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Uppers, Downers and All Arounders. Chapter 9 TREATMENT. OVERVIEW. Chemical dependency and addiction are one of the most prevalent of brain diseases Has a greater impact on society than any other brain diseases Chemical Dependency # 1 public physical health problem 16.4 anxiety disorders

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  • Chemical dependency and addiction are one of the most prevalent of brain diseases
  • Has a greater impact on society than any other brain diseases
  • Chemical Dependency # 1 public physical health problem
    • 16.4 anxiety disorders
    • 1.3% schizophrenia
    • 7.1% mood disorders
    • 11 million on alcohol
    • 3 million on illicit drugs
    • 2 million on both alcohol and other drugs
    • 25% on nicotine addiction
    • 2-6% on gambling addiction
current treatment issues
Current Treatment Issues
  • Expanding use of medications to treat withdrawal, reduce craving and promote abstinence
  • In creasing use of technology to diagnose and visualize physiological effects of addiction on brain
  • Lack of resources to provide treatment: States spend only 13% on treatment and only 4% used on prevention
    • For every $1spent, $4-$20 saved on prison costs, lost of time on jobs, health problems and extra social services.
current treatment issues4
Current Treatment Issues
  • Coercive treatment works in promoting positive outcomes
    • 33% re-arrests
    • 45% reduction of reconviction
    • 87% reduction in return to prison
  • Conflict between abstinence recovery and harm reduction
  • Large segment of society moving towards abstinence, that promotes prohibition
  • Treatment personnel do not see Harm reduction as an option or transition to abstinence
treatment effectiveness
Treatment Effectiveness
  • California Drug and Alcohol Treatment Assessment Study of 1,850 persons over 3-5 years:
    • Continual abstinence of 50%
    • 74% reduction in crime
    • State saved $7 for every $1 spent
    • TX most effective when patients treated continuously for a period of 6 -8 months
    • Group therapy more effective
    • Clients with alcohol issues had better outcomes
    • Better outcomes linked to culturally appropriate programs
  • Drug Abuse Treatment Outcome Study (DATOS)
    • 50-70% reduction in drug use
    • Short and long term residential programs work best
treatment and prisons
Treatment and Prisons
  • 1,962,220 Americans in federal and state prisons for drug offenses
  • 40-65% committed crimes while under the influence of alcohol and/or other drugs
    • 57% of federal prisoners and 21% of state prisoners serving a sentence for drug offenses
  • 5 million were on probation or parole
    • 24%drug law violation
    • 17% DUI of Alcohol
  • Only 10% with serious addictions had treatment in prisons, even though 94% of federal and 56% of state prisons and 33% of jails had some substance abuse treatment services
  • Studies showed that Treatment reduced recidivism
  • $25,000 -$45,000 a year spent on keeping an offender in jail
principles and goals of treatment
Principles and Goals of Treatment
  • Principles
    • No single treatment is appropriate for all
    • Treatment needs to be readily available
    • Effective treatment attends to all needs of individual, not just the drug use
    • Assessment needs to be continuous
    • Remaining in treatment for adequate time is critical for effectiveness
    • Counseling and other behavioral therapies is critical
principles and goals of treatment8
Principles and Goals of Treatment
  • Principles
    • Medications are important, especially combined with treatment
    • Persons with co-occurring disorders should have integrated treatment to address both drug and mental health issues
    • Treatment does not have to be voluntary to be effective
    • Possible drug use during treatment must be monitored continuously
    • Treatment programs should provide assessment for HIV/AIDS, Hepatitis A, B, and C, Tuberculosis and other infectious diseases
    • Recovery is a long-term process and may require multiple treatment episodes
principles and goals of treatment9
Principles and Goals of Treatment
  • Goals
    • Motivate clients towards abstinence
      • Education
      • Counseling
      • 12 Step Groups or Self-help Groups
      • Harm Reduction (methadone, medication)
      • Relapse Prevention
    • Reconstructing their lives: Creating a drug-free lifestyle
      • Address social and economic issues
      • Homelessness
      • Relationships
      • Jobs
      • Drug-free activities
      • Life skills
      • Education
principles and goals of treatment10
Principles and Goals of Treatment
  • Supporting Goals
    • Enriching Job or Career Functions
    • Vocational services
    • Personal Finances
    • Medical functioning
      • Checking for undiagnosed illnesses
    • Optimizing Psychiatric and Emotional Functioning
      • Over 50% of persons have coexisting mental illness
    • Spiritual Issues
      • Include spiritual options for clients
selection of a program
Selection of a Program
  • Diagnosis
    • American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)
      • Pattern of use, negative impact on the social or occupational functioning of the user, pathological effects (tolerance or withdrawal symptoms)
    • Addiction Severity Index (ASI)
      • Comprehensive and lengthy criteria for the diagnosis of chemical dependency
      • 180 items covering six items: medical, employment, drug/alcohol, legal, family/social, and psychiatric history
selection of a program12
Selection of a Program
  • Michigan Alcoholism Screening Test (MAST): Long (25 ?’s) Short (13 ?s)
    • Directed at negative life effects of alcohol
  • CAGE
    • Simplest assessment tool of 4 questions
      • Have you ever felt the need to Cut down on your drinking?
      • Do you feel Annoyed by people complaining about your drinking?
      • Do you ever feel guilty about your drinking?
      • Do you ever drink an Eye-opener in the morning to relieve the shakes?
treatment options
Treatment Options
  • No treatment has been found to be universally effective for everyone
  • Wide-range of Treatment Options
    • Cold-turkey/white knuckles dry-out to medically detoxification
    • Expensive medical or residential approaches, free peer groups, 12 step, Social Model Group Therapy
    • Outpatient treatment, half-way houses, residential programs
    • Long-term residential (2 or more years) and 7-day hospital Detox with aftercare
    • Methadone maintenance or harm reduction
      • Acupuncture, aversion therapies, etc.
    • Addicts drop-out from TX centers that they feel uncomfortable in or not relevant to their problems
treatment options14
Treatment Options
  • Medical Model Detoxification Programs
    • Supervised and managed by medical professionals: hospital inpatient, residential or outpatient
  • Office-based medical detoxification and maintenance treatment for opiate abuse
    • Qualified private medical practitioners
  • Social model detox programs
    • Nonmedical programs: in or out patient
  • Social Model Recovery Programs
    • Uses a variety of approaches to move a client towards recovery
treatment options15
Treatment Options
  • Therapeutic Communities
    • Generally long-term (1-3 years)
    • Self contained residential programs that provide full rehabilitation and social services
  • Halfway Houses
    • Permits addicts to keep their jobs and outside contacts while being involved with residential treatment program
  • Sober Living or Transitional-living Programs
    • Consists of apartments or cooperative living groups of recovering addicts who have completed a long-term residential program
treatment options16
Treatment Options
  • Partial Hospitalization and Day Hospitals
    • Medical outpatient programs that involve patients in therapeutic activities for 4-6 hours per day while living at home
  • Intensive Outpatient
    • 6-8 hours per week
  • Harm Reduction programs
    • Mainly pharmacotherapy maintenance
  • Admissions in 2000
    • 1.6 million treated in various facilities
    • Estimates that 2 million need treatment
    • 3.5 million need some care
    • 12,000 on Big Island in need of treatment
    • Only 56 CSACs on Big Island
treatment options17
Treatment Options
  • Hitting Bottom
    • Necessary since addiction is progressive disease
    • If early detection is recognized, then chances of recovery is better
  • Denial
    • Refusal to acknowledge the negative impact on life
  • Breaking Through Denial Intervention
    • Difficult but necessary since self-diagnosis is needed for treatment to be effective
treatment options18
Treatment Options
  • Intervention
    • Strategy to confront denial in drug abusers
    • Consists of members (family, friends, co-works, etc.)
    • Facilitator prepares members to expect defense mechanisms like denial, rationalization, minimization, anger, accusations
    • Timing, location and surprise is crucial
    • Successful or not, it is essential that group members continue to meet
treatment options19
Treatment Options
  • Detoxification
    • Helps to normalize client’s thinking processes so they can full participate in Treatment
    • Takes about a week to excrete cocaine
    • Takes about 4 weeks to 10 months until the body chemistry settles down
    • Medically or chemically assisted detox is aimed at minimizing life-threatening withdrawal symptoms
    • Assessment of severity is important to determine if detox is necessary
treatment options20
Treatment Options
  • Medication therapy for detox for cocaine, methamphetamine and other stimulants include:
    • Phenobarbital
    • Clonidine
    • Buprnorphine
    • Naltreone
    • Antipsychotic and antidepressants
  • Anabuse for prevention of alcohol relapse
  • Psychotherapy is also important during the detox phase
treatment options21
Treatment Options
  • Initial Abstinence
    • Environmental triggers can trigger relapse
    • HALT (hungry, angry, lonely, tired)
    • RID (restless, irritable, discontent)
    • Addicts and alcoholics must learn about their triggers and what precipitates a relapse
    • Cue (Triggers) Extinction Therapy
      • Addicts/alcoholics learn about cues and drug using situations that increase cravings then desensitize them through education, biofeedback or talk down
    • Psychosocial support
      • Clients Build a sober support network that will give them continuing advice
    • Acupuncture; relief withdrawal symptoms by stimulating the peripheral nerves that send messages to release endorphins that promote wellbeing
treatment options22
Treatment Options
  • Long-term Abstinence
    • Succeeds through continued participation in group, family, and 12 Step meetings
    • Addict must accept that addiction is:
      • Chronic
      • Progressive
      • Incurable
      • Potentially fatal
      • Relapse is always possible
      • Compulsive addicts that switch drugs always find that the same symptoms resurface in the new drug
treatment options23
Treatment Options
  • Recovery
    • Recovering addicts need to reconstruct their lives and find things they enjoy doing that give them satisfaction & natural highs
  • Outcomes and follow-up
    • Evaluations of outcomes are important to determine treatment success or failure and adjustments made
    • Aftercare is most important part of treatment.
individual therapy
Individual Therapy
  • Individual Therapy
    • Effective because counselors work one-on-one
    • Allows the counselor and client to evaluate treatment progress
    • Allows counselor and client to develop short and long term goals
    • Allows counselor and client to identify other issues client needs to work on
    • Provides a written documentary of counselor and client interaction
    • Less Threatening
individual therapy25
Individual Therapy
  • Individual Therapy
    • Cognitive behavioral therapy (CBT)
      • Looking at belief systems and changing them
      • Internal dialogue
      • Examining faulty assumptions and misconceptions and replacing these with effective beliefs
    • Cognitive Restructuring (REBT)
      • A, B, C, D, & F Theory of Personality (Albert Ellis)
        • Activating event
        • Belief of this event
        • Emotional and behavioral consequence
        • Disputing the event
        • Effect
        • New Feeling
individual therapy26
Individual Therapy
  • Cognitive Restructuring
    • Fully acknowledging that we are responsible for creating our emotional problems
    • Accepting the notion that we have the ability to change these disturbances
    • Recognizing that our emotional problems stem from irrational beliefs
    • Clearly perceiving these beliefs
    • Seeing the value of disrupting faulty thinking
    • Accepting that if we expect to change we need to work hard on changing beliefs and faulty thinking
    • Continuing to practice REBT methods is essential to recovery
individual therapy27
Individual Therapy
  • Reality Therapy
    • People have the capacity to make healthy choices
    • Each person creates their lifestyle
    • Active and Directive Therapy
    • Debating irrational beliefs
    • Homework assignments
    • Keeping records of activities
    • Learning new coping skills
    • Changing one’s language and thinking patterns
    • Role play & imagery
    • Confronting faulty beliefs
    • Aversion Therapy
    • Assertiveness Training
    • Social Skills Training Motivational Interviewing
individual therapy28
Individual Therapy
  • Motivational Interviewing
    • Counselor Skills
      • Express empathy
        • See the world through the client’s eyes
        • Reflective listening
      • Roll with the Resistance
        • Resistance is not challenged
        • Help the client explore the client’s ideas
      • Develop discrepancy
        • Help the client recognize where they are and where they want to be
        • See how their current actions will not lead them to their goals
      • Support self-efficacy
        • Empower clients to chose their own options
        • Counselor encourages them to change
individual therapy29
Individual Therapy
  • Motivational Interviewing
    • Pre-contemplation
      • Client will not admit they have a problem although others see they do
      • Counselor’s task is to raise doubt in client
    • Contemplation
      • Client begins to think he/she may have a problem
      • Counselor can evoke reasons to change by showing risks of not changing
      • Strengthen the reasons to change
    • Determination
      • The client decides to do something to change
      • Counselor helps the client choose options
    • Action
      • The client chooses a strategy to change and pursues it
      • Counselor helps the client take those steps
    • Maintenance
    • Client works on and maintaining change strategies
group therapy
Group Therapy
  • Major Focus is to have clients help each other to break the isolation of chemical dependency
  • The group is the catalysis for change
  • Facilitated Groups
    • 6 or more clients who meet with one or more therapists daily, weekly or monthly basis
  • Peer Groups
    • Therapist plays less of an active role, usually observing the process. Do not direct or lead group
    • Self-help Groups
      • 12 Step Groups: Solving problems through personal spiritual change
    • Educational Groups
      • Counselors provide psychoeducational groups that teach skill building
group therapy31
Group Therapy
  • Targeted Groups
    • Directed at a specific population of users
      • women's, men's, adolescents, gay and lesbians, dual diagnosis, etc
  • Topic Specific Groups
    • Different Issues: relapse prevention, AIDS, recovery maintenance, relationships, etc.
  • Group Therapy promotes better outcomes and sustain abstinence more than individual counseling
10 common errors made by beginning counselors
10 Common Errors Made by Beginning Counselors
  • Failure to have realistic view of group treatment
  • Self-disclosure issues and failure to drop the “mask” of professionalism
  • Agency culture issues and personal style
  • Failure to understand the stages of therapy
  • Failure to recognize counter-transference
  • Failure to clarify group rules
10 common errors made by beginning counselors33
10 Common Errors Made by Beginning Counselors

7. Failure to do Group Therapy by Focusing on Individual Problem

  • Failure to Plan in Advance
  • Failure to integrate new members
  • Failure to understand interactions in the group as a metaphor for drug-related issues occurring in the group member’s family of origin
family therapy
Family Therapy
  • Addiction is a family disease, and drugs and alcohol affect the client’s family
  • Family is often ignored
  • Goals of Family Treatment
    • Acceptance by all family members that addiction is a treatable disease not a sign of moral weakness
    • Establishing and maintaining a drug-free family
    • Developing a system for family communication
    • Processing the family’s readjustment
  • Tough Love
    • Family learns to establish limits for their interaction with addict
children of addicts and adults children of addicts
Children of Addicts and Adults Children of Addicts
  • Model Child
      • High achievers: represents family
  • Problem Child or scrape goat:
    • has multiple personal problems
  • Lost Child
      • Disconnected from family: avoids emotional confronting issues
  • Mascot Child or Family Clown
      • Uses avoidance to make everything trivial
      • Well liked
children of addicts and adults children of addicts36
Children of Addicts and Adults Children of Addicts
  • Most children of alcoholics and addicts also are:
    • Isolated and afraid
    • Approval seekers
    • Frightened by angry people
    • Become or marry alcoholics
    • Feel guilty when standing up for themselves
    • Become addicted to excitement or stimulation
    • Confuse pity and love
    • Repress feelings from traumatic childhoods
    • Judge themselves harshly
target populations
Target Populations
  • Women
    • Women tend to progress faster to addiction
    • Die younger
    • Less likely to ask for help
    • Internalize blame
    • Has less support from family members
    • Lacks childcare to enter treatment
    • Difficulty recognizing need for treatment
  • Men
    • More likely to enter treatment from criminal justice system
    • Tend to blame things on external events
target populations38
Target Populations
  • Older People
    • Less likely to seek treatment or ask for help
    • Addiction is seen as aging process or reaction to medicine
    • Few treatment programs aimed toward older people
  • Ethnic Groups
    • Treatment geared to specific ethnic groups tends to promote continued abstinence
    • Cultural competence important
target populations39
Target Populations
  • African Americans
    • 24% of admissions to publicly funded facilities
    • Have higher threshold for pain
    • Greater tolerance for delays for treatment
    • In some urban areas, high rate African American babies are born tox positive for drugs
    • Teenagers have a greater risk of dying from crack cocaine
    • More in jail for drugs than in college
target populations40
Target Populations
  • Asian & Pacific Islanders
    • Respond better to credentialed professionals than peers
    • Prefer individual counseling
    • Rely more on their own responsibility to handle their addiction rather than higher power
    • Have strong gender rules, so separate male and female groups are better
    • Family shame often keeps the family enabling and rescuing the addict
target populations41
Target Populations
  • Bicultural and bilingual treatment personal greatly increase the chances of successful treatment
  • Incorporates cultural traditions
    • Healing
    • Talking circles
    • Purification ceremonies
    • Meditative practices
    • Sweat lodges
    • Shamanistic ceremonies
    • Community Singing Ceremonies
target populations42
Target Populations
  • Physical disabilities
    • Much-neglected population
    • Counselor may focus too much on the disability and miss the signs and symptoms of relapse
    • Not take into account the extra stress from the disability
  • Gay and Lesbian
    • 20-25% are heavy alcohol users
    • High incidence of HIV/AIDS in gay male community
treatment obstacles
Treatment Obstacles
  • Denial and lack of financial resources
  • Use of psychoactive drugs can delay user’s emotional development
  • Keep them from learning how to deal with life problems
  • Poor follow through or monitoring
    • Drop out or lack of compliance
    • Conflicting goals
  • Lack of Treatment Resources