1. Uppers, Downers and All Arounders
Chapter 9
TREATMENT

2. OVERVIEW
Chemical dependency and addiction are one of the most prevalent of brain diseases
Has a greater impact on society than any other brain diseases
Chemical Dependency # 1 public physical health problem
16.4 anxiety disorders
1.3% schizophrenia
7.1% mood disorders
11 million on alcohol
3 million on illicit drugs
2 million on both alcohol and other drugs
25% on nicotine addiction
2-6% on gambling addiction

3. Current Treatment Issues
Expanding use of medications to treat withdrawal, reduce craving and promote abstinence
In creasing use of technology to diagnose and visualize physiological effects of addiction on brain
Lack of resources to provide treatment: States spend only 13% on treatment and only 4% used on prevention
For every $1spent, $4-$20 saved on prison costs, lost of time on jobs, health problems and extra social services.

4. Current Treatment Issues
Coercive treatment works in promoting positive outcomes
33% re-arrests
45% reduction of reconviction
87% reduction in return to prison
Conflict between abstinence recovery and harm reduction
Large segment of society moving towards abstinence, that promotes prohibition
Treatment personnel do not see Harm reduction as an option or transition to abstinence

5. Treatment Effectiveness
California Drug and Alcohol Treatment Assessment Study of 1,850 persons over 3-5 years:
Continual abstinence of 50%
74% reduction in crime
State saved $7 for every $1 spent
TX most effective when patients treated continuously for a period of 6 -8 months
Group therapy more effective
Clients with alcohol issues had better outcomes
Better outcomes linked to culturally appropriate programs
Drug Abuse Treatment Outcome Study (DATOS)
50-70% reduction in drug use
Short and long term residential programs work best

6. Treatment and Prisons
1,962,220 Americans in federal and state prisons for drug offenses
40-65% committed crimes while under the influence of alcohol and/or other drugs
57% of federal prisoners and 21% of state prisoners serving a sentence for drug offenses
5 million were on probation or parole
24%drug law violation
17% DUI of Alcohol
Only 10% with serious addictions had treatment in prisons, even though 94% of federal and 56% of state prisons and 33% of jails had some substance abuse treatment services
Studies showed that Treatment reduced recidivism
$25,000 -$45,000 a year spent on keeping an offender in jail

7. Principles and Goals of Treatment
No single treatment is appropriate for all
Treatment needs to be readily available
Effective treatment attends to all needs of individual, not just the drug use
Assessment needs to be continuous
Remaining in treatment for adequate time is critical for effectiveness
Counseling and other behavioral therapies is critical

8. Principles and Goals of Treatment
Medications are important, especially combined with treatment
Persons with co-occurring disorders should have integrated treatment to address both drug and mental health issues
Treatment does not have to be voluntary to be effective
Possible drug use during treatment must be monitored continuously
Treatment programs should provide assessment for HIV/AIDS, Hepatitis A, B, and C, Tuberculosis and other infectious diseases
Recovery is a long-term process and may require multiple treatment episodes

9. Principles and Goals of Treatment
Motivate clients towards abstinence
Education
Counseling
12 Step Groups or Self-help Groups
Harm Reduction (methadone, medication)
Relapse Prevention
Reconstructing their lives: Creating a drug-free lifestyle
Address social and economic issues
Homelessness
Relationships
Jobs
Drug-free activities
Life skills

10. Principles and Goals of Treatment
Supporting Goals
Enriching Job or Career Functions
Vocational services
Personal Finances
Medical functioning
Checking for undiagnosed illnesses
Optimizing Psychiatric and Emotional Functioning
Over 50% of persons have coexisting mental illness
Spiritual Issues
Include spiritual options for clients

11. Selection of a Program Diagnosis
American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)
Pattern of use, negative impact on the social or occupational functioning of the user, pathological effects (tolerance or withdrawal symptoms)
Addiction Severity Index (ASI)
Comprehensive and lengthy criteria for the diagnosis of chemical dependency
180 items covering six items: medical, employment, drug/alcohol, legal, family/social, and psychiatric history

12. Selection of a Program
Michigan Alcoholism Screening Test (MAST): Long (25 ?’s) Short (13 ?s)
Directed at negative life effects of alcohol
CAGE
Simplest assessment tool of 4 questions
Have you ever felt the need to Cut down on your drinking?
Do you feel Annoyed by people complaining about your drinking?
Do you ever feel guilty about your drinking?
Do you ever drink an Eye-opener in the morning to relieve the shakes?

13. Treatment Options
No treatment has been found to be universally effective for everyone
Wide-range of Treatment Options
Cold-turkey/white knuckles dry-out to medically detoxification
Expensive medical or residential approaches, free peer groups, 12 step, Social Model Group Therapy
Outpatient treatment, half-way houses, residential programs
Long-term residential (2 or more years) and 7-day hospital Detox with aftercare
Methadone maintenance or harm reduction
Acupuncture, aversion therapies, etc.
Addicts drop-out from TX centers that they feel uncomfortable in or not relevant to their problems

14. Treatment Options Medical Model Detoxification Programs
Supervised and managed by medical professionals: hospital inpatient, residential or outpatient
Office-based medical detoxification and maintenance treatment for opiate abuse
Qualified private medical practitioners
Social model detox programs
Nonmedical programs: in or out patient
Social Model Recovery Programs
Uses a variety of approaches to move a client towards recovery

15. Treatment Options Therapeutic Communities Halfway Houses
Generally long-term (1-3 years)
Self contained residential programs that provide full rehabilitation and social services
Halfway Houses
Permits addicts to keep their jobs and outside contacts while being involved with residential treatment program
Sober Living or Transitional-living Programs
Consists of apartments or cooperative living groups of recovering addicts who have completed a long-term residential program

16. Treatment Options Partial Hospitalization and Day Hospitals
Medical outpatient programs that involve patients in therapeutic activities for 4-6 hours per day while living at home
Intensive Outpatient
6-8 hours per week
Harm Reduction programs
Mainly pharmacotherapy maintenance
Admissions in 2000
1.6 million treated in various facilities
Estimates that 2 million need treatment
3.5 million need some care
12,000 on Big Island in need of treatment
Only 56 CSACs on Big Island

17. Treatment Options Hitting Bottom Denial
Necessary since addiction is progressive disease
If early detection is recognized, then chances of recovery is better
Denial
Refusal to acknowledge the negative impact on life
Breaking Through Denial Intervention
Difficult but necessary since self-diagnosis is needed for treatment to be effective

18. Treatment Options Intervention
Strategy to confront denial in drug abusers
Consists of members (family, friends, co-works, etc.)
Facilitator prepares members to expect defense mechanisms like denial, rationalization, minimization, anger, accusations
Timing, location and surprise is crucial
Successful or not, it is essential that group members continue to meet

19. Treatment Options Detoxification
Helps to normalize client’s thinking processes so they can full participate in Treatment
Takes about a week to excrete cocaine
Takes about 4 weeks to 10 months until the body chemistry settles down
Medically or chemically assisted detox is aimed at minimizing life-threatening withdrawal symptoms
Assessment of severity is important to determine if detox is necessary

20. Treatment Options
Medication therapy for detox for cocaine, methamphetamine and other stimulants include:
Phenobarbital
Clonidine
Buprnorphine
Naltreone
Antipsychotic and antidepressants
Anabuse for prevention of alcohol relapse
Psychotherapy is also important during the detox phase

21. Treatment Options Initial Abstinence
Environmental triggers can trigger relapse
HALT (hungry, angry, lonely, tired)
RID (restless, irritable, discontent)
Addicts and alcoholics must learn about their triggers and what precipitates a relapse
Cue (Triggers) Extinction Therapy
Addicts/alcoholics learn about cues and drug using situations that increase cravings then desensitize them through education, biofeedback or talk down
Psychosocial support
Clients Build a sober support network that will give them continuing advice
Acupuncture; relief withdrawal symptoms by stimulating the peripheral nerves that send messages to release endorphins that promote wellbeing

22. Treatment Options Long-term Abstinence
Succeeds through continued participation in group, family, and 12 Step meetings
Addict must accept that addiction is:
Chronic
Progressive
Incurable
Potentially fatal
Relapse is always possible
Compulsive addicts that switch drugs always find that the same symptoms resurface in the new drug

23. Treatment Options Recovery Outcomes and follow-up
Recovering addicts need to reconstruct their lives and find things they enjoy doing that give them satisfaction & natural highs
Outcomes and follow-up
Evaluations of outcomes are important to determine treatment success or failure and adjustments made
Aftercare is most important part of treatment.

24. Individual Therapy Individual Therapy
Effective because counselors work one-on-one
Allows the counselor and client to evaluate treatment progress
Allows counselor and client to develop short and long term goals
Allows counselor and client to identify other issues client needs to work on
Provides a written documentary of counselor and client interaction
Less Threatening

25. Individual Therapy Individual Therapy
Cognitive behavioral therapy (CBT)
Looking at belief systems and changing them
Internal dialogue
Examining faulty assumptions and misconceptions and replacing these with effective beliefs
Cognitive Restructuring (REBT)
A, B, C, D, & F Theory of Personality (Albert Ellis)
Activating event
Belief of this event
Emotional and behavioral consequence
Disputing the event
Effect
New Feeling

26. Individual Therapy Cognitive Restructuring
Fully acknowledging that we are responsible for creating our emotional problems
Accepting the notion that we have the ability to change these disturbances
Recognizing that our emotional problems stem from irrational beliefs
Clearly perceiving these beliefs
Seeing the value of disrupting faulty thinking
Accepting that if we expect to change we need to work hard on changing beliefs and faulty thinking
Continuing to practice REBT methods is essential to recovery

27. Individual Therapy Reality Therapy
People have the capacity to make healthy choices
Each person creates their lifestyle
Active and Directive Therapy
Debating irrational beliefs
Homework assignments
Keeping records of activities
Learning new coping skills
Changing one’s language and thinking patterns
Role play & imagery
Confronting faulty beliefs
Aversion Therapy
Assertiveness Training
Social Skills Training Motivational Interviewing

28. Individual Therapy Motivational Interviewing Counselor Skills
Express empathy
See the world through the client’s eyes
Reflective listening
Roll with the Resistance
Resistance is not challenged
Help the client explore the client’s ideas
Develop discrepancy
Help the client recognize where they are and where they want to be
See how their current actions will not lead them to their goals
Support self-efficacy
Empower clients to chose their own options
Counselor encourages them to change

29. Individual Therapy Motivational Interviewing Pre-contemplation
Client will not admit they have a problem although others see they do
Counselor’s task is to raise doubt in client
Contemplation
Client begins to think he/she may have a problem
Counselor can evoke reasons to change by showing risks of not changing
Strengthen the reasons to change
Determination
The client decides to do something to change
Counselor helps the client choose options
Action
The client chooses a strategy to change and pursues it
Counselor helps the client take those steps
Maintenance
Client works on and maintaining change strategies

30. Group Therapy
Major Focus is to have clients help each other to break the isolation of chemical dependency
The group is the catalysis for change
Facilitated Groups
6 or more clients who meet with one or more therapists daily, weekly or monthly basis
Peer Groups
Therapist plays less of an active role, usually observing the process. Do not direct or lead group
Self-help Groups
12 Step Groups: Solving problems through personal spiritual change
Educational Groups
Counselors provide psychoeducational groups that teach skill building

31. Group Therapy Targeted Groups Topic Specific Groups
Directed at a specific population of users
women's, men's, adolescents, gay and lesbians, dual diagnosis, etc
Topic Specific Groups
Different Issues: relapse prevention, AIDS, recovery maintenance, relationships, etc.
Group Therapy promotes better outcomes and sustain abstinence more than individual counseling

32. 10 Common Errors Made by Beginning Counselors
Failure to have realistic view of group treatment
Self-disclosure issues and failure to drop the “mask” of professionalism
Agency culture issues and personal style
Failure to understand the stages of therapy
Failure to recognize counter-transference
Failure to clarify group rules

33. 10 Common Errors Made by Beginning Counselors
7. Failure to do Group Therapy by Focusing on Individual Problem
Failure to Plan in Advance
Failure to integrate new members
Failure to understand interactions in the group as a metaphor for drug-related issues occurring in the group member’s family of origin

34. Family Therapy
Addiction is a family disease, and drugs and alcohol affect the client’s family
Family is often ignored
Goals of Family Treatment
Acceptance by all family members that addiction is a treatable disease not a sign of moral weakness
Establishing and maintaining a drug-free family
Developing a system for family communication
Processing the family’s readjustment
Tough Love
Family learns to establish limits for their interaction with addict

35. Children of Addicts and Adults Children of Addicts
Model Child
High achievers: represents family
Problem Child or scrape goat:
has multiple personal problems
Lost Child
Disconnected from family: avoids emotional confronting issues
Mascot Child or Family Clown
Uses avoidance to make everything trivial
Well liked

36. Children of Addicts and Adults Children of Addicts
Most children of alcoholics and addicts also are:
Isolated and afraid
Approval seekers
Frightened by angry people
Become or marry alcoholics
Feel guilty when standing up for themselves
Become addicted to excitement or stimulation
Confuse pity and love
Repress feelings from traumatic childhoods
Judge themselves harshly

37. Target Populations Women Men
Women tend to progress faster to addiction
Die younger
Less likely to ask for help
Internalize blame
Has less support from family members
Lacks childcare to enter treatment
Difficulty recognizing need for treatment
Men
More likely to enter treatment from criminal justice system
Tend to blame things on external events

38. Target Populations Older People Ethnic Groups
Less likely to seek treatment or ask for help
Addiction is seen as aging process or reaction to medicine
Few treatment programs aimed toward older people
Ethnic Groups
Treatment geared to specific ethnic groups tends to promote continued abstinence
Cultural competence important

39. Target Populations African Americans
24% of admissions to publicly funded facilities
Have higher threshold for pain
Greater tolerance for delays for treatment
In some urban areas, high rate African American babies are born tox positive for drugs
Teenagers have a greater risk of dying from crack cocaine
More in jail for drugs than in college

40. Target Populations Asian & Pacific Islanders
Respond better to credentialed professionals than peers
Prefer individual counseling
Rely more on their own responsibility to handle their addiction rather than higher power
Have strong gender rules, so separate male and female groups are better
Family shame often keeps the family enabling and rescuing the addict

41. Target Populations
Bicultural and bilingual treatment personal greatly increase the chances of successful treatment
Incorporates cultural traditions
Healing
Talking circles
Purification ceremonies
Meditative practices
Sweat lodges
Shamanistic ceremonies
Community Singing Ceremonies

42. Target Populations Physical disabilities Gay and Lesbian
Much-neglected population
Counselor may focus too much on the disability and miss the signs and symptoms of relapse
Not take into account the extra stress from the disability
Gay and Lesbian
20-25% are heavy alcohol users
High incidence of HIV/AIDS in gay male community

43. Treatment Obstacles Denial and lack of financial resources
Use of psychoactive drugs can delay user’s emotional development
Keep them from learning how to deal with life problems
Poor follow through or monitoring
Drop out or lack of compliance
Conflicting goals
Lack of Treatment Resources