1. Judicial Studies Board – 4 th June 2008 The Assessment & Treatment of Addiction with reference to the RATSDAM Project Dr Carol Weir

2. Historically references to Addiction Related to Alcohol and was usually termed “Alcoholism”

3. Historical Review Model Emphasised Causal Factors Examples of Interventions Date of OriginMain Group or profession involved in treatment or care Moral – personal responsibility and self-control Moral Suasion, Social and Legal Sanctions 1889Church and Religious Groups Temperance - alcohol Exhortation, just say no, control of supply 1880Church and Religious Groups Spiritual – spiritual deficit Spiritual Growth, prayer and AA. 1933Church and Religious Groups

4. Dispositional Disease – irreversible constitutional abnormality of the individual. Identification of alcoholics, confrontation and lifelong abstinence 1935Members of the self-help group AA. Educational – lack of knowledge and motivation. Education1950’s/60’sEducationalists, Voluntary Sector Workers, Nurses. Characterological –personality traits defence mechanisms and intervention of psychotherapy. Conditioning – classical and operant conditioning. Countering conditioning and extinction altered contingencies Late 1950’sPsychiatrists and Psychologists

5. Social Learning – emphasised causal factors and modelling and skills deficits. Skills training, appropriate behavioural models. Late 1970’sPsychologists Cognitive – expectancies and beliefs. Cognitive therapy, rational re-structuring. 1980’sPsychologists General Systems – boundaries and rules, family dysfunction. Family therapy, transactional analysis. 1970’sPsychiatrists and Psychologists Biological – brain physiology, risk identification Genetic counselling and medical treatment. 1970’sProfessionals with medical training.

6. * Biological Model – the emphasis was on genetic and physiological processes including hereditary factors. This model continues to the present time and much research focuses on finding the gene which causes alcoholism. ** Public Health – agent, host and environment. Inter-disciplinary multiple levels of simultaneous intervention. 1990’sA range of professionals working together in an inter- disciplinary style.

7. IN-PATIENT TREATMENT Treatment was traditionally carried out in Hospital once the person had reached “rock bottom.” An acceptance that the individual could not cope was required. Alcoholics Anonymous played a large part in the management of the “patient.”

8. Alcohol Treatment Units (ATU) sprung up in the 60s and 70s and in Northern Ireland only a few designated units existed. Alcohol Abuse was seen as a Medical condition A “Disease” model used in the ATU programmes.

9. MAJOR SHIFTS IN THE CONCEPT OF ADDICTION 1948 – 1990 – 2 Shifts Moral model – Disease model Disease – Public Health Perspective

10. One model did not replace another Clinical practice, lay beliefs and policy discourse might draw on a Moral model, Disease Model or an Epidemiological explanation. For example AA and the Minnesota model approaches to treatment follow a Disease Theory.

11. DOUBTS ABOUT THE DISEASE THEORY Disease theory by 1970’s – less tenable. ALCOHOL DEPENDENCE SYNDROME “Dependence” Assessment based on physiological psychological behavioural and social dimensions

12. Prior to late 1970’s Either the individual was Addicted or Not Addicted – No Grey Areas This was replaced by a Continuum idea Social Drinking Problem Drinking Moderately Dependent Extremely Dependent

13. Alcohol Dependence Syndrome (WHO 1979) ICD - 10

14. This shift flagged up the idea of: Early Identification Alcohol Abuse, problems and level of Dependence on a continuum Harm/Severity This was very Different to Idea that an individual either had a “disease” – or did not

15. Commonality of Addiction Any Addiction which is considered “Dependent” Focus on Substance Take over Day-Day Life Denial Guilt Minimization/Rationalisation An example of an Eating Addiction compared with Alcohol Addiction.

16. 1990’s Early intervention – Public Health Model Continuum model Individualised Treatment Programmes Focussing on Addiction Behaviour

17. Assessment:Level of Dependence Consumption Levels Behavioural problems General Problems Mental Health Issues General Health Dependence: Level Assessment Behavioural Indices Based on Consumption Levels Pattern of Use