Presentation is loading. Please wait.

Presentation is loading. Please wait.

Power Point for Addiction Treatment: A Strengths Perspective 3rd Edition Katherine van Wormer Diane Rae Davis Cengage Publishing Company 2012 copyright.

Similar presentations


Presentation on theme: "Power Point for Addiction Treatment: A Strengths Perspective 3rd Edition Katherine van Wormer Diane Rae Davis Cengage Publishing Company 2012 copyright."— Presentation transcript:

1 Power Point for Addiction Treatment: A Strengths Perspective 3rd Edition Katherine van Wormer Diane Rae Davis Cengage Publishing Company 2012 copyright

2 Part I: Introduction Addiction affects us all. Strengths perspective strengths of clients and strengths of the contemporary models: Addiction affects us all. Strengths perspective strengths of clients and strengths of the contemporary models: Harm reduction Harm reduction 12 Step approach. 12 Step approach. Rift in field. Rift in field. Book in 3 parts: bio-psycho-social Book in 3 parts: bio-psycho-social

3 Chapter I Nature of Addiction Examples of addiction---smoker dying of emphysema, crack addict arrested, pregnant mother drinking heavily, girl hooked on meth she started using to lose weight Examples of addiction---smoker dying of emphysema, crack addict arrested, pregnant mother drinking heavily, girl hooked on meth she started using to lose weight Economic costhealth, war on drugs, over 1 million in prison for drug involvement. Big businessgambling, Philip Morris, beer Economic costhealth, war on drugs, over 1 million in prison for drug involvement. Big businessgambling, Philip Morris, beer

4 What is addiction? (Latin) addictus---attached to something, positive. Today alcoholism called a brain diseaseor bad habit or sin. Leading assumption of the text: Addiction is the key, not the substance or behavior (Latin) addictus---attached to something, positive. Today alcoholism called a brain diseaseor 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 defined by researchers as a bad habit, a brain disease, helplessness, a problem of motivation

5 DSM-5 Changes to DSM in new edition: no longer dichotomy between abuse and dependence Addiction now the preferred term instead of dependence. Addiction now seen as a continuum. Substance use disorder requires 2 of following: toleranceinability to stop toleranceinability to stop withdrawal problems excessive spending or effort withdrawal problems excessive spending or effort use more than intended to obtain use more than intended to obtain reduced involvement continued use reduced involvement continued use

6 Definitions Addictionpattern of compulsive use. Has physical, psychological, social aspects. Emphasis on process rather than outcome. Gambling now considered an addiction in DSM-5 Pattern of preoccupation, lack of control, form of escape, chasing ones losses, serious consequences.

7 Box 1.1 A Social Work Major Working in a Casino What is the ethical dilemma here? What is the ethical dilemma here? How do the managers ensure that the gamblers keep spending their money? How do the managers ensure that the gamblers keep spending their money? How are the employees controlled by the establishment? How are the employees controlled by the establishment?

8 The Disease Concept Is alcoholism a disease? Is alcoholism a disease? Arguments pro: Arguments pro: Arguments con: Arguments con:

9 First, Define Disease Disease - as metaphor by Jellinek: alcoholism is like a disease 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. 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). Oxford University Dictionary– disease is absence of ease (in treatment – disease as: primary, progressive, chronic, and possibly fatal). Illness – term preferred here, less controversial, less medical. Illness – term preferred here, less controversial, less medical. Best arguments pro disease: alcoholism is a brain disease because the addicted brain has changed. Best arguments pro disease: alcoholism is a brain disease because the addicted brain has changed. Best arguments against: just a habit, a behavior, need to take responsibility, people mature out of it. Best arguments against: just a habit, a behavior, need to take responsibility, people mature out of it.

10 Biopsychosocial-spiritual Model Why (bio), what (psycho), where (social) Why (bio), what (psycho), where (social) Need for spiritual healing, connection with Higher Power Need for spiritual healing, connection with Higher Power Interactionism and cycle of pain: pain and suffering loss pain, stress and drinking more pain Interactionism and cycle of pain: pain and suffering loss pain, stress and drinking more pain Family as a system in interaction, roles Family as a system in interaction, roles

11 Why Do We Need to Know about Addiction? 80% of people behind bars have problems, pervasive in child welfare system, alcoholism in the workplace. 80% of people behind bars have problems, pervasive in child welfare system, alcoholism in the workplace. 71% of social workers worked with clients with substance use disorders in the past year. 71% of social workers worked with clients with substance use disorders in the past year. Headlines: Headlines: -When Tanning Turns into an Addiction -When Tanning Turns into an Addiction -Help! Im Addicted to Facebook -Help! Im Addicted to Facebook Relevant movies: 28 days, Traffic, Walk the Line Relevant movies: 28 days, Traffic, Walk the Line

12 Table 1.1 Contrast Traditional Approach and Strengths Perspective Traditional approach dichotomizes alcoholic and non-alcoholic Use of labelsI am an alcoholic, addict, dysfunctional family Focus on losses, client in denial, resistant Strengths approachavoids labels, focus on strengths, family as resource

13 Two Approaches to Treatment Traditional Traditional Bio Bio Dichotomy Dichotomy Psycho Psycho Problems mandateone size fits all Social Social Identify family dysfunction Strengths-based Bio Continuum Psycho Strengths-motivation Social Holistic family as resource

14 Addiction Recovery Management Strengths-based treatment approach endorsed by UN Case management Community resources for long-term care Interventions relate to personal needs in societymental health care, housing Success measured in drinking, using less, not total abstinence

15 Strengths Perspective Strengths Perspective Rapp and Goscha: Rapp and Goscha: Six critical elements: person is not the illness, choice, hope, purpose, achievement, presence of one key person to help. Six critical elements: person is not the illness, choice, hope, purpose, achievement, presence of one key person to help. Finding the strengths in divergent modelsharm reduction and 12 Step approach Finding the strengths in divergent modelsharm reduction and 12 Step approach Different models for different folks. Different models for different folks. Very negative view of disease model: Stanton Peele: Resisting 12 Step Coercion Very negative view of disease model: Stanton Peele: Resisting 12 Step Coercion Harm reduction and the strengths perspective meet the client where the client is. Harm reduction and the strengths perspective meet the client where the client is. Policy issues of reducing harm. Policy issues of reducing harm.

16 Empirical Research Project MATCH Project MATCH Directed by NIAAA – 2,000 clients over 8 yrs. What works? 12 step facilitation, cognitive, motivational enhancement therapy (MET) MET most effective for those with low motivation, 12 Step with religious persons. 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. Vaillants Research Vaillants Research 40 year longitudinal studythose who recovered had crisis with alcohol or joined AA or entered a stable relationship or had a religious conversion.

17 Empirical Research Continued Research from California: 1$ spent saves 7 across states. Research from California: 1$ spent saves 7 across states. Hester and Miller found that these treatment modalities were proven to be most effective: brief intervention, motivational interviewing (MI), use of the medication naltrexone, social skills training, aversion therapy, cognitive therapy, acupuncture. (See chapter 8) Hester and Miller found that these treatment modalities were proven to be most effective: brief intervention, motivational interviewing (MI), use of the medication naltrexone, social skills training, aversion therapy, cognitive therapy, acupuncture. (See chapter 8)

18 Treatment Trends Prescription drug misuse as increasing problem; Prescription drug misuse as increasing problem; Harm reduction recognized as important to save lives; public health approach; Harm reduction recognized as important to save lives; public health approach; Belief that punitive laws cause harm; Belief that punitive laws cause harm; Majority of Americans favor treatment over jail; Majority of Americans favor treatment over jail; De-emphasis on incarceration, reentry programming; De-emphasis on incarceration, reentry programming; Drug courts, mental health courts; Drug courts, mental health courts; Attention to co-occurring disorders and extensive use of prescribed medications to reduce craving; Attention to co-occurring disorders and extensive use of prescribed medications to reduce craving; Restorative Justice: victim-offender programming to promote healing. PEASE Academy. Restorative Justice: victim-offender programming to promote healing. PEASE Academy.

19 Chapter 2 Historical Perspectives

20 Early History Alcohol back to 5000 BC Iran Alcohol back to 5000 BC Iran Unknown to worlds indigenous people Unknown to worlds indigenous people Koran --- condemned wine. Alcohol from Arabic al-kuhul. Koran --- condemned wine. Alcohol from Arabic al-kuhul. Arabian dr. discovered evaporated distilled spirits. Technology exceeded its grasp Arabian dr. discovered evaporated distilled spirits. Technology exceeded its grasp distilling used–gin. Booze from Dutch busen distilling used–gin. Booze from Dutch busen. Great devastation from England, Great devastation from England, Infant mortality, crime Infant mortality, crime

21 North America More beer than water on Mayflower. More beer than water on Mayflower. Slaves forbidden to drink except on special occasions, taught bingeing. Slaves forbidden to drink except on special occasions, taught bingeing. Puritan traditions. Puritan traditions. 18 th – Quakers and Methodists disapproved of hard liquor. 18 th – Quakers and Methodists disapproved of hard liquor. Male drinking cult notorious. Male drinking cult notorious.

22 Temperance movement : Against hard liquor : Against hard liquor. Temperance woman for womens suffrage and ban on distilled beverages. Temperance woman for womens suffrage and ban on distilled beverages.

23 Early 1900s Cocaine in Coke Cocaine in Coke Tobacco outlawed for brief period. Tobacco outlawed for brief period Harrison Act --- restricted opioids (associated with Chinese people) cocaine must now be prescribed Harrison Act --- restricted opioids (associated with Chinese people) cocaine must now be prescribed. Marijuana (associated with Mexicans) State laws in southwest criminalized. Marijuana (associated with Mexicans) State laws in southwest criminalized. Teetotaler T =total abstinence, from Ireland. Teetotaler T =total abstinence, from Ireland.

24 U.S. Prohibition Glamorized crime. Mafia/ Hollywood/Wash. DC link. Homicide rates increased. Glamorized crime. Mafia/ Hollywood/Wash. DC link. Homicide rates increased. Great Depression created need for jobs. Great Depression created need for jobs. Giancana, Double Cross Giancana, Double Cross

25 Modern War on Drugs Johnsonwar on poverty Nixon tthrough the Busheswar on drugs 1960s heroin horror stories 1980s, crack cocaine 2000s, meth Attacks directed toward poor, minorities.

26 History of Gambling in U.S. Lotteries American Revolution Banned after Civil War and during Prohibition. 1931casino gambling legal in Nevada 1960slotteries for state revenue 1972first gambling treatment center at VA, New York 1987Supreme Court banned state regulation of tribal casinos Mississippi River casinos Internet gambling popular today History of Gambling in U.S. Lotteries American Revolution Banned after Civil War and during Prohibition. 1931casino gambling legal in Nevada 1960slotteries for state revenue 1972first gambling treatment center at VA, New York 1987Supreme Court banned state regulation of tribal casinos Mississippi River casinos Internet gambling popular today

27 Themes of First Half of Chapter Dangers of potent alcohol, role of ethnic prejudice in shaping drug legislation, unintended consequences of prohibition. Dangers of potent alcohol, role of ethnic prejudice in shaping drug legislation, unintended consequences of prohibition. Example of happy Italian family enjoying wine with their meals. Example of happy Italian family enjoying wine with their meals. Modern War on Drugs, two-thirds of money for law enforcement. Modern War on Drugs, two-thirds of money for law enforcement.

28 History of Addiction Treatment William White, Slaying the Dragon. Mistreatment of persons with mentally illness and alcoholics in asylums. William White, Slaying the Dragon. Mistreatment of persons with mentally illness and alcoholics in asylums. Getting Better by Nan Robertson tells of Bill W. and Dr. Bob. Oxford Groups. Big Book. 2 million members in AA worldwide today. Getting Better by Nan Robertson tells of Bill W. and Dr. Bob. Oxford Groups. Big Book. 2 million members in AA worldwide today. Jellinek (The Disease Concept, 1960) – 5 types of alcoholism based on world travels: Jellinek (The Disease Concept, 1960) – 5 types of alcoholism based on world travels: Alpha, Beta, Gamma, Delta, Epsilon. Alpha, Beta, Gamma, Delta, Epsilon.

29 Treatment History continued 1956 AMA declared alcoholism an illness, 1966, a disease AMA declared alcoholism an illness, 1966, a disease. Harold Hughes –founded NIAAA. Harold Hughes –founded NIAAA. Hazelden adapted 12 Step approach. Hazelden adapted 12 Step approach. Box 2:1Treatment in Norwayuniversal health care for support. Box 2:1Treatment in Norwayuniversal health care for support. Peele and Fingarette: addiction as bad habits not disease. Peele and Fingarette: addiction as bad habits not disease.

30 History of Harm Reduction AIDS in Netherlands spawned new approach, to reduce the harm. AIDS in Netherlands spawned new approach, to reduce the harm. Britain, 1960s and later. Britain, 1960s and later. Heroin prescribed. Needle exchanges-U.S. Heroin prescribed. Needle exchanges-U.S. Alan Marlatt, died in 2011, pioneer in spread of harm reduction approach to U.S., researcher at U. of Washington. Alan Marlatt, died in 2011, pioneer in spread of harm reduction approach to U.S., researcher at U. of Washington.

31 Part II BIOLOGY Chapter 3 Substance Misuse, Dependence, and the Body

32 Part II BIOLOGY Chapter 3 Substance Misuse, Dependence, and the Body

33 Recent Trends Development of PET scans, fMRI functional magnetic resonance imaging functional magnetic resonance imaging Craving research Craving research New facts on brain damage New facts on brain damage

34 Depressants Alcohol Depressants Alcohol Figure 3.1alcohol involvement: 47% of homicides; 34% of drownings; 42% of fire injuries; 47% of young male car crashes; 50% date rape; 16% child abuse (doesnt count neglect); 23% of suicide. International studies show high correlation with partner violence. College student deaths per year –1,825 (NIAAA, 2010)

35 Father MartinChalk Talks Jocose drunk, amorose, bellicose, lachrymose drunks Our additions: somnos drunk, (sleepy) clamorose, (loud), scientose (know it all)

36 Global Drinking Patterns Europeans consume six times as much alcohol as southeast Asians Europeans consume six times as much alcohol as southeast Asians Moldova, the Czech Republic, drink around 18 liters per capita each year. Moldova, the Czech Republic, drink around 18 liters per capita each year. Eastern Europeanshard liquor Eastern Europeanshard liquor British and Irishbeer British and Irishbeer French and Italianswine French and Italianswine High ratesindigenous populations Northern Sweden and Northern Canada High ratesindigenous populations Northern Sweden and Northern Canada

37 Alcohol continued Health effects of moderate drinkersheart benefits, lower death rates than teetotalers. Health effects of moderate drinkersheart benefits, lower death rates than teetotalers. 7-10% of drinkers get addicted. Signs: tolerance, withdrawal (tremors, nausea; 5% have DTs), heavy nicotine, caffeine use 7-10% of drinkers get addicted. Signs: tolerance, withdrawal (tremors, nausea; 5% have DTs), heavy nicotine, caffeine use Tolerance reversal Tolerance reversal.4 B.A.C. may be comatose..4 B.A.C. may be comatose. Blackouts: common at.3 BAC, case in Tom Sawyer Blackouts: common at.3 BAC, case in Tom Sawyer Real court cases Real court cases

38 Narcotics Narcotics Opiatesfrom opium poppy…narcotics, heroin now can be smoked or snorted. Opiatesfrom opium poppy…narcotics, heroin now can be smoked or snorted. High tolerance so need greater quantities for high. High tolerance so need greater quantities for high. Inhalantshousehold products, huffing, brain damage, coma Inhalantshousehold products, huffing, brain damage, coma Misuse of pain medication increasing today Misuse of pain medication increasing today OxyContin OxyContin

39 Stimulants Cocaine-crack and powder, in urine 8 hrs., smoked for faster high. High lasts only minutes. Cocaine-crack and powder, in urine 8 hrs., smoked for faster high. High lasts only minutes. Brain blocks reuptake of dopamine… Addicted rats die… heart attack. Brain blocks reuptake of dopamine… Addicted rats die… heart attack. Amphetamines and methsynthetic unlike cocaine suppresses appetite. Used by Nazis hour high. Amphetamines and methsynthetic unlike cocaine suppresses appetite. Used by Nazis hour high. Methland by Nick Reding about Oelwein, Iowa. Methland by Nick Reding about Oelwein, Iowa. Powder can be snorted, injected. Stay awake for long durations… Powder can be snorted, injected. Stay awake for long durations… Anhedonia---inability to feel pleasure with drug-induced brain injury. Anhedonia---inability to feel pleasure with drug-induced brain injury.

40 Nicotine Can both stimulate and relax % of alcoholics smoke, reduces alcohol effects. Over half of persons with schizophrenia smoke. Can both stimulate and relax % of alcoholics smoke, reduces alcohol effects. Over half of persons with schizophrenia smoke. Nicotine decreases BAC levels. Nicotine decreases BAC levels. American businessmans story from China. American businessmans story from China. Malachy McCourt smoked for ad and got hooked. Malachy McCourt smoked for ad and got hooked. Box 3.1 To Die for a Cigarette Box 3.1 To Die for a Cigarette Case of chewing tobaccosnuff. Case of chewing tobaccosnuff.

41 Hallucinogens Plants, LSD, synthetic, flashbacks, PCP Plants, LSD, synthetic, flashbacks, PCP Ecstasy and roofiesheightens sensory experience…raves.. Ecstasy and roofiesheightens sensory experience…raves.. Cant get back to original high due to brain changes. Cant get back to original high due to brain changes. 10% in high school have used Ecstasy. 10% in high school have used Ecstasy. Dance Safe – harm reduction strategies. Dance Safe – harm reduction strategies. Roofies: sleeping pill in Europe. Roofies: sleeping pill in Europe.

42 What Is Ecstasy? Ecstasy is a drug that has some hallucinogenic properties and is structurally related to amphetamines. Its short form chemical name is MDMA (3,4- methylenedioxymetham- phetamine). Split

43 Short Term Effects of Ecstasy Feeling of confidence Sense of arousal Increased heart rate Dry and sore mouth/throat Tension, High Body Temperature Muscle twitching Depression & Confusion

44 Other Synthetic Substances Spice Bath saltsincrease in ER visits associated with this drug. Hard to detect.

45 Cannabis Marijuana Marijuana THC, the psychoactive ingredient, lowers blood glucose, increases appetite, Stored in fat cells, long term use possibly associated with apathy. THC, the psychoactive ingredient, lowers blood glucose, increases appetite, Stored in fat cells, long term use possibly associated with apathy. Earlier reports of lung cancer after long-term use were not validated. Earlier reports of lung cancer after long-term use were not validated.

46 Costs to Get High Estimates Differ by Region [not in text] [not in text] Crack: $5-10 quick fix only lasts 30 min. Crack: $5-10 quick fix only lasts 30 min. Heroin: $ day--$20 day can by maintenance dose inject a couple of times Heroin: $ day--$20 day can by maintenance dose inject a couple of times Ecstasy: $25 may take 5 or so pills. Ecstasy: $25 may take 5 or so pills. Meth: $25 long-lasting high, popular in gay party scene in Seattle, factory workers in Iowa Meth: $25 long-lasting high, popular in gay party scene in Seattle, factory workers in Iowa Marijuana: $25 or higher, depends on quality Marijuana: $25 or higher, depends on quality

47 Metabolism Liver: organ that metabolizes alcohol, alcohol circulates in the bloodstream until metabolized. Liver: organ that metabolizes alcohol, alcohol circulates in the bloodstream until metabolized. Men have special enzymes that help. Men have special enzymes that help. People metabolize ½ oz. per hour = small glass of wine. People metabolize ½ oz. per hour = small glass of wine. One Drink ¼ One bottle of beer (12 oz.) One Drink ¼ One bottle of beer (12 oz.) ¼ One glass of wine (6 oz.) ¼ One glass of wine (6 oz.) ¼ One single drink (1¼ oz. of liquor) ¼ One single drink (1¼ oz. of liquor)

48 Metabolism continued

49 Brain Regions and Their Functions

50 Ecstasy and the Brain

51 The Brain and Addiction Neurotransmitters affect emotions and memory

52 Neurotransmitters Affect Emotions and Memory Dopaminereuptake affected by cocaine, which blocks dopamine synapse Dopaminereuptake affected by cocaine, which blocks dopamine synapse Depletion following cocaine use. Nicotine affects dopamine too. Depletion following cocaine use. Nicotine affects dopamine too. Parkinsons when too little. Dopamine-boosting drugs for Parkinsons associated with mania and gambling behavior. Parkinsons when too little. Dopamine-boosting drugs for Parkinsons associated with mania and gambling behavior. Excess of dopamine associated with schizophrenia. Excess of dopamine associated with schizophrenia. Serotonin: influenced by alcohol, involved in sleep. Decreased levels linked to depression, anxiety, impulsiveness suicide. Serotonin: influenced by alcohol, involved in sleep. Decreased levels linked to depression, anxiety, impulsiveness suicide.

53 Depletion Following Cocaine Use. The right scan is taken from someone who is on cocaine. The loss of red areas in the right scan compared to the left (normal) scan indicates that the brain is using less glucose and therefore is less active. This reduction in activity results in disruption of many brain functions.

54 Memory and Craving Addict never gets original highbrain has changed. Addiction is a brain disease. Addict never gets original highbrain has changed. Addiction is a brain disease. Cues can trigger memory…picture of alcoholic beverages activates certain areas of the brain. Cues can trigger memory…picture of alcoholic beverages activates certain areas of the brain. Prozac reduces craving by regulating serotonin levels. Prozac reduces craving by regulating serotonin levels.

55 Cocaine in the Brain Cocaine in the Brain Slides are from the National Institute on Drug Abuse (NIDA) (www.nida.nih.gov)

56 Gambling and the Brain Persons with gambling disorders may have abnormal levels of dopamine and serotonin. Lack of control may result. Highs enhanced when rewards uncertain. Near misses especially thrilling. Gambling and the Brain Persons with gambling disorders may have abnormal levels of dopamine and serotonin. Lack of control may result. Highs enhanced when rewards uncertain. Near misses especially thrilling.

57 The Role of Genes Study of mental hospitals, prisons, 50% who used chemical substances had mental disorders. Study of mental hospitals, prisons, 50% who used chemical substances had mental disorders. CloningerSweden..259 male adoptees with alcoholic fathers CloningerSweden..259 male adoptees with alcoholic fathers Type 1: late onset..75% of alcoholics, relates to harm avoidance, anxiety, guilt Type 1: late onset..75% of alcoholics, relates to harm avoidance, anxiety, guilt Type 2: risk taker, (starts about age 11) male, hyperactive, antisocial, hereditary Type 2: risk taker, (starts about age 11) male, hyperactive, antisocial, hereditary Ondansetron: works on serotonin, little effect on type 1 Ondansetron: works on serotonin, little effect on type 1 Twins: 40-60% concurrence of alcoholism. Separated at birth monkeys drank more under stress, people with low dopamine like stimulants Twins: 40-60% concurrence of alcoholism. Separated at birth monkeys drank more under stress, people with low dopamine like stimulants People with ADHD risk for drug abuse. People with ADHD risk for drug abuse.

58 Medical Consequences Wernicke Korsakoff: Wernicke Korsakoff: Cases reported of Dr. Oliver Sachs Cases reported of Dr. Oliver Sachs Peripheral neuropathy related to lack of Vitamin B Peripheral neuropathy related to lack of Vitamin B Confabulation….Dr. SachsAwakenings Confabulation….Dr. SachsAwakenings

59 Medical Consequences continued Liver damage…removes toxins from blood, bile circulates in blood stream Yellow skin tone, cirrhosis, immune system breakdown. Heart – nicotine, cocaine Fetal alcohol syndrome. See photograph in text. Short nose, indistinct groove between nose and mouth, thin upper lip, small head and eyes, learning problems. Role of sperm should be considered as well as mothers role.

60 Interventions Related to Biology Schick Shadel, Seattle treatment center Schick Shadel, Seattle treatment center Conditioning or aversion therapyfavorite drink plus emetine to induce vomiting. Conditioning or aversion therapyfavorite drink plus emetine to induce vomiting. Use of truth serum on alternate days. Use of truth serum on alternate days.

61 Changing Brain Chemistry Brain Lock (Schwartz) cognitive treatment for OCD to rewire the brain Brain Lock (Schwartz) cognitive treatment for OCD to rewire the brain Ondansetrondecreases craving Ondansetrondecreases craving Zyban and smoking; Chantix helps person produce more dopamine. Zyban and smoking; Chantix helps person produce more dopamine. Nicotine gum; patch. Nicotine gum; patch. Naltrexone, approved 1995, not a narcotic unlike methadone. Naltrexone, approved 1995, not a narcotic unlike methadone. Blocks receptors for getting high. Blocks receptors for getting high.

62 Synthetic Prescription Drugs Methadone (synthetic form of heroin); Methadone (synthetic form of heroin); Methadone maintenance Methadone maintenance Heroin maintenance in Britain, Switzerland, Vancouver. Heroin maintenance in Britain, Switzerland, Vancouver. Buprenorphine can be prescribed by GPs, reduces likelihood of overdose Buprenorphine can be prescribed by GPs, reduces likelihood of overdose Eating disorders and dopamine Eating disorders and dopamine Bulimicsrelated to depression Bulimicsrelated to depression Anorexiaanxiety Anorexiaanxiety Luvox, Prozac, and Paxil decrease binges. Luvox, Prozac, and Paxil decrease binges.

63 Holistic Treatments Herbal remedies Herbal remedies St. Johns wort St. Johns wort Hypnosis Hypnosis Acupuncture from China Acupuncture from China Massage therapy Massage therapy Physical exercise to reduce tension Physical exercise to reduce tension

64 Chapter 4 Gender and Sexual Orientation Differences Gender and Sexual Orientation Differences

65 Gender Issues Recent trendsvoices of women and gays and lesbians are increasingly heard regarding treatment, research. Recent trendsvoices of women and gays and lesbians are increasingly heard regarding treatment, research. Some emphasis on gender-sensitive treatment. Some emphasis on gender-sensitive treatment. Class and cultural differences in drug use. Class and cultural differences in drug use. Male/female ratios differ in drinking quantity ratios from 13:12 in Italy to 28:11 in Canada, 46:5 in Mexico, and 15:3 in Russia. Male/female ratios differ in drinking quantity ratios from 13:12 in Italy to 28:11 in Canada, 46:5 in Mexico, and 15:3 in Russia. In American high schools, substance use rates about the same. In American high schools, substance use rates about the same. Adult men, twice the rate of women for marijuana and cocaine use and gambling, meth and tranquilizers about the same. Adult men, twice the rate of women for marijuana and cocaine use and gambling, meth and tranquilizers about the same. More eating disorders in women More eating disorders in women

66 Gender Differences Shame factor for women in treatment. Shame factor for women in treatment. Women in treatment more likely than men to have a substance- dependent partner. Women in treatment more likely than men to have a substance- dependent partner. Treatment less accessible for mothers than fathers due to child care responsibilities. Treatment less accessible for mothers than fathers due to child care responsibilities. Many women lose custody of children over substance misuse. Many women lose custody of children over substance misuse. Abstinence demands unrealistic. Abstinence demands unrealistic. Lack of treatment availability for pregnant women. Lack of treatment availability for pregnant women. Good results with recovery coaches and family courts. Good results with recovery coaches and family courts.

67 Gender Differences continued Meth addiction rates high among women. Meth addiction rates high among women. One study showed that 80% of female meth addicts were victims of domestic violence. One study showed that 80% of female meth addicts were victims of domestic violence. Violence---3 of 4 intimate partner murders are of women. Violence---3 of 4 intimate partner murders are of women. Women alcoholics ---47% in treatment molested as children in study of 472 women (Downs). Treatment needs to focus on PTSD issues. Women smoke to control weight, males to relieve boredom. Escape gamblers (women). Women start gambling later in life than men do. Women alcoholics ---47% in treatment molested as children in study of 472 women (Downs). Treatment needs to focus on PTSD issues. Women smoke to control weight, males to relieve boredom. Escape gamblers (women). Women start gambling later in life than men do.

68 Biological Differences Women get intoxicated quicker than men. Women have a higher mortality rate with heavy drinking. Lives are shortened by 15 years on average with alcoholismheart and liver damage.

69 Womens Treatment Needs 1. Address barriers to treatment that many women experience, such as lack of transportation, child care, and treatment availability. 2. Changing program goals and processes to accommodate womens needs for more support, less confrontation, job skill training, and parenting skills. 3. Embracing an empowerment model of change. 4. Female counselors who can attend to shame and stigma issues. 5. Need to celebrate any significant decrease in substance use. 1. Address barriers to treatment that many women experience, such as lack of transportation, child care, and treatment availability. 2. Changing program goals and processes to accommodate womens needs for more support, less confrontation, job skill training, and parenting skills. 3. Embracing an empowerment model of change. 4. Female counselors who can attend to shame and stigma issues. 5. Need to celebrate any significant decrease in substance use.

70 Sexual Orientation Heterosexism and homophobia: U.S. studies of schools shows suicide is 14 times the heterosexual rates. Heterosexism and homophobia: U.S. studies of schools shows suicide is 14 times the heterosexual rates. Lesbianslowest rate of AIDS of any group, but double the drug use of other women, 55% smoke at some point in their lives; 28% are obese. Lesbianslowest rate of AIDS of any group, but double the drug use of other women, 55% smoke at some point in their lives; 28% are obese. Reasons for high drinking rategay bar, fewer are mothers….G/L AA. Reasons for high drinking rategay bar, fewer are mothers….G/L AA. Gay maleshigh risk of sexual abuse in jail cells. Gay maleshigh risk of sexual abuse in jail cells. Religious fundamentalism correlated with suicide…alcohol problems persist across life span. Religious fundamentalism correlated with suicide…alcohol problems persist across life span. Transgender….See Dos and Donts…table 11.2 Transgender….See Dos and Donts…table 11.2 Resources: Pride Institute and PFLAG Resources: Pride Institute and PFLAG

71 Chapter 5 Gambling, Eating Disorders, Shopping, and Other Behavioral Addictions

72 Gambling Addiction Gambling, has become socially acceptable Gambling, has become socially acceptable Criteria of pathological gambling---preoccupation, increasing amounts, etc. 3-7% of gamblers have problems, suicide high in gamblers Criteria of pathological gambling---preoccupation, increasing amounts, etc. 3-7% of gamblers have problems, suicide high in gamblers Cost to economy is $54 billionbankruptcies, lost work time, crime, etc. Very high among Native Americansover 14% have gambling problems Cost to economy is $54 billionbankruptcies, lost work time, crime, etc. Very high among Native Americansover 14% have gambling problems Research shows counties with gambling casinos have higher crime rates and bankruptcies than others Research shows counties with gambling casinos have higher crime rates and bankruptcies than others

73 Gambling continued Problems among the elderly Problems among the elderly Internet gambling is the fastest growing form. Internet gambling is the fastest growing form. 2-4% in Gamblers Anonymous (GA) are women. But many helpline calls. 2-4% in Gamblers Anonymous (GA) are women. But many helpline calls. Women gamble to escape; men for action. Women gamble to escape; men for action. Associated with other problems Associated with other problems Box 5.1 Reflections of a Male Compulsive Gambler. Geographical relocation helped him break his habit. Box 5.1 Reflections of a Male Compulsive Gambler. Geographical relocation helped him break his habit.

74 Questions for Screening Have you ever borrowed money in order to gamble or cover lost money? Have you ever borrowed money in order to gamble or cover lost money? Have you ever thought you might have a gambling problem or been told that you might? Have you ever thought you might have a gambling problem or been told that you might? Have you ever been untruthful about the extent of your gambling or hidden it from others? Have you ever been untruthful about the extent of your gambling or hidden it from others? Have you ever tried to stop or cut back on how much or how often you gamble? Have you ever tried to stop or cut back on how much or how often you gamble?

75 Treatment Issues Treatment: cognitive work and motivational therapy Treatment: cognitive work and motivational therapy Irrational thinking about winning: Irrational thinking about winning: I put so much money in this machine, Im bound to win. I put so much money in this machine, Im bound to win. High profile winners High profile winners Lucky machine and dates Lucky machine and dates States spending on treatment--$36 million is small compared to $20 billion in tax revenues from gambling States spending on treatment--$36 million is small compared to $20 billion in tax revenues from gambling

76 Eating Disorders The only one in this chapter related to a substance – food addiction. All others, for example, Internet addiction are behavioral…often clients in treatment for another disorder The only one in this chapter related to a substance – food addiction. All others, for example, Internet addiction are behavioral…often clients in treatment for another disorder Headline: Eating disorders start in brain Headline: Eating disorders start in brain 90% of anorexia and bulimia is found in females. 90% of anorexia and bulimia is found in females. Begins in adolescence Begins in adolescence.5% of girls and women are anorexic, 1-3% bulimic..5% of girls and women are anorexic, 1-3% bulimic.

77 Anorexia Less than 89% of normal body weight and fine body hair. Less than 89% of normal body weight and fine body hair. 10% mortality rate, often by suicide, correlated with perfectionism, ritualism, high anxiety 10% mortality rate, often by suicide, correlated with perfectionism, ritualism, high anxiety Related to obsessive compulsive disorder (OCD): Related to obsessive compulsive disorder (OCD): obsessive--recurrent and persistent thoughts; obsessive--recurrent and persistent thoughts; compulsionsritualistic practices. compulsionsritualistic practices.

78 Bulimia Gay men at risk. Gay men at risk. Bulimia with alcohol misuse %. Bulimia with alcohol misuse %. 35% of bulimics experienced childhood sexual abuse and use food as a drug. 35% of bulimics experienced childhood sexual abuse and use food as a drug. Little information on compulsive overeating. Little information on compulsive overeating. New studies show lack of dopamine receptors in the brains of morbidly obese. New studies show lack of dopamine receptors in the brains of morbidly obese. Some after gastric bypass surgery turn to heavy drinking. Some after gastric bypass surgery turn to heavy drinking.

79 Interventions Study in the British medical journal, Lancet findings from twin studies showed that a strong craving for sweets predicted alcohol abuse problems, perhaps caused by a lack of dopamine. Study in the British medical journal, Lancet findings from twin studies showed that a strong craving for sweets predicted alcohol abuse problems, perhaps caused by a lack of dopamine. Bulimiacognitive treatments; avoid strict dieting Bulimiacognitive treatments; avoid strict dieting AnorexiaProzac is effective in reducing compulsive behavior but only when weight has been gained. AnorexiaProzac is effective in reducing compulsive behavior but only when weight has been gained. Menmuscle dysmorphia, antidepressants may help here too. Menmuscle dysmorphia, antidepressants may help here too.

80 Treatment Overeaters anonymous (OA) for compulsive eating; Overeaters anonymous (OA) for compulsive eating; Group treatment.. teach moderationCBT Group treatment.. teach moderationCBT Theme of neuroplasticity brain neurons can form new connections; brain lock can be corrected (Schwartz) Theme of neuroplasticity brain neurons can form new connections; brain lock can be corrected (Schwartz) Box 5.2 compares two treatment programs; the second one in Kansas City included trauma work Box 5.2 compares two treatment programs; the second one in Kansas City included trauma work

81 Shopping or Spending Addiction Problems in about 2-8% of people Problems in about 2-8% of people Typical 31 yr.old female who has overspent for 13 years. Typical 31 yr.old female who has overspent for 13 years. DSM-5 lists kleptomania; DSM-5 lists kleptomania; Medications: Luvox Medications: Luvox Debtors Anonymous groups springing up Debtors Anonymous groups springing up

82 Cyber Addiction Caught in the Net– Internet addicts: preoccupied, excessive amounts of time involved in chat rooms, playing games; Caught in the Net– Internet addicts: preoccupied, excessive amounts of time involved in chat rooms, playing games; Jeopardized relationships. Jeopardized relationships. Fantasy worldfictitious names, office problems Fantasy worldfictitious names, office problems Self-efficacy for empowerment Self-efficacy for empowerment Korean government training psychiatrists to help treat Korean government training psychiatrists to help treat

83 FRAMES Feedback – assessment of use Feedback – assessment of use Responsibility – choice is theirs Responsibility – choice is theirs Advice – set goals together Advice – set goals together Menus – of self-directed change options (ex.- monitor computer use) Menus – of self-directed change options (ex.- monitor computer use) Empathy Empathy Self-efficacy Self-efficacy

84 Harm Reductions Strategies: - Get a timer - Get a timer -Cut mailing lists -Cut mailing lists -No detours -No detours

85 Sex Addiction Risk taker Risk taker Cognitive therapy recommended. Cognitive therapy recommended. Prone to lyingone TV broadcast looked at President Clintons background and his sexual risk taking: others disagree. Prone to lyingone TV broadcast looked at President Clintons background and his sexual risk taking: others disagree. Case of Tiger Woods. Case of Tiger Woods. Self-help group--Sex Addicts Anonymous. Self-help group--Sex Addicts Anonymous.

86 Cognitive Therapy Distortions especially with these addictions and anorexia. Tendency towards extreme behavior. Distortions especially with these addictions and anorexia. Tendency towards extreme behavior. Slogans of AA (easy does it) Slogans of AA (easy does it) Rational recovery, MET, REBT more adversarial, focus on current beliefs Rational recovery, MET, REBT more adversarial, focus on current beliefs

87 Cognitive Therapy continued Teach clients to avoid black and white thinking. Teach clients to avoid black and white thinking. Ask about times when client successfully handled a problem. Ask about times when client successfully handled a problem. Use regular assessment for disease of addiction. Use regular assessment for disease of addiction. Feeling work Feeling work Positive reinforcement and reframing Positive reinforcement and reframing Stress management--- modify thinking, exercises for group work: art work can reveal underlying feelings. Stress management--- modify thinking, exercises for group work: art work can reveal underlying feelings.

88 Therapy Positive reframing and self talk…. Cognitive therapy can be directed toward the past as well as the present. Positive reframing and self talk…. Cognitive therapy can be directed toward the past as well as the present. Feeling workanger management. Anger as a cover. Avoid all-or-nothing thinking. Feeling workanger management. Anger as a cover. Avoid all-or-nothing thinking. Stress management---- drink milk, use self talk, get exercise. Stress management---- drink milk, use self talk, get exercise. Group exercises for feeling work: art, faces, grief and loss, quiz cards, dreams, assertiveness. Group exercises for feeling work: art, faces, grief and loss, quiz cards, dreams, assertiveness.

89 Part II Psychology Of Addiction Psychology Of Addiction Chapter 6 Addiction across the life span Addiction across the life span

90 Erik Eriksons Stages Birth to old age Birth to old age Stage 1: Trust vs. Mistrust Stage 2: Autonomy vs. Shame and Doubt Stage 3: Initiative vs. Guilt Stage 4: Industry vs. Inferiority Stage 5: Identity vs. Role Confusion years old Stage 6: Intimacy vs. Isolation Stage 7: Generativity vs. Stagnation Stage 8: Ego Integrity vs. Despair Must resolve each crisis before going to next stage Carol Gilligans criticism. Carol Gilligans criticism.

91 Adolescent Brain Prefrontal cortex matures until mid-20s Prefrontal cortex matures until mid-20s Evidence of brain immaturity during the teen years comes from MRI scans of the adolescent brain Evidence of brain immaturity during the teen years comes from MRI scans of the adolescent brain

92 Teenage Drinking Use Identity vs role confusion Identity vs role confusion Alcohol is the drug of choice by American teens aged Alcohol is the drug of choice by American teens aged Less smoking by teens in the US than previously Less smoking by teens in the US than previously

93 Argentina 16 year old exchange student found: 16 year old exchange student found: No drinking age No drinking age Wine or beer with supper Wine or beer with supper Drinking to be social not to get drunk Drinking to be social not to get drunk What the U.S. can learn from Argentina What the U.S. can learn from Argentina Focus on moderation and adult supervision Focus on moderation and adult supervision

94 Parents in Prison Loss of parent plus stigma to child. Three times the odds that children will engage in antisocial or delinquent behavior (violence or drug abuse). Negative outcomes as children and adults (school failure and unemployment). Twice the odds of developing serious mental health problems. Affects 7 and ½ times more black children.

95 European vs. U.S. Youth Alcohol use more prevalent in Europe except in Mediterranean countries. Ireland vs. Italy. Driving allowed at age 18. Alcohol use more prevalent in Europe except in Mediterranean countries. Ireland vs. Italy. Driving allowed at age % Europeans smoke vs. 14% Americans at ages % Europeans smoke vs. 14% Americans at ages Peele argues in Addiction Proof Your Child for Mediterranean moderate drinking pattern in the home. Peele argues in Addiction Proof Your Child for Mediterranean moderate drinking pattern in the home. Illicit drug use in Europe half that of U.S. Illicit drug use in Europe half that of U.S.

96 SAMHSA Household survey reported Cigarette use 11.6% with 12 to 17 year olds (2010) Cigarette use 11.6% with 12 to 17 year olds (2010) Binge drinking by 17% of youths aged 16 and 17 Binge drinking by 17% of youths aged 16 and 17 drug-using rates as well. Age 21around half are binge drinkers. Heavy drinkers tend to have high drug-using rates as well. past month alcohol use for ages were: Rates of past month alcohol use for ages were: 16.1% among Asians; 20.4% among blacks; 16.1% among Asians; 20.4% among blacks; 22% among American Indians or Alaska Natives; 22% among American Indians or Alaska Natives; 25.1% among Hispanics; 25.1% among Hispanics; 27.5% among those reporting two or more races; 27.5% among those reporting two or more races; and 30.4% among whites. and 30.4% among whites.

97 SAMHSA SURVEY continued 18-25: 21.2 % illicit drug use during past month, around half of all youths used alcohol : 21.2 % illicit drug use during past month, around half of all youths used alcohol. Racial breakdown for drugs not given for youth in 2009 but previous surveys show higher rates for black than white kids, American Indians the highest. Racial breakdown for drugs not given for youth in 2009 but previous surveys show higher rates for black than white kids, American Indians the highest.

98 2010 School and ER Surveys Use of alcohol, the most dangerous drugcar crashes, drownings, etc., one-third of high school seniors get drunk once a month or more; (same in Canada) Use of alcohol, the most dangerous drugcar crashes, drownings, etc., one-third of high school seniors get drunk once a month or more; (same in Canada) Almost all current smokers also drank alcohol Almost all current smokers also drank alcohol School surveys show African American and Latino seniors have rates of illicit drug use lower than that of whites; the reverse is true among 8 th graders. School surveys show African American and Latino seniors have rates of illicit drug use lower than that of whites; the reverse is true among 8 th graders. ER visits among youth mostly for alcohol overdoses (70%). ER visits among youth mostly for alcohol overdoses (70%). Rise in use of painkilling drugs shown in high rate of ER visits among youth.OxyContin a major problem. Rise in use of painkilling drugs shown in high rate of ER visits among youth.OxyContin a major problem.

99 Business Angle Rivera Live: $10 billion alcohol consumed by under 21 Rivera Live: $10 billion alcohol consumed by under 21 Beer and liquor companies most well funded lobbies of people in Congress. Beer and liquor companies most well funded lobbies of people in Congress. 80% of adult smokers start as children so big incentive to market to kids. 80% of adult smokers start as children so big incentive to market to kids. Extensive marketing of casinos. Extensive marketing of casinos. 63–82% of teenagers (12- to 17-year-olds) gamble each year, 4– 7% of teens exhibit serious patterns of disordered gambling. 63–82% of teenagers (12- to 17-year-olds) gamble each year, 4– 7% of teens exhibit serious patterns of disordered gambling.

100 Societys Influences Tobacco companies targeting kids; Field and Streamads for smokeless tobacco Tobacco companies targeting kids; Field and Streamads for smokeless tobacco Children learn gambling on the Internet; Children learn gambling on the Internet; Video poker, slot machines, and the lottery Video poker, slot machines, and the lottery Strenuous exercise programs reduce smoking. Smoking may be considered a gateway drug. Strenuous exercise programs reduce smoking. Smoking may be considered a gateway drug.

101 Risks for Substance Misuse ADHD, trauma in early childhood, poor role models. ADHD, trauma in early childhood, poor role models. Sexual abuse leads to sense of shame. Sexual abuse leads to sense of shame. Trauma changes brain chemistry and reduces later ability to cope with stress. Trauma changes brain chemistry and reduces later ability to cope with stress. Influence of high stress and drinking, found in juvenile mouse studies. Influence of high stress and drinking, found in juvenile mouse studies.

102 Other Risk Factors Turbulent teen-father relationship Turbulent teen-father relationship Child abuse and other trauma Child abuse and other trauma Kids who start smoking early Kids who start smoking early Smoking can be considered a gateway drug; as many girls as boys smoking, low rate among African American girls. Smoking can be considered a gateway drug; as many girls as boys smoking, low rate among African American girls. Media-generated weight obsession, a major problem among girls of European American ethnicity. Media-generated weight obsession, a major problem among girls of European American ethnicity. Obsession leads to major problems with eating, such as anorexia and bulimia. Obsession leads to major problems with eating, such as anorexia and bulimia.

103 Predictions from Scandinavia: High risk: girls who cry easily when teased are anxious and shy. High risk: girls who cry easily when teased are anxious and shy. Male aggression at age 8 predicted alcoholism 18 to 20 years later. Male aggression at age 8 predicted alcoholism 18 to 20 years later. Evaluations at ages 10 and 27 showed: – High novelty seeking – Low harm avoidance (dare devil behavior) Both traits predicted early-onset alcoholism. For both sexes, poor school success predicted later drinking problems

104 Child Abuse continued Girls who are sexually abused are three times more likely than other girls to develop drinking problems later Girls who are sexually abused are three times more likely than other girls to develop drinking problems later Boys who were sexually abused more likely to be diagnosed with conduct disorder, dysthymia (mild depression), and ADHD Boys who were sexually abused more likely to be diagnosed with conduct disorder, dysthymia (mild depression), and ADHD Abused girls are more likely to be diagnosed with post-traumatic stress disorder and major depression. Abused girls are more likely to be diagnosed with post-traumatic stress disorder and major depression.

105 Risks for Girls Daughters of alcoholics at increased risk for alcoholism. Daughters of alcoholics at increased risk for alcoholism. Teenage girls who are heavy drinkers are: Teenage girls who are heavy drinkers are: five times more likely to engage in sexual intercourse. five times more likely to engage in sexual intercourse. a third less likely to use condoms a third less likely to use condoms more likely to practice unsafe sex. more likely to practice unsafe sex.

106 Risks for Boys: Study of priest abuse victims showed high heavy alcohol use rate. Study of priest abuse victims showed high heavy alcohol use rate. Biggest threat to life and health for adolescent boys is alcohol-related accidents Biggest threat to life and health for adolescent boys is alcohol-related accidents Male counterpart to anorexia in females is muscle dysmorphia. Male counterpart to anorexia in females is muscle dysmorphia. Dysmorphia a diagnosis in DSM. Dysmorphia a diagnosis in DSM.

107 More Risks for Boys Obsessive body building major problem for young males Obsessive body building major problem for young males Revealed in popularity of anabolic steroids Revealed in popularity of anabolic steroids Steroids used by 2.7 % of male high school seniors. Steroids used by 2.7 % of male high school seniors. Health hazards: stunted growth, acne, and Health hazards: stunted growth, acne, and shrinking testicles. shrinking testicles.

108 College Students Case of college pledge in Colorado who died of overdose; police not called out of fear of under-21 drinking laws. Law passed History of law1980s to curb drinking-and-driving deaths, r History of law1980s to curb drinking-and-driving deaths, role of MADD and NIAAA. 63.3% college students were current drinkers, 42.1% were binge drinkers (drank 4-5 drinks at a time), and 15.6% were heavy drinkers (binge drank 5 or more times). SAMHSA 2010 survey of past month 63.3% college students were current drinkers, 42.1% were binge drinkers (drank 4-5 drinks at a time), and 15.6% were heavy drinkers (binge drank 5 or more times). Risk of age 21 birthday celebrations.

109 Amethyst Initiative Over 120 college presidents signed statement to consider revising under-21 drinking law. Over 120 college presidents signed statement to consider revising under-21 drinking law. MADD notes lives saved from 1982 to % fewer fatal crashes under age 21 and a 56% decrease among 21-to 24-year- olds. MADD notes lives saved from 1982 to % fewer fatal crashes under age 21 and a 56% decrease among 21-to 24-year- olds. May have been result of stricter drinking laws that were passed in many states starting in New seat belt regulations, stricter drinking and driving laws. Note reduction in over age 21. May have been result of stricter drinking laws that were passed in many states starting in New seat belt regulations, stricter drinking and driving laws. Note reduction in over age 21.

110 Binge Drinking: College U.S. government imposed nationwide minimum drinking age of 21 in the 1980s, the attempt to curtail drunken driving by youth. U.S. government imposed nationwide minimum drinking age of 21 in the 1980s, the attempt to curtail drunken driving by youth. Fewer drink today, but those who do drink more. Fewer drink today, but those who do drink more. Party till you puke! signs were posted on one university campus. Party till you puke! signs were posted on one university campus.

111 Modern Form of Prohibition Critics argue students are driven to partying underground and away from faculty supervision. Critics argue students are driven to partying underground and away from faculty supervision. New campaigns for moderate drinking encouraged by University of Washington (Alan Marlatt) research. New campaigns for moderate drinking encouraged by University of Washington (Alan Marlatt) research. Social norms campaign with messages of moderation were unsuccessful. Social norms campaign with messages of moderation were unsuccessful.

112 Need for Harm Reduction College newspaper slow to restrict enticing beer ads. College newspaper slow to restrict enticing beer ads. Most binge drinkers mature out of wild drinking days of early adulthood. But over 1,800 college students die each year from alcohol-related injuries. Rape and unsafe sex. Most binge drinkers mature out of wild drinking days of early adulthood. But over 1,800 college students die each year from alcohol-related injuries. Rape and unsafe sex. Cigarettes--abstinence probably works better than moderation here. Cigarettes--abstinence probably works better than moderation here. Two paths to drug use by youths: striving to be cool, using drugs to escape Two paths to drug use by youths: striving to be cool, using drugs to escape Messages about long-term damage are apt to have little impact. Messages about long-term damage are apt to have little impact.

113 Harm Reduction Need for drug courts--important for family preservation and closely supervised treatment Need for drug courts--important for family preservation and closely supervised treatment Forbid happy hours, free drinks on 21 st birthdays at bars. Forbid happy hours, free drinks on 21 st birthdays at bars. Lower drinking age laws; discourage drinking hard liquor Lower drinking age laws; discourage drinking hard liquor Encourage adult supervision with kids who are drinking. Encourage moderate drinking as with meals. Encourage adult supervision with kids who are drinking. Encourage moderate drinking as with meals. Serve food with alcoholic beverages. Serve food with alcoholic beverages.

114 Motivational Principles from Social Psychology From Elliot Aronson, The Social Animal If you state a position, you will be wedded to it. If you state a position, you will be wedded to it. A small commitment to take action goes a long way. A small commitment to take action goes a long way. People with high self esteem can easier resist temptation. People with high self esteem can easier resist temptation. Working toward a goal might pay off eventually. Working toward a goal might pay off eventually. Change of attitude might help. Change of attitude might help. People desire to reduce dissonance. People desire to reduce dissonance.

115 Miller and Rollnick: MI Strategies Miller and Rollnick: MI Strategies Traps to avoid: – Premature focus, such as on clients addictive behavior addictive behavior – Confrontational round between therapist – Confrontational round between therapist and client over denial and client over denial – Labeling trap--forcing the individual to – Labeling trap--forcing the individual to accept a label alcoholic or addict accept a label alcoholic or addict – Blaming trap, fallacy that is especially – Blaming trap, fallacy that is especially pronounced in couples counseling pronounced in couples counseling

116 Primary Prevention Child abuse, early-prevention education and treatment programs Child abuse, early-prevention education and treatment programs Smoking education to keep youths from ever starting to smoke Smoking education to keep youths from ever starting to smoke Health and skill education at schools Health and skill education at schools Reducing ads promoting addictive behavior Reducing ads promoting addictive behavior Advocacy for the hiring of more school counselors and social workers Advocacy for the hiring of more school counselors and social workers

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

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

119 Resistance: Inevitable Inevitable Miller advises roll with it roll with resistance Miller advises roll with it roll with resistance Use reflective summarizing Use reflective summarizing

120 Contemplation Stage continued: Typical adolescent comment: Typical adolescent comment: 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. 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.

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

122 Action Stage: Adolescent comment: Staying clean may be healthy, but it sure makes for a dull life. Maybe Ill check out one of those groups. Therapist: Why dont you look at what others have done in this situation? Help locate an appropriate group. Help locate an appropriate group.

123 Maintenance Stage: Adolescent comment: Adolescent comment: Its been a few months; Im not there yet but Im hanging out with some new friends...

124 Gender Specific Approach for Girls Equality does not mean sameness. Equality does not mean sameness. Programs for girls do better when they focus on relationships. Programs for girls do better when they focus on relationships. Waterloo,Iowa --group home-- Quakerdale specializes in care of teenage girls. Waterloo,Iowa --group home-- Quakerdale specializes in care of teenage girls. Learning of life skills Learning of life skills Gaining competency as in art Gaining competency as in art

125 Problems in Middle Adulthood Relapse problems. Relapse problems. Impact of baby boom generationillicit drug use doubled in over 50 age group. Impact of baby boom generationillicit drug use doubled in over 50 age group. 6.6% use illicit drugs over age 26; most is marijuana. 6.6% use illicit drugs over age 26; most is marijuana. 10.8% of pregnant women drink; 1 in 6 smoke. 10.8% of pregnant women drink; 1 in 6 smoke.

126 Risk to Combat Veterans Most problems of VA clients with substance use and PTSD in younger age group, but 11% are older. Most problems of VA clients with substance use and PTSD in younger age group, but 11% are older. Trauma is common. PTSD among female veterans who were sexually victimized (15% were victimized). Trauma is common. PTSD among female veterans who were sexually victimized (15% were victimized). Need for treatment; more is being done today. Need for treatment; more is being done today. Need to control marketing of alcohol and cigarettes to soldiers. Need to control marketing of alcohol and cigarettes to soldiers.

127 Substance Abuse among Older Adults Substance Abuse among Older Adults 13% of U.S. population over age % of U.S. population over age 65. More men with alcohol problems More men with alcohol problems Older adults consume 20-25% of all prescription medications Older adults consume 20-25% of all prescription medications Two types of alcoholism: early and late onset Two types of alcoholism: early and late onset Early onset- - more severe levels of depression and anxiety Early onset- - more severe levels of depression and anxiety

128 Facts about Late Life Substance Use Older adults consume less alcohol than the young. Older adults consume less alcohol than the young. 5.2% over age 50 used an illicit drug in the past year; 9.1% smoke. 5.2% over age 50 used an illicit drug in the past year; 9.1% smoke. Trend toward nursing homes for short-term alcoholism rehabilitation Trend toward nursing homes for short-term alcoholism rehabilitation Many male ex-alcoholics reside in nursing homes. Many male ex-alcoholics reside in nursing homes.

129 Drinking Patterns Older adults tend to: Older adults tend to: drink smaller amounts at one time, misuse drugs prescribed by doctors, experience a hidden alcohol problem. drink smaller amounts at one time, misuse drugs prescribed by doctors, experience a hidden alcohol problem. drink in connection with a number of late-life stresses, including bereavement and loss of occupational roles. drink in connection with a number of late-life stresses, including bereavement and loss of occupational roles.

130 SAMHSA 2010 Treatment Report 1 of 8 persons over age 50 sought help for substance use in of 8 persons over age 50 sought help for substance use in Their share of treatment admissions doubled Their share of treatment admissions doubled between 1992 and between 1992 and Primary substance use problems were with alcohol, heroin, cocaine. Primary substance use problems were with alcohol, heroin, cocaine. Many late onset drug users had problems with prescription medications. Many late onset drug users had problems with prescription medications.

131 More Facts Many early onset suffer from Korsakoffs syndrome and other alcohol-related neurological problems. Many early onset suffer from Korsakoffs syndrome and other alcohol-related neurological problems. Medical complications: Medical complications: Hip fracture, suicide, brain damage Hip fracture, suicide, brain damage Late onset…more women here, close family ties Late onset…more women here, close family ties

132 Counseling Older Clients DWI and effect on self image DWI and effect on self image Age segregated vs. mixed ages in treatment Age segregated vs. mixed ages in treatment Guidelines for work in groups with elderly: Guidelines for work in groups with elderly: -Avoid strong language, rebuild support systems -Avoid strong language, rebuild support systems -Keep pace slow -Keep pace slow

133 Relapse Prevention: Teach older clients to learn the warning signs and high risk events; Teach older clients to learn the warning signs and high risk events; Review feelings that led to relapse so they can be avoided (for example, depression); HALT Review feelings that led to relapse so they can be avoided (for example, depression); HALT Focus on critical thinking skills. Focus on critical thinking skills. Help clients renew their commitment to sobriety; Help clients renew their commitment to sobriety; Find effective coping styles; Find effective coping styles; Build support systems; Build support systems; Remember that non-confrontational approach is best. Remember that non-confrontational approach is best.

134 Counselor Pitfalls: (Beechem) Anticipate feelings of guilt and shame in older clients in trouble with the law; Anticipate feelings of guilt and shame in older clients in trouble with the law; Ageism Ageism Countertransference Countertransference Denial in assessment Denial in assessment Sympathy not empathy Sympathy not empathy

135 Loss and grief in family members of addicted persons: Types of Guilt Types of Guilt Survivor guilt Survivor guilt Helplessness Helplessness Ambivalence Ambivalence Spiritual healingsense of meaning, connectedness Spiritual healingsense of meaning, connectedness Strength from 12 Steps Strength from 12 Steps

136 Spiritual Healing Today, social work education stresses importance of helping clients find spiritual meaning. Older adults often change their outlook as they look back on their lives. Seek for the meaning of life. Higher Power as nature in Norway, Native American traditions. Search for forgiveness and renewal. 12 Steps as guide to self knowledge

137 Chapter 7: Screening and Assessment Chapter focus on strengths perspective. Chapter focus on strengths perspective. Advantages of doing assessment: get information, match to counselor, get insurance reimbursement for diagnosis. Advantages of doing assessment: get information, match to counselor, get insurance reimbursement for diagnosis. Disadvantages: may set up false expectations for specialized treatment, delays actual treatment, may be inappropriate for many minority groups. Disadvantages: may set up false expectations for specialized treatment, delays actual treatment, may be inappropriate for many minority groups.

138 Screening Instruments Consist of just a few questions to determine nature of help needed. Consist of just a few questions to determine nature of help needed. Informal questions like, Do you sometimes drink? Informal questions like, Do you sometimes drink? Effective one-question screen for women: How many times in the past year have you had four or more drinks in a day? Effective one-question screen for women: How many times in the past year have you had four or more drinks in a day?

139 CAGE C Have you ever felt you ought to cut down on your drinking or drug C Have you ever felt you ought to cut down on your drinking or drug use? use? A Have people annoyed you by criticizing your drinking or drug use? A Have people annoyed you by criticizing your drinking or drug use? G Have you ever felt bad or guilty about your drinking or drug use? G Have you ever felt bad or guilty about your drinking or drug use? E Have you ever had a drink or used drugs first think in the morning E Have you ever had a drink or used drugs first think in the morning to steady your nerves or get rid of a hangover? to steady your nerves or get rid of a hangover?

140 TWEAK Tolerance Tolerance Worried Worried Eye Openers Eye Openers Amnesia Amnesia Kut down Kut down Works well with mixed ethnic populations Works well with mixed ethnic populations

141 AUDIT Recommended by WHO for global use. Recommended by WHO for global use. The AUDIT includes 10 items that cover amount and frequency of drinking, alcohol dependence symptoms, personal problems, and social problems The AUDIT includes 10 items that cover amount and frequency of drinking, alcohol dependence symptoms, personal problems, and social problems Have you or someone else been injured because of your drinking? Have you or someone else been injured because of your drinking?

142 AUDIT continued Scoring discriminates between different levels of riskhazardous, harmful, and possible dependence. Scoring discriminates between different levels of riskhazardous, harmful, and possible dependence. A prevention tool to assess future risks. A prevention tool to assess future risks. Can be given to the client as a questionnaire Can be given to the client as a questionnaire to fill out, or it can be used as interview questions. to fill out, or it can be used as interview questions. Available for free on the Internet. Available for free on the Internet.

143 Assessment Tools (CSAT) (2005) defines assessment as the process for defining the nature of the problem and developing specific treatment recommendations for addressing the problem. (CSAT) (2005) defines assessment as the process for defining the nature of the problem and developing specific treatment recommendations for addressing the problem. Can give a deeper picture of motivation to change. Can give a deeper picture of motivation to change. Can be beginning of relationship. Can be beginning of relationship.

144 Gambling Assessment Gamblers Anonymous has 20 questions to determine if someone has a problem. Examples: Gamblers Anonymous has 20 questions to determine if someone has a problem. Examples: Did you ever lose time from work or school due to gambling? Did you ever lose time from work or school due to gambling? Has gambling ever made your home life unhappy? Has gambling ever made your home life unhappy? Did gambling affect your reputation? Did gambling affect your reputation? Have you ever felt remorse after gambling? Have you ever felt remorse after gambling? Did you ever gamble to get money with which to pay debts or otherwise solve financial difficulties? Did you ever gamble to get money with which to pay debts or otherwise solve financial difficulties?

145 DRINC The Drinker Inventory of Consequences (Drinc) originally designed for Project MATCH The Drinker Inventory of Consequences (Drinc) originally designed for Project MATCH A 50-item questionnaire that covers physical, social, intrapersonal, impulse control, and interpersonal problem areas. Of proven reliability, validity. A 50-item questionnaire that covers physical, social, intrapersonal, impulse control, and interpersonal problem areas. Of proven reliability, validity. Includes positive questions such as (How often has drinking helped me to relax?), and negatives: How often has my ability to be a good parent been harmed by my drinking. Includes positive questions such as (How often has drinking helped me to relax?), and negatives: How often has my ability to be a good parent been harmed by my drinking.

146 The SASSI The Substance Abuse Screening Inventory (SASSI) (Miller & Lazowski, 1999) The Substance Abuse Screening Inventory (SASSI) (Miller & Lazowski, 1999) A different approach to assessment instrumentsdoes not ask directly about substance misuse on one side of the form. A different approach to assessment instrumentsdoes not ask directly about substance misuse on one side of the form. Consists of true-false items. such as I am often resentful, and I like to obey the law. Consists of true-false items. such as I am often resentful, and I like to obey the law.

147 Assessing Levels of Care Early Intervention Early Intervention Outpatient Treatment Outpatient Treatment Intensive Outpatient/Partial Hospitalization Treatment Intensive Outpatient/Partial Hospitalization Treatment Residential/Inpatient Treatment Residential/Inpatient Treatment Medically Managed Intensive Inpatient Treatment. Medically Managed Intensive Inpatient Treatment. Each level of care includes several layers of intensity. Each level of care includes several layers of intensity.

148 ASSESSMENT OF PERSONS WITH CO-OCCURRING DISORDERS (COD) A basic program from the CSAT provides treatment for one disorder, but screens for the other disorder; A basic program from the CSAT provides treatment for one disorder, but screens for the other disorder; An intermediate level focuses primarily on one disorder but also addresses some specific needs of the other. An intermediate level focuses primarily on one disorder but also addresses some specific needs of the other. Advanced level provides services for both disorders. Advanced level provides services for both disorders.

149 Guidelines for Assessment of COD Be familiar with latest DSM and criteria for diagnosis. Be familiar with latest DSM and criteria for diagnosis. Keep up to date on the relevant psychiatric medications. Keep up to date on the relevant psychiatric medications. Harm reduction therapists recommend only contacting family members and others if clients so wish and with the client present. Harm reduction therapists recommend only contacting family members and others if clients so wish and with the client present. Know the community resources. Know the community resources.

150 Assessment of Older Clients Risk factors for gambling problems are: Risk factors for gambling problems are: the presence of current posttraumatic stress disorder symptoms, minority race or ethnicity, and being a Veterans Affairs (VA) patient. Therefore include questions about gambling. Therefore include questions about gambling. CAGE and MASTGeriatric version are validated for use with older adults. CAGE and MASTGeriatric version are validated for use with older adults.

151 ASSESSMENT FOR STRENGTHS View clients as in charge of their own goals. View clients as in charge of their own goals. Take into account social factors as well as individual factors for a comprehensive view of the situation. Take into account social factors as well as individual factors for a comprehensive view of the situation. Move the assessment toward strengths, both intrapersonal (motivation, emotional strengths and ability to think clearly) and interpersonal (family Move the assessment toward strengths, both intrapersonal (motivation, emotional strengths and ability to think clearly) and interpersonal (family networks, etc. networks, etc. Avoid identifying the person with a label. Avoid identifying the person with a label.

152 Strengths Assessment continued Key ingredients: Key ingredients: Empathy. Empathy. Provide hope. Provide hope. Reflective listening. Reflective listening.

153 End of Chapters 1-7

154 Assessment Need for assessment forms to be sensitive to gender/cultural differences Need for assessment forms to be sensitive to gender/cultural differences Language differences, e.g., the word craving hard to translate Language differences, e.g., the word craving hard to translate CAGE and TWEAK work well with women CAGE and TWEAK work well with women

155 CAGE CAGE Have you tried Cutting down? Have you tried Cutting down? Have people Annoyed you? Have people Annoyed you? Have you felt Guilty about your ATOD use? Have you felt Guilty about your ATOD use? Have you ever used ATOD as an Eye opener? Have you ever used ATOD as an Eye opener?

156 Other Screening Forms AUDIT developed by WHO for alcohol use AUDIT developed by WHO for alcohol use NIAAA50 item instrument, Inventory of Drug Use Consequences, in public domain NIAAA50 item instrument, Inventory of Drug Use Consequences, in public domain WHO designated areas of harm caused by drinkphysical, emotional, health, family, finances, etc. WHO designated areas of harm caused by drinkphysical, emotional, health, family, finances, etc.

157 Chapter 8 Strengths- and Evidence-Based Helping Strategies

158 Dennis Saleebey Focus on possibilities, choicesproviding treatment options. Focus on possibilities, choicesproviding treatment options. Resilience, healing, and wholeness. Resilience, healing, and wholeness. Contrast with problem-solving approach. Contrast with problem-solving approach.

159 Dennis Saleebey Focus on possibilities, choicesproviding treatment options. Focus on possibilities, choicesproviding treatment options. Resilience, healing, and wholeness. Resilience, healing, and wholeness. Contrast with problem-solving approach. Contrast with problem-solving approach. Strengths-based practice defined by Saleebey as a versatile practice approach, relying heavily on ingenuity and creativity. Strengths-based practice defined by Saleebey as a versatile practice approach, relying heavily on ingenuity and creativity.

160 Issue of Self-Determination How do we honor clients self-determination when the client is harming himself-herself with substance misuse? 1.Right of choice should be extended to all social classes; as it is people in poverty have far less choice than those at high income levels. 2. Importance of providing options. Abstinence- based models do not. 3. Attend to readiness of client to change.

161 First of Four Models of Strengths-Based Approaches 1. Harm reduction: public health model, prevention, outreach. 1. Harm reduction: public health model, prevention, outreach. Abstinence not precondition to treatment; recovery can be measured through degree of improvement. Abstinence not precondition to treatment; recovery can be measured through degree of improvement. Stages of Change Model: Prochaska and DiClemente Stages of Change Model: Prochaska and DiClemente Precontemplation Precontemplation Contemplation Contemplation Preparation Preparation Action Action Maintenance Maintenance Relapse Relapse

162 Harm Reduction Strategies Practitioners are advised to focus on harms other than substance use, such as unemployment, poverty, need for housing. Practitioners are advised to focus on harms other than substance use, such as unemployment, poverty, need for housing. Gambling problems can be prevented by removing gambling machines from shopping centers, strip malls, clubs, and hotels. Gambling problems can be prevented by removing gambling machines from shopping centers, strip malls, clubs, and hotels. Other support services, such as mental health and financial counseling should be readily available. Other support services, such as mental health and financial counseling should be readily available.

163 2. Motivational Interviewing (MI)---William Miller Defined as a client-centered, directive Defined as a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. Need to ask the right questions; Tell me about a period when you were doing well? Need to ask the 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? Smoking: on a scale of 1-10 to give up smoking, where are you now?

164 MI continued Steps to enhance motivation: Express empathy Develop discrepancy Avoid argumentation Roll with resistance Support self-efficacy Asking open-ended questions helps clients evoke the decision to change.

165 3. Solution focused therapy Finding solution to problem viewed as more important than finding the cause. Strategies: Miracle question Miracle question The personal narrative The personal narrative Scaling questions Scaling questions Coping questions Coping questions

166 4. Cognitive/Behavioral Therapy (CBT) Attributed to Aaron Becks work with depression. Attributed to Aaron Becks work with depression. Albert Ellis challenged clients faulty belief systems. Albert Ellis challenged clients faulty belief systems. Currently more focus on promoting positive thoughts rather than focus on the negative. Currently more focus on promoting positive thoughts rather than focus on the negative. Studies consistently show CBT as the most empirically Studies consistently show CBT as the most empirically supported form of group therapy for addictions supported form of group therapy for addictions

167 Teaching about Distortions Gambling example: conditioning used by casino owners to get players to spend moreuse of bells, positive reinforcement. Gambling example: conditioning used by casino owners to get players to spend moreuse of bells, positive reinforcement. Gamblers often have distorted beliefs about lucky days and machines and so forth. Gamblers often have distorted beliefs about lucky days and machines and so forth. Skills training can help clients avoid succumbing to triggers that promote gambling. Skills training can help clients avoid succumbing to triggers that promote gambling. Role plays and reinforcement of behaviors to resist temptation are effective strategies. Role plays and reinforcement of behaviors to resist temptation are effective strategies.

168 CBT for Relapse Prevention Interpersonal coping skills help clients deal with high-risk relapse situations and to develop social support for their recovery. Interpersonal coping skills help clients deal with high-risk relapse situations and to develop social support for their recovery. Teaching of refusal skills. Teaching of refusal skills. Intrapersonal coping skills focus on learning how to cope with ones own internal triggers, such as anger, stress, and negative moods. Intrapersonal coping skills focus on learning how to cope with ones own internal triggers, such as anger, stress, and negative moods.

169 Group Therapy Most popular form of delivering substance abuse treatment. Most popular form of delivering substance abuse treatment. Cost effective, good source for feedback. Cost effective, good source for feedback. Of proven effectiveness in teaching skills, helping people to learn from others, getting feedback. Of proven effectiveness in teaching skills, helping people to learn from others, getting feedback.

170 Early Stages of Group Therapy First stepto establish trust, build faith in the counselor and group members. First stepto establish trust, build faith in the counselor and group members. Discuss rules of agency and group norms. Discuss rules of agency and group norms. For example, confidentialitywhat is said in the group stays in the group. For example, confidentialitywhat is said in the group stays in the group. Motivational interviewing groups for college students shown to be helpful in reducing drinking problems. Motivational interviewing groups for college students shown to be helpful in reducing drinking problems. Example of drop-in group for homeless people. Example of drop-in group for homeless people.

171 Traditional Treatment and Strengths- Based Approaches Detoxopportunity to introduce patient to choices. Detoxopportunity to introduce patient to choices. Outpatientprimarily group counseling. Outpatientprimarily group counseling. Inpatient and halfway houses. Inpatient and halfway houses. Aftercare once a month, may be 12 Step group or religious activity. Aftercare once a month, may be 12 Step group or religious activity.

172 Chapter 9 Substance Misuse With A Co-Occurring Disorder Or Disability

173 Co-Occurring Disorders Double whammysubstance dependence and mental disorder. Bipolarfeeling high can imitate drug use. Double whammysubstance dependence and mental disorder. Bipolarfeeling high can imitate drug use. Mental Health Parity and Addiction Equity Act of 2008 ended discrimination against consumers of mental health and substance abuse treatment services in insurance coverage. Mental Health Parity and Addiction Equity Act of 2008 ended discrimination against consumers of mental health and substance abuse treatment services in insurance coverage. The numbers of people with serious mental disorders who misuse substances and who smoke is double the rate of those without mental health disorders. The numbers of people with serious mental disorders who misuse substances and who smoke is double the rate of those without mental health disorders. Around half of people in treatment for substance use disorder have a serious mental disorder. Around half of people in treatment for substance use disorder have a serious mental disorder.

174 Need for Integrated Treatment Integrated Approachfits with harm reduction Integrated Approachfits with harm reduction About a third of addiction treatment programs now include treatment for psychiatric disorders. About a third of addiction treatment programs now include treatment for psychiatric disorders. Only 8.5% offer integrated programming (2006) Only 8.5% offer integrated programming (2006) Anxiety disorder diagnosed in 40% of persons with drug dependency; may be effect of stimulant drugs. Anxiety disorder diagnosed in 40% of persons with drug dependency; may be effect of stimulant drugs.

175 Co-Occurring Disorders continued Addiction counselors often explain psychosis as drug induced. Addiction counselors often explain psychosis as drug induced. Mental health professionals tend to see alcohol use as self medication. Mental health professionals tend to see alcohol use as self medication. Truth is both/and, not either/or. Truth is both/and, not either/or. Coexisting disorders: anxiety, compulsive gambling, eating and mood disorders. Coexisting disorders: anxiety, compulsive gambling, eating and mood disorders.

176 Disorders that Often Co-exist with Substance Abuse: Anxiety Anxiety Compulsive gambling Compulsive gambling Mood disorders Mood disorders Eating disorders Eating disorders Personality disorders Personality disorders Psychosis Psychosis

177 Personality Disorders: Borderline personality Borderline personality Anti-social personality Anti-social personality These diagnoses often based on cultural biases These diagnoses often based on cultural biases Integrated treatment needed Integrated treatment needed Need to offer better housing, can rely on funding by Supplemental Security Insurance (SSI) Need to offer better housing, can rely on funding by Supplemental Security Insurance (SSI)

178 PTSD Diagnosis came in 1980 in response to Vietnam war veterans and feminist movement on behalf of rape victims Diagnosis came in 1980 in response to Vietnam war veterans and feminist movement on behalf of rape victims About 25% exposed to severe trauma will develop substance related problems About 25% exposed to severe trauma will develop substance related problems High rate of relapse among women in substance abuse treatment with PTSD upon release High rate of relapse among women in substance abuse treatment with PTSD upon release High anxiety a problem High anxiety a problem Trauma from natural disasters such as Hurricane Katrina Trauma from natural disasters such as Hurricane Katrina

179 PTSD after Combat At least 1 in 6 veterans of war in Iraq has PTSD At least 1 in 6 veterans of war in Iraq has PTSD Flashbacks common Flashbacks common Immediate intervention with SSRIs recommended to offset formation of locked memories Immediate intervention with SSRIs recommended to offset formation of locked memories Women seeking help for rape trauma, someimes from attacks by fellow soldiers Women seeking help for rape trauma, someimes from attacks by fellow soldiers

180 Bipolar Disorder Most commonly diagnosed of the mental disorders for those with co-occurring disorders. Most commonly diagnosed of the mental disorders for those with co-occurring disorders. From mania to depression From mania to depression 90% with this disorder have substance- related problems in a prison sample 90% with this disorder have substance- related problems in a prison sample

181 Schizophrenia About 1% develop schizophrenia About 1% develop schizophrenia Delusions, hallucinations, apathy and loss of pleasure, problems concentrating Delusions, hallucinations, apathy and loss of pleasure, problems concentrating John Nash, A Beautiful Mind John Nash, A Beautiful Mind 48% have substance-related problems, a variety of substances used 48% have substance-related problems, a variety of substances used No wrong door to treatment No wrong door to treatment Prone to homelessness; Housing First programs Prone to homelessness; Housing First programs

182 Integrated Treatment Principles SAMSHA Integrated treatment specialists are trained to treat both substance use disorders and serious mental illnesses. Integrated treatment specialists are trained to treat both substance use disorders and serious mental illnesses. Co-occurring disorders are treated in a stage-wise fashion with different services provided at different stages. Co-occurring disorders are treated in a stage-wise fashion with different services provided at different stages. Motivational interventions are used to treat consumers in all stages, but especially in the persuasion stage. Motivational interventions are used to treat consumers in all stages, but especially in the persuasion stage.

183 Integrated Principles continued Substance abuse counseling, using a cognitive- behavioral approach for the active treatment and relapse prevention stages. Substance abuse counseling, using a cognitive- behavioral approach for the active treatment and relapse prevention stages. Multiple formats for services are available, including individual, group, self-help, and family. Multiple formats for services are available, including individual, group, self-help, and family. Medication services are integrated and coordinated with psychosocial services. Medication services are integrated and coordinated with psychosocial services.

184 Assertive Community Treatment (ACT) Unlike integrated treatment, here the counselors go to the client and are available around the clock. Only for the most severe mental illness. Principles: Unlike integrated treatment, here the counselors go to the client and are available around the clock. Only for the most severe mental illness. Principles: Team approach: ACT team members interdisciplinary and act as a whole to ensure basic needs are met. Team approach: ACT team members interdisciplinary and act as a whole to ensure basic needs are met. Small caseload: Teams of 10–12 serve 100 consumers. Small caseload: Teams of 10–12 serve 100 consumers. Time unlimited services. No individual caseloads. Time unlimited services. No individual caseloads.

185 Housing First Supportive model for chronically mentally ill with substance use problems. In contrast to housing programs requiring total abstinence. Supportive model for chronically mentally ill with substance use problems. In contrast to housing programs requiring total abstinence. Intensive case management provided. Client choices are respected. Intensive case management provided. Client choices are respected. Wet houses. Wet houses. Cost effective for communitiesNew York City, Seattle, San Francisco, Portland, OR. Cost effective for communitiesNew York City, Seattle, San Francisco, Portland, OR.

186 Physical and Cognitive Disabilities 1990 Americans with Disabilities Act for full participation in services Persons with head injuries at high risk for substance misuse; many were intoxicated when injured High among wounded war veterans Traumatic brain injury from war in Iraq Barriers to treatmentfew programs with expertise to meet the need.

187 Part IV Social Aspects of Addictions Chapter 10

188 Family Risks and Resilience Addiction is a family disease…pain and stigma. Addiction is a family disease…pain and stigma. Box 10.1 Des Moines Register Children of Addicts meth labs, family fights, and child neglect in Iowa Box 10.1 Des Moines Register Children of Addicts meth labs, family fights, and child neglect in Iowa Classic Family Structure: Classic Family Structure: Addict as symptom of carrier. Addict as symptom of carrier. Faulty communication in family >anorexia Faulty communication in family >anorexia Confusion of cause and effect Confusion of cause and effect Family therapy field, little attention to addiction problems except as symptoms Family therapy field, little attention to addiction problems except as symptoms Little attention to cultural diversity as well. See McGoldrick et als Ethnicity and Family Therapy (2005) Little attention to cultural diversity as well. See McGoldrick et als Ethnicity and Family Therapy (2005)

189 History of Family Treatment Lack of insurance prevents emphasis on family treatment Lack of insurance prevents emphasis on family treatment Virginia Satir: studied family adaptation to persons illness. Virginia Satir: studied family adaptation to persons illness. Claudia Black Claudia Black It will never happen to me It will never happen to me Dont talk, trust, feelco-alcoholic, codependent. Dont talk, trust, feelco-alcoholic, codependent. Al-Anon1950s Al-Anon1950s

190 Wegscheiders Role Theory Codependent person, chief enablerterms took on negative connotations later. Codependent person, chief enablerterms took on negative connotations later. This text uses the more positive term, family manager instead of chief enabler. This text uses the more positive term, family manager instead of chief enabler. Wegscheiders terms for family roles: hero, scapegoat, lost child, mascot Wegscheiders terms for family roles: hero, scapegoat, lost child, mascot Melody Beattie: Codependency No More popularized the term. We suggest survivor instead of codependent, a term that has taken on a life of its own. Melody Beattie: Codependency No More popularized the term. We suggest survivor instead of codependent, a term that has taken on a life of its own.

191 Figure 9.1 Family Forms Enmeshed family: Spouses are estranged: one child here is enmeshed with father, one with mother F C M C

192 Isolated family: Lack of cohesion and social support. Each member is protected by wall of defenses. C F M C

193 Healthy family: All are touching, but their boundaries are not overlapping. C M F C

194 Stages of Change and Family: 1. Precontemplation: Counselors describe family communication patterns. 1. Precontemplation: Counselors describe family communication patterns. 2. Contemplation: family concerns – look for solutions. Male partners may be hard to engage. 2. Contemplation: family concerns – look for solutions. Male partners may be hard to engage. 3. Preparation: Breaking point--formal intervention (see boxed reading by Carroll Schutey) Family members make a list of feeling responses to addicts actions. 3. Preparation: Breaking point--formal intervention (see boxed reading by Carroll Schutey) Family members make a list of feeling responses to addicts actions.

195 Stages continued 4. Action: 4. Action: Rehearsal and treatment of family without Rehearsal and treatment of family without addicted member. addicted member. Therapist feedbackExample of therapist response to family argument: I note that as you, Steve said that just then, you (kid) fell out of chair. Purpose to reveal how the family roles operate in a system. Therapist feedbackExample of therapist response to family argument: I note that as you, Steve said that just then, you (kid) fell out of chair. Purpose to reveal how the family roles operate in a system. 5. Maintenance: 5. Maintenance: Focus on process not content what to do if…. Transition with sobriety. Focus on process not content what to do if…. Transition with sobriety.

196 Cultural Considerations McGoldrick et als book on different ethnicities. Describes work with: African American familiesreciprocity a strength here African American familiesreciprocity a strength here Latino familiesavoid a businesslike approach Latino familiesavoid a businesslike approach Asian and Asian American familiesengage most powerful person in the family Asian and Asian American familiesengage most powerful person in the family Appalachian familiesengage the women who will teach health care practices Appalachian familiesengage the women who will teach health care practices

197 Situations of Domestic Violence Connection of substance use and violence. Battering intervention programs. Motivational interviewing as bridge between womens domestic violence services and substance abuse treatment. Teaching women safety plans for harm reduction. Risk of serious violence and death.

198 Rules of Fighting Fair Attack behavior, not person Attack behavior, not person Keep issues of manageable size, dont label, Keep issues of manageable size, dont label, Dont use negative labels. Dont use negative labels. Dont rehash the past. Dont rehash the past.

199 Three Rs Model Rename: No labels, shopping addiction as illness, not foolish spending. Rename: No labels, shopping addiction as illness, not foolish spending. Reframe: help client see things happen for a reason Reframe: help client see things happen for a reason Reclaim: healing, we-ness, family circles to make decisions (from Native Americans) Reclaim: healing, we-ness, family circles to make decisions (from Native Americans) Kathy and Ed: Case Study Kathy and Ed: Case Study

200 Exercises Related to Family Work 1. Drawing family maps, circles 2. Relapse prevention plan. 3. Viewing excerpt from a movie or videotape.

201 Chapter 11 Mutual-Help Groups

202 Mutual Aid Groups Confusion12 Step facilitated treatment and 12 Step self help groups (far more tolerant and non-judgmental). Confusion12 Step facilitated treatment and 12 Step self help groups (far more tolerant and non-judgmental). AA – spiritually based fellowship is free AA – spiritually based fellowship is free Voluntary treatment: consistent with harm reduction. Voluntary treatment: consistent with harm reduction. Involuntary treatment for those who failed at moderation. Involuntary treatment for those who failed at moderation.

203 Twelve Steps Presented in Box First five: 1. We admitted we were powerless over alcoholthat our lives had become unmanageable. 2. Came to believe that a Power greater than ourselves could restore us to sanity. 3. Made a decision to turn our will and our lives over to the care of God as we understood Him. 4. Made a searching and fearless moral inventory of ourselves. 5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs.

204 Alcoholics Anonymous (AA) Greater involvement in AA found to effective. Greater involvement in AA found to effective. Use of narratives…stories of powerlessness over the addiction, lives out of control… Use of narratives…stories of powerlessness over the addiction, lives out of control… Feminist objections to 12 Steps Feminist objections to 12 Steps Metaphor of diseasemental, physical, and spiritual, metaphor of powerlessness Metaphor of diseasemental, physical, and spiritual, metaphor of powerlessness Means of expanding treatment.. words in Big Book…One day at a time…Higher Power. Means of expanding treatment.. words in Big Book…One day at a time…Higher Power.

205 Other Self-Help Groups GAmembers tend to be older and have high rate of abstinence after attending for 2 months. GAmembers tend to be older and have high rate of abstinence after attending for 2 months. Addresses financial as well as spiritual problems. Addresses financial as well as spiritual problems. NAmultilingual meetings. NAmultilingual meetings. Women for Sobriety13 Steps. Women for Sobriety13 Steps. SMART Recovery----cognitive approach. Moderation Managementstarts at 30 days of abstinence, a harm reduction strategy SMART Recovery----cognitive approach. Moderation Managementstarts at 30 days of abstinence, a harm reduction strategy [Some say 12 Steps should be modernized. See one attempt9 Steps at [Some say 12 Steps should be modernized. See one attempt9 Steps at

206 Recovery Community Centers A new development in some states, follow recovery management philosophy. Provides services such as telephone support (usually by a volunteer in recovery), family support groups, housing assistance, recovery group meetings, social events, and recovery coaching.

207 Chapter 12 Racial, Ethnic, Culture and Class Issues

208 Minority Group Membership Need to know social political context of being minority. Need to know social political context of being minority. Treatment must take into account ethnoculture norms. Treatment must take into account ethnoculture norms. The Council on Social Work Education (CSWE) lists the ability to engage diversity and difference in practice as one of the ten core competencies. The Council on Social Work Education (CSWE) lists the ability to engage diversity and difference in practice as one of the ten core competencies. We need to know something about norms of particular groups to enhance treatment. We need to know something about norms of particular groups to enhance treatment.

209 Social Class Importance of classbell hooks- Class affects adolescents access to drugs. Drug use affected by unemployment and low income status. Often as acculturation increases, so does substance misuse

210 Asian Americans/Pacific Islanders Low rate of substance misusejust over 3%. Low rate of substance misusejust over 3%. Japanese Americans drink much more than Chinese Americans. Japanese Americans drink much more than Chinese Americans. Success often is related to their level of education at home and urbanization. Success often is related to their level of education at home and urbanization. Cambodians - war trauma. Cambodians - war trauma.

211 Asians and Hawaiians Asian Americans - highest income of all ethnicities, filial piety. Asian Americans - highest income of all ethnicities, filial piety. Emotional sharing may lead to loss of face. Emotional sharing may lead to loss of face. Immigration, a major stress. Immigration, a major stress. For Native Hawaiians female elders provide culturally based treatment. For Native Hawaiians female elders provide culturally based treatment. Pilot program in India uses yoga and meditation to reduce stress. Pilot program in India uses yoga and meditation to reduce stress.

212 American Indians and Alaskan Natives Historical traumaracism and children were once sent to boarding schools to destroy culture. Historical traumaracism and children were once sent to boarding schools to destroy culture. Native Americans are less than.9% of US population. Almost half report they are of mixed race. Native Americans are less than.9% of US population. Almost half report they are of mixed race. High rate of substance abuse or dependence: 15.5%. illicit drug use18.3%, binge drinking22.2%, cigarette use41.8%. High fatal accident rate, FAS. High rate of substance abuse or dependence: 15.5%. illicit drug use18.3%, binge drinking22.2%, cigarette use41.8%. High fatal accident rate, FAS. High poverty, alcohol abuse, youth inhalant use. High poverty, alcohol abuse, youth inhalant use. Use of Medicine Wheel for holistic, spiritual framework, talking circles. (Box 12.2) Use of Medicine Wheel for holistic, spiritual framework, talking circles. (Box 12.2) Red Road to Sobriety. Red Road to Sobriety.

213 Latinos 16% of population (California: 1/3 of population) 16% of population (California: 1/3 of population) 58% of Hispanics in the U.S. are Mexicans. 58% of Hispanics in the U.S. are Mexicans. Substance abuse or dependence for Hispanics 10.2%. Increase in treatment admissions for meth use. Substance abuse or dependence for Hispanics 10.2%. Increase in treatment admissions for meth use. Treatment needs for alcohol misuse among Mexican Americans (9.2%) and Puerto Ricans (6.1%). Treatment needs for alcohol misuse among Mexican Americans (9.2%) and Puerto Ricans (6.1%). In U.S. 21.1% of Latinos smoke. Less among women but increasing. In U.S. 21.1% of Latinos smoke. Less among women but increasing. High rate of gambling problems. HIV/AIDS a major problem. High rate of gambling problems. HIV/AIDS a major problem. High rate of poverty; few have health insurance. High rate of poverty; few have health insurance. Group has the highest high school drop-out rate, Puerto Ricans, the highest poverty rate. Group has the highest high school drop-out rate, Puerto Ricans, the highest poverty rate.

214 Treatment Issues for Latinos Male/female role differentiation. Male/female role differentiation. Work with family should support family strengths. Work with family should support family strengths. Need for Spanish-speaking counselors. Understand that with second generation, women have more addiction problems. Need for Spanish-speaking counselors. Understand that with second generation, women have more addiction problems. Case management services needed to get clients into GED programs where needed and job training programs. Case management services needed to get clients into GED programs where needed and job training programs.

215 African Americans Are just over 12% of population. Are just over 12% of population. Substance abuse and addiction rate is 8.8%. 24% report binge drinking. Illicit drug abuse 9.6%. About 24% of treatment population but drug use is not much more than that of general population. Substance abuse and addiction rate is 8.8%. 24% report binge drinking. Illicit drug abuse 9.6%. About 24% of treatment population but drug use is not much more than that of general population. In prison are 44% of inmates sentenced for illicit drug involvement. In prison are 44% of inmates sentenced for illicit drug involvement. Of those who gamble, high addiction rate. Of those who gamble, high addiction rate. 45% of all new HIV cases are African American. 45% of all new HIV cases are African American.

216 African Americans continued Higher social class and church attendance are protective factors. Higher social class and church attendance are protective factors. Older African American women over 85% abstain. Older African American women over 85% abstain. Twice as many are in poverty as whites. Higher social class a protective factor. Twice as many are in poverty as whites. Higher social class a protective factor. Almost half of advertising budget targets blacks. Almost half of advertising budget targets blacks. Recovery relates to spirituality and family support. Recovery relates to spirituality and family support. David Goodson quote: deals with cultural pain. Harm reduction techniques recommended. David Goodson quote: deals with cultural pain. Harm reduction techniques recommended. Treatment barrierspaper work for Medicaid, waiting period, wanting to conceal problem, waiting period. Treatment barrierspaper work for Medicaid, waiting period, wanting to conceal problem, waiting period.

217 Work with Somalis Trauma from war and refugee experiences. Trauma from war and refugee experiences. Need for translation services. Need for translation services. Gambling may be a problem among the young immigrants although forbidden in the culture. Gambling may be a problem among the young immigrants although forbidden in the culture. Immigrants will seek spiritual counseling at the mosque. Immigrants will seek spiritual counseling at the mosque.

218 Chapter 13 Public Policy

219 Policy Issues Only 11% of those who need treatment get it, but may not want it. Only 11% of those who need treatment get it, but may not want it. War on Drugs is not harm reduction, but harm maximization War on Drugs is not harm reduction, but harm maximization SSI (Supplemental Security Income) for alcohol/drugs disabilities has been discontinued SSI (Supplemental Security Income) for alcohol/drugs disabilities has been discontinued Managed care, reduced inpatient coverage, reductions in Medicare reimbursement Managed care, reduced inpatient coverage, reductions in Medicare reimbursement

220 Promising Developments Drug courts, mental health courts. Baltimore uniquely has a huge number of treatment slots available. Reduction in drug overdose deaths in Washington DC thanks to more treatment funding.

221 Welfare Reform Federal government denies benefits to needy people with alcohol and drug problems. Federal government denies benefits to needy people with alcohol and drug problems. TANF drug testing in some states. TANF drug testing in some states. Removal of coverage for substance related disabilities such as alcoholism from SSI (Supplemental Security Income), loss of Medicaid eligibility through this program for treatment. Removal of coverage for substance related disabilities such as alcoholism from SSI (Supplemental Security Income), loss of Medicaid eligibility through this program for treatment. Government encourages drug testing for welfare recipients; new laws in states now doing this. Government encourages drug testing for welfare recipients; new laws in states now doing this.

222 Managed Care Restrictions on care are familiar to all treatment providers. Cost containment and accountability are stressed. Focus on brief, outpatient visits. Cuts in mental health care by the states.

223 Federal Confidentiality Laws Federal Confidentiality Laws Confidentiality of Alcohol and Drug Abuse Confidentiality of Alcohol and Drug Abuse Patient Records (2011) apply to all agencies that provide substance abuse treatment or prevention. Patient Records (2011) apply to all agencies that provide substance abuse treatment or prevention. The rules are far more stringent than for any other category of treatment. The rules are far more stringent than for any other category of treatment. No disclosure of content that would be harmful to the patient with or without the patients signed consent. No disclosure of content that would be harmful to the patient with or without the patients signed consent. This is true even with a court subpoena. This is true even with a court subpoena. This law is protect clients who seek treatment from facts about their prior drug use or dealing. This law is protect clients who seek treatment from facts about their prior drug use or dealing.

224 Other Legal Matters Treatment options to AASupreme Court ruling related to separation of church and state. Treatment options to AASupreme Court ruling related to separation of church and state. War on Drugsfailed policy, most agree in survey: injustice, racial oppression, huge expense. War on Drugsfailed policy, most agree in survey: injustice, racial oppression, huge expense. Media hype about drug crime, mandatory minimum sentencing. Media hype about drug crime, mandatory minimum sentencing. Most inmates in federal prison are minorities. Most inmates in federal prison are minorities. Mothers of crack babies given punitive treatment. Mothers of crack babies given punitive treatment.

225 Ethical Matters Mental health professionals have their codes of ethics as do substance abuse counselors that require: Nondiscrimination of clients on the basis of race, color, gender, sexual orientation, age, disability, Nondiscrimination of clients on the basis of race, color, gender, sexual orientation, age, disability, Continuing professional and educational growth; Continuing professional and educational growth; Not exploiting clients sexually or financially; Not exploiting clients sexually or financially; Reporting professional misconduct of colleagues, such as violations of client confidentiality. Reporting professional misconduct of colleagues, such as violations of client confidentiality. Avoid dual relationships. Avoid dual relationships.

226 War on Drugs Over 40,000 killed in Mexican war on drugswar of cartels. Global Commission on Drug Policy (2011) led by former presidents from Latin America called for end to drug wars. Need to rethink zero tolerance policies. Two-thirds of Americans agree; a slight majority of Americans favor legalization of marijuana.

227 Mandatory Sentencing Women have the fastest growing prison population rate, especially in federal prisons. Women have the fastest growing prison population rate, especially in federal prisons. 1986, federal mandatory minimum sentencing laws enacted. 1986, federal mandatory minimum sentencing laws enacted. Hysteria over crack babiesharm to fetus actually was from the alcohol used. Hysteria over crack babiesharm to fetus actually was from the alcohol used. US Supreme Court in 2007 ruled the laws should serve as guidelines only. US Supreme Court in 2007 ruled the laws should serve as guidelines only. Drug conspiracy laws cause women to be arrested as their partners turn them in as a part of their plea bargaining agreements to get their sentences reduced. Drug conspiracy laws cause women to be arrested as their partners turn them in as a part of their plea bargaining agreements to get their sentences reduced.

228 The New Jim Crow Michelle Alexander (2010): The New Jim Crow: Mass Incarceration in the Age of Color-Blindness 1 in 9 young black men behind bars. Many children without fathers or both parents.

229 Civil Asset Forfeitures Police seize property (cars, houses) related to crimes committed based on a mere preponderance of evidence. Police seize property (cars, houses) related to crimes committed based on a mere preponderance of evidence. Oregon requires a conviction first. Oregon requires a conviction first. Partners of drug dealers often pay the price. Partners of drug dealers often pay the price. Informants awarded part of the value of the goods seized. Informants awarded part of the value of the goods seized.

230 Harm Reduction Strategies Needle exchange serves only 15% of drug injectors. Needle exchange serves only 15% of drug injectors. Methadone and buprenorphine maintenance Methadone and buprenorphine maintenance Heroin prescribed to addicts in some European countries Heroin prescribed to addicts in some European countries Drug courts: a promising strategy, cost effective for communities Drug courts: a promising strategy, cost effective for communities This text argues not legalization but for middle of the road policiesdecriminalizationto reduce harm. This text argues not legalization but for middle of the road policiesdecriminalizationto reduce harm.

231 Recommendations Concerning Gambling Recommendations Concerning Gambling Restrict all gambling to those who are at least 21 Restrict all gambling to those who are at least 21 years of age years of age Remove slot machines from neighborhood Remove slot machines from neighborhood stores, banning betting on collegiate and amateur stores, banning betting on collegiate and amateur athletic events. athletic events. Ban aggressive advertising that targets impoverished neighborhoods and youth, Ban aggressive advertising that targets impoverished neighborhoods and youth, Prohibit credit card machines in casinos. Prohibit credit card machines in casinos.

232 The End Addiction Treatment: A Strengths Perspective, 3rd ed.


Download ppt "Power Point for Addiction Treatment: A Strengths Perspective 3rd Edition Katherine van Wormer Diane Rae Davis Cengage Publishing Company 2012 copyright."

Similar presentations


Ads by Google