Uppers, Downers and All Arounders

1. Uppers, Downers and All Arounders Chapter 9 TREATMENT

2. 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 • 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

3. 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.

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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?

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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.

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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