Addiction Treatment:
A Strengths Perspective
2nd Edition
Katherine van Wormer
Diane Rae Davis
Wadsworth Publishing Company
2008 copyright
Part I: Introduction
• Addiction affects us all. Strengths
perspective—strengths of clients and
strengths of the contemporary models:
– harm reduction
– 12 Step approach.
• Rift in field.
• Book in 3 parts: bio-psycho-social
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
• Economic cost—health, war on drugs, over
1 million in prison for drug involvement.
Big business—gambling, Philip Morris,
beer
What is addiction?
• (Latin) addictus---attached to something,
positive. Today alcoholism called a “brain
disease”or bad habit or sin. Leading
assumption of the text: Addiction is the key,
not the substance or behavior
• Addiction defined by researchers as “a bad
habit,” “a brain disease,” “helplessness,” “a
problem of motivation”
DSM-IV-TR
Substance dependence: requires 3 of following:
tolerance
withdrawal problems
use more than intended
reduced involvement
inability to stop
excessive spending or effort
to obtain
continued use
• Rigid dichotomy here between abuse and dependence. Van
Wormer and Davis disagree, see addiction as a continuum.
People move in and out of addiction.
• DSM prefers term dependence over addiction.
Definitions
Abuse—unlike dependence does not include these
criteria: tolerance, withdrawal, pattern of compulsive
use.
Addiction—pattern of compulsive use.
•Has physical, psychological, social aspects.
•Emphasis on process rather than outcome.
Box 1.1
A Social Work Major Working in a
Casino
• What is the ethical dilemma here?
• How do the managers ensure that the
gamblers keep spending their money?
• How are the employees controlled by the
establishment?
The Disease Concept
• Is alcoholism a disease?
• Arguments by class pro:
• Arguments con:
First, Define 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.
• 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.
• 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.
Biopsychosocial-spiritual Model
• Why (bio), what (psycho), where (social)
• Need for spiritual healing, connection with
Higher Power
• Interactionism and cycle of pain: pain and
suffering  loss  pain, stress and
drinking more pain
• Family as a system in interaction, roles
Why Do We Need to Know about
Addiction?
• 80% of people behind bars have problems,
pervasive in child welfare system, alcoholics in
the workplace.
• 71% of social workers worked with clients with
substance abuse disorders in the past year.
• Headlines:
-“Hooked on Tanning?”
-“Shopaholics Climb on the Wagon”
• Relevant movies: 28 days, Traffic, Walk the Line
Strengths Perspective
Charles Rapp:
Six critical elements: person is not the illness, choice, hope, purpose,
achievement, presence of one key person to help.
• Finding the strengths in divergent models,
• Newer ones and traditional approaches.
• Different models for different folks.
• Very negative view of disease model: Stanton Peele: Resisting 12 Step
Coercion
• Harm reduction and the strengths perspective— “meet the client where
the client is.” Policy issues of reducing harm.
Empirical Research
Project MATCH
Directed by NIAAA – 2,000 clients over 8 yrs.
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.
Valliant’s Research
40 year longitudinal study—those who recovered had crisis with alcohol
or joined AA or entered a stable relationship or had a religious
conversion.
Empirical Research Continued
• 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),
medicine naltrexone, social skills training,
aversion therapy, cognitive therapy, acupuncture.
(See chapter 5)
Treatment Trends
• Harm reduction recognized important to save
lives,
• Belief that punitive laws cause harm.
• 69% of Americans favor treatment over jail.
• Treatment now often provided in prison.
• Drug courts.
• Attention to co-occurring disorders.
• Restorative Justice: Victim-offender
programming to promote healing.
Chapter 2
Historical Perspectives
Early History
• Alcohol back to 5000 BC Iran
• Unknown to world’s indigenous people
• Koran --- condemned wine. Alcohol from Arabic
al-kuhul.
• Arabian dr. discovered evaporated distilled spirits.
Technology exceeded its grasp
• 1575 --- distilling used–gin. Booze from Dutch
busen.
• Great devastation from England, 1700-1750.
• Infant mortality, crime
North America
• More beer than water on Mayflower.
• Slaves forbidden to drink except on special
occasions, taught bingeing.
• Puritan traditions.
• 18th – Quakers and Methodists disapproved
of hard liquor.
• Male drinking cult 1725-1825 notorious.
Temperance movement
• 1825-1919: Against hard liquor.
• Temperance woman for women’s suffrage
and ban on distilled beverages.
Early 1900s
• Cocaine in Coke
• 1914 Harrison Act --- restricted opioids
(associated with Chinese people) cocaine
must now be prescribed.
• Marijuana (associated with Mexicans) State
laws in southwest criminalized.
• Teetotaler T =total abstinence, from
Ireland.
U.S. Prohibition 1920-1933
• Glamorized crime. Mafia/
Hollywood/Wash. DC link. Homicide rates
increased.
• Great Depression created need for jobs.
Chapter Themes of First Half
• 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.
• Modern War on Drugs, 70% of money for
law enforcement.
History of Addiction Treatment
• 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.
• Jellinek (The Disease Concept, 1960) – 5 types of
alcoholism based on world travels:
• Alpha, Beta, Gamma , Delta, Epsilon.
Treatment History continued
• 1956 AMA declared alcoholism a disease,
1966, a disease.
• Harold Hughes –founded NIAAA.
• Hazelden adapted 12 Step approach.
• Box 2:1—“Treatment in Norway”—
universal health care for support.
• Peele and Fingarette: addiction as bad
habits not disease.
History of Harm Reduction
• AIDS in Netherlands spawned new
approach, to reduce the harm.
• Britain, 1960s and later.
• Heroin prescribed. Needle exchanges-U.S.
Chapter 3
Strengths Based Helping Strategies
Dennis Saleebey
•
Focus on possibilities, choices—providing treatment
options.
• Resilience, healing, and wholeness.
• Contrast with problem-solving approach.
Two Approaches to Treatment
Traditional
Bio
Dichotomy
Psycho
Problems mandate—one size
fits all
Social
Identify family dysfunction
Strengths-based
Bio
Continuum
Psycho
Strengths-motivation
Social
Holistic family as resource
Four Models of Strengths-Based
Approaches
1. Harm reduction: public health model, prevention,
outreach.
Abstinence not precondition to treatment
Stages of Change Model: Prochaska and
DiClemente
Precontemplation
Contemplation
Preparation
Action
Maintenance
Relapse
2. Motivational Interviewing (MI)---William
Miller
• Asking 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?
• MI Steps to enhance motivation:
Express empathy
Develop discrepancy
Avoid argumentation
Roll with resistance
Support self-efficacy
3. Solution focused therapy
•
•
•
•
Miracle question
The personal narrative
Scaling questions
Coping questions
4. Narrative Therapy
• Therapist works to uncover evidence of past
competence
• Help in rewriting a “new life story”
• Group work to discourage stories of
problems and failures
Traditional Treatment:
• Detox—opportunity to introduce patient to
choices
• Outpatient—primarily group counseling
• Inpatient and halfway houses
• Aftercare once a month, may be 12 Step
group or religious activity
Part II
BIOLOGY
Chapter 4
Substance Misuse, Dependence, and the
Body
Recent Trends
PET scans, fMRI functional magnetic
resonance imaging
Craving research
New facts on brain damage
Depressants
Alcohol
Figure 4.1—alcohol involvement: 39% of
those in prison for violence; 39% of traffic
fatalities;67% in domestic violence, 40% in
rape; 72% date rape; 50% child abuse and
neglect; 23% of suicide.
Father Martin- -Chalk Talks:
Jocose drunk, amorose, bellicose,
lachrymose drunks
Others: somnos drunk, (sleepy) clamorose,
(loud), scientose (know it all)
Alcohol continued
• Health effects—heart
• 7-10% of drinkers get addicted. Signs:
tolerance, withdrawal (tremors, nausea),
heavy nicotine, caffeine use
• Tolerance reversal
• .4 B.A.C. may be comatose.
• Blackouts: common at .3 BAC, case in Tom
Sawyer
• Real court cases
Drinking Rates in Liters of Alcohol
• Iran— 0.0
• India—.82
• Cube—3.65
• Mexico—4.62
• Norway—5.81
• Japan—7.38
• U.S.—8.51
Some have high consumption
with few problems.
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•
•
•
•
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Italy—9.14
Greece—9.30
UK—10.39
Denmark—11.93
France—13.54
Ireland—14.45
Narcotics
• Opiates—from opium poppy…narcotics,
heroin now can be smoked or snorted
• Inhalants—household products, huffing, brain
damage, coma
• Misuse of pain medication increasing today
• OxyContin
Stimulants
• Cocaine-crack and powder, in urine 8 hrs., smoked for
faster high.
• Brain blocks reuptake of dopamine… Addicted rats
die… heart attack.
• Amphetamines and meth—synthetic unlike cocaine—
suppresses appetite.
• Powder can be snorted, injected. Stay awake for long
durations…
• Anhedonia---inability to feel pleasure with druginduced brain injury.
Nicotine
• Can both stimulate and relax. 80-95% of
alcoholics smoke, reduces alcohol effects.
Over ½ of schizophrenics smoke.
• Nicotine decreases BAC levels.
• Malachy McCourt smoked for ad and got
hooked.
• Box 4.1 “To Die for a Cigarette”
• Case of chewing tobacco—snuff
Hallucinogens
• Plants, LSD, synthetic, flashbacks, PCP
• Ecstasy and roofies—heightens sensory
experience…raves..
• Can’t get back to original high due to brain
changes.
• 10% in high school have used Ecstasy.
• Dance Safe – harm reduction strategies.
• Roofies:--sleeping pill in Europe.
What Is Ecstasy?
Split
 Ecstasy is a drug that has
some hallucinogenic
properties and is
structurally related to
amphetamines. Its short
form chemical name is
MDMA (3,4methylenedioxymethamphetamine).
Short Term Effects of Ecstasy
•
•
•
•
•
•
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Feeling of confidence
Sense of arousal
Increased heart rate
Dry and sore mouth/throat
Tension, High Body Temperature
Muscle twitching
Depression & Confusion
Long Term Effects of Ecstasy
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•
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Liver damage
Anxiety disorders
Irregular heartbeats
Brain damage
Depression
Confusion
Paranoia
Cannabis
• Marijuana
• 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 longterm use were not validated.
Costs to Get High
Estimates Differ by Region
• Crack: $5-10 quick fix only lasts 30 min.
• Heroin: $100-200 day--$20 day can by
maintenance dose inject a couple of times
• Ecstasy: $10-20 may take 5 or so pills.
• Meth: $25 long-lasting high, popular in gay party
scene in Seattle, factory workers in Iowa
• Marijuana: $25 or higher, depends on quality
Metabolism
• Liver: organ that metabolizes alcohol, alcohol
circulates in the bloodstream until metabolized.
• Men have special enzymes help. People
metabolize ½ oz. Per hour = small glass of
wine….1 BAC=1/1000 parts blood.
• Acetaldehyde and Antabuse
• Flushing in Asians
• Multiplying effect of 2 sedatives.
• Tylenol plus Alcohol >liver failure.
• Valium is used to bring one down from cocaine
(ex. Robert Downey).
Brain Regions and Their Functions
The Brain and Addiction
Neurotransmitters affect emotions and memory
Neurotransmitters Affect Emotions
and Memory
• Dopamine—reuptake affected by cocaine, which
blocks dopamine synapse
• Depletion following cocaine use. Nicotine affects
dopamine too.
• Parkinson’s when too little. Dopamine-boosting
drugs for Parkinson’s associated with mania and
gambling behavior.
• Too much dopamine associated with schizophrenia
• Serotonin: influenced by alcohol, involved in sleep.
Decreased levels linked to depression, anxiety,
impulsiveness suicide.
Depletion following cocaine use. Nicotine affects dopamine too.
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.
Memory and Craving
• Addict never gets original high—brain has
changed. Addiction is a brain disease.
• Cues can trigger memory…picture of
alcoholic beverages activates certain areas
of the brain.
• Prozac reduces craving by regulating
serotonin levels.
Cocaine in the Brain
Slides are from the National Institute on Drug Abuse (NIDA) (www.nida.nih.gov)
The Role of Genes
• Study of mental hospitals, prisons, 50% who used
chemical substances had mental disorders.
• Cloninger—Sweden..259 male adoptees with alcoholic
fathers
•
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
• 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
• People with ADHD risk for drug abuse.
Medical Consequences
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Wernicke Korsakoff:
Cases reported of Dr. Oliver Sachs
Peripheral neuropathy related to lack of Vitamin B
Confabulation….Dr. Sachs—Awakenings
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 photographs in text.
Chapter 5
Interventions Related to Biology
Schick Shadel
• Seattle treatment center
• Conditioning or aversion therapy
• Interview with administrator explains use of
truth serum, etc.
Changing Brain Chemistry
• Brain Lock (Schwartz) cognitive treatment for
OCD to “rewire the brain”
• Ondansetron—decreases craving
• Zyban and smoking; Chantix helps person produce
more dopamine.
• Nicotine gum; patch.
• Naltrexone, approved 1995, not a narcotic unlike
methadone.
• Blocks receptors for getting high.
Synthetic Prescription Drugs
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Methadone (synthetic form of heroin);
Methadone maintenance
Heroin maintenance in Britain, Switzerland.
Buprenorphine can be prescribed by GP’s, reduces
likelihood of overdose
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Eating disorders and dopamine
Bulimics—related to depression
Anorexia—anxiety
Luvox decreases binges.
Holistic Treatments
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Herbal remedies
St. John’s wort
Hypnosis
Acupuncture from China
Massage therapy
Physical exercise to reduce tension
Assessment
• Need for assessment forms to be sensitive to
gender/cultural differences
• Language differences, e.g., the word
craving hard to translate
• CAGE and TWEAK work well with women
CAGE
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•
•
•
Have you tried Cutting down?
Have people Annoyed you?
Have you felt Guilty about your ATOD use?
Have you ever used ATOD as an Eye
opener?
TWEAK
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Tolerance
Worried
Eye Openers
Amnesia
Kut down
Works well with mixed ethnic
populations
Other Screening Forms
• AUDIT developed by WHO for alcohol use
• NIAAA—50 item instrument, Inventory of
Drug Use Consequences, in public domain
• WHO designated areas of harm caused by
drink—physical, emotional, health, family,
finances, etc.
UAs
• Raises ethical questions
• Inconsistent with harm reduction, MI,
strengths-based models, according to the
text
• Sweat patch a less invasive form of testing
Strengths-Based Assessment
• Focus not on pattern of use, negatives
• Emphasis on client choice, soliciting
positive information
• Note periods of using less, times of
abstinence, family rituals.
• “What has endured in your life despite
substance use?”
Work with Homeless
• Housing First programs, harm reduction, for
persons with co-occurring disorders
• “Sober housing” no more effective in
preventing harmful drug use
• Motivational strategies helpful
Group Work
•
•
•
•
Early stage: when physiological stress
Develop group norms; sets rules,
Intervene when:
- all-or-nothing thinking
-one person monopolizes group
-it turns into a gripe session
Exercises to help people find strengths:
-Cards: I feel happy when, scared when, etc.
-3 minute feeling level exercises
End of Chapter 5 and Part II