DRUGS IN PERSPECTIVE, 4TH EDITION
By Richard Fields, Ph.D.
INSTRUCTOR’S MANUAL
Chapter 1 Etiology – A Better Understanding of Drug Use –
Models, Functions and Meanings
Key Teaching Points
 Drugs will continue to be used to alter one’s state of consciousness.
 We will never do away with drugs because people will always seek to
 Alter their state of consciousness.
 Drugs are an easy way to alter consciousness. It doesn’t take much effort.
 All you have to do is take the drug in and wait for the desired effect.
 That’s why we consider drug use a “passive activity”. Even though the outcome
 May be to be more active.
 Drugs serve people; they have specific functions, and meanings.
 At low doses, and occasional use, drugs can be used to change mood, view one’s
world differently, or just to relax.
 However continued escalation in frequency of use, and increases in dose can lead
to significant negative consequences, and problems of abuse and dependence.
Chapter Outline
A.
Why Do People Abuse Alcohol/Drugs?
1.
No simple solution – “the solution to a complicated problem that is simple is
usually wrong” H.L. Mencken, Philosopher
2.
Many reasons for drug/alcohol use
3.
Primary reason or drive – innate drive to alter consciousness – much like our
innate drive of hunger, thirst and sex
4.
Drug use is a passive activity – you take the drug in, and wait for the effect
B.
Models of Drug Use
1.
Disease concept of alcoholism – defined by AMA as a disease in 1957
based on three criteria – known cause (etiology), progressive
symptoms and known outcome
2.
Genetic Model – adoption studies and twin studies confirm a genetic model.
3.
Personality – no such thing as an addictive personality, more appropriate to talk
about psychological vulnerability
– certain personality traits associated with substance abuse (see page 6)
antisocial, borderline, and narcissistic personality disorders show high
incidence of substance abuse.
Mood and Feeling (Affect) Disorders – depression and bipolar disorder
make one more vulnerable to substance abuse
4.
Risk-Taking Behavior – Impulsivity/Disinhibition
5.
Tension Reduction Models
6.
Attention-Deficit Hyperactivity Disorder (ADHD)
7.
Family Models
8.
Self-Concept
9.
Adolescence – just the fact that you are an adolescent makes one vulnerable to
substance abuse.
10.
Conditioning
11.
Psychological Models – Social Learning Theory
12.
Sociocultural Models
13.
Psychoanalytical Models
3.
C.
Factors that Contribute to Substance Abuse
Hopelessness, Pessimism and Poor Future Orientation
The loss of hope, negative attitude and negative thinking, and
a sense that one’s future doesn’t look good can influence the decision
to use or abuse drugs.
D.
FUNCTIONS OF DRUGS
Each drug has a different function
Narcotics – painkillers or numbing
CNS Depressants (including alcohol) – decreases activity, disinhibits
CNS Stimulants – increase activity
Hallucinogens – change the user’s view of the world
E.
1.
MEANING OF DRUGS
Power – the initial user may be motivated to feel more powerful, but
with time and increased levels of use, the users becomes powerless over
their use, and the drug takes control.
Self-destruction – continued use despite negative consequences leads to
significant problems and self-damaging behaviors and attitudes.
Seduction and Sexuality – at low doses and occasional use drugs are
used as social lubricants, and for loss of inhibition. As use increases, dose and
frequency, there is loss of intimacy and they cause isolation, and emotional
detachment.
2.
3.
Chapter 2: Alcohol/Drugs and Our American Society
At-Risk Factors
Key Teaching Points
 Drugs have always been portrayed as more harmful than alcohol.
 Heroin, cocaine, even marijuana are often referred to as hard drugs, or
inappropriately labeled as narcotics, when alcohol and nicotine are the two largest
drug problems.
 The moral, and political systems take positions “Against Drug Abuse”, but they
are less actively opposed to alcohol abuse. The “Just So No” approach illustrates
how out of touch the Reagan administration was with the depth of the drug
problem.
 The emphasis on the supply side of the problem, and the neglect of the demand
side, just continues the status quo and prevents us from ever limiting availability.
 The profit margin for drug trafficking is so large, that until we look at legalization
we will continue to have drugs as a major import.
 Historically we continue to ignore drug problems of people of color.
 It is when drugs impact the middle and upper class Caucasian populations that
funding for prevention, intervention, and treatment programs will be made
available.
 Drugs may be a choice due to academic failure, and the shattered hope for a
successful future. Socioeconomic inequities may shatter the American Dream,
and drugs become a way of life, whether using, and/or dealing.
Chapter Outline
1.



Alcohol and Nicotine – The Two Largest Problem Drugs in the U.S.
Too often emotional, political and moral judgments block the perception of the
two most problematic drugs – alcohol and nicotine
Alcohol problems well documented – child and spouse abuse,
Aggression and violence, driving under the influence, teenage drinking and
driving, homicides, accidents, suicide, crime, traffic accidents.
Tobacco as the most deadly drug – 20% of the deaths in the U.S. are caused by
cigarette smoking, 90% of lung cancer deaths are caused by smoking
2.
At-Risk Factors for Problems with Alcohol/Drugs
 Denial of parental alcoholism and addiction
 Academic failure
 Trauma, violence, and violation
(see table 2.6 Risk Factors and Correlates to Alcohol/Drug Use
3.

Emphasis on the Supply Side and Neglect of the Demand Side
The continued emphasis on the supply side of drugs, fails to adequately address
and fund programs that deal with prevention, intervention and treatment of
substance dependence. A balanced approach is necessary to impact drug use,
abuse and addiction.
4.
Neglect of the Alcohol/Drug Treatment Needs of People of Color
Historically drug use by people of color and minorities has been neglected. It is only
when drugs impact mainstream Caucasians that the government seems to create programs
and make funding available.
5.
Academic Failure and the Failure of the U.S. Educational System in
Motivating and Educating Young People to Strive for Productive Lives
6.
Socioeconomic Inequities Undermining the American Dream
The lack of hope for a secure future and the attainment of the basic American dream of a
good job, home, financial stability, and a good future contributes to feelings of despair
that can lead to drug use and abuse. The inequities in the planning field further
contribute to feelings of resentment, prejudice and lack of equal opportunity.
7.
The Major Perspectives of Alcohol/Drug Use
The five (5) perspectives are:
Moral- Legal Perspective – law enforcement and the criminal justice system
Medical – Health Perspective – medical and health treatment fields
Psychosocial Perspective – alcohol/drug treatment agencies – mental health
agencies
Sociocultural Perspective – most social service agencies and institutions
Your own Personal Perspective
Emphasis in helping others to maintain a Perspective of Hope
Chapter 3 Drug Specific Information
Drugs on the Street Where You Live
Key Teaching Points
 Drugs are the vehicle to alleviate pain, to change the way we feel, to distort
reality, to feel pleasure not pain, to avoid, and several other functions.
 A drug, is a drug, is a drug, they only differ in the effect on the mind and body.
Abuse, addiction are traps that have significant consequences on the soul.
 The history of American drug use is fascinating. From the credo of
 “Drugs, sex and rock n’roll”, to cocaine, crack, designer drugs, and ecstasy.
 There will always be a new drug that affects the mind and body in a different
way, and certainly there are a variety of drugs in different categories, most of
them with an addiction potential.
Chapter Outline
1. DRUGS IN OUR SOCIETY
- Drugs, Sex and Rock n’Roll –
-Drug revolution of the 60s and 70s was more than exploration it was a
revolution against the Protestant work ethic, moral and sexual values, and societal values
in general – “turn on and tune out” - it was a symbol of the conflict in Viet Nam and the
stress of the draft for adolescent and young adults, many of them college students
-In the 1980s the rise in cocaine use had a major impact through the deaths of major
media personalities and its impact on a middle to upper class population
-“Crack” was the natural progression to lower socioeconomic populations, create a new
epidemic, complicated by freebase cocaine use that made the drug quicker acting and of
even shorter duration
- Designer drugs, “ice” and methamphetamine came on the scene in the late 80s and early
90s
- Other modern drugs – rohypnol, ecstasy, purer heroin
2. DEFINITION OF TERMS
a.
b.
c.
d.
e.
f.
g.
Physical Dependence
Withdrawal
Psychological dependence
Routes of Administration
Set and setting
Tolerance
Cross tolerance
h.



i.
j.


Psychoactive drug classification
Narcotic Analgesics
Central Nervous System Depressants
Central Nervous System Stimulants
Hallucinogens
Cannabis sativa: marijuana and hashish
Inhalants: volatile solvents
Phyncyclidine (PCP)
1.
2.
3.
4.
5.
6.
7.
3.
Synergism
This is an important factor, as the use of more than one drug is not additive but
instead multiplied.
1 drug taken + another drug taken does not equal two units of potency
Instead it may have a “synergistic effect” of being 5 times more powerful an
action.
Antagonism
Classification of Drugs
Non-Psychoactive drugs are substances that in normal doses do not directly
affect the brain, such as vitamins, antibiotics, and topical skin preparations.
Psychoactive drugs affect brain functions, mood and behavior and are
subdivided primarily on the basis of physiological and psychological effects.




a.
b.
c.
d.
e.
f.
g.
NARCOTIC ANALGESICS
Term narcotic comes from the Greek term narcosis, which means to numb
Narcotic analgesics (morphine, codeine and heroin) come from the poppy plant
Term narcotic was inappropriate applied to marijuana, cocaine,
Hallucinogens, as an emotional-laden moral response
Brief History of the Narcotic Analgesics
Routes of Administration
Major Effects
Pain relief (analgesia)
Euphoria (sense of well being)
Cough suppressant (antitussive)
Respiratory Depression
Sedation or Drowsiness
Constriction of the pupils (pinpoint pupils)
Nausea and vomiting
Itching
Decrease in gastrointestinal activity (constipation)
Hazards
Tolerance
Withdrawal
Opiates and Pregnancy
4. CENTRAL NERVOUS SYSTEM DEPRESSANTS
 Of course alcohol is the major drug in this category
 This category refers to drugs as sedative-hypnotics (alcohol, barbiturates, and
tranquilizers)
a. Alcohol
 Alcohol acts as a depressant on the central nervous system
a.1 Brief History
a.2 Estimates –the most widely used psychoactive drug known
(other than tobacco products)
a.3 Major Effects on the brain, peripheral nerves, gastrointestinal tract,
heart and blood vessels, the lungs.
a.4 Sobering up – time is the only thing that works
a.5 Tolerance
a.6 Withdrawal Symptoms
a.7 Related Illnesses
a.8 Fetal Alcohol Syndrome
a.9 Antabuse
b. Barbiturates
 Prescribed to induce sleep, relax the nervous system
 Barbiturates and barbiturate like drugs seem to affect the cortex of the brain or
those areas related to sleep more than other sedative hypnotics
b.1
b.2
b.3
b.4
b.5
b.6
b.7
b.8
b.9
b.10
Estimates of use and addiction
Routes of administration – usually taken orally and readily absorbed
Major Effects
Barbiturates and Sleep
Barbiturates and Pregnancy
Tolerance
Withdrawal
Overdose Signs and Symptoms
Barbiturates Used with Other Drugs
Methaqualone
Nonbarbiturates with Barbiturate-like Action
a. Chloral hydrate
b. Methaqualone
c. Flurazapame (Dalmane)
d. Glutethimide (Doriden)
e. Ethchlorvynol (Placidyl)
f. Methprylon (Noludar)
g. Paraldehyde
c. Tranquilizers
c.1 Classification of tranquilizers – see chart on page 77
c.2 Medical uses
c.3 Estimates of Use
c.4 Routes of administration
c.5 Major effects – don’t be fooled by the word “minor tranquilizers
c.6 Tolerance
c.7 Dependence and Withdrawal
c.8 Addiction Potential with Alcoholics/Addicts – this is a major teaching point –
there is a cross tolerance, and high addiction potential to minor tranquilizers by about
only 5 percent of the population – those people are alcoholics/addicts
6.
a.
CENTRAL NERVOUS SYSTEM STIMULANTS
Amphetamines
a.1 Street Names
a.2 Estimates of use
a.3 Routes of Administration
a.4 Major effects
a.5 Adverse Effects
a.6 Dependence and Withdrawal
a.7 Bootlegged amphetamines
b.
Cocaine
b.1 Brief History
 Cocaine has a very unique, even romantic history that is almost a metaphor
for its intrigue and subtle but powerful addiction. From the original use of
coca by the Incans, to its discovery by Sigmund Freud as a remedy for
“neurasthenia” (nervous anxiety) to Freud’s own addiction and subsequent
description of its addiction in his book Fear of and Craving for Cocaine.
b.2 Street names
b.3 Estimates of Use
b.4 Routes of Administration
 Cocaine is Cocaine HCL add ether and a base and heat and you end up with
NaCl (salt) plus H2O (water) and Cocaine free of its base, hence the term
cocaine freebase
b.5 major effects
b.6 Adverse effects
b.7 Tolerance and withdrawal
b.8 Cocaine additives
c.
Tobacco
 Tobacco is the most widely abused drug
 Tobacco use is the single leading cause of preventable death in this country
c.1 Diseases Related to Smoking Tobacco
 Heart disease, peripheral vascular disease, cerebrovascular disease, cancer,
chronic obstructive lung disease
c.2 health consequences
7.
HALLUCINOGENS
The term hallucinogen is derived from the Latin word hallucinari, which means to
dram or to wander in the mind.
 LSD – 1960s timothy Leary advocated LSD as a means of “turning on, tuning in,
and dropping out” of mainstream lifestyles and thinking
 See table 3.11 – page 87 – other hallucinogens
7.a Common Street Names for LSD
7.b Brief History of LSD
7.c Estimates of Use
7.d Routes of Administration
7.e Major Effects
7.f Adverse Effects
7.g Tolerance and Dependence

CANNABIS SATIVA
Cannabis refers to any product of the plant Cannabis sativa
7.h Street names
7.i Brief history of marijuana
7.j Estimates of use
7k. Medical use
7l. Routes of administration
7m. Major effects
7 n Increased potency of marijuana
 1960s THC content of marijuana was 1-2 percent, today THC level
 Averages 6 percent, hashish 10 percent, hashish oil up to 20 percent
7.o Adverse Effects
Damage to the Respiratory system
 Combination of cannabis smoking and cigarette smoking is most damaging, and
increases risks of lung cancer
Immune System Effects
 Tends to suppress the body’s immune response when used
 Regularly, and ability to combat infections, temporarily arrests the maturation of
developing t-cells, which protect the body from colds and other bacterial
infections
Reproductive System Effect
 Chronic use of cannabis decreases sperm motility and serum testosterone in men,
and interferes with the menstrual cycle in women
Brain System Effects
 Debate continues over the effects of cannabis on the brain
 Impairment of Maturational Process
Marijuana and Driving

7.p
7.q
7.r
7.s
7.t
7.u
7.v
Impairs short-term memory, alters the user’s sense of time and space, impairs
overall coordination, and impairs motor functioning, and impairs tracking of other
vehicles, an important aspect of driving
INHALANTS
Brief history
Route of administration
Available forms of inhalants
Major Effects
Tolerance and Dependence
Acute adverse effects
Long-term effects
PHENCYCLIDINE
7w. Street Names
7.x Estimates of use
7.y Routes of administration
7.z Major Effects
7aa. Adverse Effects
7bb. Accidents
7cc. Violence
7dd. Tolerance and Dependence
8.
ATHLETES AND DRUGS
8a. Caffeine
8b. Chewing tobacco
8c. Amphetamines
8d. Steroids
 Brief History, terminology, major effects, and adverse effects
8e. Other Drugs/Alcohol in Sports
Chapter 4 Screening and Assessment of Alcohol/Drug Problems
Key Teaching Points
 Emphasis on a functional definition of addiction – 3 “C”s of addiction
 Emphasis that early stages of alcohol/drug use are easy to screen and assess,
however excessive use, periodic excessive use and actual addiction are sometimes
harder to assess
 A screening tool is a broad based tool to determine if there might be a drug
problem
 An assessment tool is used to determine the level and extent of the drug problem,
assess the nature, scope and severity of the problem, to better determine treatment
recommendations
 In assessing a drug problem, your first question is “Is there a family history of any
alcohol or drug problems?” Of course the initial response may be no, so it is
important to ask again and clarify what you mean by an alcohol/drug problem
 History of alcohol/drug problems are a significant red flag that there may be a
genetic predisposition to addiction
 Adolescent alcohol/drug problems are difficult to assess because many adolescent
behaviors are so similar to alcohol/drug abuse problems
 In assessment, especially with adolescents “trust the known facts” not necessarily
what someone says or explains – behavior speaks louder than words
Chapter Outline
A.




Definition of Addiction
The functional definition developed as a result of cocaine addiction in the 1980s,
developed by David Smith, M.D. of the Haight-Ashbury Center is the 3 “C”s:
Compulsion - (obsessive- thinking, and compulsive doing of the drug)
Control – inability to control drug use (failure to abstain for significant period of
time)
Consequences – continued use of drugs despite significant consequences
B. Stages of Drug Use (see chart page 110)
 Non-use, initial contact, experimental (situational, or circumstantial use),
integrated use, periodic excessive use, excessive use, addiction
C.
Jellinek’s types of Alcoholics
 Alpha, beta, gamma, delta, epsilon
 Helped create the awareness that there are different types of alcoholics, not just
the same.
D.
Diagnostic Criteria of Substance Abuse and Dependence
 The Diagnostic and Statistical Manual - DSM-IV describes substance abuse,
substance dependence in specific diagnostic criteria
E.
Vulnerability to Relapse
 The most relapses occur from 30-120 days
F.
Family and Recovery
 Alcohol/Drug History – important to take a good family history to determine
genetic at-risk (parents, relatives who might have or had an alcohol/drug
problem), age of onset of drinking to periods of excessive use
 Important to assess any significant periods of abstinence or sobriety from
drugs/alcohol

Individual Vulnerability to Alcohol/Drugs
(see Chapter 11 – Treatment and Relapse Prevention)
G.
Consequences of Alcohol/Drug Use
H.
Denial – Problems in Accurate Assessment
 The major denial system or defense mechanisms of drug problems are
rationalizations, and minimizations
I.
Identification of Adolescent Alcohol/Drug Problems
 It is often hard to assess an adolescent alcohol/drug problem because many of
the signs and symptoms of alcohol/drug abuse may mimic the natural
developmental, and age appropriate problems for most adolescents
 However, a continued pattern of negative consequences or problems in the
adolescents life, should lead parents and adults to suspect an alcohol/drug
problem and to seek family counseling early rather than later
J.
Alcohol/Drugs and Suicide
K.
Alcohol/Drug Screening Inventories
 The purpose of a screening inventory is to determine if an alcohol/drug problem
exists, to identify a potential alcohol/drug problem
o Michigan Alcohol Screening Test, Drug Use Screening Inventory (DUSI),
o Marijuana and Cocaine Screening Questionnaires
L.
Assessment
Once screening has established that a substance abuse problem exists, the next step is to
assess the nature, scope, and severity of the problem
Chapter 5 Substance Abuse and Family Systems
Key Teaching Points
See outline
Chapter Outline
A.
Families as Systems
 Family Rules
In an alcoholic/addict family system there is the “no talk, no feel, no trust”
rule
 Imbalanced versus Dysfunctional
Try not to use the form “dysfunctional” it has shame-based connotations,
prefer to use the term “imbalance” – there is/are imbalances in the family
system, so that homeostasis (balance) is off preventing effective functioning,
good communication and connection.
The metaphor of the family as a mobile (Virginia Satyr) demonstrates
imbalanced and balanced (functional) family systems. Alcohol/drug problems
as an issue that imbalances the family system.
 Kinds of Family Systems
Rigid family systems
Ambiguous family systems
Overextended family systems
Distorted family systems

Satir’s Family Pattern of Communication
Imbalanced styles of communicating - placaters, blamers, intellectualizers,
and distractors – are described by Satir
Leveling communication – a healthy state of communication,
words, body and feelings are consistent with the message. The individual
is congruent and communicates with congruency

Weigscheider-Cruse’s Alcoholic/Addict Family System –
Survival Roles
Chief enabler, family scapegoat, lost child, family mascot
These are some basic roles in imbalanced family systems, and
alcoholic/addict family systems
There are many more roles but these illustrate some common themes

Family Roles Played Out at the Dinner Table
This is just one example of imbalanced family interaction and
communication.
These same patterns can be played out in a number of situations

Enabling Behavior
Four major patterns
Avoiding and shielding
Attempting to control
Taking over Responsibility
Rationalizing and Accepting

Stages of Family Recovery from Substance Abuse Problems
The family goes through similar stages as the alcoholic/addict in breaking
through their own denial systems and grieving the losses, and pain of living in
an alcoholic/addict system.
The five stages of grieving DABDA, Denial, Anger, Bargaining, Depression
and Acceptance, are describe in the stages of family recovery in a substance
abuse family.
Chapter 6 Parenting: Impact on Alcohol/Drug Use and Abuse
Key Teaching Points
See Outline


Parent-Child Bonding
Abandonment Depression.
Abandonment depression is an affective disorder described by James
Masterson in the development of borderline personality disorders, it serves
to illustrate the contribution of early abandonment (lack of nurturing) can
have on a person, and the potential to abuse alcohol/drugs.
Remember borderline personality is the personality disorder that is most
frequently identified in substance abusers
Six (6) key elements of abandonment depression are:
 homicidal rage
 suicidal depression
 panic
 feelings of hopelessness and helplessness
 emptiness and void
 guilt
Impact of Early Abandonment on Adult Interpersonal Relationships
 Child’s Temperament
Evidence that extremes in certain temperaments traits, such as high activity
level, emotionality, attention span, and sociability are associated with children
of alcoholics.
Aspects of temperament may predict the behavior problems and substance
abuse problems that frequently arise during adolescence.

Parenting Styles and the Quality of the Parent-Child Relationship
SHAME
 Parenting Styles that Shame Children
Shame – the self looking on itself, and finding it lacking, flawed, inadequate
Metaphor of an “archor out there ready to get you in a public domain”
Shame – is like a flash flood of emotion that wipes out the interpersonal
Connection with people
 Differences between a shame based system and a balanced system
Shame-based system – no hope, inescapable, and exterior-based
Balanced system – hope-choice, can make amends, internally based

Parents Shame

Shame and Feelings
Shame is a very powerful feeling that when attached to feelings they are
escalated – e.g. anger plus shame equals rage
See: Affect-shame binds on page 173






Adolescent sexual Identity and Shame
Sexual Violation and Shame
Drugs, Sex and Shame
Additional Characteristics of Shame and Abandonment
Rejection sensitivity, fear and difficulty making decisions, poor frustration
tolerance, other reactions and defenses
Parental Imbalance and Boundary Setting
Knowing what boundaries are, and setting appropriate but flexible
boundaries with children and adolescents is very important to stabilize the
family
Boundary Inadequacy – defined as the inability to set consistent and appropriate
boundaries in relationships




Boundary Ambiguity
Triangulation – Another Boundary Issue
Other Family System Variables
Imbalanced Life Cycles of Families
 Relationships Between Families and the Joining of Families
 Family and the Young Child
 Family and the Adolescent
 Launching of Children

Fathers of Alcoholics/Addicts – Dealing with Resistance
 Noble Ascriptions to Counteract Defensiveness
Chapter 7 Growing Up in an Alcoholic Family System
Key Teaching Points
 Although the material in this chapter focuses on adult children of alcoholics
it can be generalized that the same patterns exist in families with drug
addiction, and imbalanced family systems
A.
The Adult Children of Alcoholics Movement
 Bosma (1972) – ACAs as victims in a hidden tragedy
 Estimated that 28 million Americans have at least one alcoholic parent
 Children of alcoholics are frequently victims of incest, child neglect, and
other forms of violence and exploitation
 ACA movement, a wildfire of information, education and treatment,
 Described by Stephanie Brown as an almost social reform movement
a.1
a.2
a.3
a.4
a.5
a.6
Characteristics of Adult Children of Alcoholics (see page 192)
Growing Up in an Alcoholic Home as Post-traumatic Stress Disorder
childhood in an Alcoholic Home
Identification of Children of Alcoholic Families
Perspective of the Child in an Alcoholic Family
Codependency
 Metaphor of codependency “Codependency is like being a
lifeguard
 On a crowded beach, knowing that you cannot swim, and not
telling anyone
 For fear of a panic.
 Tim Cermak, MD., an adult child of an alcoholic himself,
attempted to
 Define “codependency” in diagnostic criteria in an attempt to have
it accepted
 As a diagnosis in the Diagnostic and Statistical Manual (DSM-IV),
to no
 Avail, the diagnostic criteria were continual investment of selfesteem in the ability to influence or control
 Feelings and behaviors in the self and others in the face of obvious
 Adverse consequences assumptions of responsibility for meeting
others’ needs to the exclusion of one’s own needs
 Anxiety and boundary distortions
 Enmeshment in relationship
 Maintenance of a primary relationship with an active substance
abuser
 Three or more of the following – constriction of emotions,
depression, hypervigilance, compulsions, anxiety, excessive
reliance on denial, substance abuse, recurrent physical or sexual
abuse, stress-related medical illness.
a.7 Family Disease Model
a.8 Alcoholism/drug Addiction – Impact on Marriage
a.9 Overattachment and overseparation
B.
Recovery from ACA
b.1 Grief work
This is the core of unlocking the deep feelings and learning to accept
the loss, often individual and group therapy
b. 2 Choice Making
Skills to make better choices and set better boundaries
b.3 Second Order Change
Changing the repetitive, almost rhetorically imbalanced communication
patterns with family members, and the alcoholic/addict
b. 4 Changes in Interaction with Family
Setting appropriate functional boundaries with family members, and
obtaining support in setting these boundaries
b.5 Group Psychotherapy
Is necessary and one of the most powerful modalities for recovery, the
groups are with other adult children of alcoholics, and involvement in an
ACA support group is also recommended, as well as a sponsor
Chapter 8 Prevention of Substance Abuse Problems
Key Teaching Points
 Unfortunately we have a long history of failures in preventing substance abuse
 We have learnt a lot over the years, and the newer prevention efforts are not only
 Effective, but very hopeful in their messages.
 However, funding for prevention programs is limited, and long-term effectiveness
of these programs are often not proven.
 Prevention is a noble and much needed approach that compliments treatment,
intervention, and relapse prevention.
Chapter Outline
A.
Early Prevention Approaches
 These approaches were only effective with kids who already had these values,
otherwise they were generally ineffective
 Converting programs – attempted to dissuade young people from using drugs
 Methods included – directing, preaching, convincing, scaring
 Drug-specific approaches – heightened curiosity and alleviated fears of drugs
rather than deterring drug use
 1973 Special Office on Drug Abuse Prevention (SAODAP) declared a
 Moratorium on prevention materials and efforts
 1974 – Prevention Branch of National Institute on Drug Abuse defining

B.
C.
Primary prevention as “a constructive process designed to promote personal and
social growth of the individual to full human potential”
Alternative Activities as a Prevention Approach
Alan Cohen (1972) defines alternative activities as pursuits that are valued and truly
preferred by individuals and seen as incompatible with drugs. They are not just a
substitute for drugs, but also an integrated and valued part of the person’s life
b.1 Alternatives Are Actively Pursued by the Individual
b.2 Alternatives are Acceptable, Attractive, and Attainable
b.3 Alternatives have Mentors and Role Models
b.4 Alternatives Integrate Self-concepts
Prevention Approaches in the 1980s
Educational information
 Coping skills
 Personal competence
 Decision making
 Refusal skills
 Alternative activities
D. School-base prevention Curricula- Examples
Here’s Looking at You – Kindergarten through Senior High School
 Counseling Leadership Against Smoking Pressure (CLASP)
 Cognitive-Behavioral Skills Training
 Cognitive Interpersonal Skills Training
 Life Skills Training
 Law-Related Education
 Skills for Adolescence
 Skills for Living
E. Other Prevention Elements
Prevention Skills in Decision Making
 Empowerment
 Goal Setting
 Capability Development
 The 10 C’s of Capability
F. Components of a Prevention Program in the 1990s
 Address Community Needs
 Include Youth in Prevention Planning
 Promote Proactivity
 Develop a Long-term Perspective
Social Stress Model
 Attachments, competence and coping skills are the key components
 Describes the formula


Level of stress divided by attachments, coping skills and resourceswill predict abuse tact or coping tract
Programs aimed at at-risk youth (see page 224) American Youth –
High Risk for Alcohol Use and Other Problems
G. Risk Factors for Substance Abuse
H. Resiliency
 Key factors of resiliency identified by Stephen and Sybil Wolin
 In their studies of children growing up in alcoholic systems is that
 The resilient child has a plan, builds on their strengths, develops their
 Own lifestyle and values, establishes healthy rituals
 7 resilient factors – insight, independence, relationships, initiative,
 Creativity, humor, morality
I. Emotional Intelligence as defined by Daniel Goleman (1995)
 Being able to motivate oneself and persist in the face of frustration
 Being able to control impulse and delay gratification
 Being able to regulate one’s mood and keep distress from swamping
 The ability to think
 Being able to empathize and hope.
J. Domains of Prevention
K. Prevention Programs and Prevention Emphasis in the New Millennium
 Developmental Assets Model (See page 235-236)
 Forty Developmental Assets
 School Based Programs
 The Personal Growth Class
 Jump Start
 The Iowa Strengthening Families Program
 Comprehensive Community Prevention Program
 Resolving Conflict Creativity Program (RCCP)
 Community Partnership Program
 Healthy People 2010
L. Prevention and Special Populations
 People of Color and other minorities
 Elders and prevention
 College Students At-Risk
 Prevention and the Family
Chapter 9 Motivation and Intervention for Substance Abuse Problems
Key Teaching Points
 Every attempt at questioning, providing feedback, or expressing concern about a
person’s alcohol/drug problem is an intervention
 There are various stages of readiness for change; sometimes people are
“Browsing” they are not quite ready to buy “recovery”. Motivational
interviewing teaches a method of approaching the belief systems, thoughts, and
attitudes that may block healthy choices.
 We are sometimes “romancing the stoned” in an attempt to establish rapport,
trust, and respect that this is their decision.
Chapter Outline
A.





B.
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Motivational Interviewing
Overview – Stages of Change and Therapist Tasks (see page 244)
Client-Centered Motivational Strategies
Effective Motivational Strategies
Active Ingredients of Effective Brief Counseling (see page 250)
O.A.R.S.
Intervention
Common Defense components of Resistance to Change
Interventions at Various Stages of the Alcohol/Drug Use Continuum
Nonuse Interventions
Initial contact interventions
Experimentation Interventions
Interventions at the Integrated Stage
Interventions at the Excessive Use and Addiction Stages
Obstacles to Intervention
Intervention Services
Intervention Approaches
Professional Intervention Assistance
Interventions as a Caring Response
Goals of intervention
Family Interventions
Candidates for Intervention
Stages of Formal Intervention
Assessment
Preintervention
Intervention
Postintervention
Chapter 10 Co-occurring Disorders with Substance Abuse
Key Teaching Points



Co-occurring disorders should be the “expectation not the exception” as stated by
Kenneth Minkoff, M.D.
We should expect that alcoholics/addicts and substance abusers would also have
some co-occurring disorder.
Co-occurring disorders can be treated or addressed at the same time in most cases.
Of course the disorder that requires the most stabilization would be of more focus,
before working on the other comorbid disorder.
Chapter Outline
A.
Definition of a Co-occurring Disorder
B.
Affective (Feeling) Disorders and Substance Use Disorders

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C.
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D.
The Difference Between a Depressive Mood and a Depressive Disorder
Denial and Depression
Categories of Mood Disorders
Major Depression
Dysthymic Disorder
Atypical Depression
Organic Depression
Bipolar Disorder
Mood Cycling Disorder
Personality Disorders and Substance Use Disorders
Personality traits vs. a Personality Disorder
Personality Disorder vs. Chemical Dependency Disorder
Antisocial Personality Disorder
Antisocial Personality Disorder and Chemical Dependency
Childhood Precursors of antisocial Personality Disorder
Denial, Alcohol/Drugs and Antisocial Personality Disorder
Borderline Personality Disorder and Chemical Dependency
Affective Disorders and Suicide
Chapter 11
Alcohol/Drug Treatment and Relapse Prevention
Key Teaching Points
 Treatment for chemical dependency is multifaceted.
 Although there are many common standards for chemical dependency treatment,
one size does not fit all. There is a universality of addiction and alcoholism but
each individual presents unique issues and problems in their quest for recovery.
 The more the treatment center and staff are capable of addressing these problems
the better the prognosis for sustained recovery.
Chapter Outline
A.
Self-Help Meetings
 Alcoholics Anonymous
 Advantages of AA as a Recovery Model
 Resistance to Attending AA and Other Self-Help Groups
 Application of Self-Help to Other Problems
 Rational Recovery
History of Alcohol/Drug Treatment
B.
Drug Addiction Treatment, 1960-1980
 Therapeutic communities
 Methadone treatment
 Outpatient Programs
 University Research Centers
C.
Alcohol Treatment, 1970-1980
D.
Disinterest in Alcohol/Drug Treatment, 1979s and 1980s
E.
Changes in the 1980s
 Cocaine Epidemic
 Risk of AIDS
 Treatment Trends
F.
Stages of Alcohol/Drug Recovery
 Withdrawal Stage
 Honeymoon Stage
 The Wall Stage
 Adjustment Stage
 Resolution Stage
 Period After the Resolution Stage
G.
Counseling and Chemical Dependency
 Early Phases: Safety and Stabilization
 Affect (Feeling), Recognition, and Modulation
 Family Treatment
 Group Therapy
 Intensive Treatment
H.
Relapse Prevention
 Recognition of the Signs of Relapse
 Habit
 Causes of Relapse
 Cravings and Urges
 Drug Relapse Induced by Alcohol Use
 Relapse Prevention Strategies
Lifestyle Imbalance
Interpersonal and Social Recovery support System
Health and Physical Well-Being
Cognitive, Emotional and Spiritual Self
Desire for Indulgence
AA Serenity Prayer as a relapse-Prevention Technique
I.
Controlled Drinking Controversy
Harm reduction approach
J.
An Effective Alcohol/Drug Recovery Strategy
K.
Treatment of Co-occurring Disorders
 Boundaries with Co-occurring Disorders Patients
 Dependent clinger, demanders, manipulative help-rejecters, selfdestructive deniers (see chart on page 324)
 Counseling for Co-occurring Disorders
Breaking Denial – Educating and Empowering Patients
Developing Skills for Co-occurring Disorder Patients
Feelings and emotional buildup
Cognitive-Behavioral Approaches
 Treatment Compliance – Medications
 The Family of the Co-occurring Disorders Client
L.
Suicide and Alcohol/Drugs
 Clues to suicide