older women. One
reason younger women are particularly vulnerable to eating disorders is their tendency to go on strict diets to
achieve an "ideal" figure. This obsessive dieting behavior reflects a great deal of today's societal pressure to
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be thin, which is seen in advertising and the media. Others especially at risk for eating disorders include
athletes, actors, and models for whom thinness has become a professional requirement.
How many people suffer from anorexia?
Conservative estimates suggest that one-half to one percent of females in the U.S. develop anorexia.
Because more than 90 percent of all those who are affected are adolescent and young women, the disorder
can be characterized as primarily a women's illness. It should be noted, however, that children as young as 7
have been diagnosed and women 50, 60, 70, and even 80 fit the diagnosis.
How is the weight lost?
People with anorexia usually lose weight by reducing their total food intake and exercising excessively. Many
persons with anorexia nervosa restrict their intake to 1,000 calories a day or less. Most avoid fattening,
high-calorie foods and eliminate red meat or meat altogether. The diet of persons with anorexia may consist
almost completely of low-calorie vegetables like lettuce and carrots or popcorn.
Common signs of anorexia
The hallmark of anorexia nervosa is denial and preoccupation with food and weight. In fact, all eating
disorders share this trait including binge eating disorder and compulsive eating. One of the most frightening
aspects of the disorder is that people with anorexia continue to think they look fat, even when they are
bone-thin. Their nails and hair become brittle, and their skin may become dry and yellow. Depression is
common in patients suffering from this disorder. People with anorexia often complain of feeling cold
(hypothermia) because their body temperature drops. They may develop long, fine hair on their body as a way
of trying to conserve heat.
Persons with anorexia develop strange eating habits such as cutting their food into tiny pieces, refusing to eat
in front of others, or fixing elaborate meals for others that they themselves don't eat. Food and weight become
obsessions as people with this illness constantly think about their next encounter with food. Generally, if a
person fears she may have anorexia, she should see a doctor to rule out other physical disorders.
What are the causes of anorexia?
Knowledge about the causes of anorexia is inconclusive, and the causes may be varied. In an attempt to
understand and uncover the origins of eating disorders, scientists have studied the personalities, genetics,
environments, and biochemistry of people with these illnesses. Certain personality traits common in persons
with anorexia are low self-esteem, social isolation, and a perfectionist attitude. These people tend to be good
students and excellent athletes.
Eating disorders also tend to run in families, with female relatives most often affected. A girl has a 10- to
20-times higher risk of developing anorexia, for instance, if she has a sibling with the disease. This finding
suggests that genetic factors may predispose some people to eating disorders or acceptance of the social
ideal of thinness by selves and parents. Behavioral and environmental influences may also play a role. Eating
disorders are seen primarily in Western and industrialized countries, where slimness is a model of
attractiveness. Stressful events are likely to increase the risk of eating disorders as well, but this is the case
for psychiatric disorders in general.
In studies of the biochemical functions of people with eating disorders, scientists have found that the
neurotransmitters serotonin and norepinephrine are decreased in those with anorexia, which links them with
patients suffering from depression. This link is supported by studies showing that certain antidepressants can
be used to successfully treat some people with eating disorders. People with anorexia also tend to have higher
than normal levels of cortisol (a brain hormone released in response to stress) and vasopressin (a brain
chemical found to be abnormal in patients with obsessive-compulsive disorder). Other psychiatric disorders
can occur together with anorexia, such as OCD, self mutilation, or bipolar disorder. In general, people with
anorexia nervosa have responded minimally to antidepressants. The most effective strategy for treating a
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Module Five Notes
patient has been weight restoration within 10% of normal and individual and family therapy.
Are there medical complications?
The starvation experienced by persons with anorexia nervosa can cause damage to vital organs such as the
heart and brain. Breathing, pulse, and blood pressure rates drop, and those suffering from this illness may
experience irregular heart rhythms or heart failure. Nutritional deprivation causes calcium loss from bones,
which become brittle and prone to breakage. In the worst-case scenario, people with anorexia can starve
themselves to death. Eating disorders have among the highest mortality rates of all mental disorders, killing up
to 6 percent of their victims.
Bulimia nervosa
Bulimia nervosa is a serious eating disorder marked by a destructive pattern of binge-eating and recurrent
inappropriate behavior to control one's weight. It can occur together with other psychiatric disorders such as
bipolar disorder, self mutilation, obsessive-compulsive disorder, or dissociative identity disorder. Binge-eating
is defined as the consumption of large amounts of food within a short period of time. The food is often sweet,
high in calories, and has a texture that makes it easy to eat fast. "Inappropriate compensatory behavior" to
control one's weight may include purging behaviors (such as self-induced vomiting, abuse of laxatives,
diuretics, or enemas) or non-purging behaviors (such as fasting or excessive exercise). For those who binge
eat, sometimes any amount of food, even a salad or half an apple, is perceived as a binge and is vomited.
People with bulimia nervosa often feel a lack of control during their eating binges. Their food is usually eaten
secretly and gobbled down rapidly with little chewing. A binge is usually ended by abdominal discomfort. When
the binge is over, the person with bulimia feels guilty and purges to rid his or her body of the excess calories.
To be diagnosed with bulimia, a person must have had, on average, a minimum of two binge-eating episodes
a week for at least three months. The first problem with any eating disorder is constant concern with food and
weight to the exclusion of almost all other personal concerns.
Who develops bulimia?
Bulimia nervosa typically begins in adolescence or early adulthood. Like anorexia nervosa, bulimia mainly
affects females. Only ten percent to 15 percent of its victims are male. An estimated two percent to three
percent of young women develop bulimia, compared with the one-half to one percent that is estimated to
suffer from anorexia. Studies indicate that about 50 percent of those who begin an eating disorder with
anorexia nervosa later become bulimic.
It is believed that more than seven million women and one million men experience an eating disorder in this
country alone. This indicates a need for concern and preventive measures on college campuses across the
country, especially for female students.
How do people with bulimia control their weight?
People with bulimia are overly concerned with body shape and weight. They make repeated attempts
to control their weight by fasting and dieting, vomiting, using drugs to stimulate bowel movements and
urination, and exercising excessively. Weight fluctuations are common because of alternating binges and
fasts. Unlike people with anorexia, people with bulimia are usually within a normal weight range. However,
many heavy people who lose weight begin vomiting to maintain the weight loss.
What are the common signs of bulimia?
Constant concern about food and weight is a primary sign of bulimia. Common indicators that suggest the
self-induced vomiting that persons with bulimia experience are the erosion of dental enamel (due to the acid in
the vomit) and scarring on the backs of the hands (due to repeatedly pushing fingers down the throat to induce
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Module Five Notes
vomiting).
A small percentage of people with bulimia show swelling of the glands near the cheeks called parotid glands.
People with bulimia may also experience irregular menstrual periods and a decrease in sexual interest. A
depressed mood is also commonly observed as are frequent complaints of sore throats and abdominal pain.
Despite these telltale signs, bulimia nervosa is difficult to catch early. Binge eating and purging are often done
in secret and can be easily concealed by a normal-weight person who is ashamed of his or her behavior, but
compelled to continue it because he or she believes it controls weight. This preoccupation and these
behaviors allow the person to shift their focus from painful feelings and reduce tension and anxiety
perpetuating the need for these behaviors.
Are there any serious medical complications?
Persons with bulimia--even those of normal weight--can severely damage their bodies by frequent binging and
purging. Electrolyte imbalance and dehydration can occur and may cause cardiac complications and,
occasionally, sudden death. In rare instances, binging can cause the stomach to rupture, and purging can
result in heart failure due to the loss of vital minerals like potassium.
Do we know what causes bulimia?
The current obsession with thinness in our culture certainly has a large influence. There is some evidence that
obesity in adolescence or obese parents predisposes an individual to the development of the disorder.
Parents' anxiety over a chubby child can perhaps also be a contributor. Some bulimics report feeling a "kind of
high" when they vomit. People with bulimia are often compulsive and may also abuse alcohol and drugs.
Eating disorders like anorexia and bulimia tend to run in families, and girls are most susceptible. Recently,
scientists have found certain neurotransmitters (serotonin and norepinephrine) to be decreased in some
persons with bulimia. Most likely, it is a combination of environmental and biological factors that leads to the
development of this disorder. During the early 1970s almost all persons with an eating disorder believed they
had invented the behaviors and that no one else had such a problem. As in anorexia nervosa, the behaviors
associated with bulimia provide temporary relief from tension and allow ill persons to focus less on problems
perceived as irresolvable and to instead focus on body weight and food.
Compulsive/Pathological Gambling
According to the Webster’s New Collegiate Dictionary; gamble is defined as: to play a game of chance for
stakes (i.e. money or property); to bet on an uncertain outcome. Gambling takes on many forms in this
country. The most common is pari-mutuals such as horse and dog racing, off-track-betting parlors, lotteries,
casinos (slot machines, table games), bookmaking (sports books and horse books), card rooms, bingo, on
line gambling now brings gambling into the office or home. Some even speculate that the stock market is a
form of gambling. Based on the definition it would seem to be. Pathological gambling is a progressive
disease that devastates not only the gambler but everyone around them. Much of the information in this
section is complements of the Texas Council on Problem and Compulsive Gambling.
Women Gamblers
Generally, women begin gambling later in life as a coping strategy to mask underlying emotional pain. They
rely on the excitement of gambling to make themselves feel good. They gamble for the sense of
"empowerment" or for the freedom that they lack in other areas of their lives. Women usually play bingo,
lottery or casino machines (slots and video poker) to "escape". Women are also "closet" gamblers and seldom
brag about their wins.
While nearly all problem gamblers suffer from guilt and shame over the problems gambling creates, women
seem to do so much more deeply. When entering treatment they are more likely to be subdued, withdrawn
and frightened, and are more hesitatant to talk about their gambling experience. As one recovering gambler
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Module Five Notes
said, "Men wear both their gambling and recovery as a badge of honor. Women are ashamed and don't want
to talk about it".
Senior Gamblers
Seniors are very often socially isolated due to physical restrictions or lack of social outlets. They become
involved in gambling via mail or sweepstakes companies. Some have limited financial resources or are looking
for that big payoff to compensate an ever-shrinking limited retirement income. Casinos push bus trips to
casinos.
Senior problem gambling can start with loss of interest and participation in normal activities with friends and
family, or when confronted with lots of time on their hands. They may also have feeling of oppression from
family and others, that they need to find relief from. Loneliness and boredom are the two conditions that drive
seniors to gamble.
Teen Gamblers
Problem gambling is an obsession that can overtake and destroy a young person's life Gambling attracts kids
from all types of families, economic background, ethic groups and religious faiths. Most teens with serious
gambling problems were introduced to gambling by a parent or other adult close to them. While society
increasingly frowns on youthful smoking, sex, alcohol and other drug use kids have been given the message
that gambling is "legitimate, fun and safe".
Teens with problem gambling will gamble to escape other problems and /or reality. They may be lonely,
depressed or bored. Teens may feel pressure from their peers and want to impress others. They may want to
be the center of attention and they think they can win friends if they buy things for them. They think it's a quick
way to get rich. Winning provides an instant, temporary boost of self-confidence.
GA 20 Questions
One of the first indicators that gambling is becoming a problem in an individual's life is when the gambling "just
isn't fun anymore." If you are wondering about your own gambling behavior or that of a loved one, consider the
following questions:
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Did you ever lose time from work or school due to gambling?
Has gambling ever made your home life unhappy?
Did gambling affect your reputation?
Have you ever felt remorse after gambling?
Did you ever gamble to get money with which to pay debts or otherwise solve financial difficulties?
Did gambling cause a decrease in your ambition or efficiency?
After losing did you feel you must return as soon as possible and win back your losses?
After a win did you have a strong urge to return and win more?
Did you often gamble until your last dollar was gone?
Did you ever borrow to finance your gambling?
Have you ever sold anything to finance gambling?
Were you reluctant to use "gambling money" for normal expenditures?
Did gambling make you careless of the welfare of yourself or your family?
Did you ever gamble longer than you had planned?
Have you ever gambled to escape worry or trouble?
Have you ever committed, or considered committing, an illegal act to finance gambling?
Did gambling cause you to have difficulty in sleeping?
Do arguments, disappointments or frustrations create within you an urge to gamble?
Did you ever have an urge to celebrate any good fortune by a few hours of gambling?
Have you ever considered self destruction or suicide as a result of your gambling?
Most compulsive gamblers will answer yes to at least seven of these questions.
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According to Dr. Henry Lesieur, M.D., there are two types of gamblers, those who are action seeking and
those who gamble to escape some aspect of life:
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Module Five Notes
ACTION SEEKERS
ESCAPE SEEKERS
Predominantly Male
Predominantly Female
Prefers competitive gambling
Prefers noncompetitive gambling
Starts gambling young
Starts gambling later in life
Stereotypical gambler
Has a short gambling career
Has gambling “friends”
Experiences relationship issues as a result of
gambling
Acts grandiose, like a big shot, big tipper
Gambling replaces or becomes an emotional
issue
Engages in criminal activity, has an arrest record
Gambling is often triggered by desire to lower
debts
May have a Narcissistic personality
Limited attempts to control behavior
Money is a relapse issue
Emotion is a relapse issue
Becomes escape seekers late in life
The bottom looks milder for these gamblers than
the action seekers
Dr. Robert Custer, M.D., identified three distinctive phases in the progression of gambling addiction:
Winning Phase:
Losing Phase:
Desperation Phase:
during this phase the gambler experiences a big win or a series of wins that leaves
them with unreasonable optimism that their winning will continue. This leads them to
become very excited when gambling and they begin to increase the amounts of their
bets, or how much time they spend gambling.
during the losing phase, the gambler often begins to brag about wins they have had
in the past, they start gambling alone, think more about gambling and borrow money
to gamble. Borrowing may be done legally or illegally. They being lying to family and
friends and become more irritable, restless and withdrawn. They begin to “chase”
their losses, believing they must gamble again as soon as possible to win back what
they have lost.
during this phase there is a marked increase in the time spent gambling. This is
accompanied by remorse, blaming others and alienating family and friends.
Eventually, the gambler may engage in illegal acts to finance their gambling. They
may experience hopelessness, suicidal thoughts and attempts, arrests, divorce,
alcohol and/or other drug abuse, or a complete emotional break down.
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Phases in a Gambler’s Career
Characteristic
Winning Phase
Losing Phase
Desperate Phase
Reason for
gambling
gambling to win & have fun
or to escape
gambling to recoup
losses, “chasing” to get
even
gambling because they
cannot keep from it
Gambling attitude
plans carefully and bets
cautiously
bets are impulsive &
rash
unreasonable; panicky,
bets hunches
eager,
optimism
fearful & depressed
feels powerless, blames
others,
feels
great
remorse and panic
part-time activity
most of life devoted to
chasing losses
only thing in life
Work activity
normal pre-gambling, some
time spent planning next
wagers
begins to miss work to
gamble, or may have
two jobs to have more to
gamble
has probably lost job
Family life
splits time between gambling
activities and family activities
preoccupied
with
gambling, relationships
begin to suffer
life is out of control,
alienation from family
and friends
Source of
gambling money
winnings
coverts assets into
cash, heavy borrowing,
loans
gets money any way
they can, often resorts
to criminal activity
Length of phase
1-3 years
5-15 years
short
How phase ends
The Big Win
Bail Out
Help
Mood
Time spent
gambling
unreasonable
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Types of Gamblers
Dr. Custer identified six types of gamblers:
Types of Gamblers
Gambler
Description
Level of Control
Length of Stay at this
level
Professional
Makes their living by
gambling and considers it
their profession.
Very controlled,
patiently waits for the
best opportunity.
Indefinite
Antisocial/Pers
onality
Uses gambling as a way to
get money by illegal means;
tries to fix games.
Cannot control their
criminal personality.
Indefinite
Casual/Social
Gambling is one of many
forms of entertainment.
Gambles infrequently.
If they couldn’t
participate in gambling
would not miss it.
Rarely escalates to
compulsive gambling, if
they do its is usually a
stress response.
Serious Social
Gambles as a major source
of entertainment; plays
regularly at one or more
types of gambling.
Comparable to a “tennis or
golf nut”.
Can stop but would
miss it.
Rarely escalates to
compulsive gambling, if
they do its is usually a
stress response.
Relief/Escape
Major activity in individuals
life - of equal importance
with family and work.
Can stop, but with
more difficulty than
casual or serious social
gamblers.
Rarely escalates to
compulsive gambling, if
they do its is usually a
stress response.
Compulsive
Gambling is only thing in
life; ignores family and
business and often turns to
crime to support habit.
Cannot stop without
help, no matter how
hard they try.
Quality of life is limited.
In 1996, Congress authorized The National Gambling Impact Study Commission by passing Public Law
104-169. The Commission is responsible for conducing comprehensive legal and factual studies of the social
and economic impacts of gambling on (1) federal, state, local, and Native American tribal governments; and
(2) communities and social institutions including: individuals, families and businesses. The Commission must
report its finding and conclusions together with its recommendations to the President of the United States, the
United States Congress, the State Governors, and Native American tribal governments. The Commission
filed its report on June 18, 1999. You may visit the National Gambling Impact Study Commission at
www.ngisc.gov/ .
In this section of the module we will review six different special population categories and the impact of
addiction on each. The categories include: cultural and ethnic diversity, adolescents, gender and sexual
preference issues, the elderly, the disabled, and individuals in the criminal justice system. Each category
presents with differences that effect how counselors should work with clients and their families. Dual
disordered clients, another category of significance, will be discussed in Module Seven.
Culturally and Ethnically Diverse Groups
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Module Five Notes
The text book does an outstanding job of reviewing four major cultural groups: Native Americans and Alaska
Natives, Asian Americans, African Americans, and Latino/Hispanic Americans.
Native American & Alaska Native Groups
We have known for some time that substantial differences in patterns of substance abuse exist among ethnic
groups. Overall rates of alcohol and other drug use are high among members of Native American and Alaska
Native groups, although the rates vary by age and gender across and within tribes. Native Americans and
Alaska Natives are currently the smallest minority group in the United States, constituting 0.7 % (about 2
million) of the population in 1997. It is important to recognize that Native American tribes cannot be placed
into a large “melting pot”, because tribally-specific differences must be acknowledged. Each tribe, whether
from the Plains, Plateau, or Costal Regions, have separate and often vastly different beliefs, ceremonies,
governments, practices and traditions. Differences may occur within a tribe, since the bands and clans within
it often possess practical and theoretical differences. In 1995, the large majority of admissions (77%) to
substance abuse treatment among Native Americans was due to alcohol. American Native youth have very
high rates of drug use compared to their non-Native American counterparts. They also tend to begin using
alcohol, illicit substances, cigarettes, and inhalants at a younger age, at higher rates and in combination with
one another. They also have the highest level of need of illicit drug abuse treatment compared to any other
group.
Asian American and Pacific Islanders
The Asian American and Pacific Islander populations poses intellectual and pragmatic challenges to providers
of substance abuse treatment. First, they are the fastest growing minority group in the United States. Census
figures from 1997 estimate that about 9.6 million Asian Americans and Pacific Islanders reside in the United
States. This represents 4 % of the total population. Based on projected growth rates, this group will number
in excess of 41 million by 2040. Chinese are the largest Asian subgroup residing in the United States (23 %),
followed by Filipinos (19 %), Korean Americans and Asian Indians at 11 % each. Vietnamese represent 8 %
of all Asians and Pacific Islanders in the United States, followed by Cambodians and Laotians with 2 % each
and Hmong and Thai with 1 % each. As you can see this population is characterized by huge ethnic, cultural
and socio-demographic heterogeneity. Until recently, this population’s substance abuse problems have not
received close attention. Asian Americans and Pacific Islanders have been under represented in most
surveys because they do not reside in the areas sampled. Although it is largely agreed that they tend to have
fewer substance abuse-related problems than the other groups, these problems are on the rise, particularly
among specific subgroups.
African Americans
According to the 1997 U.S. Census Bureau figures, non-Hispanic African Americans make up about 12.1 % of
the total U.S. population and number approximately 32.5 million. While a large number of African Americans
abstain from alcohol and other substances, a significant number use and abuse alcohol and other
substances. To make an already complex picture more complicated, substances abuse patterns vary by age
group. African Americans tend not to use and abuse substance at an early age, but there is a high prevalence
of alcohol and other substance use among those age 21 and older. African Americans 18 and older are
second only to Native Americans in their need for substance abuse treatment. There are no universally
accepted theoretical perspectives that explain the causes for the high incidence of substance abuse among
African Americans. There is agreement that poverty, overcrowding, illiteracy, unemployment, the breakdown
of two-parent families, and environmental stressors associated with both structural and interpersonal racism
are contributing factors.
Latino/Hispanic Populations
Latino/Hispanic Americans constituted the second largest ethnic minority group in the United States. In 1997,
they comprised 11.1 % of the total population, numbering approximately 30 million). This figure does not
include the approximately 3.8 million people residing in Puerto Rico. At the current rate of growth, projections
indicate that Latino/Hispanic Americans will become the largest ethnic minority group in the United States by
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DAAC 1319: Intro to AOD
Module Five Notes
the year 2010. This group is diverse in terms of their country of origin and in their geographic location in the
United States. Sixty-four % of all Latino/Hispanics residing in the Untied States are Mexicans living in the
Southwest and West. Puerto Ricans living in the U.S. constitute 10.4 % of the Latino/Hispanic population,
most of whom reside in the Northeast, although a significant number have recently moved to the Southeast.
Cubans account for 4.2 %, and are located primarily in the Southeast. The remaining 21 % are comprised of
a large number of immigrants from Central and South American and the Dominican Republic. Dominicans are
the fasting growing subgroup within the Latino/Hispanic population.
Barriers to Treatment
Individuals with substance abuse problems from racial/ethnic groups tend to underutilize health care, prenatal
care, mental health care, and substance abuse treatment, or they seek them as a last resort. Treatment may
be sought only when the resources of the traditional family/social support network have been exhausted; at
this point, problems may be so chronic and severe that treatment outcomes may be poor. This pattern of
utilization is the result of complex factors.
Those needing treatment may live in areas where access to health care providers is limited because of
distance or transportation problems. Those with access often find that services are inadequate or
inconveniently scheduled. Others may not realize that they are eligible, or may not know what services a local
program offers. Many treatment providers are not able to address treatment needs of individuals from cultural
backgrounds different than their own even when they speak the client’s language of origin. This is further
compounded when trying to develop written materials for linguistic and culturally diverse populations. Issues
such as literacy levels and regional language differences need to be taken into account when developing
written treatment program materials.
Health and illness beliefs and attitudes may act as obstacles keeping racial and ethnic populations from
seeking treatment for a substance abuse problem. More is known about the impact of health beliefs and
attitudes on physical health than on drug treatment behavior. Reliance on folk remedies may cause some
underutilization of treatment services. Cultural stigma attached to psychiatric care may involve fear of losing
status and of being judged a failure by the family and the community. Cultures differ in their explanations,
views, and acceptance of abnormal behaviors; what is defined as abnormal behavior in one culture may be
sanctioned or encouraged in another. Abnormal behaviors may be attributed to physical or psychological
causes or they may be viewed as the direct result of supernatural or spiritual forces.
Regardless of the treatment model in use, racism on an institutional or individual level can be a barrier to
treatment effectiveness. Institutional racism within a treatment system is evident when the program or
treatment design is oblivious to the racial, cultural, or ethnic backgrounds, values, and mores of its client
population. Latent prejudice on the part of treatment staff as well as language and cultural differences
undermine efforts to help clients succeed. The use of indigenous treatment professionals (individuals who
come from the same community as those being served) is strongly encouraged to assist programs in
accessing community networks and to help ensure that program design accounts for the belief systems,
cultural values, attitudes and behaviors of the clients to be served.
The significant majority of minorities live in the Border States of Texas, California, New Mexico and Arizona.
They include: 59.5 % of Latino/Hispanics; 44.5 % of Asian Americans/Pacific Islanders; 33 % of Native
Americans/Alaska Natives; 14.6 % of African Americans; while only 16.3 % of Caucasian Americans reside in
these states. These specific minority groups make up 24.8 % of the total U.S. population, but constitute 41.5
% of the population in these four states according the U.S. Bureau of Census. This has significant
implications for treatment providers in these states. The need to develop strategies for addressing minority
populations must include designing programs that:
· acknowledge and utilize cultural strengths and values in the treatment setting;
· recruit and retain bilingual/multi-ethnic and multicultral indigenous staff;
· provide ongoing training to address issues of cultural diversity and competence;
· and utilize research and program outcome measures that are culturally sensitive.
Examining Cultural Beliefs Related to Chemical Dependency:
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DAAC 1319: Intro to AOD
Module Five Notes
Myth:
Fact:
“Most people in the U.S. who use alcohol and other drugs are people of color.”
Unfortunately, most of our impressions about who uses or abuses drugs are shaped by the media and
the entertainment industry. We are bombarded by stereotyped images that depict people of color as
being “the problem”. These stereotypes conflict with the fact about actual alcohol or drug use. Use
and abuse of AOD cuts across all racial, cultural, gender, age, and socioeconomic lines. The lifetime
prevalence rates clearly reveal that Caucasians in the U.S. consume more alcohol and drugs than all
other populations combined (CWLA, 1993).
Myth:
“Families of color are more likely to refer chemically dependent family members to treatment
programs and to be more involved and supportive of the treatment process than chemically
dependent Caucasian families.”
Research on treatment suggest that families of color are not as likely as Caucasian families to refer
chemically dependent family members to treatment, or to be as involved and supportive of the
treatment process. This difference is most apparent in low-income, urban families of color. There
are several plausible explanations for the apparent lack of support. Consider the following:
· Treatment programs, designed for and run by predominantly Caucasian staff members, have not
reached out to other racial/cultural populations in the community to encourage entry into
treatment.
· Treatment programs are often based on “12-Step Models”, that encourage open disclosure to a
group by family members and the chemically dependent individual. Airing personal information to
strangers or individuals outside their ethnic group may be difficult or unacceptable for members of
some racial/cultural groups.
· Chemically dependent individuals of color are more likely than their Caucasian peers to access
treatment through the court system at the latter stages of dependency when the individual is more
likely to have serious social/legal problems related to their drinking or drug use. At this point it is
also likely that family members, regardless of racial, ethnic, or cultural group, are going to be less
willing to participate actively in treatment.
· Few treatment programs build upon cultural values and the importance of the family in the
recovery process. The few that do exist are even less likely to try to engage or structure the
program around the needs of the “working poor” who cannot afford to take days off from work to
participate in traditional “family week programs” (CWLA. 1993).
Fact:
Myth:
“All racial and cultural populations share similar attitudes about the nature of chemical dependency.”
Fact:
There are many different views and beliefs about the nature of chemical dependency. Throughout
history, families from all cultural backgrounds have often shrouded chemical dependency in secrecy.
A chemically dependent family member was often a source of embarrassment or ridicule. Since
many AOD programs were initially designed for Caucasian, middle-class Americans, it is not
surprising that members of this population have been most willing to view chemical dependency as a
treatable condition. Because of this de-stigmatization of the condition, chemically dependent
Caucasian individuals and families may be more open to entering treatment programs that are based
on medical models, firmly grounded in the values and attitudes of their culture.
In contract, other racial, ethnic, and/or cultural populations in our society might not view chemical
dependency as a primary problem requiring professional intervention. Instead, they may see the
problems as one of willful misconduct, a moral failing, or an unfortunate condition caused by other
outside forces such as poverty or racism. AOD abuse may be seen as a consequence of the stress
and pain of living in a society that is racist and restrictive, and that often destroys an individual’s spirit
and self-esteem. If this is a commonly held attitude of an individual’s cultural group, it is less likely
that they will feel comfortable seeking help outside of their own cultural community (CWLA. 1993).
Myth:
Fact:
“Afford ability is the only barrier to the use of alcohol and drug treatment programs by people with
various cultural identifications who are chemically dependent.”
Economic barriers do exist, but many other factors deter people from entering the treatment system.
Until recently, little attention was given to tailoring the program or services to the needs of minority
cultures. Barriers have included:
· Even if treatment were affordable, the demand for multifaceted, comprehensive, culturally
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Module Five Notes
·
Myth:
Fact:
responsive, coordinated prevention, treatment, and aftercare services far exceeds the supply.
This is particularly true for programs tailored to the unique needs of women. Finding appropriate,
accessible and affordable services may be quite difficult.
Cultural values or attitudes may discourage an individual or family from accessing appropriate
services. While cultural and racial groups vary, there are some commonly held attitudes or
beliefs that may affect alcohol or drug use or recovery. Families form some cultures may not
approach chemical dependency as an illness, and therefore, may not appreciate efforts to
engage the chemically involved person in treatment (CWLA. 1993).
“The negative consequences of alcohol or drug use/dependency affect all racial and cultural groups
equally.”
Although over 60% of AOD users are Caucasian, Native Americans/Alaska Natives, African
Americans and Latino/Hispanic Americans are more likely to experience more negative
consequences as a result of alcohol or drug use or dependency. There is no evidence to suggest that
people of color abuse alcohol and drugs more than Caucasians but rather, that they are more often
identified and reported in the latter stages of dependency when problems are more acute.
Additional Resources
Reference materials used in this module have been taken from the following sources:
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Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; 1994. American Psychiatric Association,
Washington D.C.
CSAT. TIP 9: Treatment Improvement Protocol: Assessment of Patients with Coexisting Mental Illness and Alcohol
and Other Drug Abuse
Other Resources of Interest:
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American Psychiatric Association @ www.psych.org/
Fact Sheets @ www.psych.org/public_info/dpa_fact.html
Fact Sheets on Mental Disorders @ the National Mental Health Association
www.nmha.org/infoctr/factsheets/index.cfm
Addiction & the Addictive Disorders @ the American Academy of Health Care Providers
www.americanacademy.org/resources/info.html
Interfaces Between Criminal Behavior, AOD and Psychiatric Disorders
@ www.treatment.org/Communique/Comm93/peper.html
National Alliance for the Mentally Ill @ www.nami.org/
APA Links on Psychiatric Medications
@ www.psych.org/psych/htdocs/public_info/psy_med_links.html
Dual Diagnosis and the Schizotypal Personality Disorder
@ www.monumental.com/arcturus/dd/schtypal.htm
Dual Diagnosis and the Schizoid Personality Disorder
@ www.monumental.com/arcturus/dd/schizoid.htm
Dual Diagnosis and the Paranoid Personality Disorder
@ www.monumental.com/arcturus/dd/paranoid.htm
Dual Diagnosis and the Borderline Personality Disorder
@ www.monumental.com/arcturus/dd/borderln.htm
Dual Diagnosis and the Histrionic Personality Disorder
@ www.monumental.com/arcturus/dd/histrion.htm
Dual Diagnosis: Personality Disorders and Addiction
@ www.monumental.com/arcturus/dd/pdsa.htm#1
Dual Diagnosis and the Passive-Aggressive Personality Disorder
@ www.monumental.com/arcturus/dd/papd.htm
Dual Diagnosis and the Obsessive-Compulsive Personality Disorder
@ www.monumental.com/arcturus/dd/ocpd.htm
Dual Diagnosis and the Dependent Personality Disorder
@ www.monumental.com/arcturus/dd/depend.htm
Dual Diagnosis and the Narcissistic Personality Disorder
@ www.monumental.com/arcturus/dd/narc.htm
Dual Diagnosis and the Avoidant Personality Disorder
@ www.monumental.com/arcturus/dd/avoid.htm
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DAAC 1319: Intro to AOD
Module Five Notes
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Dual Diagnosis and the Antisocial Personality Disorder
@ www.monumental.com/arcturus/dd/antisoc.htm
Information on Gambling
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National Gambling Impact Study Commission @ www.ngisc.gov/
Gamblers Anonymous International Service Office @ www.gamblersanonymous.org/
Heartskober Manor @ www.heartskobermanor.com/
America a Bettor Nation
@ www.abcnews.go.com/sections/living/DailyNews/gambling990319.html
Gambling Treatment @ www.robertperkins.com/gambling-treatment.htm
Illinois Institute for Addiction Recovery @ http://addictionrecov.org/addicgam.htm
Youth Gambling Growing In Prevalence Article from the American Psychological Association @
www.apa.org/releases/gamble.html
Researchers Identify Cognitive Process That Contributes to Gambling Behavior Article from the American
Psychological Association @ www.apa.org/releases/gambling.html
National Council on Problem Gambling, Inc. @ www.ncpgambling.org/
Problem Gambling Association @ www.problemgambling.com/
Gambling in Texas: 1995 Survey: Executive Summary from TCADA
@ www.tcada.state.tx.us/research/gambling/1995/
References
Reference materials used in this module have been taken from the following sources:
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U.S. DHHS, CSAP, 1999. Cultural Issues in Substance Abuse Treatment.
U.S. DHHS, Bureau of the Census, 1997.
U.S. DHHS, Bureau of the Census, 1998.
Beauvais, F. 1996. Trends in Drug Use Among American Indian Students and Drop-outs, 1975-1994. American
Journal of Public Health 86(1): 1594-1598.
U.S. DHHS, CDC, HIV/AIDS Surveillance Report, 1997.
Gray, M. 1997. Cultural competence in Substance Abuse Prevention. Washington D.C., National Association of
Social Workers Press.
Jones-Webb, Snowden, L., Herd, D. Short, B. and Hannen, P. 1997. Alcohol-related Problems among Black,
Hispanic and White Men: The Contributions of Neighborhood Poverty. Journal of Studies on Alcohol 58(5): 539545.
Child Welfare League of America CWLA. 1993. Act 1 Alcohol and Other Drugs: A Competency-Based Training.
TIP 31: Screening & Assessing Adolescents for Substance Use Disorders
@ www.health.org/survey/31.htm
TIP 32: Treatment of Adolescents with Substance Use Disorders
@ www.health.org/survey/32.htm
U.S. DHHS, CSAT, 1994. Practical Approaches in the Treatment of Women Who Abuse Alcohol and Other
Drugs.
U.S. DHHS, CDC, Office on Smoking and Health, 1989. Smoking Tobacco & Health: A Fact Book.
U.S. DHHS, CDC, Morbidity and Mortality Weekly Report, Vol 44, No. 5, Feb 10,1995.
U.S. DHHS, NIDA, 1993. Eighth Special Report to U.S. Congress on Alcohol and Health.
TIP 25: Substance Abuse Treatment and Domestic Violence @ www.health.org/survey/25.htm
U.S. DHHS, CSAP, 1992. Cultural Competence for Evaluators.
TIP 26: Substance Abuse Among Older Adults @ www.health.org/survey/26.htm
National Alliance for the Mentally Ill, The ADA-Americans with Disabilities Act
@ www.nami.org/helpline/ada.htm
TIP 30: Continuity of Offender Treatment for Substance Use Disorders From Institutions to Community @
www.health.org/survey/30.htm
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