Substance Abuse Ch 22

Roles children can take on in alcoholic families (Treadway)

*Hero* assumed by the eldest who takes parental responsibility for the other children. sense of self is being a competent caretaker. tend to be high achievers, but inwardly feel inadequate. *Scapegoat* repository for the family tension and conflict. By acting out child deflects attention from the drinking problem. outwardly they appear hostile, angry, but inwardly feel hurt and guilt.

Roles children can take on in alcoholic families #2

*Lost child* copes by being invisible. Difficulty forming relationships. Appears withdrawn and isolated. Prone to depression, binges, sexual identity problems. Masking feelings of being lonely or unimportant. *Mascot* diverts the family's attention with comic relief or problems such as hyperactivity ***Some roles help get children through craziness, but hurt children later in life.

The Intervention (Johnson 1986) -A

- This approach confronts denial if the alcoholic unwilling to seek help on his own It has its roots in Network Family Therapy. Involves a group of participants , each of whom has a a relationship to the alcoholic. - Choose a time/location, anticipate potential excuses, choose a chairperson, determine speaking order, find an appropriate treatment program, plan for walk outs, plan a follow-up plan. -The group gathers for training sessions without the knowledge of the alcoholic.

Illicit drugs

-21.8 million Americans age 12 or older used illegal drugs (2010). -The most illicit drug abuse is Marijuana, with 14.6 million users. -On regular basis 2.4 million use cocaine. -Youths receiving mental health treatment were more likely to abuse substances.

Tranquilizers abuse

-60 million prescriptions of Valium and other tranquilizers were written in a year. -Tranquilizers like Valium, Soma or Xanax are mix with small amounts of alcohol to amplify effects. -1.8 million abused tranquilizers (2005) -Vicodin is the most frequently narcotic prescription of abuse.

Behavioral Marital Therapy/Behavioral Couple Therapy

-A conjoint intervention for active treatment for individuals affected by substance use disorders. -Treatment lasts for 4-6 months and targets abstinence or use reduction and marital functioning. -Primary treatment ingredients include communication skills training, assigned shared activities, and contingency contracting. -Additional elements; Disulfiram Contract and Cognitive Behavioral Relapse Prevention.

CRAFT (Community Reinforcement and Family Training)

-A scientifically developed and tested system -Helps family members influence change while learning how better to live with a substance abusing family member. -CRAFT works to affect the loved one's behavior by changing the way the family interacts with him or her.

Epidemiology

-Alcohol and illicit drugs are *more likely to affect men than women* and frequently co-occur with mood, anxiety, and personality disorders.

Children of alcoholics

-Become distrustful, isolated or prematurely self sufficient -As adults, while seeming independent, they may harbor unrealistic expectations for their relationships. Hoping that other will compensate for early deprivation.

Theories of addiction According to Brooks and Rice (1997) -A-

-Disease model: addiction is based in illness that is chronic and progressive. -Psychiatric models: addiction is a psychiatric condition, follows medical model of care. -Trauma model: because of trauma the individual has a diminish or absent inner capacity for self-soothing causing to turn to external sources.

Warning signs for alcohol abuse

-Drinking alone or secretively -Using alcohol to cope -Feeling uncomfortable on occasions when alcohol is not available -Escalating consumption beyond an already established pattern -Consuming during risky situations -Getting drunk regularly or more frequently than in the past. -Drinking in the morning or unusual times.

Treatment - Treadway (1987) #2

-Formulate a drinking contract involving controlled use or abstaining. Family will confront the drinker if broken. -Family experiences a crisis when drinking stops because they were organized around the symptom. -Repressed feelings most be acknowledge, normalized and work through according to the family needs. before the relationship can reorganize.

Type of use-related involment

-Habit- is a behavior a person regularly engages by choice, but can stop with some efforts and few ill effects. -Compulsive- The behavior is more repetitive and excessive, loosing its original meaning. Often has feelings of conflict and ambivalence. -Addiction- the behavior escalates until is out of control, addiction is chronic and progressive.

Biobehavioral researchers have identified several types of alcoholics:

-Hyperaroused alcoholics have high levels of arousal and tend to seek the sedating qualities of alcohol. -Anhedonic alcoholics have chronically low levels of arousal and may drink for the stimulating effect. -Depressed alcoholics may have low levels of seratonin. -Mixed-type alcoholics may show combinations of symptoms from the above types.

Causes of Alcoholism

-It is likely that alcoholism is a biopsychosocial process. -Components are biological, such as a genetic or familial predisposition. -Psychological such as depression. -Social as peer group pressure.

The Intervention (Johnson 1986) -B

-Schedule the meeting in the morning since most likely sober and hung over. - Each person begins by expressing his affection for the alcoholic followed by an explanation of how substance abuse has affected speaker's life. - When all speakers are finished, substance abuser can speak. -Chairperson asks him/her to accept the request for treatment. -Therapist should schedule a follow-up session regardless of outcome. Mixed empirical support.

Theories of addiction According to Brooks and Rice (1997) -B-

-Social-cognitive:Individual has equal deficits of coping capacity and familial modeling. -Systems theory: Addiction is a family disease, each person is affected and plays a role. The disease is the central organizing principal. -Social model: Environmental factors: poverty, lack of education, lack of jobs and housing, racism, sexism, etc.

Substance abuse - overview

-Study in 2001 showed that 7.3% of general population is affected. -Related consequences of substance abuse: Impaired health Loss of employment Criminality Automotive Accidents -Substance abuse and dependence are now widely understood as a biopsychosocial process.

Substance abuse disorders

-Substance abuse in the DSM-V is a single disorder measure from mild to severe. -DSM-V now require 2 or 3 symptoms from a list of 11 for diagnostic criteria. -Each substance is now listed as a separated use disorder (no distinction between abuse and dependence).

7 stages of acknowledging an alcohol problem: Jackson

1) The family attempts to deny the problem 2) The family tries to eliminate/hide/control the problem 3) The family becomes disorganized 4) The family makes a first attempt at reorganization 5) The family attempts to escape the problem 6) The family makes a second attempt at reorganization 7) The family reorganizes with the substance abuser seeking help

Five stage treatment model

1. Confrontation 2. Detoxification 3. Education 4. Therapy 5. Reintegration

Multi-dimensional family therapy 3 stages

1. Multi-level assessment 2. Problem solving skill enhancement 3. Generalization of treatment gains to the environment.

AA's 12 steps.

1. We admitted we were powerless over alcohol - that our lives had become unmanageable. 2. We came to believe that a power greater than ourselves could restore us to sanity. 3. We made a decision to turn our will and our lives over the care of God, as we understand Him. 4. We made a searching and fearless inventory of ourselves. 5. We admitted to God, to ourselves, and to another human being the exact nature of our wrongs. 6. We were entirely ready to have God remove all these defects of character. 7. We humbly asked Him to remove our shortcomings.

CRAFT is designed to accomplish three goals:

1. When a loved one is abusing substances and refusing to get help, CRAFT helps families move their loved one toward treatment. 2. CRAFT helps reduce the loved one's alcohol and drug use, whether or not the loved one has engaged in treatment yet. 3. CRAFT improves the lives of the concerned family and friends.

AA's 12 steps. continues...

8. We made a list of all persons we had harmed and became willing to make amends to them all. 9. We made direct amends to such people wherever possible, except when to do so would injure them or others. 10. We continued to take personal inventory and when we were wrong, promptly admit it. 11. We sought through prayer and meditation to improve our conscious contact with God, as we understand Him, praying only for knowledge of His will for us and the power to carry that out. 12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.

Alcohol

Alcohol abuse is one of the most studied phenomena in family therapy research. - 13 million men, women and children are thought to be alcoholics -16 to 19 million adults are problem-drinkers -*Alcohol is the leading cause of death among 16-24 years old*. -Violence in families is more severe when alcohol is a factor.

Traditional psychiatric models

Consider addiction to be a maladaptive response to underlying psychopathology. These models now view addiction as a primary psychiatric condition. Treatment follows a medical model, but with a concurrent emphasis on psychiatric symptomatology.

Disease model

Considers addiction to be a biologically based illness that is chronic and progressive. Disease model of addiction is most characterized by denial and a loss of control. Treatment follows a medical model of hospitalization, medication, and education.

Systems theory model

Considers addiction to be a family disease in which is person is affected and plays a role in the family drama. The disease of addiction is the central organizing principle.

Alcoholics Anonymous (AA)

Defines alcoholism as a disease beyond one's control rather than a moral relapse. -Fellowship of alcoholics of anonymous participants. - AA participants embrace the 12 steps. -They believe in the presence of a higher power on which to relay for help. -Transformation to sobriety is the explicit goal of AA. -Desire for abstinence is the only requirement for membership. -Members who have reached the 12 step also help maintain sobriety by helping others. -A sponsor is available 24 hours a day. => The model is useful for many addicts; Narcotics Anonymous, Over-eaters Anonymous.

Defenses common in alcoholics

Denial Minimization Rationalization Projection Gradiousity Selective attention

Unilateral Interventions

Facilitate treatment initiation among resistant substance abusers through work with one or more family members. Relies on motivational enhancement, communication skills training, behavioral analysis, and contingency contracting.

Al-anon family support group

Focus on family members themselves with an emphasis on education on the disease of alcoholism, enhanced coping and support, and reduced enabling behaviors. -Philosophy of "powerlessness" over the using partner's behavior.

Social cognitive model

Identifies the reciprocal influence of deficits in coping capacity and familial modeling in the development of a substance use disorder.

Process addictions

Include shopping, sexual activity, exercise, work, gambling, food or even relationships (co-dependency).

Multi-dimensional family therapy

Involves developmental and systems oriented case formulation; targeting individual, familial, and social areas of risk that are understood as symptom maintaining factors. -Typically lasts 4 to 6 months in three stages: -MD therapy has shown superior effectiveness to adolescent group therapy on use reduction and pro-social functioning at post treatment.

Family Roles - Alcoholism- Enabler

Is outwardly super responsible, self-righteous, and powerless. keeps family functioning. Inner feeling anger.

Family Roles - Alcoholism- Dependent

Outwardly appears hostile, rejecting, angry, grandiose, the inner feeling is shame.

Family treatments

Overall studies support the efficacy of family treatments over individual treatments.

Social model

Proposes that environmental factors such as poverty contribute to addiction.

Trauma model

Recognizes the reciprocal influence of trauma and addiction. Because of trauma the capacity for inner self-soothing and self-regulation are greatly diminished or absent, causing the person to turn to external sources for comfort and relief.

Treatment - Treadway (1987)

The drinking has to be acknowledged as a problem by the drinker and family members before treatment can begin. -First step is confrontation by someone that the person trusts. -Although the family is the unit of treatment, therapists should be clear that the drinking is the drinker's problem.

Robert J. Meyers and Jane Ellen Smith of the University of New Mexico developed the CRAFT program

To teach families how to impact their loved one while avoiding both detachment and confrontation. -The substance user is confronted by family members and friends during a surprise meeting. -CRAFT has proven to be significantly more effective in engaging loved ones in treatment and decreasing their substance use, in comparison to the Johnson Institute Intervention or Al-Anon/Nar-Anon facilitation therapy.

Multi-systemic family therapy

Utilizes a systemic lens through which to identify a constellation of intervention. Compared with individual counseling, it has shown greater decreases in substance use rates at post treatment and 4 year follow-ups.

Dependence

is the need to continue taking the substance in order to avoid unpleasant withdrawal symptoms.

Tolerance

is the need to increase the amount of the substance used to achieve the same effect.