Download Addiction Treatment: A Strengths Perspective 3rd Edition

Addiction Treatment:
A Strengths Perspective
3rd Edition
Katherine van Wormer
Diane Rae Davis
Cengage Publishing Company
2012 copyright
Part I: Introduction
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Addiction affects us all. Strengths perspective—
strengths of clients and strengths of the
contemporary models:
Harm reduction
 12 Step approach.
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Rift in field.
Book in 3 parts: bio-psycho-social
Chapter I
Nature of Addiction
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Examples of addiction---smoker dying of
emphysema, crack addict arrested, pregnant
mother drinking heavily, girl hooked on meth
she started using to lose weight
Economic cost—health, war on drugs, over 1
million in prison for drug involvement. Big
business—gambling, Philip Morris, beer
What is addiction?
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(Latin) addictus---attached to something,
positive. Today alcoholism called a “brain
disease”or bad habit or sin. Leading assumption
of the text: Addiction is the key, not the
substance or behavior
Addiction defined by researchers as “a bad
habit,” “a brain disease,” “helplessness,” “a
problem of motivation”
DSM-5
Changes to DSM in new edition: no longer dichotomy
between abuse and dependence
Addiction now the preferred term instead of dependence.
Addiction now seen as a continuum.
Substance use disorder requires 2 of following:
tolerance
withdrawal problems
use more than intended
reduced involvement
inability to stop
excessive spending or effort
to obtain
continued use
Definitions
Addiction—pattern of compulsive use.
•Has physical, psychological, social aspects.
•Emphasis on process rather than outcome.
Gambling now considered an addiction in DSM-5
Pattern of preoccupation, lack of control, form of
escape, chasing one’s losses, serious consequences.
Box 1.1
A Social Work Major Working in a
Casino
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What is the ethical dilemma here?
How do the managers ensure that the gamblers
keep spending their money?
How are the employees controlled by the
establishment?
The Disease Concept
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Is alcoholism a disease?
Arguments pro:
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Arguments con:
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First, Define Disease
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Disease - as metaphor by Jellinek: “alcoholism is like a disease”
Random House Dictionary, disease is a condition of the body in
which this is incorrect function.
Oxford University Dictionary– disease is absence of ease (in
treatment – disease as: primary, progressive, chronic, and
possibly fatal).
Illness – term preferred here, less controversial, less medical.
Best arguments pro disease: alcoholism is a brain disease because
the addicted brain has changed.
Best arguments against: just a habit, a behavior, need to take
responsibility, people mature out of it.
Biopsychosocial-spiritual Model
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Why (bio), what (psycho), where (social)
Need for spiritual healing, connection with
Higher Power
Interactionism and cycle of pain: pain and
suffering  loss  pain, stress and drinking
more pain
Family as a system in interaction, roles
Why Do We Need to Know about
Addiction?
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80% of people behind bars have problems, pervasive in
child welfare system, alcoholism in the workplace.
71% of social workers worked with clients with
substance use disorders in the past year.
Headlines:
-“When Tanning Turns into an Addiction”
-“Help! I’m Addicted to Facebook”
Relevant movies: 28 days, Traffic, Walk the Line
Table 1.1 Contrast Traditional Approach and
Strengths Perspective
Traditional approach dichotomizes alcoholic and
non-alcoholic
Use of labels—I am an alcoholic, addict,
dysfunctional family
Focus on losses, client in denial, resistant
Strengths approach—avoids labels, focus on
strengths, family as resource
Two Approaches to Treatment
Traditional
Bio
Dichotomy
Psycho
Problems mandate—one size
fits all
Social
Identify family dysfunction
Strengths-based
Bio
Continuum
Psycho
Strengths-motivation
Social
Holistic family as resource
Addiction Recovery Management
Strengths-based treatment approach endorsed
by UN
Case management
Community resources for long-term care
Interventions relate to personal needs in
society—mental health care, housing
Success measured in drinking, using less, not
total abstinence
Strengths Perspective
Rapp and Goscha:
Six critical elements: person is not the illness, choice, hope, purpose,
achievement, presence of one key person to help.
 Finding the strengths in divergent models—harm reduction and 12 Step
approach
 Different models for different folks.
 Very negative view of disease model: Stanton Peele: Resisting 12 Step
Coercion
 Harm reduction and the strengths perspective— “meet the client where
the client is.”
 Policy issues of reducing harm.
Empirical Research
Project MATCH
Directed by NIAAA – 2,000 clients over 8 yrs.
What works? 12 step facilitation, cognitive, motivational enhancement therapy
(MET)
MET most effective for those with low motivation, 12 Step with religious
persons.
Criticism: lack of a control group. MET, a shorter intervention. Models only
tested on alcoholic clients.
Project MATCH confirms the effectiveness of diverse treatments. New measure
for recovery is improvement, not total abstinence.
Vaillant’s Research
40 year longitudinal study—those who recovered had crisis with alcohol or joined
AA or entered a stable relationship or had a religious conversion.
Empirical Research Continued
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Research from California: 1$ spent saves 7 across
states.
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Hester and Miller found that these treatment modalities
were proven to be most effective: brief intervention,
motivational interviewing (MI), use of the medication
naltrexone, social skills training, aversion therapy,
cognitive therapy, acupuncture. (See chapter 8)
Treatment Trends
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Prescription drug misuse as increasing problem;
Harm reduction recognized as important to save lives; public
health approach;
Belief that punitive laws cause harm;
Majority of Americans favor treatment over jail;
De-emphasis on incarceration, reentry programming;
Drug courts, mental health courts;
Attention to co-occurring disorders and extensive use of
prescribed medications to reduce craving;
Restorative Justice: victim-offender programming to promote
healing. PEASE Academy.
Chapter 2
Historical Perspectives
Early History
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Alcohol back to 5000 BC Iran
Unknown to world’s indigenous people
Koran --- condemned wine. Alcohol from Arabic
al-kuhul.
Arabian dr. discovered evaporated distilled spirits.
Technology exceeded its grasp
1575 --- distilling used–gin. Booze from Dutch
busen.
Great devastation from England, 1700-1750.
Infant mortality, crime
North America
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More beer than water on Mayflower.
Slaves forbidden to drink except on special
occasions, taught bingeing.
Puritan traditions.
18th – Quakers and Methodists disapproved
of hard liquor.
Male drinking cult 1725-1825 notorious.
Temperance movement
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1825-1919: Against hard liquor.
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Temperance woman for women’s suffrage and
ban on distilled beverages.
Early 1900s
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Cocaine in Coke
Tobacco outlawed for brief period.
1914 Harrison Act --- restricted opioids
(associated with Chinese people) cocaine
must now be prescribed.
Marijuana (associated with Mexicans) State
laws in southwest criminalized.
Teetotaler T =total abstinence, from Ireland.
U.S. Prohibition 1920-1933
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Glamorized crime. Mafia/ Hollywood/Wash.
DC link. Homicide rates increased.
Great Depression created need for jobs.
Giancana, Double Cross
Modern War on Drugs
Johnson—war on poverty
Nixon tthrough the Bushes—war on drugs
1960s heroin horror stories
1980s, crack cocaine
2000s, meth
Attacks directed toward poor, minorities.
History of Gambling in U.S.
Lotteries American Revolution
Banned after Civil War and during Prohibition.
1931—casino gambling legal in Nevada
1960s—lotteries for state revenue
1972—first gambling treatment center at VA, New York
1987—Supreme Court banned state regulation of tribal casinos
Mississippi River casinos
Internet gambling popular today
Themes of First Half of Chapter
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Dangers of potent alcohol, role of ethnic
prejudice in shaping drug legislation,
unintended consequences of prohibition.
Example of happy Italian family enjoying
wine with their meals.
Modern War on Drugs, two-thirds of money
for law enforcement.
History of Addiction Treatment
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William White, Slaying the Dragon. Mistreatment of
persons with mentally illness and alcoholics in
asylums.
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Getting Better by Nan Robertson tells of Bill W. and
Dr. Bob. Oxford Groups. Big Book. 2 million
members in AA worldwide today.
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Jellinek (The Disease Concept, 1960) – 5 types of
alcoholism based on world travels:
Alpha, Beta, Gamma , Delta, Epsilon.
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Treatment History continued
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1956 AMA declared alcoholism an illness, 1966,
a disease.
Harold Hughes –founded NIAAA.
Hazelden adapted 12 Step approach.
Box 2:1—“Treatment in Norway”—universal
health care for support.
Peele and Fingarette: addiction as bad habits not
disease.
History of Harm Reduction
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AIDS in Netherlands spawned new approach, to
reduce the harm.
Britain, 1960s and later.
Heroin prescribed. Needle exchanges-U.S.
Alan Marlatt, died in 2011, pioneer in spread of
harm reduction approach to U.S., researcher at
U. of Washington.
Part II
BIOLOGY
Chapter 3
Substance Misuse, Dependence, and the Body
Part II
BIOLOGY
Chapter 3
Substance Misuse, Dependence, and the Body
Recent Trends
Development of PET scans, fMRI—
functional magnetic resonance imaging
Craving research
New facts on brain damage
Depressants
Alcohol
Figure 3.1—alcohol involvement: 47% of
homicides; 34% of drownings; 42% of fire
injuries; 47% of young male car crashes;
50% date rape; 16% child abuse (doesn’t
count neglect); 23% of suicide.
International studies show high correlation
with partner violence.
College student deaths per year –1,825
(NIAAA, 2010)
Father Martin—Chalk Talks
Jocose drunk, amorose, bellicose,
lachrymose drunks
Our additions: somnos drunk, (sleepy)
clamorose, (loud), scientose (know it all)
Global Drinking Patterns
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Europeans consume six times as much alcohol as
southeast Asians
Moldova, the Czech Republic, drink around 18 liters
per capita each year.
Eastern Europeans—hard liquor
British and Irish—beer
French and Italians—wine
High rates—indigenous populations Northern Sweden
and Northern Canada
Alcohol continued
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Health effects of moderate drinkers—heart
benefits, lower death rates than teetotalers.
7-10% of drinkers get addicted. Signs: tolerance,
withdrawal (tremors, nausea; 5% have DTs),
heavy nicotine, caffeine use
Tolerance reversal
.4 B.A.C. may be comatose.
Blackouts: common at .3 BAC, case in Tom
Sawyer
Real court cases
Narcotics
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Opiates—from opium poppy…narcotics,
heroin now can be smoked or snorted.
High tolerance so need greater quantities for
high.
Inhalants—household products, huffing, brain
damage, coma
Misuse of pain medication increasing today
OxyContin
Stimulants
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Cocaine-crack and powder, in urine 8 hrs., smoked for faster
high. High lasts only 15-20 minutes.
Brain blocks reuptake of dopamine… Addicted rats die…
heart attack.
Amphetamines and meth—synthetic unlike cocaine—
suppresses appetite. Used by Nazis. 4-16 hour high.
Methland by Nick Reding about Oelwein, Iowa.
Powder can be snorted, injected. Stay awake for long
durations…
Anhedonia---inability to feel pleasure with drug-induced brain
injury.
Nicotine
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Can both stimulate and relax. 80-95% of alcoholics
smoke, reduces alcohol effects. Over half of persons
with schizophrenia smoke.
Nicotine decreases BAC levels.
American businessman’s story from China.
Malachy McCourt smoked for ad and got hooked.
Box 3.1 “To Die for a Cigarette”
Case of chewing tobacco—snuff.
Hallucinogens
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Plants, LSD, synthetic, flashbacks, PCP
Ecstasy and roofies—heightens sensory
experience…raves..
Can’t get back to original high due to brain
changes.
10% in high school have used Ecstasy.
Dance Safe – harm reduction strategies.
Roofies: sleeping pill in Europe.
What Is Ecstasy?

Split
Ecstasy is a drug that has
some hallucinogenic
properties and is
structurally related to
amphetamines. Its short
form chemical name is
MDMA (3,4methylenedioxymethamphetamine).
Short Term Effects of Ecstasy
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Feeling of confidence
Sense of arousal
Increased heart rate
Dry and sore mouth/throat
Tension, High Body Temperature
Muscle twitching
Depression & Confusion
Other Synthetic Substances
Spice
Bath salts—increase in ER visits
associated with this drug.
Hard to detect.
Cannabis
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Marijuana
THC, the psychoactive ingredient, lowers blood
glucose, increases appetite, Stored in fat cells,
long term use possibly associated with apathy.
Earlier reports of lung cancer after long-term
use were not validated.
Costs to Get High
Estimates Differ by Region
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[not in text]
Crack: $5-10 quick fix only lasts 30 min.
Heroin: $100-200 day--$20 day can by maintenance
dose inject a couple of times
Ecstasy: $25 may take 5 or so pills.
Meth: $25 long-lasting high, popular in gay party
scene in Seattle, factory workers in Iowa
Marijuana: $25 or higher, depends on quality
Metabolism
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Liver: organ that metabolizes alcohol, alcohol
circulates in the bloodstream until metabolized.
Men have special enzymes that help.
People metabolize ½ oz. per hour = small glass of
wine.
One Drink ¼ One bottle of beer (12 oz.)
¼ One glass of wine (6 oz.)
¼ One “single” drink (1¼ oz. of liquor)
Metabolism continued
Brain Regions and Their Functions
Ecstasy and the Brain
The Brain and Addiction
Neurotransmitters affect emotions and memory
Neurotransmitters Affect
Emotions and Memory
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Dopamine—reuptake affected by cocaine, which
blocks dopamine synapse
Depletion following cocaine use. Nicotine affects
dopamine too.
Parkinson’s when too little. Dopamine-boosting drugs
for Parkinson’s associated with mania and gambling
behavior.
Excess of dopamine associated with schizophrenia.
Serotonin: influenced by alcohol, involved in sleep.
Decreased levels linked to depression, anxiety,
impulsiveness suicide.
Depletion Following Cocaine Use.
The right scan is taken from someone who is on cocaine. The loss of red areas in
the right scan compared to the left (normal) scan indicates that the brain is using
less glucose and therefore is less active. This reduction in activity results in
disruption of many brain functions.
Memory and Craving
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Addict never gets original high—brain has
changed. Addiction is a brain disease.
Cues can trigger memory…picture of
alcoholic beverages activates certain areas of
the brain.
Prozac reduces craving by regulating
serotonin levels.
Cocaine in the Brain
Slides are from the National Institute on Drug Abuse (NIDA) (www.nida.nih.gov)
Gambling and the Brain
Persons with gambling disorders may
have abnormal levels of dopamine
and serotonin.
Lack of control may result.
Highs enhanced when rewards
uncertain.
Near misses especially thrilling.
The Role of Genes
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Study of mental hospitals, prisons, 50% who used
chemical substances had mental disorders.
Cloninger—Sweden..259 male adoptees with alcoholic
fathers
Type 1: late onset..75% of alcoholics, relates to harm
avoidance, anxiety, guilt
Type 2: risk taker, (starts about age 11) male,
hyperactive, antisocial, hereditary
Ondansetron: works on serotonin, little effect on type 1
Twins: 40-60% concurrence of alcoholism. Separated at
birth monkeys drank more under stress, people with low
dopamine like stimulants
People with ADHD risk for drug abuse.
Medical Consequences
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Wernicke Korsakoff:
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Cases reported of Dr. Oliver Sachs
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Peripheral neuropathy related to lack of Vitamin B
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Confabulation….Dr. Sachs—Awakenings
Medical Consequences continued
Liver damage…removes toxins from blood,
bile circulates in blood stream
Yellow skin tone, cirrhosis, immune system
breakdown.
Heart – nicotine, cocaine
Fetal alcohol syndrome. See photograph in
text. Short nose, indistinct groove between
nose and mouth, thin upper lip, small head
and eyes, learning problems. Role of sperm
should be considered as well as mother’s role.
Interventions Related to Biology
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Schick Shadel, Seattle treatment center
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Conditioning or aversion therapy—favorite
drink plus emetine to induce vomiting.
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Use of truth serum on alternate days.
Changing Brain Chemistry
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Brain Lock (Schwartz) cognitive treatment for OCD to
“rewire the brain”
Ondansetron—decreases craving
Zyban and smoking; Chantix helps person produce
more dopamine.
Nicotine gum; patch.
Naltrexone, approved 1995, not a narcotic unlike
methadone.
Blocks receptors for getting high.
Synthetic Prescription Drugs
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Methadone (synthetic form of heroin);
Methadone maintenance
Heroin maintenance in Britain, Switzerland, Vancouver.
Buprenorphine can be prescribed by GPs, reduces likelihood of
overdose
Eating disorders and dopamine
Bulimics—related to depression
Anorexia—anxiety
Luvox, Prozac, and Paxil decrease binges.
Holistic Treatments
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Herbal remedies
St. John’s wort
Hypnosis
Acupuncture from China
Massage therapy
Physical exercise to reduce tension
Chapter 4
Gender and Sexual Orientation
Differences
Gender Issues
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•
•
•
•
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Recent trends—voices of women and gays and lesbians
are increasingly heard regarding treatment, research.
Some emphasis on gender-sensitive treatment.
Class and cultural differences in drug use.
Male/female ratios differ in drinking quantity ratios
from 13:12 in Italy to 28:11 in Canada, 46:5 in Mexico,
and 15:3 in Russia.
In American high schools, substance use rates about
the same.
Adult men, twice the rate of women for marijuana and
cocaine use and gambling, meth and tranquilizers
about the same.
More eating disorders in women
Gender Differences
•
Shame factor for women in treatment.
•
Women in treatment more likely than men to have a substancedependent partner.
•
Treatment less accessible for mothers than fathers due to child care
responsibilities.
•
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Many women lose custody of children over substance misuse.
Abstinence demands unrealistic.
•
Lack of treatment availability for pregnant women.
•
Good results with recovery coaches and family courts.
Gender Differences continued
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Meth addiction rates high among women.
One study showed that 80% of female meth
addicts were victims of domestic violence.
Violence---3 of 4 intimate partner murders are
of women.
Women alcoholics ---47% in treatment molested
as children in study of 472 women (Downs).
Treatment needs to focus on PTSD issues.
Women smoke to control weight, males to
Biological Differences
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Women get intoxicated quicker than men.
Women have a higher mortality rate with heavy drinking.
Lives are shortened by 15 years on average with alcoholism—heart
and liver damage.
Women’s Treatment Needs
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1. Address barriers to treatment that many women experience,
such as lack of transportation, child care, and treatment
availability.
2. Changing program goals and processes to accommodate
women’s needs for more support, less confrontation, job skill
training, and parenting skills.
3. Embracing an empowerment model of change.
4. Female counselors who can attend to shame and stigma issues.
5. Need to celebrate any significant decrease in substance use.
Sexual Orientation
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Heterosexism and homophobia: U.S. studies of schools
shows suicide is 14 times the heterosexual rates.
Lesbians—lowest rate of AIDS of any group, but double
the drug use of other women, 55% smoke at some point
in their lives; 28% are obese.
Reasons for high drinking rate—gay bar, fewer are
mothers….G/L AA.
Gay males—high risk of sexual abuse in jail cells.
Religious fundamentalism correlated with
suicide…alcohol problems persist across life span.
Transgender….See Do’s and Don’ts…table 11.2
Resources: Pride Institute and PFLAG
Chapter 5
Gambling, Eating Disorders,
Shopping, and Other Behavioral
Addictions
Gambling Addiction
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Gambling, has become socially acceptable
Criteria of pathological gambling---preoccupation,
increasing amounts, etc. 3-7% of gamblers have
problems, suicide high in gamblers
Cost to economy is $54 billion—bankruptcies, lost
work time, crime, etc. Very high among Native
Americans—over 14% have gambling problems
Research shows counties with gambling casinos
have higher crime rates and bankruptcies than
others
Gambling continued
•
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•
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Problems among the elderly
Internet gambling is the fastest growing form.
2-4% in Gamblers Anonymous (GA) are women.
But many helpline calls.
Women gamble to escape; men for action.
Associated with other problems
Box 5.1 Reflections of a Male Compulsive
Gambler. Geographical relocation helped him
break his habit.
Questions for Screening
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•
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Have you ever borrowed money in order to gamble
or cover lost money?
Have you ever thought you might have a gambling
problem or been told that you might?
Have you ever been untruthful about the extent of
your gambling or hidden it from others?
Have you ever tried to stop or cut back on how
much or how often you gamble?
Treatment Issues
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Treatment: cognitive work and motivational
therapy
Irrational thinking about winning:
• “I put so much money in this machine,
I’m bound to win.”
• High profile winners
• Lucky machine and dates
States’ spending on treatment--$36 million is
small compared to $20 billion in tax revenues
from gambling
Eating Disorders
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•
•
•
The only one in this chapter related to a substance –
food addiction. All others, for example, Internet
addiction are behavioral…often clients in treatment for
another disorder
Headline: “Eating disorders start in brain”
90% of anorexia and bulimia is found in females.
Begins in adolescence
.5% of girls and women are anorexic, 1-3% bulimic.
Anorexia
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Less than 89% of normal body weight and
fine body hair.
10% mortality rate, often by suicide,
correlated with perfectionism, ritualism, high
anxiety
Related to obsessive compulsive disorder
(OCD):
•
•
obsessive--recurrent and persistent thoughts;
compulsions—ritualistic practices.
Bulimia
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•
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Gay men at risk.
Bulimia with alcohol misuse--30-70%.
35% of bulimics experienced childhood sexual
abuse and use food as a drug.
Little information on compulsive overeating.
New studies show lack of dopamine receptors in
the brains of morbidly obese.
Some after gastric bypass surgery turn to heavy
drinking.
Interventions
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•
•
Study in the British medical journal, Lancet—
findings from twin studies showed that a strong
craving for sweets predicted alcohol abuse
problems, perhaps caused by a lack of dopamine.
Bulimia—cognitive treatments; avoid strict dieting
Anorexia—Prozac is effective in reducing
compulsive behavior but only when weight has been
gained.
Men—muscle dysmorphia, antidepressants may
help here too.
Treatment
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Overeaters anonymous (OA) for compulsive
eating;
Group treatment.. teach moderation—CBT
Theme of neuroplasticity—brain neurons can
form new connections; “brain lock” can be
corrected (Schwartz)
Box 5.2 compares two treatment programs; the
second one in Kansas City included trauma
work
Shopping or Spending Addiction
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Problems in about 2-8% of people
Typical 31 yr.old female who has overspent for
13 years.
DSM-5 lists kleptomania;
Medications: Luvox
Debtors Anonymous groups springing up
Cyber Addiction
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Caught in the Net– Internet addicts: preoccupied,
excessive amounts of time involved in chat
rooms, playing games;
Jeopardized relationships.
Fantasy world—fictitious names, office
problems
Self-efficacy for empowerment
Korean government training psychiatrists to
help treat
FRAMES
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Feedback – assessment of use
Responsibility – choice is theirs
Advice – set goals together
Menus – of self-directed change options (ex.monitor computer use)
Empathy
Self-efficacy
Harm Reductions Strategies:
-Get a timer
-Cut mailing lists
-No detours
Sex Addiction
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Risk taker
Cognitive therapy recommended.
Prone to lying—one TV broadcast looked at
President Clinton’s background and his sexual
risk taking: others disagree.
Case of Tiger Woods.
Self-help group--Sex Addicts Anonymous.
Cognitive Therapy
•
•
•
Distortions especially with these addictions and
anorexia. Tendency towards extreme behavior.
Slogans of AA (“easy does it”)
Rational recovery, MET, REBT more
adversarial, focus on current beliefs
Cognitive Therapy continued
•
•
•
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Teach clients to avoid black and white thinking.
Ask about times when client successfully handled a
problem.
Use regular assessment for disease of addiction.
Feeling work
•
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Positive reinforcement and reframing
Stress management--- modify thinking, exercises for
group work: art work can reveal underlying feelings.
Therapy
•
•
•
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Positive reframing and self talk…. Cognitive therapy
can be directed toward the past as well as the present.
Feeling work—anger management. Anger as a cover.
Avoid all-or-nothing thinking.
Stress management---- drink milk, use self talk, get
exercise.
Group exercises for feeling work: art, faces, grief and
loss, quiz cards, dreams, assertiveness.
Part II
Psychology Of Addiction
Chapter 6
Addiction across the life span
Erik Erikson’s Stages
Birth to old age
Stage 1: Trust vs. Mistrust
Stage 2: Autonomy vs. Shame and Doubt
Stage 3: Initiative vs. Guilt
Stage 4: Industry vs. Inferiority
Stage 5: Identity vs. Role Confusion 12-17 years old
Stage 6: Intimacy vs. Isolation
Stage 7: Generativity vs. Stagnation
Stage 8: Ego Integrity vs. Despair
Must resolve each crisis before going to next stage
Carol Gilligan’s criticism.
Adolescent Brain
•
•
Prefrontal cortex matures until mid-20s
Evidence of brain immaturity during the teen
years comes from MRI scans of the
adolescent brain
Teenage Drinking Use
•
Identity vs role confusion
•
Alcohol is the drug of choice by American
teens aged 12-17
•
Less smoking by teens in the US than
previously
Argentina
•
16 year old exchange student found:
•
•
•
•
•
No drinking age
Wine or beer with supper
Drinking to be social not to get drunk
What the U.S. can learn from Argentina
Focus on moderation and adult supervision
Parents in Prison
•
•
•
•
•
Loss of parent plus stigma to child.
Three times the odds that children will engage in antisocial or delinquent
behavior (violence or drug abuse).
Negative outcomes as children and adults (school failure and
unemployment).
Twice the odds of developing serious mental health problems.
Affects 7 and ½ times more black children.
European vs. U.S. Youth




Alcohol use more prevalent in Europe except in
Mediterranean countries. Ireland vs. Italy.
Driving allowed at age 18.
22% Europeans smoke vs. 14% Americans at
ages 15-16.
Peele argues in Addiction Proof Your Child for
Mediterranean moderate drinking pattern in the
home.
Illicit drug use in Europe half that of U.S.
SAMHSA Household survey reported
•
•


Cigarette use 11.6% with 12 to 17 year olds (2010)
Binge drinking by 17% of youths aged 16 and 17
Age 21—around half are binge drinkers. Heavy drinkers tend
to have high drug-using rates as well.
Rates of past month alcohol use for ages 12-20 were:





16.1% among Asians; 20.4% among blacks;
22% among American Indians or Alaska Natives;
25.1% among Hispanics;
27.5% among those reporting two or more races;
and 30.4% among whites.
SAMHSA SURVEY continued


18-25: 21.2 % illicit drug use during past month,
around half of all youths used alcohol.
Racial breakdown for drugs not given for youth
in 2009 but previous surveys show higher rates
for black than white kids, American Indians the
highest.
2010 School and ER Surveys
•
•
•
•
•
Use of alcohol, the most dangerous drug—car crashes,
drownings, etc., one-third of high school seniors get drunk
once a month or more; (same in Canada)
Almost all current smokers also drank alcohol
School surveys show African American and Latino seniors
have rates of illicit drug use lower than that of whites; the
reverse is true among 8th graders.
ER visits among youth mostly for alcohol overdoses
(70%).
Rise in use of painkilling drugs shown in high rate of ER
visits among youth.—OxyContin a major problem.
Business Angle
Rivera Live: $10 billion alcohol consumed by under 21
• Beer and liquor companies most well funded lobbies of people in
Congress.
 80% of adult smokers start as children so big incentive to market
to kids.
 Extensive marketing of casinos.
 63–82% of teenagers (12- to 17-year-olds) gamble each year, 4–
7% of teens exhibit serious patterns of disordered gambling.

Society’s Influences
•
•
•
•
Tobacco companies targeting kids; Field and
Stream—ads for smokeless tobacco
Children learn gambling on the Internet;
Video poker, slot machines, and the lottery
Strenuous exercise programs reduce
smoking. Smoking may be considered a
gateway drug.
Risks for Substance Misuse




ADHD, trauma in early childhood, poor role
models.
Sexual abuse leads to sense of shame.
Trauma changes brain chemistry and reduces
later ability to cope with stress.
Influence of high stress and drinking, found in
juvenile mouse studies.
Other Risk Factors
•
•
•
•
•
•
Turbulent teen-father relationship
Child abuse and other trauma
Kids who start smoking early
Smoking can be considered a gateway drug; as many
girls as boys smoking, low rate among African
American girls.
Media-generated weight obsession, a major problem
among girls of European American ethnicity.
Obsession leads to major problems with eating, such as
anorexia and bulimia.
Predictions from Scandinavia:
• High risk: girls who cry easily when teased are anxious
and shy.
• Male aggression at age 8 predicted alcoholism 18 to 20
years later.
Evaluations at ages 10 and 27 showed:
– High novelty seeking
– Low harm avoidance (dare devil behavior)
Both traits predicted early-onset alcoholism.
For both sexes, poor school success predicted later
drinking problems
Child Abuse continued
• Girls who are sexually abused are three times
more likely than other girls to develop drinking
problems later
• Boys who were sexually abused more likely to be
diagnosed with conduct disorder, dysthymia
(mild depression), and ADHD
• Abused girls are more likely to be diagnosed
with post-traumatic stress disorder and major
depression.
Risks for Girls
•
•
Daughters of alcoholics at increased risk for
alcoholism.
Teenage girls who are heavy drinkers are:
•
•
•
five times more likely to engage in sexual
intercourse.
a third less likely to use condoms
more likely to practice unsafe sex.
Risks for Boys:
• Study of priest abuse victims showed high heavy
alcohol use rate.
• Biggest threat to life and health for adolescent
boys is alcohol-related accidents
• Male counterpart to anorexia in females is
muscle dysmorphia.
• Dysmorphia a diagnosis in DSM.
More Risks for Boys
•
•
•
•
Obsessive body building major problem for
young males
Revealed in popularity of anabolic steroids
Steroids used by 2.7 % of male high school
seniors.
Health hazards: stunted growth, acne, and
shrinking testicles.
College Students
• Case of college pledge in Colorado who died of overdose;


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police not called out of fear of under-21 drinking laws. Law
passed 1984.
History of law—1980s to curb drinking-and-driving deaths,
role of MADD and NIAAA.
SAMHSA 2010 survey of past month— 63.3% college
students were current drinkers, 42.1% were binge drinkers
(drank 4-5 drinks at a time), and 15.6% were heavy drinkers
(binge drank 5 or more times).
Risk of age 21 birthday celebrations.
Amethyst Initiative



Over 120 college presidents signed statement to consider
revising under-21 drinking law.
MADD notes lives saved from 1982 to 1998. 61% fewer fatal
crashes under age 21 and a 56% decrease among 21-to 24-yearolds.
May have been result of stricter drinking laws that were passed in
many states starting in 1984. New seat belt regulations, stricter
drinking and driving laws. Note reduction in over age 21.
Binge Drinking: College
• U.S. government imposed nationwide minimum
drinking age of 21 in the 1980s, the attempt to curtail
drunken driving by youth.
• Fewer drink today, but those who do drink more.
• “Party till you puke!” signs were posted on one
university campus.
Modern Form of Prohibition
• Critics argue students are driven to partying
underground and away from faculty
supervision.
• New campaigns for moderate drinking
encouraged by University of Washington
(Alan Marlatt) research.
• Social norms campaign with messages of
moderation were unsuccessful.
Need for Harm Reduction
•
•
•
•
•
College newspaper slow to restrict enticing beer ads.
Most binge drinkers mature out of wild drinking
days of early adulthood. But over 1,800 college
students die each year from alcohol-related injuries.
Rape and unsafe sex.
Cigarettes--abstinence probably works better than
moderation here.
Two paths to drug use by youths: striving to be
cool, using drugs to escape
Messages about long-term damage are apt to have
little impact.
Harm Reduction
•
•
•
•
•
Need for drug courts--important for family
preservation and closely supervised treatment
Forbid “happy hours,” free drinks on 21st birthdays at
bars.
Lower drinking age laws; discourage drinking hard
liquor
Encourage adult supervision with kids who are
drinking. Encourage moderate drinking as with meals.
Serve food with alcoholic beverages.
Motivational Principles from Social
Psychology
From Elliot Aronson, The Social Animal
• If you state a position, you will be wedded to it.
• A small commitment to take action goes a long way.
• People with high self esteem can easier resist
temptation.
• Working toward a goal might pay off eventually.
• Change of attitude might help.
• People desire to reduce dissonance.
Miller and Rollnick: MI Strategies
Traps to avoid:
– Premature focus, such as on client’s
addictive behavior
– Confrontational round between therapist
and client over denial
– Labeling trap--forcing the individual to
accept a label alcoholic or addict
– Blaming trap, fallacy that is especially
pronounced in couples’ counseling
Primary Prevention





Child abuse, early-prevention education and
treatment programs
Smoking education to keep youths from ever
starting to smoke
Health and skill education at schools
Reducing ads promoting addictive behavior
Advocacy for the hiring of more school
counselors and social workers
Stage-Specific Motivational
Statements:
Stage of Change: Precontemplation
– Goals are to establish rapport
– Counselor reinforces discrepancies
Adolescent comment: “My parents can’t tell
me what to do; I still use and I don’t see the
harm in it- do you?”
Motivational Enhancement
continued:
Stage of change: Contemplation
•
•
•
Ask: How was life better before drug use?
Emphasize choices
Typical questions are:
-What do you get out of drinking?
-What’s the down side?
Resistance:



Inevitable
Miller advises roll with it— “roll with
resistance”
Use reflective summarizing
Contemplation Stage continued:
•
•
• Typical adolescent comment:
I’m on top of the world when I’m high, but then
when I come down, I’m really down. It was
better before I got started on these things.
Preparation Stage:
•
•
•
Setting the date
What do you think will work for you?
Adolescent comments, “I’m feeling good about
setting a date to quit, but who knows?”
Action Stage:
Adolescent comment: “Staying clean may be healthy,
but it sure makes for a dull life. Maybe I’ll check out
one of those groups.”
“Therapist: “Why don’t you look at what others
have done in this situation?”
Help locate an appropriate group.
Maintenance Stage:

Adolescent comment:
“It’s been a few months; I’m not there yet but I’m
hanging out with some new friends...”
Gender Specific Approach for Girls
•
•
•
Equality does not mean sameness.
Programs for girls do better when they focus
on relationships.
Waterloo,Iowa --group home-- Quakerdale
specializes in care of teenage girls.
•
•
Learning of life skills
Gaining competency as in art
Problems in Middle Adulthood

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
Relapse problems.
Impact of baby boom generation—illicit drug
use doubled 2002-2007 in over 50 age group.
6.6% use illicit drugs over age 26; most is
marijuana.
10.8% of pregnant women drink; 1 in 6 smoke.
Risk to Combat Veterans

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
Most problems of VA clients with substance use and
PTSD in younger age group, but 11% are older.
Trauma is common. PTSD among female veterans who
were sexually victimized (15% were victimized).
Need for treatment; more is being done today.
Need to control marketing of alcohol and cigarettes to
soldiers.
Substance Abuse among Older
Adults
•
•
•
•
•
13% of U.S. population over age 65.
More men with alcohol problems
Older adults consume 20-25% of all prescription
medications
Two types of alcoholism: early and late onset
Early onset- - more severe levels of depression
and anxiety
Facts about Late Life Substance Use
•
•
•
•
Older adults consume less alcohol than the
young.
5.2% over age 50 used an illicit drug in the
past year; 9.1% smoke.
Trend toward nursing homes for short-term
alcoholism rehabilitation
Many male ex-alcoholics reside in nursing
homes.
Drinking Patterns

Older adults tend to:
drink smaller amounts at one time, misuse drugs
prescribed by doctors, experience a hidden alcohol
problem.
 drink in connection with a number of late-life
stresses, including bereavement and loss of
occupational roles.

SAMHSA 2010 Treatment Report





1 of 8 persons over age 50 sought help for
substance use in 2008.
Their share of treatment admissions doubled
between 1992 and 2008.
Primary substance use problems were with
alcohol, heroin, cocaine.
Many late onset drug users had problems with
prescription medications.
More Facts
•
•
Many early onset suffer from Korsakoff’s
syndrome and other alcohol-related
neurological problems.
Medical complications:
•
•
Hip fracture, suicide, brain damage
Late onset…more women here, close family
ties
Counseling Older Clients
•
•
•
•
•
DWI and effect on self image
Age segregated vs. mixed ages in treatment
Guidelines for work in groups with elderly:
-Avoid strong language, rebuild support
systems
-Keep pace slow
Relapse Prevention:
•
•
•
•
•
•
•
Teach older clients to learn the warning signs and high
risk events;
Review feelings that led to relapse so they can be
avoided (for example, depression); HALT
Focus on critical thinking skills.
Help clients renew their commitment to sobriety;
Find effective coping styles;
Build support systems;
Remember that non-confrontational approach is best.
Counselor Pitfalls: (Beechem)
•
•
Anticipate feelings of guilt and shame in older
clients in trouble with the law;
Ageism
•
•
•
Countertransference
Denial in assessment
Sympathy not empathy
Loss and grief in family members of addicted
persons:

Types of Guilt
Survivor guilt
 Helplessness
 Ambivalence



Spiritual healing—sense of meaning,
connectedness
Strength from 12 Steps
Spiritual Healing
Today, social work education stresses importance of
helping clients find spiritual meaning.
Older adults often change their outlook as they look back
on their lives. Seek for the meaning of life.
Higher Power as nature in Norway, Native American
traditions.
Search for forgiveness and renewal.
12 Steps as guide to self knowledge
Chapter 7: Screening and Assessment



Chapter focus on strengths perspective.
Advantages of doing assessment: get
information, match to counselor, get insurance
reimbursement for diagnosis.
Disadvantages: may set up false expectations for
specialized treatment, delays actual treatment,
may be inappropriate for many minority groups.
Screening Instruments



Consist of just a few questions to determine
nature of help needed.
Informal questions like, “Do you sometimes
drink?”
Effective one-question screen for women:
“How many times in the past year have you had
four or more drinks in a day?”
CAGE

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C Have you ever felt you ought to cut down on your drinking or
drug
use?
A Have people annoyed you by criticizing your drinking or drug
use?
G Have you ever felt bad or guilty about your drinking or drug
use?
E Have you ever had a drink or used drugs first think in the
morning
to steady your nerves or get rid of a hangover?
TWEAK
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Tolerance
Worried
Eye Openers
Amnesia
Kut down
Works well with mixed ethnic
populations
AUDIT



Recommended by WHO for global use.
The AUDIT includes 10 items that cover
amount and frequency of drinking, alcohol
dependence symptoms, personal problems, and
social problems
“Have you or someone else been injured
because of your drinking?”
AUDIT continued

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

Scoring discriminates between different levels of
risk—hazardous, harmful, and possible
dependence.
A prevention tool to assess future risks.
Can be given to the client as a questionnaire
to fill out, or it can be used as interview
questions.
Available for free on the Internet.
Assessment Tools



(CSAT) (2005) defines assessment as the
“process for defining the nature of the problem
and developing specific treatment
recommendations for addressing the problem.”
Can give a deeper picture of motivation to
change.
Can be beginning of relationship.
Gambling Assessment

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Gamblers Anonymous has 20 questions to determine if someone
has a problem. Examples:
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?
DRINC



The Drinker Inventory of Consequences (Drinc) originally
designed for Project MATCH
A 50-item questionnaire that covers physical, social,
intrapersonal, impulse control, and interpersonal problem areas.
Of proven reliability, validity.
Includes positive questions such as (“How often has drinking
helped me to relax?”), and negatives: “How often has my ability
to be a good parent been harmed by my drinking”.
The SASSI



The Substance Abuse Screening Inventory (SASSI) (Miller &
Lazowski, 1999)
A different approach to assessment instruments—does not ask
directly about substance misuse on one side of the form.
Consists of true-false items. such as “I am often resentful,” and
“I like to obey the law.”
Assessing Levels of Care

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Early Intervention
Outpatient Treatment
Intensive Outpatient/Partial Hospitalization Treatment
Residential/Inpatient Treatment
Medically Managed Intensive Inpatient Treatment.
Each level of care includes several layers of intensity.
ASSESSMENT OF PERSONS WITH
CO-OCCURRING DISORDERS (COD)



A basic program from the CSAT provides
treatment for one disorder, but screens for the
other disorder;
An intermediate level focuses primarily on one
disorder but also addresses some specific needs
of the other.
Advanced level provides services for both
disorders.
Guidelines for Assessment of
COD




Be familiar with latest DSM and criteria for diagnosis.
Keep up to date on the relevant psychiatric
medications.
Harm reduction therapists recommend only contacting
family members and others if clients so wish and with
the client present.
Know the community resources.
Assessment of Older Clients
Risk factors for gambling problems are:
the presence of current posttraumatic stress disorder
symptoms, minority race
or ethnicity, and being a Veterans Affairs (VA) patient.
 Therefore include questions about gambling.
CAGE and MAST—Geriatric version are validated for
use with older adults.

ASSESSMENT FOR
STRENGTHS





View clients as in charge of their own goals.
Take into account social factors as well as individual
factors for a comprehensive view of the situation.
Move the assessment toward strengths, both
intrapersonal (motivation, emotional strengths and
ability to think clearly) and interpersonal (family
networks, etc.
Avoid identifying the person with a label.
Strengths Assessment continued

Key ingredients:
Empathy.
 Provide hope.
 Reflective listening.

End of Chapters 1-7
Assessment

Need for assessment forms to be sensitive to
gender/cultural differences

Language differences, e.g., the word craving hard
to translate

CAGE and TWEAK work well with women
CAGE




Have you tried Cutting down?
Have people Annoyed you?
Have you felt Guilty about your ATOD use?
Have you ever used ATOD as an Eye opener?
Other Screening Forms

AUDIT developed by WHO for alcohol use

NIAAA—50 item instrument, Inventory of
Drug Use Consequences, in public domain

WHO designated areas of harm caused by
drink—physical, emotional, health, family,
finances, etc.
Chapter 8
Strengths- and Evidence-Based
Helping Strategies
Dennis Saleebey
•
Focus on possibilities, choices—providing treatment
options.
•
Resilience, healing, and wholeness.
•
Contrast with problem-solving approach.
Dennis Saleebey
•
Focus on possibilities, choices—providing treatment
options.
•
Resilience, healing, and wholeness.
•
Contrast with problem-solving approach.
•
Strengths-based practice defined by Saleebey as “a versatile
practice approach, relying heavily on ingenuity and creativity.”
Issue of Self-Determination
How do we honor client’s self-determination when
the client is harming himself-herself with
substance misuse?
1.Right of choice should be extended to all social
classes; as it is people in poverty have far less
choice than those at high income levels.
2. Importance of providing options. Abstinencebased models do not.
3. Attend to readiness of client to change.
First of Four Models of Strengths-Based
Approaches
1. Harm reduction: public health model, prevention,
outreach.
Abstinence not precondition to treatment; recovery
can be measured through degree of improvement.
Stages of Change Model: Prochaska and DiClemente
Precontemplation
Contemplation
Preparation
Action
Maintenance
Relapse
Harm Reduction Strategies
•
•
•
Practitioners are advised to focus on harms
other than substance use, such as
unemployment, poverty, need for housing.
Gambling problems can be prevented by
removing gambling machines from shopping
centers, strip malls, clubs, and hotels.
Other support services, such as mental health
and financial counseling should be readily
available.
2. Motivational Interviewing (MI)---William
Miller
•
•
Defined as a “client-centered, directive
method for enhancing intrinsic motivation to
change by exploring and resolving ambivalence.”
•
Need to ask the right questions; “Tell me about a
period when you were doing well?”
•
Smoking: on a scale of 1-10 to give up smoking,
where are you now?
MI continued
Steps to enhance motivation:
Express empathy
Develop discrepancy
Avoid argumentation
Roll with resistance
Support self-efficacy
Asking open-ended questions helps clients evoke
the decision to change.
3. Solution focused therapy
Finding solution to problem viewed as more
important than finding the cause. Strategies:
• Miracle question
• The personal narrative
• Scaling questions
• Coping questions
4. Cognitive/Behavioral Therapy
(CBT)
•
•
•
•
•
Attributed to Aaron Beck’s work with depression.
Albert Ellis challenged clients’ faulty belief systems.
Currently more focus on promoting positive thoughts
rather than focus on the negative.
Studies consistently show CBT as the most empirically
supported form of group therapy for addictions
Teaching about Distortions
•
Gambling example: conditioning used by casino owners to get
players to spend more—use of bells, positive reinforcement.
•
Gamblers often have distorted beliefs about lucky days and
machines and so forth.
•
Skills training can help clients avoid succumbing to triggers that
promote gambling.
•
Role plays and reinforcement of behaviors to resist temptation
are effective strategies.
CBT for Relapse Prevention
•
•
•
Interpersonal coping skills help clients deal with
high-risk relapse situations and to develop social
support for their recovery.
Teaching of refusal skills.
Intrapersonal coping skills focus on learning
how to cope with one’s own internal triggers,
such as anger, stress, and negative moods.
Group Therapy
•
Most popular form of delivering substance
abuse treatment.
•
Cost effective, good source for feedback.
•
Of proven effectiveness in teaching skills,
helping people to learn from others, getting
feedback.
Early Stages of Group Therapy
•
•
•
•
•
First step—to establish trust, build faith in the
counselor and group members.
Discuss rules of agency and group norms.
For example, confidentiality—what is said in the group
stays in the group.
Motivational interviewing groups for college students
shown to be helpful in reducing drinking problems.
Example of drop-in group for homeless people.
Traditional Treatment and StrengthsBased Approaches
•
•
•
•
Detox—opportunity to introduce patient to
choices.
Outpatient—primarily group counseling.
Inpatient and halfway houses.
Aftercare once a month, may be 12 Step
group or religious activity.
Chapter 9
Substance Misuse With A Co-Occurring
Disorder Or Disability
Co-Occurring Disorders
•
•
•
•
Double whammy—substance dependence and mental
disorder. Bipolar—feeling high can imitate drug use.
Mental Health Parity and Addiction Equity Act of 2008
ended discrimination against consumers of mental
health and substance abuse treatment services in
insurance coverage.
The numbers of people with serious mental disorders
who misuse substances and who smoke is double the
rate of those without mental health disorders.
Around half of people in treatment for substance use
disorder have a serious mental disorder.
Need for Integrated Treatment
•
Integrated Approach—fits with harm reduction
About a third of addiction treatment programs
now include treatment for psychiatric disorders.
•
Only 8.5% offer integrated programming (2006)
•
Anxiety disorder diagnosed in 40% of persons
with drug dependency; may be effect of
stimulant drugs.
•
Co-Occurring Disorders continued
•
•
•
•
Addiction counselors often explain psychosis as
drug induced.
Mental health professionals tend to see alcohol
use as self medication.
Truth is both/and, not either/or.
Coexisting disorders: anxiety, compulsive
gambling, eating and mood disorders.
Disorders that Often Co-exist with
Substance Abuse:
•
•
•
•
•
•
Anxiety
Compulsive gambling
Mood disorders
Eating disorders
Personality disorders
Psychosis
Personality Disorders:
•
•
•
•
•
Borderline personality
Anti-social personality
These diagnoses often based on cultural
biases
Integrated treatment needed
Need to offer better housing, can rely on
funding by Supplemental Security Insurance
(SSI)
PTSD
•
•
•
•
•
Diagnosis came in 1980 in response to Vietnam
war veterans and feminist movement on behalf of
rape victims
About 25% exposed to severe trauma will develop
substance related problems
High rate of relapse among women in substance
abuse treatment with PTSD upon release
High anxiety a problem
Trauma from natural disasters such as Hurricane
Katrina
PTSD after Combat
•
•
•
•
At least 1 in 6 veterans of war in Iraq has
PTSD
Flashbacks common
Immediate intervention with SSRIs
recommended to offset formation of locked
memories
Women seeking help for rape trauma,
someimes from attacks by fellow soldiers
Bipolar Disorder
•
•
•
Most commonly diagnosed of the mental
disorders for those with co-occurring
disorders.
From mania to depression
90% with this disorder have substancerelated problems in a prison sample
Schizophrenia
•
•
•
•
•
•
About 1% develop schizophrenia
Delusions, hallucinations, apathy and loss of
pleasure, problems concentrating
John Nash, A Beautiful Mind
48% have substance-related problems, a
variety of substances used
“No wrong door” to treatment
Prone to homelessness; Housing First
programs
Integrated Treatment Principles
SAMSHA
•
Integrated treatment specialists are trained to treat both
substance use disorders and serious mental illnesses.
•
Co-occurring disorders are treated in a stage-wise fashion with
different services provided at different stages.
•
Motivational interventions are used to treat consumers in all
stages, but especially in the “persuasion” stage.
Integrated Principles continued
Substance abuse counseling, using a cognitivebehavioral approach for the active treatment and
relapse prevention stages.
• Multiple formats for services are available,
including individual, group, self-help, and family.
• Medication services are integrated and
coordinated with psychosocial services.
•
Assertive Community Treatment
(ACT)
•
•
•
•
Unlike integrated treatment, here the counselors go to
the client and are available around the clock. Only
for the most severe mental illness. Principles:
Team approach: ACT team members interdisciplinary
and act as a whole to ensure basic needs are met.
Small caseload: Teams of 10–12 serve 100
consumers.
Time unlimited services. No individual caseloads.
Housing First
•
•
•
•
Supportive model for chronically mentally ill
with substance use problems. In contrast to
housing programs requiring total abstinence.
Intensive case management provided. Client
choices are respected.
“Wet” houses.
Cost effective for communities—New York
City, Seattle, San Francisco, Portland, OR.
Physical and Cognitive Disabilities
1990 Americans with Disabilities Act for full
participation in services
Persons with head injuries at high risk for
substance misuse; many were intoxicated
when injured
High among wounded war veterans—
Traumatic brain injury from war in Iraq
Barriers to treatment—few programs with
expertise to meet the need.
Part IV
Social Aspects of Addictions
Chapter 10
Family Risks and Resilience
•
•
•
Addiction is a family disease…pain and stigma.
Box 10.1 Des Moines Register “Children of Addicts”—
meth labs, family fights, and child neglect in Iowa
Classic Family Structure:
•
•
•
•
•
Addict as symptom of carrier.
Faulty communication in family >anorexia
Confusion of cause and effect
Family therapy field, little attention to addiction problems
except as symptoms
Little attention to cultural diversity as well. See McGoldrick
et al’s Ethnicity and Family Therapy (2005)
History of Family Treatment
•
•
•
Lack of insurance prevents emphasis on
family treatment
Virginia Satir: studied family adaptation
to person’s illness.
Claudia Black
•
•
•
“It will never happen to me”
Don’t talk, trust, feel—co-alcoholic,
codependent.
Al-Anon—1950s
Wegscheider’s Role Theory
•
•
•
•
Codependent person, chief enabler—terms took on
negative connotations later.
This text uses the more positive term, family
manager instead of chief enabler.
Wegscheider’s terms for family roles: hero,
scapegoat, lost child, mascot
Melody Beattie: Codependency No More
popularized the term. We suggest survivor instead
of codependent, a term that has taken on a life of
its own.
Figure 9.1 Family Forms
Enmeshed family: Spouses are estranged: one
child here is enmeshed with father, one with
mother
F
C
M
C
Isolated family:
Lack of cohesion and social support. Each
member is protected by wall of defenses.
F
C
C
M
Healthy family:
All are touching, but their boundaries are
not overlapping.
F
C
C
M
Stages of Change and Family:
•
•
•
1. Precontemplation: Counselors describe
family communication patterns.
2. Contemplation: family concerns – look
for solutions. Male partners may be hard to
engage.
3. Preparation: Breaking point--formal
intervention (see boxed reading by Carroll
Schutey) Family members make a list of
feeling responses to addict’s actions.
Stages continued
•
4. Action:
•
•
Rehearsal and treatment of family without
addicted member.
•
Therapist feedback—Example of therapist response to family
argument: “I note that as you, Steve said that just then, you
(kid) fell out of chair.” Purpose to reveal how the family roles
operate in a system.
Maintenance:
•
5.
•
Focus on process not content “what to do
if….” Transition with sobriety.
Cultural Considerations
McGoldrick et al’s book on different ethnicities.
Describes work with:
• African American families—reciprocity a strength
here
• Latino families—avoid a businesslike approach
• Asian and Asian American families—engage most
powerful person in the family
• Appalachian families—engage the women who
will teach health care practices
Situations of Domestic Violence
Connection of substance use and violence.
Battering intervention programs.
Motivational interviewing as bridge between
women’s domestic violence services and substance
abuse treatment.
Teaching women safety plans for harm reduction.
Risk of serious violence and death.
Rules of Fighting Fair
•
•
•
•
Attack behavior, not person
Keep issues of manageable size, don’t
label,
Don’t use negative labels.
Don’t rehash the past.
Three R’s Model
•
•
•
•
Rename: No labels, shopping addiction as
illness, not foolish spending.
Reframe: help client see things happen for a
reason
Reclaim: healing, we-ness, family circles to
make decisions (from Native Americans)
Kathy and Ed: Case Study
Exercises Related to Family Work
1.
Drawing family maps, circles
2.
Relapse prevention plan.
3.
Viewing excerpt from a movie or
videotape.
Chapter 11
Mutual-Help Groups
Mutual Aid Groups
•
•
•
•
Confusion—12 Step facilitated treatment and 12
Step self help groups (far more tolerant and
non-judgmental).
AA – spiritually based fellowship is free
Voluntary treatment: consistent with harm
reduction.
Involuntary treatment for those who failed at
moderation.
Twelve Steps
Presented in Box 11.1. First five:
1. We admitted we were powerless over alcohol—that our
lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could
restore us to sanity.
3. Made a decision to turn our will and our lives over to the
care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves and to another human being
the exact nature of our wrongs.
Alcoholics Anonymous (AA)
•
•
•
•
•
Greater involvement in AA found to effective.
Use of narratives…stories of powerlessness over
the addiction, lives out of control…
Feminist objections to 12 Steps
Metaphor of disease—mental, physical, and
spiritual, metaphor of powerlessness
Means of expanding treatment.. words in Big
Book…One day at a time…Higher Power.
Other Self-Help Groups
•
•
•
•
•
•
GA—members tend to be older and have high rate of
abstinence after attending for 2 months.
Addresses financial as well as spiritual problems.
NA—multilingual meetings.
Women for Sobriety—13 Steps.
SMART Recovery----cognitive approach.
Moderation Management—starts at 30 days of
abstinence, a harm reduction strategy
[Some say 12 Steps should be modernized. See one
attempt—9 Steps at www.katherinevanwormer.com]
Recovery Community Centers
A new development in some states, follow
recovery management philosophy.
Provides services such as telephone support
(usually by a volunteer in recovery), family support
groups, housing assistance, recovery group
meetings, social events, and recovery coaching.
Chapter 12
Racial, Ethnic, Culture
and Class Issues
Minority Group Membership
•
•
•
•
Need to know social political context of
being minority.
Treatment must take into account
ethnoculture norms.
The Council on Social Work Education
(CSWE) lists the ability to “engage diversity
and difference in practice” as one of the ten
core competencies.
We need to know something about norms of
particular groups to enhance treatment.
Social Class
Importance of class—bell hooksClass affects adolescents access to drugs.
Drug use affected by unemployment and low
income status.
Often as acculturation increases, so does substance
misuse
Asian Americans/Pacific Islanders
•
Low rate of substance misuse—just over 3%.
•
Japanese Americans drink much more than Chinese
Americans.
•
Success often is related to their level of education at
home and urbanization.
•
Cambodians - war trauma.
Asians and Hawaiians
•
Asian Americans - highest income of all ethnicities, filial
piety.
•
Emotional sharing may lead to loss of face.
•
Immigration, a major stress.
•
For Native Hawaiians female elders provide culturally
based treatment.
•
Pilot program in India uses yoga and meditation to reduce
stress.
American Indians and Alaskan
Natives
•
•
•
•
•
•
Historical trauma—racism and children were once sent to
boarding schools to destroy culture.
Native Americans are less than .9% of US population.
Almost half report they are of mixed race.
High rate of substance abuse or dependence: 15.5%.
illicit drug use—18.3%, binge drinking—22.2%,
cigarette use—41.8%. High fatal accident rate, FAS.
High poverty, alcohol abuse, youth inhalant use.
Use of Medicine Wheel for holistic, spiritual
framework, talking circles. (Box 12.2)
Red Road to Sobriety.
Latinos
•
•
•
•
•
•
•
•
16% of population (California: 1/3 of population)
58% of Hispanics in the U.S. are Mexicans.
Substance abuse or dependence for Hispanics 10.2%.
Increase in treatment admissions for meth use.
Treatment needs for alcohol misuse among Mexican
Americans (9.2%) and Puerto Ricans (6.1%).
In U.S. 21.1% of Latinos smoke. Less among women
but increasing.
High rate of gambling problems. HIV/AIDS a major
problem.
High rate of poverty; few have health insurance.
Group has the highest high school drop-out rate, Puerto
Ricans, the highest poverty rate.
Treatment Issues for Latinos
•
Male/female role differentiation.
•
Work with family should support family strengths.
•
Need for Spanish-speaking counselors. Understand that
with second generation, women have more addiction
problems.
•
Case management services needed to get clients into GED
programs where needed and job training programs.
African Americans
•
Are just over 12% of population.
•
Substance abuse and addiction rate is 8.8%. 24% report
binge drinking. Illicit drug abuse 9.6%. About 24% of
treatment population but drug use is not much more
than that of general population.
•
In prison are 44% of inmates sentenced for illicit drug
involvement.
Of those who gamble, high addiction rate.
45% of all new HIV cases are African American.
•
•
African Americans continued
•
•
•
•
•
•
•
Higher social class and church attendance are protective
factors.
Older African American women— over 85% abstain.
Twice as many are in poverty as whites. Higher social class
a protective factor.
Almost half of advertising budget targets blacks.
Recovery relates to spirituality and family support.
David Goodson quote: “ deals with cultural pain.” Harm
reduction techniques recommended.
Treatment barriers—paper work for Medicaid, waiting
period, wanting to conceal problem, waiting period.
Work with Somalis
•
•
•
•
Trauma from war and refugee experiences.
Need for translation services.
Gambling may be a problem among the young
immigrants although forbidden in the culture.
Immigrants will seek spiritual counseling at the
mosque.
Chapter 13
Public Policy
Policy Issues
•
•
•
•
Only 11% of those who need treatment get it,
but may not want it.
War on Drugs is not harm reduction, but
harm maximization
SSI (Supplemental Security Income) for
alcohol/drugs disabilities has been
discontinued
Managed care, reduced inpatient coverage,
reductions in Medicare reimbursement
Promising Developments
Drug courts, mental health courts.
Baltimore uniquely has a huge number of
treatment slots available.
Reduction in drug overdose deaths in Washington
DC thanks to more treatment funding.
Welfare Reform
•
•
•
•
Federal government denies benefits to needy people
with alcohol and drug problems.
TANF drug testing in some states.
Removal of coverage for substance related disabilities
such as alcoholism from SSI (Supplemental Security
Income), loss of Medicaid eligibility through this
program for treatment.
Government encourages drug testing for welfare
recipients; new laws in states now doing this.
Managed Care
Restrictions on care are familiar to all treatment
providers.
Cost containment and accountability are stressed.
Focus on brief, outpatient visits.
Cuts in mental health care by the states.
Federal Confidentiality Laws
•
•
•
•
•
•
“Confidentiality of Alcohol and Drug Abuse
Patient Records” (2011) apply to all agencies that provide
substance abuse treatment or prevention.
The rules are far more stringent than for any other category of
treatment.
No disclosure of content that would be harmful to the patient
with or without the patient’s signed consent.
This is true even with a court subpoena.
This law is protect clients who seek treatment from facts about
their prior drug use or dealing.
Other Legal Matters
•
•
•
•
•
Treatment options to AA—Supreme Court ruling
related to separation of church and state.
War on Drugs—failed policy, most agree in survey:
injustice, racial oppression, huge expense.
Media hype about drug crime, mandatory minimum
sentencing.
Most inmates in federal prison are minorities.
Mothers of crack babies given punitive treatment.
Ethical Matters
Mental health professionals have their codes of ethics as
do substance abuse counselors that require:
• Nondiscrimination of clients on the basis of race,
color, gender, sexual orientation, age, disability,
• Continuing professional and educational growth;
• Not exploiting clients sexually or financially;
• Reporting professional misconduct of colleagues,
such as violations of client confidentiality.
• Avoid dual relationships.
War on Drugs
Over 40,000 killed in Mexican war on drugs—war
of cartels.
Global Commission on Drug Policy (2011) led by
former presidents from Latin America called for
end to drug wars.
Need to rethink zero tolerance policies.
Two-thirds of Americans agree; a slight majority
of Americans favor legalization of marijuana.
Mandatory Sentencing
•
•
•
•
•
Women have the fastest growing prison population
rate, especially in federal prisons.
1986, federal mandatory minimum sentencing laws
enacted.
Hysteria over “crack babies”—harm to fetus actually
was from the alcohol used.
US Supreme Court in 2007 ruled the laws should serve
as guidelines only.
Drug conspiracy laws cause women to be arrested as
their partners turn them in as a part of their plea
bargaining agreements to get their sentences reduced.
The New Jim Crow
Michelle Alexander (2010): The New Jim Crow: Mass
Incarceration in the Age of Color-Blindness
1 in 9 young black men behind bars.
Many children without fathers or both parents.
Civil Asset Forfeitures
•
•
•
•
Police seize property (cars, houses) related to
crimes committed based on “a mere
preponderance of evidence.”
Oregon requires a conviction first.
Partners of drug dealers often pay the price.
Informants awarded part of the value of the
goods seized.
Harm Reduction Strategies
•
•
•
•
•
Needle exchange serves only 15% of drug injectors.
Methadone and buprenorphine maintenance
Heroin prescribed to addicts in some European
countries
Drug courts: a promising strategy, cost effective for
communities
This text argues not legalization but for middle of the
road policies—decriminalization—to reduce harm.
Recommendations Concerning
Gambling
•
•
•
•
Restrict all gambling to those who are at least 21
years of age
Remove slot machines from neighborhood
stores, banning betting on collegiate and amateur
athletic events.
Ban aggressive advertising that targets
impoverished neighborhoods and youth,
Prohibit credit card machines in casinos.
The End
Addiction Treatment: A Strengths
Perspective, 3rd ed.