Sherry Dockins, MASA, LCPC, CADC, ICDVP

HSR 1204: Addictive Disorders Addiction Treatment: A Strengths

Perspective 2nd Ed.

Katherine van Wormer Diane Rae Davis

Introduction • Addiction affects us all

• Strengths perspective—strengths of clients & strengths of the models:

– harm reduction

– 12 Step approach

• Rift in field

• Book in 3 parts: bio-psycho-social

Nature of Addiction

• Examples of addiction— – smoker dying of emphysema,

– crack addict arrested,

– pregnant mother drinking heavily,

– girl hooked on meth; started using to lose weight

• Economic cost – health, war on drugs,

– over 1 million in prison for drug involvement.

• Big business—gambling, Philip Morris, beer

Box 1.1

Social Work Major Working in a Casino*

• What is the ethical dilemma here?

• How do the managers ensure that the gamblers keep spending their money?

• How are the employees controlled by the establishment?

What is addiction?

• (Latin) addictus—

– Attached to something, positive.

– Today alcoholism called a “brain disease” or bad habit or sin.

– Leading assumption of the text:

Addiction is the key, not the substance or behavior

• Addiction defined by researchers as:

– “a bad habit,”

– “a brain disease,”

– “helplessness,”

– “a problem of motivation”

Addiction (of any kind)

• Progression

• Preoccupation

• Perceived loss of control

• Negative long term consequences

• Relapse

Definitions

• Abuse—unlike dependence does not include;

– Tolerance, withdrawal, pattern of compulsive use

– Book prefers misuse

• Addiction (Dependence)—pattern of compulsive use

– Has physical, psychological, social aspects

– Emphasis on process rather than outcome

Substance dependence: 3 criteria in 12 months*

1. Tolerance

a. Need for markedly increased amounts to get desired effect

b. Markedly diminished effect with continued use of substance

2. Persistent desire to or unsuccessful efforts to cut down or control use

3. Withdrawal

a. Withdrawal syndrome

b. The same substance taken to relieve or avoid withdrawal symptoms

4. Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been abused or exacerbated by use.

5. Substance taken in larger amounts or over a longer period of time

6. Reduced involvement in social occupational or recreational activities due to use

7. Excessive time spent to obtain, use or recover from use

Substance Abuse: 1 or more in 12 month a period*

1. Recurrent use; failure to fulfill major role obligations

2. Recurrent use in situations that are physically hazardous (driving)

3. Recurrent substance-related legal problems (DUI, disorder conduct)

4. Continued use despite persistent / recurrent social or interpersonal problems related to use

Remission

• Early full remission –

– 1 month but less than 12

– no criteria for abuse or dependence

• Early partial remission - • 1 month but less than 12

• one or more criteria for abuse or dependence

• Sustained full remission –

– None of the criteria for abuse or dependence in 12 month period or longer

• Sustained partial remission –

– Full criteria for dependence not met for 12 or more months

– 1 or more criteria for dependence or abuse have been met

withdrawal

• The development of a substance-specific syndrome due to the cessation of (or reduction in) substance use that has been heavy and prolonged.

• The substance specific syndrome causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

• The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

CiWA-Ar (clinical Institute withdrawal assessment for Alcohol)

1. Nausea and vomiting

2. Tremor

3. Paroxysmal sweats

4. Anxiety

5. Agitation

6. Tactile disturbances

7. Auditory disturbances

8. Visual disturbances

9. Headaches or fullness in head

10.Orientation or clouding of sensorium

Dependence VS. Abuse

• Rigid dichotomy between abuse and dependence.

• Van Wormer and Davis disagree

– addiction as a continuum

– people move in and out of addiction

The Disease Concept

• Is alcoholism a disease?

– Arguments by class pro:

– Arguments con:

PRO and Con • Best arguments pro disease:

– alcoholism is a brain disease – the addicted brain has changed

• Best arguments against:

– just a habit, – a behavior, – need to take responsibility, – people mature out of it

First, Define Disease* • Jellinek:

– a metaphor; “alcoholism is like a disease”

• Random House Dictionary,

– disease is a condition of the body in which this is an incorrect function

• Oxford University Dictionary–

– disease is absence of ease (in treatment – disease as: primary, progressive, chronic, and possibly fatal)

• Illness –

– Preferred by book – Non victim blaming – Non judgmental – Medical problem

Serious illness applies to addiction*

• Germaine (1984)

• Serious illness

– Perceived demands exceed perceived recourses for coping

– Source of stress

– Stress of illness = stress in family, work, community roles

– These stressors then interfere with recovery / mgt of disability

• A bio-psycho-social-spiritual model

Case Studies

Bio-psycho-social-spiritual model

• Biology (why)

– Chemical impact

– Hereditary components

– Physical problems

– Complex brain disease

– Endorphin deficiency

– Withdrawal

Bio-psycho-social-spiritual

• Psychological (what)

– Thinking

– Irrational or unhealthy thought process

– Depression / anxiety

Bio-psycho-social-spiritual

• Social (where)

– Where does it take place

– Where is the impact felt

– Socioeconomic ramifications

Bio-psycho-social-spiritual

• Spiritual

– Some think the key component to recovery

– Sense of meaning and interconnectedness

– Shift from negative punishing to positive forgiving

– Cause and effect are intertwined

– “what comes around goes around”

– Dependence is shame based; guilt

– Pain and suffering loss pain, stress and drinking more pain

Why Do We Need to Know about Addiction?*

• 80% of people behind bars

• Alcohol misuse = 3rd leading case of death after heart disease and cancer

• 80% of people with substance dependence have mental health dx

• Pervasive in child welfare system

• Alcoholics in the workplace

• 71% of social workers worked with clients with substance abuse disorders in the past year

• Headlines: -“Hooked on Tanning?” -“Shopaholics Climb on the Wagon” • Relevant movies: 28 days, Traffic, Walk the Line

What is Recovery?

Old school

• Confrontational

• Break denial

• Clients were resistant

• Catch’em being bad

Strengths perspective

• Charles Rapp: • Six critical elements:

– person vs illness (abuse to moderation) – control or choice (find their own way) – hope (resiliency) – purpose (meaning) – achievement ( way from grief and loss) – presence of one key person to help

Strengths perspective

• Finding the strengths in divergent models

• Newer ones and traditional approaches

• Different models for different folks

• Very negative view of disease model: – Stanton Peele: Resisting 12 Step Coercion

• Harm reduction & the strengths perspective “meet the client where the client is.” Policy issues of reducing harm.

Empirical Research* Project MATCH • Directed by NIAAA – 2,000 clients over 8 yrs (National Institute on Alcohol Abuse and

Alcoholism) • What type of treatment works?

– 12 step facilitation – cognitive – motivational enhancement therapy (MET)

• One on One; No Group

» MET most effective for those with low motivation » 12 Step with religious persons

Project Match

• Criticism: – lack of a control group – MET, a shorter intervention – Models only tested on alcoholic clients

• Project MATCH confirms the effectiveness of diverse treatments • New measure for recovery is improvement, not total abstinence

Empirical Evidence continued

• Valliant’s Research – 40 year longitudinal study – those who recovered had crisis with alcohol, or – joined AA, or – entered a stable relationship or – had a religious conversion.

• Research from California:

– $1 spent saves $7 across states

Empirical Research Continued*

• Hester & Miller found that these treatment modalities were proven to be most effective:

– brief intervention,

– motivational interviewing (MI),

– medicine naltrexone (reduce the high),

– social skills training,

– aversion therapy,

– cognitive therapy,

– acupuncture

Hester and Miller

• There is no single superior approach for individuals

• Treatment programs and systems should be constructed to include a variety of approaches inasmuch as different individuals respond best to different approaches

Treatment Trends

• Harm reduction recognized important to save lives

• Belief that punitive laws cause harm

• 69% of Americans favor treatment over jail

• Treatment now often provided in prison

• Attention to co-occurring disorders

• Restorative Justice: – Victim-offender programming to promote healing

Drug Court* – Decarceration

– Treatment in community

– Many people involved

• Treatment

• State’s attorney

• Probation

• TASC

• Law Enforcement

• Judge

• Drug court: improving retention rate:

– increased # case managers for increased monitoring

– increased minority staffing

– cognitive-behavioral curriculum

– counseling sessions that include family members