Chemical Dependency

1. Chemical Dependency ARTSS Internship June 7, 2011

2. Behavior Disorders • Behavior disorders are disorders in which the individual persistently engages in a dysfunctional and problematic behavior and does not stop. • Behavior disorders are characterized by their chronicity and high relapse rate. • People with behavior disorders are not normal people with problems; they are problem people who appear normal.

3. Behavior Disorders • Addictive Behaviors • Alcoholism • Drug dependence • Smoking • Pathological Gambling • Sexual – pedophilia, exhibitionism, voyeurism • Antisocial Behaviors • Antisocial Personality

4. Addictive Behaviors • Addictive behaviors in general • Addictive behaviors may be viewed as a complex progressive behavioral pattern with biological, psychological, sociological, and behavioral components • What sets it apart from other behavioral patterns is: • Pathological involvement with the behavior • Subjective compulsion to continue the behavior

5. Addictive Behaviors • Reduced control over the behavior • Object is to experience physical, emotional or environmental elements of involvement in the behavior • Behavior continues despite its negative consequences • Behavior continues despite more gratifying sources of reinforcement

6. Addictive Behaviors • Dependence is experienced as a subjective distress when this behavior is not carried out • Tolerance is shown by a need to escalate the behavior to achieve prior levels of reinforcement • Urges are experienced as a strong desire for the behavior • Cravings are experienced as a strong desire for the positive effects of the behavior • Power of the addiction is shown by its rapid reinstatement after cessation

7. Addictive Behaviors • Common features of addictive behaviors • Potent means of rapid mood change and sensation because of physiological effects and learned expectations • Improvidence - short-term pleasure vs. long-term negative consequences (one night with Venus, ten years with Mercury) • Psychological states, arousal levels, stress, pain and negative moods be come associated with and influence the likelihood of the behavior

8. Addictive Behaviors • Classical and operant conditioning are important parts of the addictive process • Paradox of control - a behavior over which the individual has diminished control is used as an attempt to cope or exert more control • High relapse rate • Alternative behaviors often trigger return to the target behavior

9. Addictive Behaviors • Alternative behaviors often have a potential for developing into an addictive behavior • The stages of spontaneous remission are similar across behavior

10. Addictive Behaviors • Diagnostic Characteristics of Substance Dependence • Loss of control • Physiological symptoms • Tolerance • Withdrawal • Life problems • Health (physical and mental) • Legal • Employment

11. Addictive Behaviors • Social relationships • Feeling dependent on the substance • Urges to use the substance and cravings for its positive effects • Inability to function without the substance • Studying substance abuse by studying the substance is like studying holy water by analyzing the water

12. Addictive Behaviors • Evaluation • History • Onset, remissions, relapses, treatment, intoxication symptoms, withdrawal symptoms, life problems • Other sources of information - significant others, other professionals, old records • Lab tests • Must make accurate diagnoses • Real comorbidity vs. psychiatric symptoms due to the substance use (MICAA vs. CAMI)

13. Dual Diagnosis • Terminology • The term dual diagnosis is ambiguous and in 1986 the New York State Commission on Quality of Care for the Mentally Disabled introduced the terms:

14. Dual Diagnosis • What is dual diagnosis? • This term refers to patients who have serious DSM - IV Axis I psychiatric disorders and chemical dependency • Prevalences of substance use disorders in: • Schizophrenia - 50% • Bipolar AD - 60% • PTSD - 60% to 80% • Mentally ill chemical abusers and addicted (MICAA) • Chemical abusing mentally ill (CAMI)

15. Dual Diagnosis • MICAA - individuals with severe and persistent mental illness accompanied by chemical abuse or dependency • The mental illness is independent of the substance abuse and would exist without it • The mental illness is a DSM - IV Axis I disorder (schizophrenia, schizoaffective, bipolar, severe chronic depression)

16. Dual Diagnosis • MICAA patients usually require medication to control their psychiatric illness and relapse without it • Substance abuse may exacerbate existing psychiatric symptoms but symptoms persist beyond withdrawal of the substance • MICAA patients frequently display residual effects of their psychiatric disorders (social isolation, flat affect, lack of initiative, cognitive impairment)

17. Dual Diagnosis • CAMI - individuals with severe chemical dependence with symptoms of mental illness but who are not persistently mentally ill • CAMI patients have severe substance dependence • CAMI patients usually require treatment in programs • CAMI patients often have coexistent Axis II • disorders

18. Dual Diagnosis • CAMI patients appear in the mental health system due to the “toxic” effects of the substance that resemble the acute symptoms of a psychiatric disorder (psychosis, suicidal ideation). The acute symptoms are always precipitated by the substance abuse. • CAMI patients’ acute psychiatric symptoms remit with detoxification and abstinence from the substance - usually in weeks but it may take months

19. Dual Diagnosis • CAMI patients do not exhibit the residual effects of a major mental illness when the substance abuse is in remission

20. Addictive Behaviors • Planning Treatment • Alcohol withdrawal • Tremors • Alcoholic hallucinosis • Seizures • Delirium tremens

21. Alcohol Behaviors • Comorbidity • Depression • Drug abuse/dependence • Post traumatic stress disorder • Schizophrenia • Bipolar affective disorder

22. Alcohol Behaviors • Treatment • Continued out patient alcoholism treatment • Continued out patient psychiatric treatment • Psychosocial • Marital/family issues • Employment issues • Housing issues

23. Relapse Prevention • Primary focus of relapse prevention is the maintenance of habit change (it is easy to stop smoking; I’ve done it 1000 times) • To prevent slips • To prevent slips from turning into relapses • Addictive behaviors are over learned habit patterns that can be changed through self monitoring and self management.

24. Relapse Prevention • Three main areas of self control strategies are: • Acquiring coping skills instead of addiction • Fostering new cognitions, attitudes, attributions, and expectancies about the nature of the addiction and of the ability to control one’s life • Developing a life style that includes positive self care activity and non destructive satisfaction

25. Relapse Prevention • Three premises • Addictive behaviors are controlled by the same variables that control non addictive behaviors • The factors that initiate a behavior often differ from the factors that maintain it • To change the way people behave, it is imperative to change the way they think.

26. Relapse Prevention • Cognitive concepts • Expectancies • Outcome • Efficacy • Attributions • Inferred causality in the explanation of one’s own or another’s behavior

27. Relapse Prevention • Cognitive distortions • Overgeneralization • Selective abstraction • Excessive responsibility • Generalizing over time

28. Relapse Prevention • Self reference • Catastrophizing • Dichotomous thinking • Absolute willpower breakdown • Body over mind

29. Problem Analysis

30. Decision making • Motivation • Apparently irrelevant decisions • Poor decisions

31. Decision Making Cost Benefit Drink Don’t drink

32. Relapse Prevention • Reference • Marlatt and Gordon, Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors, Guilford Press, 1985 • Marlatt and Donovan, second edition, 2007

33. Motivational Interviewing

34. Motivation • Motivation is the readiness for change • The most common misconception is that motivation is a fixed characteristic of the client • Motivation is not fixed and external factors have a major influence on motivation • Motivation is controlled by the interaction of the client with those around him or her

35. Motivation • Technique - designed to minimize the client’s resistance to changing his or her behavior • To understand motivational interviewing one must understand • Cognitive dissonance • Psychological reactance

36. Motivational Interviewing • Purpose is to increase client motivation for change • Confrontational but not in the usual sense • Intent is to bring client to a greater awareness of his personal responsibility for the problem • Underlying strategy is to create a dissonance between the clients current behavior and his personal goals

37. FRAMES • Feedback of personal risk or impairment • Responsibility of the individual for change • Advice on how to change • Menu of change options • Empathy by the therapist • Self-efficacy support by the therapist

38. Increasing Client Motivation • Remove barriers • Decrease attractiveness of current behavior • External contingencies - letter for work, commitment • Goal setting - help the client set a clear goal for change • Helping attitude - reflective listening

39. Motivational Principles • Express empathy - reflective listening • Develop discrepancy between where client is and where he or she wants to be • Avoid argumentation - this decreases client defensiveness • Roll with resistance - solutions are evoked from the client and not imposed by the therapist

40. Motivational Interviewing • Reference • Miller WR, Rollnick S, Motivational Interviewing: Preparing for Change, 2nd Edition, Guilford Press, 2002

41. Strategies for Remaining Sober • Remember sobriety is your number one priority. • Avoid risky people and places. • Remember the problems that drinking caused you. Do you want them back again? • Go to meetings and self help groups. • Stay in alcohol free environments. • Avoid thinking about alcohol. • Remember the benefits of being sober.

42. Just Do It • You do not need to understand something to make it work for you. • I get to the airport on time, get on the plane, and get off when it lands. I do not need to know aerodynamics to get to where I am going. • The sun rises in the east and sets in the west. Your child does not need to know that this is due to the earth’s rotation to get home before dark.