Addictions Final

Abstinence is viewed as

only one of several means of improving and is a goal only when the client proposes it as a goal

One standard drink is equivalent to

12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80 proof spirits

The healthy family (Figure 10.1)

All are touching, but their boundaries are not overlapping.

TWEAK W:

Worried: Have close friends or relatives worried or complained about your drinking in the past year?

Mental Health Screening Form-III (MHSF-III)

designed to screen for present or past symptoms of most of the main mental disorders "rough screening device"

"Ethnicity and Family Therapy" (2005)

edited by McGoldrick, Giordano, and Garcia-Petro - best approaches to treat families from diverse backgrounds.

TIP 42 Fully integrated program

is a one-stop shop that actively provides treatment for both disorders by the same clinicians who are trained in psychopathology, assessment, and treatment strategies for both mental and substance use disorders, and the funding streams are fully integrated (good but very expensive).

Contingency management

is based on the principles of operant conditioning - Uses reinforcing and punishing consequences to alter substance use behavior

Recovery capital

is concept that identifies strengths and resources within communities that have been overlooked in traditional acute care models.

Twelve-Step Facilitation (TSF) practiced in

professional treatment programs

TIP 42 Advanced level

provides services for both disorders using an integrated perspective.

TIP 42 (CSAT, 2005) on Co-occurring Disorders is to divide levels of care into basic, intermediate, advanced, or fully integrated levels of service need, Basic program

provides treatment for one disorder but screens for the other disorder.

Family systems therapists work with

the whole family because the illness is located in the family dynamics. The family systems therapist does not do individual therapy; The patient is viewed within the context of the family (origin of symptoms/problems)

The third basic tenet of strength-based approach is

to pay attention to the readiness of the clients and/or clients system to make changes in the areas they have chosen

Asian American and Native Hawaiian & Pacific Islanders

"Asian" refers to people having origins in the East Asia, Southeast Asia, or the Indian subcontinent, Cambodian, Asian Indian, Chinese, Filipino, Korean, Japanese, Vietnamese, Burmese, Hmong, Pakistani, Thai, or Malaysian. Asian American label is only adopted by about 19% of the people and most Asians refer to themselves by their countries of origin. Asian Americans are the highest income, best educated, and recently passed. Hispanics as the fastest growing. They have the largest group of new immigrants to the United States (approximately 20.3 million - US Census).

Reframe

"Can you find anything positive that has come out of this experience?" (Source of hope and pride in one's accomplishments)

Prescreening questions to rule out abstinence:

"Do you drink?" "Do you sometimes gamble?" "Do you sometimes use drugs of any kind?"

Several AA slogans underscore concept of limited control:

"Easy does it", "Progress not perfection", and "One day at a time"

Storytelling as Metaphor

"Hi, My name is and I'm an alcoholic." (peer) "Hi ." (group)

National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends a simple one question screen for men and women to rule out alcohol problems (For men):

"How many times in the past year have you had five or more drinks in a day?"

National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends a simple one question screen for men and women to rule out alcohol problems (For men): (For women):

"How many times in the past year have you had four or more drinks in a day?" In this screen, one or more heavy drinking days indicates the client is an at- risk drinker, and further assessment is warranted

MM is not intended

"for those who experience significant withdrawal symptoms when they stop drinking, or those with any physical or mental condition, including pregnancy, that could be adversely affected by alcohol, even in moderate amounts. Also this association is not intended for former dependent drinkers who are now abstaining." The majority of members are women, middle class, and highly educated; and they do not have severe drinking problems.

Motivational Interviewing Assumes the state of motivation may fluctuate from one time or situation to another and motivation itself has several different meanings:

(1) Motivation of desire (want to change, wish to change) (2)Motivation of ability (I can, I could) (3)Motivation based on reasons for change (pros and cons) (4)Motivation signaling commitment to change (I will, I guess I will, I might)

Four effective strength-based approaches include:

(1) harm reduction practices, (2) motivational interviewing, (3) solution-focused interventions, (4) cognitive behavioral therapy.

Myths of harm reduction practices:

(1)A conspiracy to seduce alcoholics or addicts into thinking they can use alcohol or drugs moderately, thus prolonging their agony (2)A potent excuse for an alcoholic, compulsive gambler, or drug addict to continue to use alcohol or drugs or gamble (3)A foolish, dangerous model designed by academics or people who do not know anything about addiction or do not care about the consequences of not getting people to abstain from their addiction (4)A misguided approach that makes it easier for addicts to keep on being addicted by furnishing shelter, food, clean needles, methadone, and even heroin to people who are addicted.

TSF Client goals include:

(1)Achieve abstinence (2)Acknowledge that willpower alone cannot maintain sobriety (3)Long-term recovery requires spiritual renewal (4)Basic 12 steps explained/AA readings discussed/AA meetings encouraged

Typical CBT models addressing interpersonal coping skills include:

(1)Assertiveness training/Refusal skills/Developing social support networks (2)Communication skills (including conversation) (3)Giving and receiving positive feedback (4)Listening skills/Resolving relationship problems (5)Giving and receiving constructive feedback.

Essential prerequisites before a counselor can screen and assess for COD:

(1)Be familiar with the diagnostic criteria for common mental disorders (DSM-5). (2)Be familiar with the names and indications of common psychiatric medications and the potential interactions that may occur (Psychotherapeutic Medications 2015: What Every Counselor Should Know - updated annually) (3)Understand the policies of your particular agency or helping context on the procedures for gathering information (4)Do not be afraid that you do not have all the answers (5)Know your community resources (ASAM levels of care/COD programs).

Modern Developments, Concept and composition of family has changed:

(1)Blended families (2)Divorced single mothers or fathers with children (3)Never married women with children (4)Cohabitating heterosexual partners (5)Gay or lesbian families

Drawbacks/Challenges of group therapy:

(1)Confidentiality is not a group norm, no legality to hold them to (ethical requirement) (2)Group members need to know to "save it for group" (3)No forming outside clicks/surrogate group (4)Violence towards other should not be tolerated (5)People may show up to group intoxicated (plan to address ongoing participation).

Cost effectiveness of mutual help groups important:

(1)Continual rise of health care costs (2)Many alcoholics and drug addicts have financial problems (3)Can go to AA and spend $1.00 as voluntary contribution to assist sobriety (4)Traditional treatment programs can cost thousands of dollars.

Group therapy is the most popular context of delivering treatment because:

(1)Cost effective (2)People learn from other's experiences (3)Loss of the feeling of uniqueness/isolation

Contingency management guidelines:

(1)Deciding what specific behavior you want to reinforce through contingency management (2) Setting up a specific plan to quickly monitor the attainment of that behavior (3)Deciding what kind of tangible positive rewards are feasible (4)Decide if negative consequences will be employed.

Traditional Treatment and the Continuum of Care for people with alcohol or drug misuse problem:

(1)Detoxification (medical stabilization and withdrawal symptom management) (2)Intensive treatment (few financial resources, risky environment, COD) (3)Residential programs (halfway house, sober living) (4)Outpatient services (group counseling - multiple sessions for 8-12 weeks) (5)Aftercare services (case management, AA/NA, counseling, support systems).

A foundation of clinical skills is needed to utilize strength based assessment:

(1)Empathy (2)Reflective listening (3)Open-ended questions (4)Affirm the client's experiences (5)Make short summaries (6)Hope (gives clients the sense they aren't crazy or alone) (7)OARS skills

Two primary goals of SMART:

(1)Help individuals gain independence from addictive behavior (through abstinence) (2)Teach people how to enhance and maintain motivation to abstain; cope with urges; manage thoughts, feelings, and behavior; and balance monetary and enduring satisfactions.

Each family has its own style of adaptation (coping):

(1)Hiding key resources (money/possessions) (2)Blaming (3)Covering up for the addictive behavior (4)Joining in the addiction (5)Becoming defensive towards outsiders who criticize

Alcoholic could mean:

(1)I have suffered and caused others to suffer, just like you. (2)I'm grateful to be an alcoholic because having this condition put me on a spiritual path that I never would have found otherwise. (3)I don't buy into the shame attached to this label by the outside world.

The United States historically supported an abstinence only approach to addiction but changes have emerged with administration changes:

(1)Increased support for treatment instead of incarceration. (2)Growing public understanding that addiction problems occur in co-occurring context with social, economic, medical, and mental health problems. (3)Increased reliance on evidence-based practices instead of tradition and ideology. (4) A pledge by the Obama administration to support science over ideology in the treatment of addiction

Typical barriers in treatment programs include:

(1)Location inaccessible to community they are trying to target (2)Professional staff clients cannot relate to experientially or culturally (3)Waiting lists for intake and treatment (4)Financial costs (5)Requirement that abstinence be the goal of treatment (6)Having to sit in waiting rooms (homeless/mental health problems) (7)Filling out intake paperwork (homeless/mental health problems) (8)Closed office door sessions with staff (homeless/mental health problems).

Roles of CBT in the initiation, maintenance, and recovery of addiction:

(1)Reinforcement (shaping behavior based on rewards and consequences) (2)Modeling (observational learning) (3)Conditioned responding (Pavlov's dog - respond/react to environmental cues) (4)Cognitive factors (address irrational thinking fueling addiction)

Harm Reduction Psychotherapy, The clinical principles of harm reduction (Tatarsky & Marlatt, 2010):

(1)Substance use problems are best understood and addressed in context of the whole person in his or her environment. (2)Meet the client as an individual (3)The client has strengths that can be supported (4)Challenge stigmatization (5)Substances are used for adaptive reasons (6)Drug use falls on a continuum of harmful consequences - safe to life threatening (7)Not holding abstinence as a precondition of therapy before getting to know client (8)Engagement in treatment is the primary goal (9)Start where the patient is (10)Look for and mobilize the client's strengths in service of change (11)Develop a collaborative, empowering relationship with the client (12)Goals and strategies emerge from the therapeutic process.

Specific techniques for SFT include:

(1)The Miracle question (2)Scaling questions (3)Coping questions (4)"Not knowing stance" *go back and get defintions from book

When bridges are broken the family typically adapts in three (3) ways:

(1)The family may adapt to the social isolation and continual stress of addiction (2)Members may regroup and reconstitute the family without the addicted member (3)Substance abuse treatment for the individual separately and within the context of the family (focus on nondestructive communication patterns and adaptation to recovery changes) "All happy families are alike, but every unhappy family is unhappy in its own way" - Leo Tolstoy (pg. 402). Example: "Don't talk, don't trust, and don't feel." (pg. 402).

Reducing Barriers for Women Gamblers

(1)Timely access to other supporting services (mental health and financial counseling) instead of leaving it up to the "victims" to cope. (2)Access to female counselors because of the need to disclose problems (e.g., physical, sexual, and emotional abuse) (3)Easily accessible services in downtown areas as well as rural environments where services are co-located with other supportive services to reduce stigmatization and promote referrals (4)Establishing alternative recreations for women in neighborhoods. (5)Decreasing the accessibility to gaming venues, removing them from shopping centers, strip malls, clubs, and hotels throughout the states.

Cultural Considerations

(a)Work with Native/American Indian Families (Traditions, history, values, extended family, rituals, communication styles) (b)Work with African American Families (Extended family is also core family) (c)Work with Latino Families (Less formal and more familiar/hope & patience) (d)Work with Asian and Asian American Families (Be the expert) (e)Work with Appalachian Families (Speak plainly - just the facts) (f)Work with Gay and Lesbian Families (Be open-minded & flexible) (g)Assume nothing, ask questions for clarity (h)Be aware of boundaries (personal and professional).

Contemplation

(aware there is a problem but ambivalent about change)

Preparation

(change is intended in the near future but no action towards goal yet)

Maintenance

(consolidates gains and works to prevent relapse)

Precontemplation

(defensiveness about substance use)

Coaddiction

(instead of codependent) = family member sinking into the abyss of addiction with loved one

Relapse

(may occur repeatedly and is considered normal part of change process)

OARS skills

(open-ended questions, affirmations, reflections, and summaries)

Action

(person takes action to change his/her negative behavior/environment)

Michigan Alcoholism Screening Test

- Geriatric Version (MAST-G) consists of 24 questions with special relevance to the elderly.

Motivational Interviewing

- a "client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence"

Monique is poor and black; Becky is middle-class and white. Their unequal socioeconomic status determines:

1. How potent the available drugs are (crack in poor inner cities vs. powder cocaine in affluent suburbs) 2. Relationship between sex and drugs in the social scene (Monique had to prostitute for money vs. Becky had a well paying job) 3. Ability of person to maintain a "nondeviant" identity - Can stay out of jail and hide drug use 4. Availability of resources to cushion consequences of illegal drug use 5. Availability of option to leave the drug "scene" and move on to different way of life (Monique - homeless shelter vs. Becky - Hawaii with her dad).

Barriers to access treatment in the community:

1. Lack of money, skills, and language to negotiate the treatment system. 2. High tolerance for pain and suffering (poor people have a really high tolerance for pain & suffering). 3. illegal status. 4. Negative experiences in other service systems (courts, child welfare, schools). 5. Cultural or religious beliefs that conflict with mainstream treatment centers. 6. Fear of "losing face" or bringing shame on the family by disclosing personal problems.

U.S. Department of Health and Human Services (DHHS) launched first HHS Action Plan to Reduce Racial and Ethnic Health Disparities, Major goals include:

1. Reducing disparities in health insurance coverage (Affordable Care Act) 2. Increasing diversity of public health care workers 3. Streamlining the infrastructure and educating the work force of health care 4. Advancing community-based programs 5. Creating first health disparities data collection strategy across HHS.

The 10 Components of Recovery developed by APA (American Psychological Association)

1. Self-direction (depends a lot of levels of maturity). 2. Individualized and person-centered treatment (very important, gives people what they need). 3. Empowerment (just the ability to think you can is so important). 4. Holistic (we can't get caught up in one tract, we have to look at the whole person, we need a wide range of things). 5. Nonlinear (some people get stuck on the program, everything needs to be individualized). 6. Strengths-Based. 7. Peer Support (huge, recovery peers is a real job, but prosocial peers is a big thing). 8. Respect (respect goes both ways, respect is given but trust is earned). 9. Responsibility . 10. Hope - HUGE Hope is EVERYTHING, if you have hope then you have will, where there's a will there is a way

Recent research identified specific sociodemographic factors that contribute to racial/ethnic differences:

1. Unemployment and homelessness 2. Family income and insurance status for adolescents 3. Neighborhood deprivation 4. Use of Medicaid funding in addiction treatment financing 5. Gender, homelessness, and mental health status.

GA is a

12-step mutual self-help program of men and women who "share their experience, strength, and hope with each other that they may solve their common problem and help others to recover from a gambling problem". GA program is modeled after the 12-Step AA program and traditions. The only requirement for membership is a "desire to stop gambling." Abstinence from gambling is the goal of GA. GA groups are formatted similar to AA groups and include a short reading from GA literature, a suggested topic, sharing of thoughts and feelings by members, and a reading and response from The 20 Questions (See Chap. 7, Box 7.1). People attending GA more likely to be successful during and after treatment

AA was started in

1935 by Bill Wilson and Dr. Bob Smith. Published experiences and ideas in original volume of Alcoholics Anonymous affectionately called "The Big Book" due to 1st edition's paper bound size.

The CAGE (Ewing, 1984) is a screener for alcohol problems A

: Have people annoyed you by criticizing your drinking or drug use?

The CAGE (Ewing, 1984) is a screener for alcohol problems G

: Have you ever felt bad or guilty about your drinking or drug use?

The CAGE (Ewing, 1984) is a screener for alcohol problems C

: Have you felt you ought to cut down on your drinking or drug use?

Substance abuser's ecosystem

= family, peers (clean & using), treatment providers, non-family support sources, workplace, and legal system

Codependent

= survivor or caring family member (man/woman) who have done whatever is necessary to protect themselves and family members from the consequences of their partners' drinking, drugging, or gambling

ABC model of emotions with CBT:

A = Activating event B = Belief or interpretation of the activating event C = Consequences of the interpretation of the activating event *Re-evaluating/Reframing/Reshaping B changes the outcomes of C

Religion

A communal, organized, and structured experience within a specific church, synagogue, mosque, or religious setting.

Mutual help/self-help

A group of people who feel they have a common problem and voluntarily get together to do something about it, usually because of a sense of powerlessness in the broader health care system.

The Metaphor of Powerlessness

AA invites people who declare themselves eligible to survey their world and embrace the idea of Step 1: "I am powerless over alcohol, and my life has become unmanageable"

How can counselors learn to be culturally sensitive and at the same time not stereotype a whole culture or race?

According to the Ontario Resource Group on Gambling, Ethnicity and Culture: 1. Client-driven problem-solving skills 2. Assessment skills that identify role of socioeconomic disadvantage, racism, homophobia, and ableism in presenting problems 3. Networking skills to learn more about community resources, services, and cultures from other social service agencies working with ethnocultural groups 4. Advocacy skills to work toward enhancing access to services and culturally competent care and to raise awareness of cultural issues 5. Interpersonal skills to build rapport with family and other support systems in crosscultural interactions, being aware of culture specific power dynamics and levels of hierarchy within families.

One of the most significant referrals the addictions counselor can make to family members of alcoholics is

Al-Anon group. The Twelve Steps used by Al-Anon were modified to pertain to persons who are powerless over another's use of alcohol. Recognition of one's powerlessness over another's addiction goes a long way towards reducing feelings of guilt.

TWEAK A:

Amnesia: Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?

Domestic Violence

Any time families present for mental health or relationship counseling and substance use or other addictions are involved, screen for domestic violence

Transparency model

Appropriate for clinician to share their spiritual or religious beliefs provided the discussion focuses on the client's spiritual needs

Two well known alcohol screening devices validated for older adults are

CAGE and the Geriatric MAST

If there is violence against children or children are endangered then

CPS must be notified

The hallmark of a strength-based intervention is

Choice, Choice about the goals of the helping relationship (harm reduction), Informed choice about a variety of treatment contexts (ind, grp, inpatient), Informed choice about treatment methods (CBT, 12 Steps, SFT, MI, etc.).

Assessing Levels of Care

Clients are evaluated for optimal level of care based on: (1) acute intoxication or withdrawal potential; (2) biomedical conditions and complications; (3) emotional, behavioral, or cognitive conditions and complications; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery/living environment.

Empowerment model

Clinician's decision to share religious/spiritual experiences requires the clinician and agency policy to be ethical and offer education as well as debriefing as necessary

The Alcohol Use Disorders Identification Test (AUDIT) -

Developed by the World Health Organization. The only screening test designed and validated for international use in a wide variety of populations, cultures, and languages. The AUDIT is comprised of 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?)

Client-centered model

Discussion of spirituality is appropriate provided it centers on only the client's beliefs and issues (practitioner's views hidden)

Network therapy

Disease-based approach designed to reinforce social networks (family members and peers function as support team) PEERS model.

The CAGE (Ewing, 1984) is a screener for alcohol problems

E: Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover?

TWEAK E:

Eye openers: Do you sometimes take a drink in the morning when you first get up?

Other 12-Step groups provide support to family members and significant others such as

Families Anonymous, Al-Anon/Alateen, Nar-Anon, and Gam- Anon. New Latino group is the "4th and 5th Step Group", which focuses on the spiritual aspects of the program through intensive retreats.

Twelve-Step Facilitation Minnesota Model

Featured integration of professional staff with trained recovering alcoholics and embraced the disease model and the link to 12-Step groups, family involvement, abstinence from all addictive drugs, client and family education on effects of addiction, individual treatment plans and aftercare.

How Does AA Really Work?

First, AA is an "unapologetically spiritual program" that promotes spiritual growth as a way of living a meaningful life and stop alcohol misuse. Difficult to grasp for some helping professionals that may not have an established belief system in God or a Higher Power. Secondly, Brain imaging studies now show how addiction seriously affects brain function. NIMH scientists have described addiction as a "brain disease" because of the way neurotransmitters are altered when a person is addicted to drugs, alcohol, and gambling. Finally, AA works by reframing the meaning of AA in terms of a narrative perspective - Life story for others to relate to as their own (See pg. 365).

Research on AA Effectiveness, AA provides multiple challenges to traditional methodological requirements

First, no one person is in charge and the chairpersons of the meetings change. Second, no one selects who comes or goes. Third, membership is anonymous. Use of randomization and control groups (gold standard of research design) is very difficult to achieve. Many studies draw samples from treatment programs rather than community samples because of limitations.

Intrapersonal coping skills for relapse prevention

Focus on learning how to cope with one's own internal triggers such as anger, stress, and negative mood states

Solution-Focused Therapy (SFT)

Founded through the work of Milton Erickson (1954) - Solving the problem was more important than determining the root cause of the problem, not about emotion.

Assessment Tools

Gamblers Anonymous Twenty Questions, Open ended questions help determine the nature and severity of substance abuse problems (e.g., costs and benefits, what, how much, method of use). The Addiction Research Institute, Center for Social Work Research - UT Austin Addiction Severity Index (ASI). Alcohol Dependence Scale. Drinker Inventory of Consequences (Drinc). Inventory of Drug Use Consequences (InDUC). Substance Abuse Screening Inventory (SASSI).

Reclaim

Healing what was lost either through drug addiction/alcoholism or in living in a family consumed with another's addiction. This process may result in separation or divorce.

Interpersonal coping skills for relapse prevention

Help clients deal with high risk relapse situations and develop social support for their recovery

TWEAK K:

Kut down: Do you sometimes feel the need to cut down on your drinking?

American Society of Addiction Medicine's Patient Placement Criteria (ASAM PPC-2R):

Level 0.5: Early Intervention. Level I: Outpatient Treatment. Level II: Intensive Outpatient/Partial Hospitalization Treatment. Level III: Residential/Inpatient Treatment. Level IV: Medically Managed Intensive Inpatient Treatment

Reducing disparities

Major goals include: 1. Reducing disparities in health insurance coverage (Affordable Care Act) 2. Increasing diversity of public health care workers 3. Streamlining the infrastructure and educating the work force of health care 4. Advancing community-based programs 5. Creating first health disparities data collection strategy across HHS.

Comparable groups to Al-Anon:

Nar-Anon (family members of narcotics users) Gam-Anon (family members of compulsive gamblers) Adult Children of Alcoholics (ACOA) - members grew up in alcoholic homes.

Whom Does AA Benefit?

Native Americans, Hispanic Americans, African Americans, Asian Americans, Pacific Islanders, White Americans. LGBTQ communities. Women, Veterans. Elders. See pages 370-371 for discussion of specialized groups and adaptations to AA treatment programs.

Moderation Management (MM)

Only mutual-help group dedicated to supporting individuals who have a desire to drink moderately. Drinking problems are viewed as a bad habit rather than a disease

Rename

Positive attributions (e.g., recovering alcoholic) Stay away from labels like "alcoholic" and "addict". Key Questions for the therapist to consider: (1)Are the new truths and realizations derived from treatment having a positive effect on your life" (2)Are these new concepts consistent with a positive self concept?

The second tenet of strength-based approaches is

Providing options

Motivational Interviewing (MI)

Scaling questions & Specific follow-up questions, Decisional balance sheet (unresolved ambivalence is obstacle to change, how has this worked for you? I studied for the test, I passed, my sheet balanced out).

AA is

Spiritually based fellowship that supports maintenance of abstinence for those who want it & sobriety steps for character development.

Abstinence: One Day at a Time

The basic text of Alcoholics Anonymous (2001) suggests "for those who are unable to drink moderately the question is how to stop all together..."

Self-Management and Recovery Training (SMART)

The group's approach is drawn from the principles of cognitive-behavioral therapy and rational-emotive behavior therapy (Albert Ellis, PhD). Addiction is viewed as a maladaptive behavior than a disease and could arise from both substance use (e.g., alcohol, food, illicit drugs) and involvement in activities (e.g., gambling, sexual behavior, eating)

Spirituality

The more individual subjective experience and/or search for the sacred or the transcendent and not embedded in religious organization

Diagnosis

The process that determines whether a person meets certain predetermined criteria for substance abuse, dependence, or pathological gambling

Stages of Change Model Also known as Prochaska and DiClemente (1986) transtheoretical model

The stages are: Precontemplation, Contemplation, Preparation, Action, Maintenance, Relapse

TWEAK T:

Tolerance: How many drinks can you hold? (6 or more drinks = tolerance)

Screening instruments

Tools (one question or series of questions) that can quickly help detect the possibility of a problem with substance abuse, gambling, or other disorders

Stages of Change & Family

TreatmentProchaska and DiClemente's transtheoretical model (stages of change): (1)Precontemplation (2)Contemplation (3)Preparation (4)Action (5)Maintenance

Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

U.S. clinicians use this manual to diagnose disorders (American Psychiatric Association). gives you research and background on it, and give you a diagnostic criteria.

Lie/Bet Questionnaire

Valid tool for pathological gambling vs non-problem gambling. Have you ever felt the need to bet more and more money? Have you ever had to lie to people important to you about how much you gambled?

The term "alcoholic" may have

a negative connotation in general terms

Adaptation is defined as

an active process of self-change, environmental change, or both (not a passive adjustment to circumstances, some people fight and argue)

TSF considered

an evidence based practice by SAMHSA. Based on behavioral, spiritual, and cognitive principles of AA

The HOPE Questions (www.aafp.org) developed

as teaching tool for medical students, residents, and practicing physicians ( H—sources of hope, strength, comfort, meaning, peace, love and connection; O—the role of organized religion for the patient; P—personal spirituality and practices; E—effects on medical care and end-of-life decisions)

CBT is

based on the idea maladaptive thinking and bad habits are the mechanism that cause problems and keep them going.

"Spiritual practices" are increasingly

being taught to clients in the health care field (e.g., mindfulness, tai chi, yoga, meditation). Researchers have suggested a "spiritual/religious" framework is a protective factor against addiction and an aid to recovery (See pgs. 381-382)

Recovery Community Centers, Recovery Management philosophy

believes healing takes place in the community over the long term and through the support of others

A guiding principle of strength-based practice is

clients are in charge of setting their own goals and deciding how to achieve them.

medication-assisted treatment (MAT) and 12-Step drug-free treatment often

combined. Uses paid professionals, people admit they're alcoholics, complete 12 steps and attend prescribed number of AA meetings.

Simple Screening Instrument for Substance Abuse (SSI-SA)

commonly used in correctional settings - can be completed by interview or self-administered. See Box 7.2

The family is a system

composed of members in constant and dynamic interaction with one another. Patterns of interaction get established (roles and rhythm). Change in the behavior of one member can affect the whole system

"Faith-based" treatment

continued to expand from its historical roots (See pgs. 383-384). Practitioners are urged to "break the silence" and become more active in discussing spirituality/religion in the context of addictions treatment

Wegscheider's Role Theory Wegscheider (1981)

created roles based on observations of roles played in chemically dependent families (not scientifically validated): (1)The chemically dependent person (2)The chief enabler (family manager) (3)The hero child (typically 1st born - perfectionist/high achiever/approval seeker) (4)The scapegoat (typically 2nd born - blamed for irresponsible nature) (5)The lost child (lives in fantasy world - little/no trouble ) (6)The mascot (clown/stress reliever for family)

Open-ended questions

designed to offer practitioners a staring point to incorporate spiritual/religious dimensions into the assessment process.

If there is violence against adults (disabled or elderly) or said adults are

endangered then APS must be notified. The aggressor (usually men but may also be women) referred to BIP

Family involvement can mobilize substance users to

enter treatment and have a successful recovery

Addiction is often defined in terms of the entire

family and not just the individual in treatment or in need of treatment. For every person who suffers from alcohol, cocaine, gambling, and other addictive problems, the lives of at least four (4) other people are altered

Family Adaptation to Addiction, Adaptation is

family's response to a member's destructive addiction behavior

Mental illness, anorexia, or alcoholism is viewed as stemming from

faulty family communication or functioning (not always the case)

TIP 42 Intermediate level

focuses primarily on one disorder but also addresses some specific needs of the other disorder.

AA in the community is Significantly different

from TSF. AA in the community is not "treatment"

The AA notion of powerlessness in groups connects others through

group narratives of experience, strength, and hope. Provides complementary relationship with other alcoholics who are in the same boat and in the same meeting engaged in the same process of change.

Group therapy that teaches coping skills and relapse prevention using CBT approaches ranked

highest ineffectiveness and possibly better or as good as individual behavior therapy

McGrady (2006) concluded family

involved treatment is associated with higher rates of treatment compliance and retention than solo treatment

Assessment

is the "process of defining the nature of the problem and developing specific treatment recommendations for addressing the problem (Center for Substance Abuse Treatment - CSAT)

The isolated family (Figure 10.1)

lack of cohesion and social support. Each member is protected by a wall of defenses.

Traditional educational group using films and lecture to illustrate the nature of addiction, costs, brain functioning is

least effective of treatment methods

Many studies suggest people with substance abuse problems who self-identify as black, Hispanic, or Native American are

less likely than those who selfidentify as white or Asian American to enter treatment, complete treatment, and are more likely to present higher rates and more serious substance abuse problems.

Group feedback is

more powerful than individual feedback.

Moderation is defined for females as

no more than 3 standard drinks per day, no more than 4 drinking days per week, and no more than 9 drinks per week

Moderation is defined for males as

no more than 4 drinks per day, no more than 4 drinking days per week, and no more than 14 standard drinks per week

The CAGE and TWEAK are

optimal screening tests for women

The Big Book suggests drinking experientially to figure out

personal control over alcohol (See pg. 366)

The enmeshed family (Figure 10.1)

pg 409. Spouses are estranged: one child enmeshed with the father, the other with the mother. Not a healthy family. They have boundaries problems

Techniques for enhancing motivation:

pg.330 (1)Express empathy (Client seen as "stuck" not pathological) (2)Develop discrepancy (Amplify discrepancy between behavior and client goals) (3)Avoid argumentation (Don't persuade, confront, or argue with clients) (4)Roll with resistance ("It's really up to you") (5)Support self-efficacy (Reframe relapses or failures to "getting closer to goal")

Harm reduction consists of

pragmatic interventions that have good evidence of public health benefit (clean needles for IV drug users, HIV testing, etc.)

Recovery management partnerships challenge

prevailing ideas of professional treatment programs that an "expert" is required to diagnose and treat a person's addiction problems. A basic assumption of the model is that addiction is a chronic disease that needs long-term support in the community to combat it, and there is no universally effective professional intervention for severe alcohol or drug problems. We need at least one pro-social person in our lives. This is more of a helping model, you have AA meetings, and then you have others to help you with other things like jobs, one circle touches another circle and then you have communities that are helpful. Happens over a long period of time.

Protective factors for sustained abstinence:

prior alcohol dependence & AA attendance, acquiring a sponsor, working on 12 steps, reading AA literature.

Risk factors for elders include

problems with gambling, binge drinking, Posttraumatic Stress Disorder, and being a Veterans Affairs (VA) patient.

A significant part of how we help people through shame, guilt, humiliation, and alienation from friends and family

relationship building with clients.

Healing (The three R's)

rename, reframe, reclaim

Accepting the metaphor, "I am powerless" goes against Western ideals of

rugged individualism, will power, competition, and self-sufficiency

Training encourages

self care and to provide positive feedback to family member/partner once they are sober. This can happen at like private schools or community centers

In everyday AA practice the meaning of "alcoholic" is

self-determined and can vary depending on the person and the context (See pg. 369)

Individual and family counseling are valuable tools to improve

self-esteem and coping skills to reduce/extinguish codependence (coaddiction).

Codependence originally used to describe

strain of being partner to chemically dependent person

International clinicians use

the International Classification of Diseases (ICD) from the World Health Organization.

TSF therapy is dominant alcohol treatment model in

the United States

Based on a public health model of primary, secondary, and tertiary prevention, harm reduction (tertiary level) attempts to alleviate

the social, legal, and medical problems associated with unmanaged addiction.

Alcoholics want to stop drinking precisely because

their own experience and numerous experiments tell them they can no longer control it once they start (fundamental concept of the AA program). Abstinence (never drinking again) as a concept was considered too unrealistic or too absolute by AA program creators. Developed concept of limited control - Not drinking "one day at a time" instead of forever

Couples should not initially be referred to conjoint counseling (husband & wife) or family counseling with children

to prevent further abuse. Safety for all family members must be the first consideration.

Resilience is more than the ability of an individual family member

to recover; It involves protective factors within the entire family system (or dynamics).

Community Reinforcement and Family Training Approach (CRAFT)created by Robert Meyers

twelve one hour sessions for communication & coping skills to deal with the drinker or drug user

Charlotte Kasl started alternative group (Women for Sobriety)

viewed AA as another white, middle-class male organization depending on a "Higher Power usually described as an all-powerful male God"

Ecosystem perspective

views people as nested in constant interaction with their environment (individuals in families; families in communities, etc.)

MM strategies included

voluntary abstinence from alcohol for 30 days, during which time the person is asked to examine how drinking has affected his/her life, write down priorities, and look at how much, how often, and under what circumstances drinking occurs. MM recommends 6-18 months of weekly meetings. Audrey Kishline founded MM in 1994; In 2000 she quit MM and joined AA, After a binge drinking relapse, she killed 2 people drunk driving. For the large part this method doesn't work, very very small population.

Narcotics Anonymous (NA)

was started in 1950s when polyaddiction became more common and "pure alcoholics" were uncomfortable discussing drugs. NA is a multilingual, multicultural organization that has 63,000 weekly meetings and members in 132 countries. More than 58% of members have more than 5 years of abstinence ("clean")

As the illness progresses, the bridges between the alcoholic/addict and his or her social world

will be broken.