Part III
Psychology Of Addiction
Chapter 6
Addiction across the life span
Erik Erikson’s Stages
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 12-17 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 Gilligan’s criticism.
Adolescent Brain
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Prefrontal cortex matures until mid-20s
Evidence of brain immaturity during the teen
years comes from MRI scans of the
adolescent brain
Teenage Drinking Use
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Identity vs role diffusion
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Alcohol is the drug of choice by American
teens aged 12-17
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Less smoking by teens in the US then
previously
Argentina
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16 year old exchange student found:
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No drinking age
Wine or beer with supper
Drinking to be social not to get drunk
What the U.S. can learn from Argentina
Focus on moderation and adult supervision
SAMHSA Household survey reported
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Cigarette use 10.8% with 12 to 17 year olds (2006)
Binge drinking by almost 20% of youths aged 16 and 17
Rates of current illicit drug use for ages 12-17 for major
social/ethnic groups:
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Whites 8.1%
Hispanic 7.6%
African American 9.7%
American Indian/Alaska Native 12.8%
Persons reporting multiple race 12.2% (high rates of drinking and
smoking as well)
Asian Americans 3.1%
2006 School Surveys Reported:
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Use of alcohol, the most dangerous drug—car 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
School surveys show African Americans and Latinos
have rates of illicit drug use lower than that of whites
Rise in use of painkilling drugs—OxyContin used by 4%
in recent survey; 9.5% used Vicodin.
In Europe WHO survey :
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European kids: 16% tried marijuana, 6% another illicit
drug, 37% smoke regularly
vs. 41% in US tried marijuana, 16% amphetamines
Smoking age 13—10% Europe vs. 4% US
Alcohol used regularly 24% Europe compared to 16%
US
Drunkenness in European teens highest in Denmark,
Ireland, UK; lowest in Mediterranean countries
College Students
• 40 % binged on alcohol in past two weeks
• Rivera Live: $10 billion alcohol consumed by under
21
• Beer and liquor companies most well funded
lobbies
• $1 billion White House advertising
campaign anti-drug ads.
• Proposal to include alcohol in ads, measures failed.
• New law promises to change this, 2007.
Risk Factors for Later Problems:
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Turbulent teen-father relationship
Child abuse and other trauma
Kids who start smoking early
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.
Obsession leads to major problems with eating, such as
anorexia and bulimia.
Society’s Influences
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Tobacco companies targeting kids; Field
and Stream—ads for smokeless tobacco
Children learn gambling on the Internet;
Video poker, slot machines, and the
lottery
Strenuous exercise programs reduce
smoking. Smoking may be considered a
gateway drug.
Predictions from Scandinavia:
• High risk: girls who cry easily when teased are anxious
and shy.
• 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
Child Abuse
Alcohol and other drug abuse are factors in 7 out of 10
cases of child abuse or neglect. Treatment for parents is
scarce.
• According to one study, children who are spanked and
slapped are twice as likely to develop alcohol and other
drug abuse problems.
• Traumatized children often are unable to cope with
psychological stress later. Depression, a key factor; trauma
> changes in the brain.
• Animal studies show stress and alcohol consumption levels
are highly correlated.
• Sexual abuse is correlated with earlier onset of alcohol and
illicit drug use.
•
Child Abuse continued
• 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
• Abused girls are more likely to be diagnosed
with post-traumatic stress disorder and major
depression.
Risks for Girls
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Daughters of alcoholics at increased risk
for alcoholism.
Teenage girls who are heavy drinkers are:
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five times more likely to engage in sexual
intercourse.
a third less likely to use condoms
which can result in pregnancy and
contraction of sexually transmitted diseases
including HIV/AIDS
Risks for Boys:
• Biggest threat to life and health for adolescent
boys is alcohol-related accidents
• Male counterpart to anorexia in females is
muscle dysmorphia.
• Dysmorphia-- newly identified psychiatric
disorder in DSM IV.
More Risks for Boys
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DSM-IV-TR discusses body dysmorphic
disorder—muscle dysmorphia only briefly
Obsessive body building major problem for
young males
Revealed in popularity of anabolic steroids
Steroids used by 2.7 % of all male high school
students.
Health hazards: stunted growth, acne, and
shrinking testicles.
Binge Drinking: College
• 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.
• 44.8% of college students report binge drinking; about
half of them under age 21
• “Party till you puke!” signs were posted on one
university campus
Modern Form of Prohibition
• 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.
• Social norms campaign with messages of
moderation were unsuccessful.
Need for Harm Reduction
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College newspaper slow to restrict enticing beer ads.
Most binge drinkers mature out of wild drinking
days of early adulthood. But 1,700 college students
die each year from alcohol-related injuries.
Cigarettes--abstinence probably works better than
moderation here.
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.
Harm Reduction:
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Need for drug courts--important for family
preservation and closely supervised treatment
Forbid “happy hours,” free drinks on 21st birthdays at
bars.
Lower drinking age laws; discourage drinking hard
liquor
Encourage adult supervision with kids who are
drinking. Encourage moderate drinking as with meals.
Serve food with alcoholic beverages.
Motivational Principles from Social
Psychology
From Elliot Aronson, The Social Animal
• If you state a position, you will be wedded to it.
• A small commitment to take action goes a long way.
• People with high self esteem can easier resist
temptation.
• Working toward a goal might pay off eventually.
• Change of attitude might help.
• People desire to reduce dissonance.
Miller and Rollnick: MI Strategies
They list the following traps to avoid:
– Premature focus, such as on client’s
addictive behavior
– Confrontational round between therapist
and client over denial
– Labeling trap--forcing the individual to
accept a label alcoholic or addict
– Blaming trap, fallacy that is especially
pronounced in couples’ counseling
Primary Prevention to Reduce
Risks:
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Child abuse, early-prevention education and
treatment programs
Smoking education to keep youths from ever
starting to smoke
Health and skill education at schools
Reducing ads promoting addictive behavior
Advocacy for the hiring of more school counselors
and social workers
Stage-Specific Motivational
Statements:
Stage of Change: Precontemplation
– Goals are to establish rapport
– Counselor reinforces discrepancies
Adolescent comment: “My parents can’t tell
me what to do; I still use and I don’t see the
harm in it- do you?”
Motivational Enhancement
continued:
Stage of change: Contemplation
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Ask: How was life better before drug use?
Emphasize choices
Typical questions are:
-What do you get out of drinking?
-What’s the down side?
Contemplation Stage continued:
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• Typical adolescent comment:
I’m on top of the world when I’m high, but
then when I come down, I’m really down. It was
better before I got started on these things.
Preparation Stage:
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Setting the date
What do you think will work for you?
Adolescent comments, “I’m feeling good about
setting a date to quit, but who knows?”
Action Stage:
Adolescent comment: “Staying clean may be healthy,
but it sure makes for a dull life. Maybe I’ll check out
one of those groups.”
“Therapist: “Why don’t you look at what others
have done in this situation?”
Help locate an appropriate group.
Maintenance Stage:
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Adolescent comment:
“It’s been a few months; I’m not there yet but I’m
hanging out with some new friends...”
Resistance:
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Inevitable
Miller advises roll with it— “roll with
resistance”
Use reflective summarizing
Gender Specific Approach for Girls
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Equality does not mean sameness.
Programs for girls do better when they focus
on relationships.
Waterloo,Iowa --group home-- Quakerdale
specializes in care of teenage girls.
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Learning of life skills
Gaining competency as in art
Elderly Substance Abusers
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13% of U.S. population over age 65
More men with alcohol problems
Elderly consume 20-25% of all prescription
medications
Two types of elderly alcoholics: early and late
onset
Early onset- - more severe levels of depression
and anxiety
Facts about Elderly Drinking
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Elderly consume less alcohol than the young.
Trend toward nursing homes for short-term
alcoholism rehabilitation
Many male ex-alcoholics reside in nursing
homes
More Facts
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Many early onset suffer from Korsakoff ’s
syndrome and other alcohol-related
neurological problems.
Medical complications:
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Hip fracture, suicide, brain damage
Late onset…more women here, close family
ties
Counseling Older Clients
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DWI and effect on self image
Age segregated vs. mixed ages in treatment
Guidelines for work in groups with elderly:
-Avoid strong language, rebuild support
systems
-Keep pace slow
Relapse Prevention:
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Teach elderly 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
Focus on critical thinking skills.
Help clients renew their commitment to sobriety;
Find effective coping styles;
Build support systems;
Remember that non-confrontational approach is best.
Counselor Pitfalls: (Beechem, 2002)
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Anticipate feelings of guilt and shame in elderly
clients in trouble with the law;
Ageism
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Countertransference
Denial in assessment
Sympathy not empathy
Loss and grief in family members of addicted
persons:
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Types of Guilt
Survivor guilt
 Helplessness
 Ambivalence
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Spiritual healing—sense of meaning,
connectedness
Strength from 12 Steps
Spiritual Healing
If there be grief, then let it be but rain,
And this but silver grief for grieving’s sake.
William Faulkner
Today, social work education stresses importance of
helping clients find spiritual meaning.
Higher Power as nature in Norway, Native American
traditions.
Search for forgiveness and renewal
12 Steps as guide to self knowledge
Chapter 7
Eating Disorders, Gambling,
Shopping, and Other Behavioral
Addictions
Eating Disorders
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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”
90% of anorexia and bulimia is found in females.
Begins in adolescence
.5% of girls and women are anorexic, 1-3% bulimic.
Anorexia
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Less than 89% of normal body weight and
fine body hair.
10% mortality rate, often by suicide,
correlated with perfectionism, ritualism, high
anxiety
Related to obsessive compulsive disorder
(OCD):
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obsessive--recurrent and persistent thoughts;
compulsions—ritualistic practices.
Bulimia
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Gay men at risk.
Bulimia with alcohol misuse--30-70%
35% of bulimics experienced childhood
sexual abuse and use food as a drug
Little information on compulsive overeating.
New studies show lack of dopamine
receptors in the brains of morbidly obese
Some after gastric bypass surgery turn to
heavy drinking
Interventions
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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.
Bulimia—cognitive treatments; avoid
strict dieting
Anorexia—Prozac is effective in reducing
compulsive behavior but only when
weight has been gained.
Men—muscle dysmorphia,
antidepressants may help here too;.
Treatment
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Overeaters anonymous (OA) for compulsive
eating;
Group treatment.. teach moderation—CBT
Theme of neuroplasticity—brain neurons
can form new connections; “brain lock” can
be corrected (Schwartz)
Box 7.1 compares two treatment programs;
the second one in Kansas City included
trauma work
Gambling Addiction
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Gambling, has become socially acceptable
Criteria of pathological gambling--preoccupation, increasing amounts, etc. 3-7%
of gamblers have problems, suicide high in
gamblers
Cost to economy is $54 billion—bankruptcies,
lost work time, crime, etc. Very high among
Native Americans—over 14% have gambling
problems
Research shows counties with gambling casinos
have higher crime rates and bankruptcies than
others
Gambling continued
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Problems among the elderly
Internet gambling is the fastest growing form.
2-4% in Gamblers Anonymous (GA) are women.
But many helpline calls.
Women gamble to escape; men for action.
Associated with other problems
Box 7.1 Reflections of a Male Compulsive
Gambler. Geographical relocation helped him
break his habit.
Questions for Screening
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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 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?
Treatment Issues
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Treatment: cognitive work and
motivational therapy
Irrational thinking about winning:
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“I put so much money in this machine,
I’m bound to win.”
High profile winners
Lucky machine and dates
States’ spending on treatment--$36
million is small compared to $20 billion in
tax revenues from gambling
Shopping Addiction
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Problems in about 2-8% of people
Typical 31 yr.old female who has overspent
for 13 years.
DSM-IV-TR lists Kleptomania;
Medications: Luvox
Debtors Anonymous groups springing up
Cyber Addiction
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Caught in the Net– Internet addicts:
preoccupied, excessive amounts of time
involved in chat rooms, playing games;
Jeopardized relationships.
Fantasy world—fictitious names, office
problems
Self-efficacy for empowerment
Korean government training psychiatrists to
help treat
FRAMES
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Feedback – assessment of use
Responsibility – choice is theirs
Advice – set goals together
Menus – of self-directed change options (ex.monitor computer use)
Empathy
Self-efficacy
Harm Reductions Strategies:
-Get a timer
-Cut mailing lists
-No detours
Sex Addiction
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Risk taker
Cognitive therapy recommended.
Prone to lying—one TV broadcast looked at
President Clinton’s background and his
sexual risk taking: he grew up in alcoholic
home, engaged in risk taking, having out of
bounds sex
Self-help group--Sex Addicts Anonymous.
Cognitive Therapy
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Distortions especially with these addictions
and anorexia. Tendency towards extreme
behavior.
Slogans of AA (“easy does it”)
Rational recovery, MET, REBT more
adversarial, focus on current beliefs
Cognitive Therapy continued
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Teach clients to avoid black and white thinking.
Ask about times when client successfully
handled a problem.
Use regular assessment for disease of
addiction.
Feeling work
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Positive reinforcement and reframing
Stress management--- modify thinking,
exercises for group work: art work can reveal
underlying feelings.
Therapy
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Positive reframing and self talk…. Cognitive
therapy can be directed toward the past as well as
the present.
Feeling work—Anger management. Anger as a
cover. Avoid all-or-nothing thinking.
Stress management---- drink milk, use self talk,
get exercise.
Group exercise: art, faces, grief and loss, quiz
cards, dreams, assertiveness.
Chapter 8
Substance Misuse With A Co-Occurring
Disorder Or Disability
Co-Occurring Disorders
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Double whammy—substance dependence and
mental disorder. Bipolar—feeling high can imitate
drug use;
Integrated Approach—fits with harm reduction
About a third of addiction treatment programs
now include treatment for psychiatric disorders.
Only 8.5% offer integrated programming (2006)
Sample of people with schizophrenia—79% had
alcohol problems, 46% cocaine, 32% marijuana,
8% opiates.
Co-Occurring Disorders continued
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Addiction counselors often explain
psychosis as drug induced.
Mental health professionals tend to see
alcohol use as self medication.
Truth is both/and, not either/or.
Coexisting disorders: anxiety, compulsive
gambling, eating and mood disorders.
Disorders that Often Co-exist with
Substance Abuse:
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Anxiety
Compulsive gambling
Mood disorders
Eating disorders
Personality disorders
Psychosis
Personality Disorders:
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Borderline personality
Anti-social personality
These diagnoses often based on cultural
biases
Integrated treatment needed
Need to offer better housing, can rely on
funding by Supplemental Security Insurance
(SSI)
PTSD
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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
High rate of relapse among women in substance
abuse treatment with PTSD upon release
High anxiety a problem
Trauma from natural disasters such as Hurricane
Katrina
PTSD after Combat
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At least 1 in 6 veterans of war in Iraq has
PTSD
Flashbacks common
Immediate intervention with SSRIs
recommended to offset formation of locked
memories
Women seeking help for rape trauma,
someimes from attacks by fellow soldiers
Bipolar Disorder
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From mania to depression
90% with this disorder have substancerelated problems in a prison sample
Schizophrenia
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About 1% develop schizophrenia
Delusions, hallucinations, apathy and loss
of pleasure, problems concentrating
John Nash, A Beautiful Mind
48% have substance-related problems, a
variety of substances used
“No wrong door” to treatment
Prone to homelessness; Housing First
programs
Case Management of Homeless
Persons with Co-Occurring
Disorders
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Read “ A Day in the Life of a Mental health
Case Manager” (Box 8.2)
Case management--housing, shopping,
medications
Harm reduction, the goal
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 treatment
Part IV
Social Aspects of Addictions
Chapter 9
Family Risks and Resilience
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Addiction is a family disease…pain and stigma.
Box 9.1 Des Moines Register “Children of Addicts”—meth
labs, family fights, and child neglect in Iowa
Classic Family Structure:
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Addict as symptom of carrier.
Faulty communication in family >anorexia
Confusion of cause and effect
Family therapy field, little attention to addiction problems
except as symptoms
Little attention to cultural diversity as well. See McGoldrick
et al’s Ethnicity and Family Therapy (2005)
History of Family Treatment
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Lack of insurance prevents emphasis on
family treatment
Virginia Satir: studied family adaptation
to person’s illness.
Claudia Black
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“It will never happen to me”
Don’t talk, trust, feel—co-alcoholic,
codependent.
Al-Anon—1950s
Wegscheider’s Role Theory
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Codependent person, chief enabler—terms took
on negative connotations later.
This text uses the more positive term, family
manager instead of chief enabler.
Wegscheider’s 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.
Figure 9.1 Family Forms
Enmeshed family: Spouses are estranged: one
child here is enmeshed with father, one with
mother
F
C
M
C
Isolated family:
Lack of cohesion and social support. Each
member is protected by wall of defenses.
F
C
C
M
Healthy family:
All are touching, but their boundaries are
not overlapping.
F
C
C
M
Stages of Change and Family:
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1. Precontemplation: Counselors describe
family communication patterns.
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 addict’s actions.
Stages continued
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4. Action:
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Rehearsal and treatment of family without
addicted member.
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Therapist feedback—Example 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.
Maintenance:
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5.
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Focus on process not content “what to do
if….” Transition with sobriety.
Cultural Considerations
McGoldrick et al’s book on different ethnicities.
Describes work with:
• African American families—reciprocity a strength
here
• Latino families—avoid a businesslike approach
• Asian and Asian American families—engage most
powerful person in the family
• Appalachian families—engage the women who
will teach health care practices
Rules of Fighting Fair
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Attack behavior, not person
Keep issues of manageable size, don’t
label,
Don’t use negative labels.
Don’t rehash the past.
Three R’s Model
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Rename: No labels, shopping addiction as
illness, not foolish spending.
Reframe: help client see things happen for a
reason
Reclaim: healing, we-ness, family circles to
make decisions (from Native Americans)
Kathy and Ed: Case Study
Exercises Related to Family Work
1.
Drawing family maps, circles
2.
Relapse prevention plan.
3.
Viewing excerpt from a movie or
videotape.
Chapter 10
Racial, Ethnic, and Cultural Issues
Minority Group Membership
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Need to have social political context of
being minority.
Treatment must take into account
ethnoculture norms.
Importance of class—bell hooksClass affects adolescents access to drugs
Often as acculturation increases, so does
substance misuse
Asian Americans/Pacific Islanders
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Low rate of substance addiction—around 4.5%
High rate of meth use in Hawaii
Japanese Americans drink much more than Chinese
Americans
Success often is related to their level of education at
home and urbanization.
Cambodians - war trauma.
Asian Americans - highest income of all ethnicities,
filial piety.
Emotional sharing may lead to loss of face.
Immigration, a major stress
For Native Hawaiians female elders provide culturally
based treatment
American Indians and Alaskan
Natives
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Historical trauma—racism and children sent to
boarding schools
Native Americans are less than 1.5% of US
population: highest rate of substance misuse:
12.8%. Drug use--21%
About double rest of population, cigarettes--53%
use.
High poverty, alcohol abuse, youth inhalant use
Use of Medicine Wheel for holistic, spiritual
framework, talking circles. (Box 10.2)
Red Road to Sobriety.
Latinos
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14% of population (California: 1/3 of population)
58% of Hispanics in the U.S. are Mexicans.
Substance abuse higher among Mexican Americans
(5.6%) and Puerto Ricans (3%) than Cuban Americans
(.9%).
In U.S. 30% of Latinos smoke. Less among women but
increasing.
AIDS, the 2nd leading cause of death.
Group has the highest high school drop-out rate, Puerto
Ricans, the highest poverty rate at 31%.
Male/female role differentiation.
Work with family should support family strengths.
African Americans
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About 24% of treatment population but drug use is not
much more than that of general population.
Women tend to abstain..
52% of all new HIV cases are African American.
Higher social class and church attendance are
protective factors.
Twice as many are in poverty as whites.Higher social
class a protective factor.
Almost half of advertising budget targets blacks.
Recovery relates to spirituality and family support.
David Goodson quote: “ deals with cultural pain.”
Harm reduction techniques recommended.
Project Safe
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Rockford, Illinois child welfare program was
highlighted in the Bill Moyers PBS series on
addiction.
Graduation ceremony
Remarkable outreach worker.
Chapter 11
Gender and Sexual Orientation
Differences
Gender Issues
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Prevalence of addiction varies by culture, low rate of
Korean women.
In American high schools, substance use rates about
the same. Adult men, higher drug use rates
Female prescription drug problems higher
More eating disorders in women
Women in treatment tend to have male drinking
partners.
South Dakota---forces pregnant women with alcohol
and drug problems into treatment.
240 women in the U.S. criminally prosecuted for
harming unborn children but Supreme Court says only
testing of hospital patients with their consent.
Gender Differences
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War on Drugs---in states 45% of female prisoners are in need
substance abuse treatment compared to 22% of men.
Violence---3 of 4 intimate partner murders are of women.
Women alcoholics ---47% in treatment molested as children in
study of 472 women (Down’s).
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.
Biological differences—women get intoxicated quicker, have a
higher mortality rate with heavy drinking, lives are shortened by 15
years on average with alcoholism.
Sexual Orientation
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Heterosexism and homophobia: U.S. studies of schools
shows suicide is 14 times the heterosexual rates.
Lesbians—lowest 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 rate—gay bar, fewer are
mothers….G/L AA.
Gay males—high risk of sexual abuse in jail cells.
Religious fundamentalism correlated with
suicide…alcohol problems persist across life span.
Transgender….See Do’s and Don’ts…table 11.2
Resources: Pride Institute and PFLAG
Chapter 12
Mutual-Help Groups
Mutual Aid Groups
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Confusion—12 Step facilitated treatment and 12
Step self help groups (far more tolerant and
non-judgmental).
AA – spiritually based fellowship is free
Voluntary treatment: consistent with harm
reduction.
Involuntary treatment for those who failed at
moderation.
Twelve Steps
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Presented in Box, p. 494 . Starts with Step 1: We
admitted we were powerless over alcohol—that
our lives had become unmanageable.
Greater involvement in AA found to effective.
Use of narratives…stories of powerlessness
over the addiction, lives out of control…
Feminist objections to 12 Steps
Metaphor of disease—mental, physical, and
spiritual, metaphor of powerlessness
Means of expanding treatment.. words in Big
Book…One day at a time…Higher Power.
Other Self-Help Groups
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GA
NA
Women for Sobriety
SMART Recovery----cognitive approach.
Moderation Management—starts at 30 days of
abstinence, a harm reduction strategy
[Some say 12 Steps should be modernized. See
one attempt—9 Steps at
www.katherinevanwormer.com]
Chapter 13
Public Policy
Policy Issues
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•
•
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War on Drugs is not harm reduction, but
harm maximization
SSI (Supplemental Security Income) for
alcohol/drugs disabilities has been
discontinued
Managed care, reduced inpatient coverage,
reductions in Medicare reimbursement
Promising developments—drug court, mental
health courts
Welfare Reform
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•
•
Federal government denies benefits to needy
people with alcohol and drug problems
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
Federal Laws
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Confidentiality: need consent forms signed.
Treatment options to AA—Supreme Court ruling
related to separation of church and state.
War on Drugs—failed policy, most agree in survey:
injustice, racial oppression, huge expense.
Media hype about drug crime, mandatory minimum
sentencing.
52% of men in federal prison are black.
Mothers of crack babies given punitive treatment.
Mandatory Sentencing
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•
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Women have the fastest growing prison population rate,
especially in federal prisons
1986, federal mandatory minimum sentencing laws
enacted
Impact on the imprisoned mothers’ children is
considerable
US Supreme Court 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
Civil Asset Forfeitures
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•
Police seize property (cars, houses) related to
crimes committed based on “a mere
preponderance of evidence”
Oregon requires a conviction first.
Partners of drug dealers often pay the price
Informants awarded part of the value of the
goods seized
Harm Reduction Strategies
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Needle exchange serves only 15% of drug injectors.
Methadone and buprenorphine maintenance
Heroin prescribed to addicts in some European
countries
Drug courts: a promising strategy, cost effective for
communities
This text argues not legalization but for middle of the
road policies—decriminalization—to reduce harm.
The End
Addiction Treatment: A Strengths
Perspective, 2nd ed.