Treatment Models of Addiction

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Treatment Models of Addiction

• Addiction affects us all. Strengths
  perspectivestrengths of clients and strengths of
  the contemporary modelsharm reduction and 12
  Step approach.
• Rift in field over which model is true
• Moral, Psychological model, Sociocultural model,
  Mediaca, Biopsychocial Model, and Harm Reduction
  Model

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What is addiction?

• (Latin) addictus---attached to something,
  positive. Today alcoholism called a brain
  diseaseor bad habit or sin. Addiction is the
  key, not the substance or behavior

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DSM-IV-TR

• Substance dependence requires 3 of following.
• tolerance inability to stop
• withdrawal problems excessive spending or effort
• use more than intended obtain
• reduced involvement continued use
• Rigid dichotomy here between abuse and
  dependence. Addiction is a continuum. People
  move in and out of addiction.

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The Disease Concept

• Disease - as metaphor by Jellinek alcoholism is
  like a disease
• Random House Dictionary, disease is a condition
  of the body in which this is incorrect function.
• Oxford University Dictionary disease is absence
  of ease (in treatment disease as primary,
  progressive, chronic, and possibly fatal).
• Illness term preferred here, less
  controversial.
• Alcoholism as disease pro and con
• Addiction is a brain disease because the
  addicted brain is changed.
• Debate against habit, behavior, responsibility,
  mature out of.

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Biopsychosocial Model

• Why (bio), what (psycho), where (social)
• Interactionism pain and suffering ? loss ? pain,
  stress and drinking ?
• Family as a system, roles
• Why need to know about addiction? 80 behind
  bars, child welfare, alcoholics at work.

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The biopsychosocial model

Biological and cellular processes
Psychological processes
Social processes and contexts
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Moral Psychological

• Addict is degenerate
• Cause is moral weakness
• Punishment is ineffective unless tx is involved

• Personal pathology
• Unconscious conflicts tx ineffective
• Personality traits some change in tx
• Learning /behavioral
• AOD reinforced by environment with tx some
  change

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Sociocultural Medical/Disease

• Situation problem is addicts view
• Cause are social forces and context
• Tx approach cl. Change reinforcers

• View of addict as patient
• Cause is physiological dysfunction progressive
• Tx includes mind, body and spirit (no specific
  tx)

Learning the Language, Miller page 13
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• Historical Perspectives

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• Alcohol back to 5000 BC Iran
• Unknown to worlds indigenous people
• Koran --- condemned wine. Alcohol from Arabic
  al-kuhul.
• Arabian dr. discovered evaporated distilled
  spirits. Technology exceeded its grasp
• 1575 --- distilling usedgin. Booze from Dutch
  BUSEN.
• Great devastation from England, 1700-1750.
• Infant mortality, crime

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• North America
• More beer than water on Mayflower.
• 18th Quakers and Methodists disapproved of hard
  liquor.
• Male drinking cult 1725-1825 notorious.

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• Cocaine in Coke.
• 1914 Harrison Act --- restricted opioids with
  (associated with Chinese) prescription for
  cocaine.
• Marijuana (associated with Mexicans) State laws
  in southwest criminalized.
• Teetotaler fun. T total abstinence from
  Ireland.
• Temperance woman and suffrage movement.
• U.S. Prohibition 1920-1933
• Glamorized crime. Mafia/ Hollywood/Wash. DC
  link. Homicide rates increased.
• Great Depression created need for jobs.

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• AA Getting Better. Nan Robetson.
• Bill W. and Dr. Bob. Oxford Groups. Big Book. 1
  million members today
• Jellinek (The Disease Concept, 1960) 5 types of
  alcoholism based on world travels
• Alpha, Beta, Gamma , Delta, Epsilon.
• The Disease Concept
• 1966 AMA Alcoholism as disease.
• Harold Hughes NIAAA.
• Looking back on how tech gt social changes gt law.
• Themes of Chapter dangers of potent alcohol,
  role of ethnic prejudice in shaping drug
  legislation, of mentally ill and alcoholic
  persons, unintended consequences of prohibition.
•  

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History of Treatment

• William White, Slaying the Dragon. Mistreatment
  of mentally ill in asylums.
• Hazelden
• Peele and Fingarette addiction as bad habits.

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Models of Strengths-Based Approaches

• 1. Harm reduction public health model,
  prevention, outreach. 
• Abstinence not precondition
• Stages of Change Model
• Precontemplation
• Contemplation
• Preparation
• Actions
• Maintenance
• Relapse

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2. Motivational Interviewing (MI)---William
Miller

• Asking right questions Tell me about a period
  when you were doing well?
• Smoking on a scale of 1-10 to give up smoking,
  where are you now?
• MI Steps
• Enhance Motivation
• Express empathy
• Develop discrepancy
• Avoid argumentation
• Roll with resistance
• Support self-efficacy

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3. Solution focused therapy and Narrative
therapy

• Miracle question
• Narrative

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Traditional Treatment

• Detox
• Outpatient
• Inpatient
• After care once a month

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Harm Reduction

•   Need for drug courts--important for family
  preservation and closely supervised treatment
•   Miller and Rollnick motivational
• interviewing strategies

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•   Traps for therapists to avoid are
•  Premature focus, such as ones addictive
  behavior
•  Confrontational/denial round between
  therapist and client
•  Labeling trap-forcing the individual to
  accept a label alcoholic or addict
•  Blaming trap, fallacy that is especially
  pronounced in couples counseling

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•    Primary prevention interventions to reduce
  primary risk factors such as
•    Child abuse, early-prevention education and
  treatment programs
•    Smoking education to keep youths from ever
  starting
•    Health and skill education at schools
•    Reducing ads
•    Advocacy for the hiring of more school
  counselors and social workers

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Stage-Specific Motivational Statements

•      Stage of Change
•      Precontemplation
•    Goals are to establish rapport
•    Counselor reinforces discrepancies
•    Adolescent comment
• My parents cant tell me what to do I
  still use and I dont see the harm in it- do
  you?

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Motivational Enhancement continued

•   Stage of change Contemplation
•  How was life better before drug use?
• Emphasize choices
•   Typical questions are
• -What do you get out of drinking?
• -Whats the down side?

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Contemplation Stage continued

•  Adolescent comments
•    Im on top of the world when Im high, but
  then when I come down, Im really down. It was
  better before I got started on these things.

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Preparation Stage

•   Setting date
•   What do you think will work for you?
•    Adolescent comments
•   Im feeling good about setting a date to quit,
  but who knows?

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Action Stage

• Adolescent comments
• Staying clean may be healthy, but it sure makes
  for a dull life. Maybe Ill check out one of
  those groups.
• Therapist check out groups
• Why dont you look at what others have done in
  this situation?

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Maintenance Stage

• Adolescent comments
• Its been a few months Im not there yet but Im
  hanging out with some new friends

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Resistance

• Inevitable
• Miller advises roll with it
• Use reflective summarizing

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Relapse Prevention

• Learn warning signs
• Renew feelings that led to relapse
• Help them renew their commitment
• Find coping style
• Build support systems
• Non-confrontational approach is best

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Pitfalls (Beechem, 2002)

• Anticipate feelings of guilt and shame
• Ageism
• Countertransference
• Denial in assessment
• Sympathy not empathy

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Loss and grief in family members

• Types of Guilt
• Survivor guilt
• Helplessness
• Ambivalence
• Spiritual healing
• Strength from 12 Steps

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William Faulkner

• Poem
• If there be grief, then let it be but rain,
• And this but silver grief for grievings sake
• If these green woods be dreaming here to wake
• Within my heart, if I should rouse again.
• But I shall sleep, for where is any death
• While in these blue hills slumbrous overhead
• Im rooted like a tree? Though I be dead,
• This earth that holds me fast will find me
  breath.
• (Wilde Borsten, 1978, p.75)

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Harm reduction

• Needle exchange serves only 15 of drug
  injection.
• Methadone maintenance---too low a level of the
  drug. Not legalization but middle of road.