Week Nine - Lecture notes 9 PDF

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General Theories on Substance Abuse & Treatment There are five general (historical?) categories that can help explain why people become addicted to drugs (and other behaviours). Each theory has implications for designing treatment (and/or policy) of substance abuse. In thinking back to your own perspectives on addictions, which of the following general theories most aligns with your opinion on how to explain an addiction?

Moral Model In this very historical theory, individuals are seen as personally responsible for problems they may have from their drug use. It is regarded in this way, “If you choose to drink, smoke or shoot up, it’s your own fault. You can choose differently”. Blame is on the individual user and this person is often seen as ‘weak-willed’. Despite this theory being the most historical in nature, many people still have a strong perspective that addicts are lesser and weaker than others.  If you chose this model as the best explanation for the cause of addiction, then the treatment philosophy follows that the person should be punished for their illegal acts and put in jail or fined; also, the person should be treated spiritually (i.e. in order to rid them of their weak-will).

Disease Model jellinek In this popular medical theory, addiction is seen as a progressive, irreversible disease based on physiological (Biological), spiritual, psychological causes. The idea of progression is important to be recognized, as addiction is not seen as happening overnight, but as a condition that gets worse and worse until ‘rock bottom’ (See The Jellinek Curve --->) If you choose this model as the best explanation for the cause of addiction, then the treatment philosophy follows that identification of those with addiction is necessary in order to treat, confront, and persuade them to avoid continuation of the addiction. Abstinence is the goal to ‘recover’ from addiction, but not rid of it. Similar to cancer patients – they can go into remission, but may not be ‘cured’ of cancer.

Social Learning Theory In this psychological theory, it is believed that the cause of addiction is a result of learning and interaction with others in the environment that promotes positive outcomes of drug abuse. For example, seeking satisfaction from drugs while engaging with friends and fun promotes the continuation of drug-taking behaviours. (I.e. the belief that drugs are helpful to get through difficult times or failure to learn how to cope in other ways). We do what we learn from others, especially if we are rewarded for that behaviour. 

If you choose this model as the best explanation for the cause of addiction, then the treatment philosophy follows that changing the environment to reinforce non-abuse is most important. The goal of treatment is to focus on positive ways to engage with the environment and teach alternatives to drug-taking.

Sociocultural Theory In this cultural theory, addiction and abuse behaviours are a result of societal and subcultural norms and attitudes. Both society and culture shape and influence the way we behave and interact with drugs and other addictive behaviours. Our social norms and laws demonstrate what our society views as acceptable and not acceptable regarding drug use and addiction. That's why our society looks at drugs such as marijuana and alcohol differently than other illicit drugs, like cocaine.  If you choose this model as the best explanation for the cause of addiction, then the treatment philosophy that follows is to intervene in ways that affect society or large subgroups of society. In other words, change the attitudes, beliefs and values regarding addiction to inform new norms in society. A good example is smoking laws - Think about how culture has changed our ideas of how safe we thought smoking was in the past! 

Biopsychosocial Model You may have noticed that the above five general theories of substance abuse and treatment do not have much overlap and their implications for treatment depend heavily on the perspective. biopsychosocial model Much research on the complexities of addiction support a more comprehensive theory – biopsychosocial model – which focuses on more than one domain of causes for an individual’s addiction. For example, not all children of alcohol dependent families also have an addiction to alcohol. The biopsychosocial model considers, together, biological, psychological and social factors that may influence a person’s susceptibility towards addiction.

Self-Help Groups

Alcoholics Anonymous (AA) AA is probably the most well-known Anonymous group regarding addiction treatment. What makes AA a self-help group is that they are run by non-professionals with life experience. It is considered an historical model that still continues today. The ultimate GOAL of AA (and all other Anonymous groups) is abstinence! 

These models outline 12-successive measures (steps) that substance abusers (alcohol, narcotics, etc) need to accomplish during the recovery process. For example, members aid recovery through peer identification and learning from the experiences of others, and building social relationships and networks. Anonymous groups often run in conjunction with professional services in the community or treatment centres. You can review the Twelve Steps of Alcoholic Anonymous on page 341 Table 14.1 of the textbook.

Women for Sobriety (WFS) WFS groups look at addiction as a progressive illness, like a disease, and focus on the person’s responsibility and acceptance of changed ways. Similar to AA, a moderator leads weekly groups which focus on peer identification and special psychological and social needs for women in achieving sobriety.  Self-Management & Recovery Treatment (SMART) self-help groups focus on four key areas of recovery: Enhancing and maintaining motivation, Coping with urges, Managing thoughts, feelings and behaviours, and Living a balanced life. Its goals are similar to cognitive-behavioural principles which focus on aligning positive thoughts with positive behaviours by providing alternative ways to think and behave.

Treatment is defined in your textbook as “planned activities designed to change some pattern of behaviour(s) of individuals or their families” (p. 337). There are several ways that individuals can go about treatment. Some drug abusers simply decide to quit on their own and can remain successful; while others seek support from self-help groups, such as Alcoholics Anonymous. If individuals initiate formal treatment, such as therapy, or counseling, there must be some type of assessment completed to help understand and move towards treatment goals.

Historically, ambivalence and lack of motivation was seen as 'denial':

Denial was seen as resistance, an unwillingness to change, a trait of addicts that required confrontation. Watch the following clip to learn more about denial from the perspective of individuals previously dependent on alcohol:

Today, we understand that… Ambivalence is not pathological to the addict, it is a universal human trait that reflects our tendency to ignore or resist confronting behaviours that require change. Motivation is a state of commitment that is changeable over time and requires focus and action. Resistance needs to be met with reflection in order to move forward with changing behaviours. Client (addict) is the “expert” and should be involved in setting goals when in treatment for success.

Professional Treatment Professional treatment for addictions typically undergoes a process that entails an assessment of the individual’s influencing factors and a treatment plan to meet specific goals. An overarching assumption in professional settings is that good assessment underlies good treatment. Remember: The goals of drug treatment may be more than the stoppage of drug addiction. Changes in a person’s family, work and social functioning may also be important for successful treatment to occur.

General Therapeutic Strategies

Pharmacological Treatment: Medical Detoxification It may be necessary for a patient to be systematically withdrawn from drugs (heroin or alcohol are good examples). Detoxification removes the physiological (physical) withdrawal symptoms to minimize the brutal and overwhelming physical complications with stopping the use of drugs. However, detoxification does not remove the psychological withdrawal symptoms (i.e. cravings, mood). Detoxification is often used as a precursor to treatment and is most successful with formal assessment and treatment of psychological dependence.

Alcohol is a depressant - Which means it slows down your CNS and slows down the brain firing (remember action potential) resulting in slower reaction times and impaired judgement while intoxicated. As it changes the cell functioning it also effects our short term and long term memory. Alcohol abuse also impacts other systems in the body such as liver functioning. Alcohol is one of the only drugs that withdrawal symptoms can actually lead to death. Antabuse (disulfiram) - One example of medical detoxification for alcohol dependency is the drug, Antabuse (disulfiram). Antabuse makes the individual throw up if taken with alcohol in the body. This negative consequence (i.e. vomiting) becomes associated with drinking. Antabuse and other forms of detox including opioid agonists and antagonists are typically administered at methadone clinics.

Cognitive-Behavioural Treatment: Motivation Enhancement Therapy (MET)  MET is a behavioural counselling approach to treatment that seeks to promote and enhance the client’s (the individual with addiction) readiness to make the change, and facilitates self-change. The counselor monitors behavioural changes of the client and provides feedback about the connections between drug use and negative consequences. Key things: Client is provided with feedback to focus on self-motivational statements (positive statements toward abstinence, for example: “I do not need to drink today”) and self-talk  Coping strategies are discussed for high-risk situations to anticipate and move forward

Sociocultural Treatment: Managed Care Managed care is a sociocultural strategy for controlling access to continuing care to establish a process for assessment and follow-up for addictions and services. Typically managed care approaches offer outpatient follow-up for addicts to reduce repeat visits to the Emergency Room and In-patient services. Example 1: Outpatient Treatment Focus on drug education, warnings, advice Group counseling is often emphasized Example 2: Residential Treatment** This is what Quentin Warner House does Can be short-term or long-term Focus on daily care for ‘resocialization’ back into the community – offers an examination of individual’s personal accountabilities, etc.

Motivation to Change There are many different factors that can motivate an individual to seek help for their addiction. While an intervention by family members or law enforcement can lead to formal treatment, an individual’s readiness to change is a key factor in the success of any treatment. Research has shown that motivation to change is not just all or nothing. They suggest that it is stage like. Some individuals never go through all of the stages, while others remain at some stages for a long time. Relapse is considered a normal part of the change process in these models.  Common sense tells us that in order for someone to change (i.e. quit their addiction), they need to acknowledge they have a problem and be motivated to change. Motivation to change is seen as an important factor for behavioural treatment of addictions. 

For detailed information about each of the Stages of Change, click here You should understand each of the markers of change for each stage and the key decisional balance for each. (This will also help you with the Wellness Activity). In this model, motivation is the central and necessary driver of behaviour change. This model explains how people change, not why they change. Each stage represents a different level of motivation, marker of change, and challenges associated with goals. Understanding a person’s motivation level, perception of the problem and readiness to change plays a role in determining the timing and type of treatment or intervention.

 Recent Research Indicates No single approach works for all individuals The right treatment improves outcomes Brief interventions can be effective Treating other life areas improves outcomes Cutting down addictive behaviours improves other life areas There are multiples measures of success (i.e. moderation)...