Chapter Eleven: Chemical Dependency: The Crisis of Addiction

Costs Long history of attempting to treat substance abuse. Whole economies have been founded on drug use. Big business for legal and illegal drugs Big business for drug-related medical care Lost productivity Murders, fractured families, suicide Insurance, property crime, law enforcement Treatment

Prevalence in US 10% of those who drink, consume 50% of the alcohol 16M people who are heavy drinkers 55M binge drinkers (5 or more drinks at one setting) 18.7M who need treatment for alcohol use 22M who need treatment for legal and illegal drugs 71.5 M Tobacco use Controlled use Is this a reality for an abuser or an addict?

Prevalence in US Drug-abusing behavior in 15-54 year age group 1 in 13 will become dependent on controlled substance 1 in 6 will become dependent on alcohol

Sociocultural Determinants of Substance Abuse Set vs. setting - have a great effect on the behavior of the drug used Set = the mental and emotional state of the user - including expectations, intelligence, personality, feelings, and so on Setting = the social and physical environment of the user at the time of use -immediate surrounding, such as a living room, bar, legal and religious perspective

Sociocultural Determinants of Substance Abuse Alcohol and drugs have culturally specific: Rules Sanctions Prohibitions Admonitions Permissions Although there are cultural implications, do not stereotype!

Alcohol: Number One Abused Substance Duration (longevity, legacy, and history) Legality (limited conditions for jail) Widespread use Indirect financial costs Psychological costs Physical costs Links to crime Implication in accidents Suicide Alcohol IS a drug Interpersonal relationships Polyuse Embroilment in controversy (physical or mental disease?)

Models of Addiction Behavioral Learning Model Biopsychosocial Models Cognitive Models Disease Model Final Common Pathway Gateway Model Genetic Predisposition Model Lifestyle Model Moral Model Parental Influence Model

Models of Addiction Cont. Peer-Cluster Model Personality Model Prescriptive Model Problem Behavior Model Psychoanalytic Model Psychosocial Model Sanctioned-Use Model Sociocultural Models Stress-Coping Model

Definitions of Commonly Used Terms (Pg. 354-356) Abuse Chronic, recurrent misuse of chemicals. One or more of the following occur in a maladaptive pattern during a 12 month period: Failure to fulfill major role obligations (work, school, or family) Physical impairment that creates a hazard Recurrent legal or social problems Addiction Physical reactions include the development of tolerance and withdrawal. Psychologically, it is the compulsion to use drugs regardless of the negative consequences. Progressive, potentially fatal, and marked by preoccupation with chemical use. Addictive behavior Preferred by many in the field because it focuses on behavior. Is used to describe a broad spectrum of problematic compulsions. Alcoholism Addiction to alcohol.

Definitions of Commonly Used Terms Cont. Chemical dependent Addiction to drugs. Codependent Reciprocal dependency of the addict in need of care and a caretaker’s need to control the addict’s behavior. Dependence Cognitive, behavioral, and physiological symptoms indicating that the individual continues to use the substance despite significant chemical- related problems. Drug Psychoactive substance that has a direct and significant impact on the processes of the mind with respect to thinking, feeling, and acting. Enabler A person who allows the addict to continue the addiction rather than suffering the full extent of the substance-related consequences.

Definitions of Commonly Used Terms Cont. Habituation Degree to which one is accustomed to taking a certain drug. Misuse Use of a substance with some adverse physical, psychological, social, or legal consequence. Relapse/Slip Use of a substance after a period of abstinence. Tolerance When more of a substance is needed to achieve the same effect. Use The intake of a chemical substance with the intent of altering one’s state of consciousness. Withdrawal Physical and psychological symptoms as a result of the reduction or cessation of a drug.

Defense Mechanisms (pg. 356-357) Denial - (refuse to acknowledge) Displacement - (venting toward another) Fantasy - Escape Projection - (Attribute motives to others) Rationalization (Excuses) Intellectualization (impersonalization) Minimizing (Play down the seriousness) Reaction formation (defense against perceived threat) Regression (reverting back) Repression (burying in unconscious)

Enabling and Codependency Enabling - has to do with one's behavior toward a chemical dependent. Codependency - has to do with one's relationship to the chemical dependent

Enabling and Codependency Suppression (stiff upper lip) Dissociation (distancing) Repression (bury in unconscious memory) Escape to therapy (catharsis, but no change) Intellectualization (distance with details/control) Displacement (moving feelings elsewhere) Reaction formation (taking over for the addict) Passive aggression (covert behavior) Hypochondriasis (converts anger into physical complaints)

Children in Alcoholic Families Personality Roles The Scapegoat (acting out child) The Hero (the little adult) The Lost Child (adjusts without feelings) The Family Mascot (placates and comforts everyone) Family Rules in Alcoholic Families - that children have to adopt to survive) Do not talk/do not have problems Do not trust Do not feel Do not behave differently Do not blame chemical dependency Do behave as I want Do be better and more responsible Do not have fun

Adult Children of Alcoholics (ACOA) Facts Addiction has a genetic component Addictive behavior can be learned ACOA’s tend to marry addicts Emotional issues Trust Dependency Control Guilt Identification and expression of feelings Effects of childhood roles Adaptive roles from childhood follow them into adulthood (heroes, lost child, placaters, family mascots, acting-out)

Treatment Approaches Alcoholics Anonymous (AA) (pg. 365 - 12 Steps) Cognitive-Behavioral Therapy (CBT) (Stinking-thinking) Inpatient Treatment: The Minnesota Model (28 days) Outpatient Programs (1-2 times per week, with much criticism) Contingency Management (CM) (reward/reinforcement based)

Intervention Strategies Motivation and Stages of Change Precontemplation (using but seen as a problem) Contemplation (using but thinking about it) Determination/Preparation (quit in the future) Action (taking active steps/treatment) Maintenance - about 6 months (behavior change with continued work) Termination - about 5 years (cognitive and emotional changes, support system in place)

Assessment Personality Inventories Direct Measures Parsimony (simple questions) Computer-Administered Direct Measures The Problem Is . . . (double what ever the person self reports) Motivation to Change (instruments) Intake Assessment Assessment of Spirituality Triage Assessment (seek collateral info. and assume deception) Diagnostic Intake (formal clinical assessment)

Detoxification Can be a serious medical process Addict may be given small, controlled amount of the addicted substance to reduce severe symptoms Common symptoms Delirium Tremens (DTs) Somatic complaints Excessive sleep Mood swings Detoxification without treatment is nearly always futile.

Principles of Treatment Treatment Techniques (solution-focused, 12 step, cognitive behavioral, reinforcement based, rational-emotive behavioral) Treatment Goals (actions) Treatment Protocol (schedule in activities) Individual Therapy The Treatment Group Learning Relationship Skills Accepting Responsibility ("what part did you play") Getting Past Denial (1. presence and magnitude, 2. life problems) Confrontation (potent, but dangerous)

Principles of Treatment Cont. Overcoming Environmental Cues That Lead to Drinking (playmates and playgrounds) Treating the Family Family Therapy Session Therapy for the Children Aftercare and Relapse Prevention Cognitive-Behavioral Boosters (statements, messages) Pharmacology Euphoria (over kill) AA's Role in Aftercare