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1、PowerPointforAddictionTreatment:AStrengthsPerspective3rdEditionKatherinevanWormerDianeRaeDavisCengagePublishingCompany2012copyrightPartI:Introductionn nAddictionaffectsusall.Strengthsperspectivestrengthsofclientsandstrengthsofthecontemporarymodels:n nH Harmreductionarmreductionn n12Stepapproach.12St

2、epapproach.n nRiftinfield.n nBookin3parts:bio-psycho-socialChapterINatureofAddictionn nExamplesofaddiction-smokerdyingofemphysema,crackaddictarrested,pregnantmotherdrinkingheavily,girlhookedonmethshestartedusingtoloseweightn nEconomiccosthealth,warondrugs,over1millioninprisonfordruginvolvement.Bigbu

3、sinessgambling,PhilipMorris,beerWhatisaddiction?n n(Latin)addictus-attachedtosomething,positive.Todayalcoholismcalleda“braindisease”orbadhabitorsin.Leadingassumptionofthetext:Addictionisthekey,notthesubstanceorbehaviorn nAddictiondefinedbyresearchersas“abadhabit,”“abraindisease,”“helplessness,”“apro

4、blemofmotivation”DSM-5ChangestoDSMinnewedition:nolongerdichotomyChangestoDSMinnewedition:nolongerdichotomybetweenabuseanddependencebetweenabuseanddependenceAddictionnowthepreferredterminsteadofdependence.Addictionnowthepreferredterminsteadofdependence.Addictionnowseenasacontinuum.Addictionnowseenasa

5、continuum.Substance use disorder Substance use disorder requires2offollowing:requires2offollowing:tolerancetoleranceinabilitytostopinabilitytostopwithdrawalproblemswithdrawalproblems excessivespendingoreffortexcessivespendingoreffortusemorethanintendedusemorethanintendedtoobtaintoobtainreducedinvolv

6、ementreducedinvolvement continuedusecontinueduseDefinitionsAddictionpatternofcompulsiveuse.Hasphysical,psychological,socialaspects.Emphasisonprocessratherthanoutcome.GamblingnowconsideredanaddictioninDSM-5Patternofpreoccupation,lackofcontrol,formofescape,chasingoneslosses,seriousconsequences.Box1.1A

7、SocialWorkMajorWorkinginaCasinon nWhatistheethicaldilemmahere?n nHowdothemanagersensurethatthegamblerskeepspendingtheirmoney?n nHowaretheemployeescontrolledbytheestablishment?TheDiseaseConceptn nIsalcoholismadisease?n nArgumentspro:n nArgumentscon:First,DefineDiseasen nDiseaseDisease-asmetaphorbyJel

8、linek:“alcoholismis-asmetaphorbyJellinek:“alcoholismislikelikeaadisease”disease”n n Random House Dictionary, Random House Dictionary,diseaseisaconditionofthebodydiseaseisaconditionofthebodyinwhichthisisincorrectfunction.inwhichthisisincorrectfunction.n nOxford University DictionaryOxford University

9、Dictionarydiseaseisabsenceofease(indiseaseisabsenceofease(intreatmentdiseaseas:primary,progressive,chronic,andtreatmentdiseaseas:primary,progressive,chronic,andpossiblyfatal).possiblyfatal).n nIllnessIllnesstermpreferredhere,lesscontroversial,lessmedical.termpreferredhere,lesscontroversial,lessmedic

10、al.n nBestargumentsprodisease:Bestargumentsprodisease:alcoholismisabraindiseasealcoholismisabraindiseasebecausetheaddictedbrainhaschanged.becausetheaddictedbrainhaschanged.n nBestargumentsagainst:Bestargumentsagainst:justahabit,abehavior,needtotakejustahabit,abehavior,needtotakeresponsibility,people

11、matureoutofit.responsibility,peoplematureoutofit.Biopsychosocial-spiritualModeln nWhy(bio),what(psycho),where(social)n nNeedforspiritualhealing,connectionwithHigherPowern nInteractionismandcycleofpain:painandsufferinglosspain,stressanddrinkingmorepainn nFamilyasasystemininteraction,rolesWhyDoWeNeedt

12、oKnowaboutAddiction?n n80%ofpeoplebehindbarshaveproblems,pervasive80%ofpeoplebehindbarshaveproblems,pervasiveinchildwelfaresystem,alcoholismintheworkplace.inchildwelfaresystem,alcoholismintheworkplace.n n71%ofsocialworkersworkedwithclientswith71%ofsocialworkersworkedwithclientswithsubstanceusedisord

13、ersinthepastyear.substanceusedisordersinthepastyear.n nHeadlines:Headlines:-“WhenTanningTurnsintoanAddiction”-“WhenTanningTurnsintoanAddiction”-“Help!ImAddictedtoFacebook”-“Help!ImAddictedtoFacebook”n nRelevantmovies:Relevantmovies:28 days28 days, ,Traffic, Walk the LineTraffic, Walk the LineTable1.

14、1ContrastTraditionalApproachandStrengthsPerspectiveTraditionalapproachdichotomizesalcoholicandTraditionalapproachdichotomizesalcoholicandnon-alcoholicnon-alcoholicUseoflabelsIamanalcoholic,addict,UseoflabelsIamanalcoholic,addict,dysfunctionalfamilydysfunctionalfamilyFocusonlosses,clientindenial,resi

15、stantFocusonlosses,clientindenial,resistantStrengthsapproachavoidslabels,focusonStrengthsapproachavoidslabels,focusonstrengths,familyasresourcestrengths,familyasresourceTwoApproachestoTreatmentTraditionalTraditional BioBio DichotomyDichotomy PsychoPsychoProblemsmandateonesizeProblemsmandateonesizefi

16、tsallfitsallSocialSocialIdentifyfamilydysfunctionIdentifyfamilydysfunction Strengths-basedStrengths-based BioBio ContinuumContinuum PsychoPsychoStrengths-motivationStrengths-motivationSocialSocialHolisticfamilyasresourceHolisticfamilyasresource AddictionRecoveryManagementStrengths-basedtreatmentappr

17、oachendorsedbyUNCasemanagementCommunityresourcesforlong-termcareInterventionsrelatetopersonalneedsinsocietymentalhealthcare,housingSuccessmeasuredindrinking,usingless,nottotalabstinence StrengthsPerspective RappandGoscha:RappandGoscha:Sixcriticalelements:personisnottheillness,choice,hope,purpose,Six

18、criticalelements:personisnottheillness,choice,hope,purpose,achievement,presenceofonekeypersontohelp.achievement,presenceofonekeypersontohelp.n nFindingthestrengthsindivergentmodelsharmreductionand12Findingthestrengthsindivergentmodelsharmreductionand12StepapproachStepapproachn nDifferentmodelsfordif

19、ferentfolks.Differentmodelsfordifferentfolks.n nVerynegativeviewofdiseasemodel:StantonPeele:Verynegativeviewofdiseasemodel:StantonPeele:Resisting 12 Step Resisting 12 Step CoercionCoercionn nHarmreductionandthestrengthsperspective“meettheclientwhereHarmreductionandthestrengthsperspective“meettheclie

20、ntwheretheclientis.”theclientis.”n nPolicyissuesofreducingharm.Policyissuesofreducingharm.EmpiricalResearchProjectMATCHProjectMATCHDirectedbyNIAAA2,000clientsover8yrs.DirectedbyNIAAA2,000clientsover8yrs.Whatworks?12stepfacilitation,cognitive,motivationalenhancementtherapyWhatworks?12stepfacilitation

21、,cognitive,motivationalenhancementtherapy(MET)(MET)METmosteffectiveforthosewithlowmotivation,12StepwithreligiousMETmosteffectiveforthosewithlowmotivation,12Stepwithreligiouspersons.persons.Criticism:lackofacontrolgroup.MET,ashorterintervention.ModelsonlyCriticism:lackofacontrolgroup.MET,ashorterinte

22、rvention.Modelsonlytestedonalcoholicclients.testedonalcoholicclients.ProjectMATCHconfirmstheeffectivenessofdiversetreatments.NewmeasureProjectMATCHconfirmstheeffectivenessofdiversetreatments.Newmeasureforrecoveryisimprovement,nottotalabstinence.forrecoveryisimprovement,nottotalabstinence.VaillantsRe

23、searchVaillantsResearch40yearlongitudinalstudythosewhorecoveredhadcrisiswithalcoholorjoined40yearlongitudinalstudythosewhorecoveredhadcrisiswithalcoholorjoinedAAorenteredastablerelationshiporhadareligiousconversion.AAorenteredastablerelationshiporhadareligiousconversion.EmpiricalResearchContinuedn n

24、ResearchfromCalifornia:1$spentsaves7acrossResearchfromCalifornia:1$spentsaves7acrossstates.states.n nHesterandMillerfoundthatthesetreatmentHesterandMillerfoundthatthesetreatmentmodalitieswereproventobemosteffective:briefmodalitieswereproventobemosteffective:briefintervention,motivationalinterviewing

25、(MI),useofintervention,motivationalinterviewing(MI),useofthemedicationnaltrexone,socialskillstraining,themedicationnaltrexone,socialskillstraining,aversiontherapy,cognitivetherapy,acupuncture.aversiontherapy,cognitivetherapy,acupuncture.(Seechapter8)(Seechapter8)TreatmentTrendsn nPrescriptiondrugmis

26、useasincreasingproblem;Prescriptiondrugmisuseasincreasingproblem;n nHarmreductionrecognizedasimportanttosavelives;publicHarmreductionrecognizedasimportanttosavelives;publichealthapproach;healthapproach;n nBeliefthatpunitivelawscauseharm;Beliefthatpunitivelawscauseharm;n nMajorityofAmericansfavortrea

27、tmentoverjail;MajorityofAmericansfavortreatmentoverjail;n nDe-emphasisonincarceration,reentryprogramming;De-emphasisonincarceration,reentryprogramming;n nDrugcourts,mentalhealthcourts;Drugcourts,mentalhealthcourts;n nAttentiontoco-occurringdisordersandextensiveuseofAttentiontoco-occurringdisordersan

28、dextensiveuseofprescribedmedicationstoreducecraving;prescribedmedicationstoreducecraving;n nRestorativeJusticeRestorativeJustice: :victim-offenderprogrammingtopromotevictim-offenderprogrammingtopromotehealing.PEASEAcademy.healing.PEASEAcademy.Chapter2HistoricalPerspectivesEarlyHistoryn nAlcoholbackt

29、o5000BCIranAlcoholbackto5000BCIrann nUnknowntoworldsindigenouspeopleUnknowntoworldsindigenouspeoplen nKoran-condemnedwine.AlcoholfromArabicKoran-condemnedwine.AlcoholfromArabical-kuhul.al-kuhul.n nArabiandr.discoveredevaporateddistilledspirits.Arabiandr.discoveredevaporateddistilledspirits.Technolog

30、yexceededitsgraspTechnologyexceededitsgraspn n1575-distillingusedgin.BoozefromDutch1575-distillingusedgin.BoozefromDutchbusenbusen. .n nGreatdevastationfromEngland,1700-1750.GreatdevastationfromEngland,1700-1750.n nInfantmortality,crimeInfantmortality,crimeNorthAmerican nMorebeerthanwateronMayflower

31、.n nSlavesforbiddentodrinkexceptonspecialoccasions,taughtbingeing.n nPuritantraditions.n n18thQuakersandMethodistsdisapprovedofhardliquor.n nMaledrinkingcult1725-1825notorious.Temperancemovementn n1825-1919:Againsthardliquor.n nTemperancewomanforwomenssuffrageandbanondistilledbeverages.Early1900sn n

32、CocaineinCoken nTobaccooutlawedforbriefperiod.n n1914HarrisonAct-restrictedopioids(associatedwithChinesepeople)cocainemustnowbeprescribed.n nMarijuana(associatedwithMexicans)Statelawsinsouthwestcriminalized.n nTeetotaler T=totalabstinence,fromIreland.U.S.Prohibition1920-1933n nGlamorizedcrime.Mafia/

33、Hollywood/Wash.DClink.Homicideratesincreased.n nGreatDepressioncreatedneedforjobs.n nGiancana,Double CrossModernWaronDrugsJohnsonwaronpovertyNixontthroughtheBusheswarondrugs1960sheroinhorrorstories1980s,crackcocaine2000s,methAttacksdirectedtowardpoor,minorities.HistoryofGamblinginU.S.LotteriesAmeric

34、anRevolutionLotteriesAmericanRevolutionBannedafterCivilWarandduringProhibition.BannedafterCivilWarandduringProhibition.1931casinogamblinglegalinNevada1931casinogamblinglegalinNevada1960slotteriesforstaterevenue1960slotteriesforstaterevenue1972firstgamblingtreatmentcenteratVA,NewYork1972firstgambling

35、treatmentcenteratVA,NewYork1987SupremeCourtbannedstateregulationoftribal1987SupremeCourtbannedstateregulationoftribalcasinoscasinosMississippiRivercasinosMississippiRivercasinosInternetgamblingpopulartodayInternetgamblingpopulartodayThemesofFirstHalfofChaptern nDangersofpotentalcohol,roleofethnicpre

36、judiceinshapingdruglegislation,unintendedconsequencesofprohibition.n nExampleofhappyItalianfamilyenjoyingwinewiththeirmeals.n nModernWaronDrugs,two-thirdsofmoneyforlawenforcement.HistoryofAddictionTreatmentn nWilliamWhite,WilliamWhite,Slaying the Dragon.Slaying the Dragon.MistreatmentMistreatmentofp

37、ersonswithmentallyillnessandalcoholicsinofpersonswithmentallyillnessandalcoholicsinasylums.asylums.n nGetting Better Getting Better byNanRobertsontellsofBillW.byNanRobertsontellsofBillW.andDr.Bob.OxfordGroups.BigBook.2millionandDr.Bob.OxfordGroups.BigBook.2millionmembersinAAworldwidetoday.membersinA

38、Aworldwidetoday.n nJellinek(Jellinek(The Disease ConceptThe Disease Concept,1960)5typesof,1960)5typesofalcoholismbasedonworldtravels:alcoholismbasedonworldtravels:n nAlpha,Beta,Gamma,Delta,Epsilon.Alpha,Beta,Gamma,Delta,Epsilon.TreatmentHistorycontinuedn n1956AMAdeclaredalcoholismanillness,1966,adis

39、ease.n nHaroldHughesfoundedNIAAA.n nHazeldenadapted12Stepapproach.n nBox2:1“TreatmentinNorway”universalhealthcareforsupport.n nPeeleandFingarette:addictionasbadhabitsnotdisease.HistoryofHarmReductionn nAIDSinNetherlandsspawnednewapproach,toreducetheharm.n nBritain,1960sandlater.n nHeroinprescribed.N

40、eedleexchanges-U.S.n nAlanMarlatt,diedin2011,pioneerinspreadofharmreductionapproachtoU.S.,researcheratU.ofWashington.PartIIBIOLOGYChapter3SubstanceMisuse,Dependence,andtheBodyPartIIBIOLOGYChapter3SubstanceMisuse,Dependence,andtheBodyRecentTrendsDevelopmentofPETscans,fMRIDevelopmentofPETscans,fMRI fu

41、nctionalmagneticresonanceimagingfunctionalmagneticresonanceimagingCravingresearchCravingresearchNewfactsonbraindamageNewfactsonbraindamageDepressantsAlcoholFigure3.1alcoholinvolvement:47%ofFigure3.1alcoholinvolvement:47%ofhomicides;34%ofdrownings;42%offirehomicides;34%ofdrownings;42%offireinjuries;4

42、7%ofyoungmalecarcrashes;injuries;47%ofyoungmalecarcrashes;50%daterape;16%childabuse(doesnt50%daterape;16%childabuse(doesntcountneglect);23%ofsuicide.countneglect);23%ofsuicide.InternationalstudiesshowhighcorrelationInternationalstudiesshowhighcorrelationwithpartnerviolence.withpartnerviolence.Colleg

43、estudentdeathsperyear1,825Collegestudentdeathsperyear1,825(NIAAA,2010)(NIAAA,2010)FatherMartinChalkTalksJocosedrunk,amorose,bellicose,lachrymosedrunksOuradditions:somnosdrunk,(sleepy)clamorose,(loud),scientose(knowitall)GlobalDrinkingPatternsn nEuropeansconsumesixtimesasmuchalcoholasEuropeansconsume

44、sixtimesasmuchalcoholassoutheastAsianssoutheastAsiansn nMoldova,theCzechRepublic,drinkaround18litersMoldova,theCzechRepublic,drinkaround18literspercapitaeachyear.percapitaeachyear.n nEasternEuropeanshardliquorEasternEuropeanshardliquorn nBritishandIrishbeerBritishandIrishbeern nFrenchandItalianswine

45、FrenchandItalianswinen nHighratesindigenouspopulationsNorthernHighratesindigenouspopulationsNorthernSwedenandNorthernCanadaSwedenandNorthernCanadaAlcoholcontinuedn nHealtheffectsofmoderatedrinkersheartbenefits,lowerdeathratesthanteetotalers.n n7-10%ofdrinkersgetaddicted.Signs:tolerance,withdrawal(tr

46、emors,nausea;5%haveDTs),heavynicotine,caffeineusen nTolerancereversaln n.4B.A.C.maybecomatose.n nBlackouts:commonat.3BAC,caseinTom Sawyern nRealcourtcasesNarcoticsn nOpiatesfromopiumpoppynarcotics,heroinnowcanbesmokedorsnorted.n nHightolerancesoneedgreaterquantitiesforhigh.n nInhalantshouseholdprodu

47、cts,huffing,braindamage,coman nMisuseofpainmedicationincreasingtodayn nOxyContinStimulantsn nCocaine-crackandpowder,inurine8hrs.,smokedforCocaine-crackandpowder,inurine8hrs.,smokedforfasterhigh.Highlastsonly15-20minutes.fasterhigh.Highlastsonly15-20minutes.n nBrainblocksreuptakeofdopamineAddictedrat

48、sdieBrainblocksreuptakeofdopamineAddictedratsdieheartattack.heartattack.n nAmphetaminesandmethsyntheticunlikecocaineAmphetaminesandmethsyntheticunlikecocainesuppressesappetite.UsedbyNazis.4-16hourhigh.suppressesappetite.UsedbyNazis.4-16hourhigh.n nMethlandMethlandbyNickRedingbyNickReding aboutOelwei

49、n,Iowa.aboutOelwein,Iowa.n nPowdercanbesnorted,injected.StayawakeforlongPowdercanbesnorted,injected.Stayawakeforlongdurationsdurationsn nAnhedoniaAnhedonia-inabilitytofeelpleasurewithdrug-induced-inabilitytofeelpleasurewithdrug-inducedbraininjury.braininjury.Nicotinen nCanbothstimulateandrelax.80-95

50、%ofalcoholicsCanbothstimulateandrelax.80-95%ofalcoholicssmoke,reducesalcoholeffects.Overhalfofpersonssmoke,reducesalcoholeffects.Overhalfofpersonswithschizophreniasmoke.withschizophreniasmoke.n nNicotinedecreasesBAClevels.NicotinedecreasesBAClevels.n nAmericanbusinessmansstoryfromChina.Americanbusin

51、essmansstoryfromChina.n nMalachyMcCourtsmokedforadandgothooked.MalachyMcCourtsmokedforadandgothooked.n nBox3.1“ToDieforaCigarette”Box3.1“ToDieforaCigarette”n nCaseofchewingtobaccosnuff.Caseofchewingtobaccosnuff.Hallucinogensn nPlants,LSD,synthetic,flashbacks,PCPn nEcstasyandroofiesheightenssensoryex

52、perienceraves.n nCantgetbacktooriginalhighduetobrainchanges.n n10%inhighschoolhaveusedEcstasy.n nDanceSafeharmreductionstrategies.n nRoofies:sleepingpillinEurope.WhatIsEcstasy?EcstasyisadrugthathasEcstasyisadrugthathassomehallucinogenicsomehallucinogenicpropertiesandispropertiesandisstructurallyrela

53、tedtostructurallyrelatedtoamphetamines.Itsshortamphetamines.ItsshortformchemicalnameisformchemicalnameisMDMA(3,4-MDMA(3,4-methylenedioxymetham-methylenedioxymetham-phetamine).phetamine).SplitShortTermEffectsofEcstasyn nFeelingofconfidenceFeelingofconfidencen nSenseofarousalSenseofarousaln nIncreased

54、heartrateIncreasedheartraten nDryandsoremouth/throatDryandsoremouth/throatn nTension,HighBodyTemperatureTension,HighBodyTemperaturen nMuscletwitchingMuscletwitchingn nDepression&ConfusionDepression&ConfusionOtherSyntheticSubstancesSpiceBathsaltsincreaseinERvisitsassociatedwiththisdrug.Hardtodetect.C

55、annabisn nMarijuanan nTHC,thepsychoactiveingredient,lowersbloodglucose,increasesappetite,Storedinfatcells,longtermusepossiblyassociatedwithapathy.n nEarlierreportsoflungcancerafterlong-termusewerenotvalidated.CoststoGetHighEstimatesDifferbyRegionn nnotintextnotintextn nCrack:$5-10quickfixonlylasts30

56、min.Crack:$5-10quickfixonlylasts30min.n nHeroin:$100-200day-$20daycanbyHeroin:$100-200day-$20daycanbymaintenancedoseinjectacoupleoftimesmaintenancedoseinjectacoupleoftimesn nEcstasy:$25maytake5orsopills.Ecstasy:$25maytake5orsopills.n nMeth:$25long-lastinghigh,popularingaypartyMeth:$25long-lastinghig

57、h,popularingaypartysceneinSeattle,factoryworkersinIowasceneinSeattle,factoryworkersinIowan nMarijuana:$25orhigher,dependsonqualityMarijuana:$25orhigher,dependsonqualityMetabolismn nLiver:organthatmetabolizesalcohol,alcoholLiver:organthatmetabolizesalcohol,alcoholcirculatesinthebloodstreamuntilmetabo

58、lized.circulatesinthebloodstreamuntilmetabolized.n nMenhavespecialenzymesthathelp.Menhavespecialenzymesthathelp.n nPeoplemetabolizeoz.perhour=smallglassofPeoplemetabolizeoz.perhour=smallglassofwinewine. .n nOneOneDrinkOnebottleofbeer(12oz.)DrinkOnebottleofbeer(12oz.)n nOneglassofwine(6oz.)Oneglassof

59、wine(6oz.)n nOne“single”drink(1oz.ofliquorOne“single”drink(1oz.ofliquor) )MetabolismcontinuedBrain Regions and Their Functions Brain Regions and Their Functions EcstasyandtheBrainTheBrainandAddictionNeurotransmittersaffectemotionsandmemoryNeurotransmittersaffectemotionsandmemoryNeurotransmittersAffe

60、ctEmotionsandMemoryn nDopaminereuptakeaffectedbycocaine,whichDopaminereuptakeaffectedbycocaine,whichblocksdopaminesynapseblocksdopaminesynapsen nDepletionfollowingcocaineuse.NicotineaffectsDepletionfollowingcocaineuse.Nicotineaffectsdopaminetoo.dopaminetoo.n nParkinsonswhentoolittle.Dopamine-boostin

61、gParkinsonswhentoolittle.Dopamine-boostingdrugsforParkinsonsassociatedwithmaniaanddrugsforParkinsonsassociatedwithmaniaandgamblingbehavior.gamblingbehavior.n nExcessofdopamineassociatedwithschizophrenia.Excessofdopamineassociatedwithschizophrenia.n nSerotonin:influencedbyalcohol,involvedinsleep.Sero

62、tonin:influencedbyalcohol,involvedinsleep.Decreasedlevelslinkedtodepression,anxiety,Decreasedlevelslinkedtodepression,anxiety,impulsivenesssuicide.impulsivenesssuicide.DepletionFollowingCocaineUse.Therightscanistakenfromsomeonewhoisoncocaine.ThelossofredareasinTherightscanistakenfromsomeonewhoisonco

63、caine.Thelossofredareasintherightscancomparedtotheleft(normal)scanindicatesthatthebrainisusingtherightscancomparedtotheleft(normal)scanindicatesthatthebrainisusinglessglucoseandthereforeislessactive.Thisreductioninactivityresultsinlessglucoseandthereforeislessactive.Thisreductioninactivityresultsind

64、isruptionofmanybrainfunctions.disruptionofmanybrainfunctions.MemoryandCravingn nAddictnevergetsoriginalhighbrainhaschanged.Addictionisabraindisease.n nCuescantriggermemorypictureofalcoholicbeveragesactivatescertainareasofthebrain.n nProzacreducescravingbyregulatingserotoninlevels. Cocaine in the Bra

65、inSlidesarefromtheNationalInstituteonDrugAbuse(NIDA)(www.nida.nih.gov)GamblingandtheBrainPersonswithgamblingdisordersmayhaveabnormallevelsofdopamineandserotonin.Lackofcontrolmayresult.Highsenhancedwhenrewardsuncertain.Nearmissesespeciallythrilling.TheRoleofGenesn nStudyofmentalhospitals,prisons,50%w

66、housedStudyofmentalhospitals,prisons,50%whousedchemicalsubstanceshadmentaldisorders.chemicalsubstanceshadmentaldisorders.n nCloningerSweden.259maleadopteeswithalcoholicCloningerSweden.259maleadopteeswithalcoholicfathersfathersn n Type1Type1:lateonset.75%ofalcoholics,relatestoharm:lateonset.75%ofalco

67、holics,relatestoharmavoidance,anxiety,guiltavoidance,anxiety,guiltn n Type2Type2:risktaker,(startsaboutage11)male,:risktaker,(startsaboutage11)male,hyperactive,antisocial,hereditaryhyperactive,antisocial,hereditaryn nOndansetron:worksonserotonin,littleeffectontype1Ondansetron:worksonserotonin,little

68、effectontype1n nTwinsTwins:40-60%concurrenceofalcoholism.Separated:40-60%concurrenceofalcoholism.Separatedatbirthmonkeysdrankmoreunderstress,peoplewithatbirthmonkeysdrankmoreunderstress,peoplewithlowdopaminelikestimulantslowdopaminelikestimulantsn nPeoplewithADHDriskfordrugabuse.PeoplewithADHDriskfo

69、rdrugabuse.MedicalConsequencesn nWernickeKorsakoff:WernickeKorsakoff:n nCasesreportedofDr.OliverSachsCasesreportedofDr.OliverSachsn nPeripheralneuropathyrelatedtolackofVitaminBPeripheralneuropathyrelatedtolackofVitaminBn nConfabulation.Dr.SachsAwakeningsConfabulation.Dr.SachsAwakenings MedicalConseq

70、uencescontinuedLiverdamageremovestoxinsfromblood,bilecirculatesinbloodstreamYellowskintone,cirrhosis,immunesystembreakdown.Heartnicotine,cocaineFetalalcoholsyndrome.Seephotographintext.Shortnose,indistinctgroovebetweennoseandmouth,thinupperlip,smallheadandeyes,learningproblems.Roleofspermshouldbecon

71、sideredaswellasmothersrole.InterventionsRelatedtoBiologyn nSchickShadel,Seattletreatmentcentern nConditioningoraversiontherapyfavoritedrinkplusemetinetoinducevomiting.n nUseoftruthserumonalternatedays.ChangingBrainChemistryn nBrain LockBrain Lock(Schwartz)cognitivetreatmentforOCD(Schwartz)cognitivet

72、reatmentforOCDto“rewirethebrain”to“rewirethebrain”n nOndansetrondecreasescravingOndansetrondecreasescravingn nZybanZybanandsmoking;Chantixhelpspersonproduceandsmoking;Chantixhelpspersonproducemoredopamine.moredopamine.n nNicotinegum;patch.Nicotinegum;patch.n nNaltrexone,approved1995,notanarcoticunli

73、keNaltrexone,approved1995,notanarcoticunlikemethadone.methadone.n nBlocksreceptorsforgettinghigh.Blocksreceptorsforgettinghigh.SyntheticPrescriptionDrugsn nMethadone(syntheticformofheroin);Methadone(syntheticformofheroin);n nMethadonemaintenanceMethadonemaintenancen nHeroinmaintenanceinBritain,Switz

74、erland,Vancouver.HeroinmaintenanceinBritain,Switzerland,Vancouver.n nBuprenorphinecanbeprescribedbyGPs,reduceslikelihoodBuprenorphinecanbeprescribedbyGPs,reduceslikelihoodofoverdoseofoverdosen nEatingdisordersanddopamineEatingdisordersanddopaminen nBulimicsrelatedtodepressionBulimicsrelatedtodepress

75、ionn nAnorexiaanxietyAnorexiaanxietyn nLuvox,Prozac,andPaxildecreasebinges.Luvox,Prozac,andPaxildecreasebinges.HolisticTreatmentsn nHerbalremediesn nSt.Johnswortn nHypnosisn nAcupuncturefromChinan nMassagetherapyn nPhysicalexercisetoreducetensionChapter4GenderandSexualOrientationDifferences GenderIs

76、sues RecenttrendsvoicesofwomenandgaysandlesbiansRecenttrendsvoicesofwomenandgaysandlesbiansareincreasinglyheardregardingtreatment,research.areincreasinglyheardregardingtreatment,research. Someemphasisongender-sensitivetreatment.Someemphasisongender-sensitivetreatment. Classandculturaldifferencesindr

77、uguse.Classandculturaldifferencesindruguse. Male/femaleratiosdifferindrinkingquantityratiosMale/femaleratiosdifferindrinkingquantityratiosfrom13:12inItalyto28:11inCanada,46:5inMexico,from13:12inItalyto28:11inCanada,46:5inMexico,and15:3inRussia.and15:3inRussia. InAmericanhighschools,substanceuserates

78、aboutInAmericanhighschools,substanceuseratesaboutthesame.thesame. Adultmen,twicetherateofwomenformarijuanaandAdultmen,twicetherateofwomenformarijuanaandcocaineuseandgambling,methandtranquilizerscocaineuseandgambling,methandtranquilizersaboutthesame.aboutthesame. MoreeatingdisordersinwomenMoreeatingd

79、isordersinwomenGenderDifferences Shamefactorforwomenintreatment.Shamefactorforwomenintreatment. Womenintreatmentmorelikelythanmentohaveasubstance-Womenintreatmentmorelikelythanmentohaveasubstance-dependentpartner.dependentpartner. TreatmentlessaccessibleformothersthanfathersduetochildTreatmentlessac

80、cessibleformothersthanfathersduetochildcareresponsibilities.careresponsibilities. Manywomenlosecustodyofchildrenoversubstancemisuse.Manywomenlosecustodyofchildrenoversubstancemisuse. Abstinencedemandsunrealistic.Abstinencedemandsunrealistic. Lackoftreatmentavailabilityforpregnantwomen.Lackoftreatmen

81、tavailabilityforpregnantwomen. Goodresultswithrecoverycoachesandfamilycourts.Goodresultswithrecoverycoachesandfamilycourts.GenderDifferencescontinuedn nMethaddictionrateshighamongwomen.n nOnestudyshowedthat80%offemalemethaddictswerevictimsofdomesticviolence.n nViolence-3of4intimatepartnermurdersareo

82、fwomen.n nWomenalcoholics-47%intreatmentmolestedaschildreninstudyof472women(Downs).TreatmentneedstofocusonPTSDissues.Womensmoketocontrolweight,malestorelieveboredom.Escapegamblers(women).Womenstartgamblinglaterinlifethanmendo.BiologicalDifferencesWomengetintoxicatedquickerthanmen.Womenhaveahighermor

83、talityratewithheavydrinking.Livesareshortenedby15yearsonaveragewithalcoholismheartandliverdamage.WomensTreatmentNeedsn n1.Addressbarrierstotreatmentthatmanywomenexperience,1.Addressbarrierstotreatmentthatmanywomenexperience,suchaslackoftransportation,childcare,andtreatmentsuchaslackoftransportation,

84、childcare,andtreatmentavailability.availability.2.Changingprogramgoalsandprocessestoaccommodate2.Changingprogramgoalsandprocessestoaccommodatewomensneedsformoresupport,lessconfrontation,jobskillwomensneedsformoresupport,lessconfrontation,jobskilltraining,andparentingskills.training,andparentingskill

85、s.3.Embracinganempowermentmodelofchange.3.Embracinganempowermentmodelofchange.4.Femalecounselorswhocanattendtoshameandstigma4.Femalecounselorswhocanattendtoshameandstigmaissues.issues.5.Needtocelebrateanysignificantdecreaseinsubstanceuse.5.Needtocelebrateanysignificantdecreaseinsubstanceuse.SexualOr

86、ientation Heterosexismandhomophobia:U.S.studiesofschoolsHeterosexismandhomophobia:U.S.studiesofschoolsshowssuicideis14timestheheterosexualrates.showssuicideis14timestheheterosexualrates. LesbianslowestrateofAIDSofanygroup,butLesbianslowestrateofAIDSofanygroup,butdoublethedruguseofotherwomen,55%smoke

87、atdoublethedruguseofotherwomen,55%smokeatsomepointintheirlives;28%areobese.somepointintheirlives;28%areobese. Reasonsforhighdrinkingrategaybar,fewerareReasonsforhighdrinkingrategaybar,feweraremothers.G/LAA.mothers.G/LAA. Gaymaleshighriskofsexualabuseinjailcells.Gaymaleshighriskofsexualabuseinjailcel

88、ls. ReligiousfundamentalismcorrelatedwithReligiousfundamentalismcorrelatedwithsuicidealcoholproblemspersistacrosslifespan.suicidealcoholproblemspersistacrosslifespan. Transgender.SeeDosandDontstableTransgender.SeeDosandDontstable11.211.2 Resources:PrideInstituteandPFLAGResources:PrideInstituteandPFL

89、AGChapter5Gambling,EatingDisorders,Shopping,andOtherBehavioralAddictionsGamblingAddiction Gambling,hasbecomesociallyacceptableGambling,hasbecomesociallyacceptable Criteriaofpathologicalgambling-preoccupation,Criteriaofpathologicalgambling-preoccupation,increasingamounts,etc.3-7%ofgamblershaveincreas

90、ingamounts,etc.3-7%ofgamblershaveproblems,suicidehighingamblersproblems,suicidehighingamblers Costtoeconomyis$54billionbankruptcies,lostCosttoeconomyis$54billionbankruptcies,lostworktime,crime,etc.VeryhighamongNativeworktime,crime,etc.VeryhighamongNativeAmericansover14%havegamblingproblemsAmericanso

91、ver14%havegamblingproblems ResearchshowscountieswithgamblingcasinosResearchshowscountieswithgamblingcasinoshavehighercrimeratesandbankruptciesthanhavehighercrimeratesandbankruptciesthanothersothersGamblingcontinued ProblemsamongtheelderlyProblemsamongtheelderly Internetgamblingisthefastestgrowingfor

92、m.Internetgamblingisthefastestgrowingform. 2-4%inGamblersAnonymous(GA)arewomen.2-4%inGamblersAnonymous(GA)arewomen.Butmanyhelplinecalls.Butmanyhelplinecalls. Womengambletoescape;menforaction.Womengambletoescape;menforaction. AssociatedwithotherproblemsAssociatedwithotherproblems Box5.1Reflectionsofa

93、MaleCompulsiveBox5.1ReflectionsofaMaleCompulsiveGambler.GeographicalrelocationhelpedhimGambler.Geographicalrelocationhelpedhimbreakhishabit.breakhishabit.QuestionsforScreening HaveyoueverborrowedmoneyinordertoHaveyoueverborrowedmoneyinordertogambleorcoverlostmoney?gambleorcoverlostmoney? Haveyouever

94、thoughtyoumighthaveagamblingHaveyoueverthoughtyoumighthaveagamblingproblemorbeentoldthatyoumight?problemorbeentoldthatyoumight? HaveyoueverbeenuntruthfulabouttheextentofHaveyoueverbeenuntruthfulabouttheextentofyourgamblingorhiddenitfromothers?yourgamblingorhiddenitfromothers? Haveyouevertriedtostopo

95、rcutbackonhowHaveyouevertriedtostoporcutbackonhowmuchorhowoftenyougamble?muchorhowoftenyougamble?TreatmentIssues Treatment:cognitiveworkandmotivationalTreatment:cognitiveworkandmotivationaltherapytherapy Irrationalthinkingaboutwinning:Irrationalthinkingaboutwinning: “Iputsomuchmoneyinthismachine,“Ip

96、utsomuchmoneyinthismachine,Imboundtowin.”Imboundtowin.” HighprofilewinnersHighprofilewinners LuckymachineanddatesLuckymachineanddates Statesspendingontreatment-$36millionisStatesspendingontreatment-$36millionissmallcomparedto$20billionintaxrevenuessmallcomparedto$20billionintaxrevenuesfromgamblingfr

97、omgamblingEatingDisorders TheonlyoneinthischapterrelatedtoasubstanceTheonlyoneinthischapterrelatedtoasubstancefoodaddiction.Allothers,forexample,Internetfoodaddiction.Allothers,forexample,Internetaddictionarebehavioraloftenclientsintreatmentaddictionarebehavioraloftenclientsintreatmentforanotherdiso

98、rderforanotherdisorder Headline:“Eatingdisordersstartinbrain”Headline:“Eatingdisordersstartinbrain” 90%ofanorexiaandbulimiaisfoundinfemales.90%ofanorexiaandbulimiaisfoundinfemales. BeginsinadolescenceBeginsinadolescence .5%ofgirlsandwomenareanorexic,1-3%bulimic.5%ofgirlsandwomenareanorexic,1-3%bulim

99、ic.Anorexia Lessthan89%ofnormalbodyweightandfinebodyhair. 10%mortalityrate,oftenbysuicide,correlatedwithperfectionism,ritualism,highanxiety Relatedtoobsessivecompulsivedisorder(OCD): obsessive-recurrentandpersistentthoughts;obsessive-recurrentandpersistentthoughts; pulsionsritualisticpractices.Bulim

100、ia Gaymenatrisk. Bulimiawithalcoholmisuse-30-70%. 35%ofbulimicsexperiencedchildhoodsexualabuseandusefoodasadrug. Littleinformationoncompulsiveovereating. Newstudiesshowlackofdopaminereceptorsinthebrainsofmorbidlyobese. Someaftergastricbypasssurgeryturntoheavydrinking.Interventions StudyintheBritishm

101、edicaljournal,StudyintheBritishmedicaljournal, Lancet Lancetfindingsfromtwinstudiesshowedthatastrongfindingsfromtwinstudiesshowedthatastrongcravingforsweetspredictedalcoholabusecravingforsweetspredictedalcoholabuseproblems,perhapscausedbyalackofdopamine.problems,perhapscausedbyalackofdopamine. Bulim

102、iacognitivetreatments;avoidstrictdietingBulimiacognitivetreatments;avoidstrictdieting AnorexiaProzaciseffectiveinreducingAnorexiaProzaciseffectiveinreducingcompulsivebehaviorbutonlywhenweighthascompulsivebehaviorbutonlywhenweighthasbeengained.beengained. Menmuscledysmorphia,antidepressantsmayMenmusc

103、ledysmorphia,antidepressantsmayhelpheretoo.helpheretoo.Treatment Overeatersanonymous(OA)forcompulsiveeating; Grouptreatment.teachmoderationCBT Themeofneuroplasticitybrainneuronscanformnewconnections;“brainlock”canbecorrected(Schwartz) Box5.2comparestwotreatmentprograms;thesecondoneinKansasCityinclud

104、edtraumaworkShoppingorSpendingAddictionn nProblemsinabout2-8%ofpeoplen nTypical31yr.oldfemalewhohasoverspentfor13years.n nDSM-5listskleptomania;n nMedications:Luvoxn nDebtorsAnonymousgroupsspringingupCyberAddictionn nCaught in the NetInternetaddicts:preoccupied,excessiveamountsoftimeinvolvedinchatro

105、oms,playinggames;n nJeopardizedrelationships.n nFantasyworldfictitiousnames,officeproblemsn nSelf-efficacyforempowermentn nKoreangovernmenttrainingpsychiatriststohelptreatFRAMES Feedbackassessmentofuse Responsibilitychoiceistheirs Advicesetgoalstogether Menusofself-directedchangeoptions(ex.-monitorc

106、omputeruse) Empathy Self-efficacyHarmReductionsStrategies:-Getatimer-Cutmailinglists-NodetoursSexAddiction Risktaker Cognitivetherapyrecommended. PronetolyingoneTVbroadcastlookedatPresidentClintonsbackgroundandhissexualrisktaking:othersdisagree. CaseofTigerWoods. Self-helpgroup-SexAddictsAnonymous.C

107、ognitiveTherapy Distortionsespeciallywiththeseaddictionsandanorexia.Tendencytowardsextremebehavior. SlogansofAA(“easydoesit”) Rationalrecovery,MET,REBTmoreadversarial,focusoncurrentbeliefsCognitiveTherapycontinued Teachclientstoavoidblackandwhitethinking.Teachclientstoavoidblackandwhitethinking. Ask

108、abouttimeswhenclientsuccessfullyhandledAskabouttimeswhenclientsuccessfullyhandledaproblem.aproblem. Useregularassessmentfordiseaseofaddiction.Useregularassessmentfordiseaseofaddiction. FeelingworkFeelingwork PositivereinforcementandreframingPositivereinforcementandreframing Stressmanagement-modifyth

109、inking,exercisesStressmanagement-modifythinking,exercisesforgroupwork:artworkcanrevealunderlyingforgroupwork:artworkcanrevealunderlyingfeelings.feelings.Therapy Positivereframingandselftalk.CognitivetherapyPositivereframingandselftalk.Cognitivetherapycanbedirectedtowardthepastaswellasthepresent.canb

110、edirectedtowardthepastaswellasthepresent. Feelingworkangermanagement.Angerasacover.Feelingworkangermanagement.Angerasacover.Avoidall-or-nothingthinking.Avoidall-or-nothingthinking. Stressmanagement-drinkmilk,useselftalk,getStressmanagement-drinkmilk,useselftalk,getexercise.exercise. Groupexercisesfo

111、rfeelingwork:art,faces,griefandGroupexercisesforfeelingwork:art,faces,griefandloss,quizcards,dreams,assertiveness.loss,quizcards,dreams,assertiveness.PartIIPsychologyOfAddictionChapter6AddictionacrossthelifespanErikEriksonsStagesBirthtooldageBirthtooldageStage1:Trustvs.MistrustStage1:Trustvs.Mistrus

112、tStage2:Autonomyvs.ShameandDoubtStage2:Autonomyvs.ShameandDoubtStage3:Initiativevs.GuiltStage3:Initiativevs.GuiltStage4:Industryvs.InferiorityStage4:Industryvs.InferiorityStage5:Identityvs.RoleConfusion12-17yearsoldStage5:Identityvs.RoleConfusion12-17yearsoldStage6:Intimacyvs.IsolationStage6:Intimac

113、yvs.IsolationStage7:Generativityvs.StagnationStage7:Generativityvs.StagnationStage8:EgoIntegrityvs.DespairStage8:EgoIntegrityvs.DespairMustresolveeachcrisisbeforegoingtonextstageMustresolveeachcrisisbeforegoingtonextstageCarolGilliganscriticism.CarolGilliganscriticism.AdolescentBrain Prefrontalcorte

114、xmaturesuntilmid-20s EvidenceofbrainimmaturityduringtheteenyearscomesfromMRIscansoftheadolescentbrainTeenageDrinkingUse Identityvsroleconfusion AlcoholisthedrugofchoicebyAmericanteensaged12-17 LesssmokingbyteensintheUSthanpreviouslyArgentina 16yearoldexchangestudentfound: NodrinkingageNodrinkingage

115、WineorbeerwithsupperWineorbeerwithsupper DrinkingtobesocialnottogetdrunkDrinkingtobesocialnottogetdrunk WhattheU.S.canlearnfromArgentina FocusonmoderationandadultsupervisionParentsinPrisonLossofparentplusstigmatochild.Threetimestheoddsthatchildrenwillengageinantisocialordelinquentbehavior(violenceor

116、drugabuse).Negativeoutcomesaschildrenandadults(schoolfailureandunemployment).Twicetheoddsofdevelopingseriousmentalhealthproblems.Affects7andtimesmoreblackchildren.Europeanvs.U.S.Youthn nAlcoholusemoreprevalentinEuropeexceptinMediterraneancountries.Irelandvs.Italy.Drivingallowedatage18.n n22%European

117、ssmokevs.14%Americansatages15-16.n nPeelearguesinAddiction Proof Your Child forMediterraneanmoderatedrinkingpatterninthehome.n nIllicitdruguseinEuropehalfthatofU.S.SAMHSAHouseholdsurveyreported Cigaretteuse11.6%with12to17yearolds(2010)Cigaretteuse11.6%with12to17yearolds(2010) Bingedrinkingby17%ofyou

118、thsaged16and17Bingedrinkingby17%ofyouthsaged16and17nAge21aroundhalfarebingedrinkers.Heavydrinkerstendtohavehighdrug-usingratesaswell.drug-usingratesaswell.nRatesofpastpastmonthalcoholmonthalcoholuseforages12-20were:useforages12-20were:n n16.116.1%amongAsians;20.4%amongblacks;%amongAsians;20.4%amongb

119、lacks;n n22%among22%amongAmericanIndiansorAlaskaNatives;AmericanIndiansorAlaskaNatives;n n25.125.1%among%amongHispanics;Hispanics;n n27.527.5%amongthosereportingtwoormoreraces;%amongthosereportingtwoormoreraces;n nandand30.4%amongwhites30.4%amongwhites. .SAMHSASURVEYcontinuedn n18-25:21.2%illicitdru

120、guseduringpastmonth,aroundhalfofallyouthsusedalcohol.n nRacialbreakdownfordrugsnotgivenforyouthin2009butprevioussurveysshowhigherratesforblackthanwhitekids,AmericanIndiansthehighest.2010SchoolandERSurveys Useofalcohol,themostdangerousdrugcarcrashes,Useofalcohol,themostdangerousdrugcarcrashes,drownin

121、gs,etc.,one-thirdofhighschoolseniorsgetdrunkdrownings,etc.,one-thirdofhighschoolseniorsgetdrunkonceamonthormore;(sameinCanada)onceamonthormore;(sameinCanada) AlmostallcurrentsmokersalsodrankalcoholAlmostallcurrentsmokersalsodrankalcohol SchoolsurveysshowAfricanAmericanandLatinoseniorsSchoolsurveyssh

122、owAfricanAmericanandLatinoseniorshaveratesofillicitdruguselowerthanthatofwhites;thehaveratesofillicitdruguselowerthanthatofwhites;thereverseistrueamong8reverseistrueamong8ththgraders.graders. ERvisitsamongyouthmostlyforalcoholoverdosesERvisitsamongyouthmostlyforalcoholoverdoses(70%).(70%). Riseinuse

123、ofpainkillingdrugsshowninhighrateofERRiseinuseofpainkillingdrugsshowninhighrateofERvisitsamongyouth.OxyContinamajorproblem.visitsamongyouth.OxyContinamajorproblem.BusinessAnglen nRiveraLive:$10billionalcoholconsumedbyunder21RiveraLive:$10billionalcoholconsumedbyunder21Beerandliquorcompaniesmostwellf

124、undedBeerandliquorcompaniesmostwellfundedlobbiesoflobbiesofpeopleinCongress.peopleinCongress.n n80%ofadultsmokersstartaschildrensobigincentiveto80%ofadultsmokersstartaschildrensobigincentivetomarkettokids.markettokids.n nExtensivemarketingofcasinos.Extensivemarketingofcasinos.n n63826382%ofteenagers

125、ofteenagers(12-to17-year-olds)gambleeach(12-to17-year-olds)gambleeachyear,47%ofteensexhibityear,47%ofteensexhibitseriouspatternsseriouspatternsofofdisordereddisorderedgambling.gambling.SocietysInfluences Tobaccocompaniestargetingkids;Field andStreamadsforsmokelesstobacco ChildrenlearngamblingontheIn

126、ternet; Videopoker,slotmachines,andthelottery Strenuousexerciseprogramsreducesmoking.Smokingmaybeconsideredagatewaydrug.RisksforSubstanceMisusen nADHD,traumainearlychildhood,poorrolemodels.n nSexualabuseleadstosenseofshame.n nTraumachangesbrainchemistryandreduceslaterabilitytocopewithstress.n nInflu

127、enceofhighstressanddrinking,foundinjuvenilemousestudies.OtherRiskFactors Turbulentteen-fatherrelationshipTurbulentteen-fatherrelationship ChildabuseandothertraumaChildabuseandothertrauma KidswhostartsmokingearlyKidswhostartsmokingearly Smokingcanbeconsideredagatewaydrug;asmanySmokingcanbeconsidereda

128、gatewaydrug;asmanygirlsasboyssmoking,lowrateamongAfricangirlsasboyssmoking,lowrateamongAfricanAmericangirls.Americangirls. Media-generatedweightobsession,amajorproblemMedia-generatedweightobsession,amajorproblemamonggirlsofEuropeanAmericanethnicity.amonggirlsofEuropeanAmericanethnicity. Obsessionlea

129、dstomajorproblemswitheating,suchObsessionleadstomajorproblemswitheating,suchasanorexiaandbulimia.asanorexiaandbulimia.PredictionsfromScandinavia:Highrisk:girlswhocryeasilywhenteasedareHighrisk:girlswhocryeasilywhenteasedareanxiousandshy.anxiousandshy.Maleaggressionatage8predictedalcoholismMaleaggres

130、sionatage8predictedalcoholism18to20yearslater.18to20yearslater.Evaluationsatages10and27showed:Evaluationsatages10and27showed:HighnoveltyseekingHighnoveltyseekingLowharmavoidance(daredevilbehavior)Lowharmavoidance(daredevilbehavior)Bothtraitspredictedearly-onsetalcoholism.Bothtraitspredictedearly-ons

131、etalcoholism.Forbothsexes,poorschoolsuccesspredictedForbothsexes,poorschoolsuccesspredictedlaterdrinkingproblemslaterdrinkingproblemsChildAbusecontinuedGirlswhoaresexuallyabusedarethreetimesmorelikelythanothergirlstodevelopdrinkingproblemslaterBoyswhoweresexuallyabusedmorelikelytobediagnosedwithcond

132、uctdisorder,dysthymia(milddepression),andADHDAbusedgirlsaremorelikelytobediagnosedwithpost-traumaticstressdisorderandmajordepression.RisksforGirls Daughtersofalcoholicsatincreasedriskforalcoholism. Teenagegirlswhoareheavydrinkersare: fivetimesmorelikelytoengageinsexualfivetimesmorelikelytoengageinse

133、xualintercourse.intercourse. athirdlesslikelytousecondomsathirdlesslikelytousecondoms mmorelikelytopracticeunsafesex.orelikelytopracticeunsafesex.RisksforBoys:Studyofpriestabusevictimsshowedhighheavyalcoholuserate. Biggestthreattolifeandhealthforadolescentboysisalcohol-relatedaccidentsMalecounterpar

134、ttoanorexiainfemalesismuscledysmorphia.DysmorphiaadiagnosisinDSM.MoreRisksforBoys Obsessivebodybuildingmajorproblemforyoungmales Revealedinpopularityofanabolicsteroids Steroidsusedby2.7%ofmalehighschoolseniors. Healthhazards:stuntedgrowth,acne,andshrinkingtesticles.CollegeStudentsCaseofcollegepledge

135、inColoradowhodiedofoverdose;policenotcalledoutoffearofunder-21drinkinglaws.Lawpassed1984.n nHistoryoflaw1980stocurbdrinking-and-drivingHistoryoflaw1980stocurbdrinking-and-drivingdeaths,rdeaths,roleofMADDandNIAAA.nSAMHSA2010surveyofpastmonth63.3%college63.3%collegestudentswerestudentswerecurrentdrink

136、ers,42.1%currentdrinkers,42.1%werewerebingedrinkersbingedrinkers( (drank4-5drank4-5drinksatadrinksatatime),time),and15.6%and15.6%wereheavywereheavydrinkersdrinkers(bingedrank5ormoretimes).(bingedrank5ormoretimes).nRiskofage21birthdaycelebrations.AmethystInitiativen nOver120collegepresidentssignedsta

137、tementtoconsiderOver120collegepresidentssignedstatementtoconsiderrevisingunder-21drinkinglaw.revisingunder-21drinkinglaw.n nMADDnoteslivessavedfrom1982to1998.MADDnoteslivessavedfrom1982to1998.61%61%fewerfewerfatalfatalcrashesunderage21anda56%decreaseamongcrashesunderage21anda56%decreaseamong21-to21-

138、to24-24-year-olds.year-olds.n nMayhavebeenresultofstricterMayhavebeenresultofstricterdrinkinglawsthatwerepasseddrinkinglawsthatwerepassedinmanystatesinmanystatesstartinginstartingin1984.Newseatbeltregulations,1984.Newseatbeltregulations,stricterdrinkingstricterdrinkinganddrivinganddrivinglaws.Notere

139、ductioninoveragelaws.Notereductioninoverage21.21.BingeDrinking:CollegeU.S.governmentimposednationwideminimumU.S.governmentimposednationwideminimumdrinkingageof21inthe1980s,theattempttodrinkingageof21inthe1980s,theattempttocurtaildrunkendrivingbyyouth.curtaildrunkendrivingbyyouth.Fewerdrinktoday,butt

140、hosewhododrinkmore.Fewerdrinktoday,butthosewhododrinkmore.“Partytillyoupuke!”signswerepostedonone“Partytillyoupuke!”signswerepostedononeuniversitycampus.universitycampus. ModernFormofProhibitionCriticsarguestudentsaredriventopartyingundergroundandawayfromfacultysupervision.Newcampaignsformoderatedri

141、nkingencouragedbyUniversityofWashington(AlanMarlatt)research.Socialnormscampaignwithmessagesofmoderationwereunsuccessful.NeedforHarmReduction CollegenewspaperslowtorestrictenticingbeerCollegenewspaperslowtorestrictenticingbeerads.ads. MostbingedrinkersmatureoutofwilddrinkingMostbingedrinkersmatureou

142、tofwilddrinkingdaysofearlyadulthood.Butover1,800collegedaysofearlyadulthood.Butover1,800collegestudentsdieeachyearfromalcohol-relatedstudentsdieeachyearfromalcohol-relatedinjuries.Rapeandunsafesex.injuries.Rapeandunsafesex. Cigarettes-abstinenceprobablyworksbetterthanCigarettes-abstinenceprobablywor

143、ksbetterthanmoderationhere.moderationhere. Twopathstodrugusebyyouths:strivingtobeTwopathstodrugusebyyouths:strivingtobecool,usingdrugstoescapecool,usingdrugstoescape Messagesaboutlong-termdamageareapttohaveMessagesaboutlong-termdamageareapttohavelittleimpact.littleimpact.HarmReduction Needfordrugcou

144、rts-importantforfamilyNeedfordrugcourts-importantforfamilypreservationandcloselysupervisedtreatmentpreservationandcloselysupervisedtreatment Forbid“happyhours,”freedrinkson21Forbid“happyhours,”freedrinkson21st stbirthdaysatbirthdaysatbars.bars. Lowerdrinkingagelaws;discouragedrinkinghardLowerdrinkin

145、gagelaws;discouragedrinkinghardliquorliquor EncourageadultsupervisionwithkidswhoareEncourageadultsupervisionwithkidswhoaredrinking.Encouragemoderatedrinkingaswithmeals.drinking.Encouragemoderatedrinkingaswithmeals. Servefoodwithalcoholicbeverages.Servefoodwithalcoholicbeverages.MotivationalPrinciple

146、sfromSocialPsychologyFromElliotAronson,FromElliotAronson,The Social AnimalThe Social Animal Ifyoustateaposition,youwillbeweddedtoit.Ifyoustateaposition,youwillbeweddedtoit. Asmallcommitmenttotakeactiongoesalongway.Asmallcommitmenttotakeactiongoesalongway. PeoplewithhighselfesteemcaneasierresistPeopl

147、ewithhighselfesteemcaneasierresisttemptation.temptation. Workingtowardagoalmightpayoffeventually.Workingtowardagoalmightpayoffeventually. Changeofattitudemighthelp.Changeofattitudemighthelp. Peopledesiretoreducedissonance.Peopledesiretoreducedissonance.MillerandRollnick:MIStrategiesTrapstoavoid:Prem

148、aturefocus,suchasonclientsaddictivebehaviorConfrontationalroundbetweentherapistandclientoverdenialLabelingtrap-forcingtheindividualtoacceptalabelalcoholicoraddictBlamingtrap,fallacythatisespecially pronouncedincouplescounselingPrimaryPreventionn nChildabuse,early-preventioneducationandtreatmentprogr

149、amsn nSmokingeducationtokeepyouthsfromeverstartingtosmoken nHealthandskilleducationatschoolsn nReducingadspromotingaddictivebehaviorn nAdvocacyforthehiringofmoreschoolcounselorsandsocialworkersStage-SpecificMotivationalStatements:StageofChange:PrecontemplationGoalsaretoestablishrapportCounselorreinf

150、orcesdiscrepanciesAdolescentcomment:“Myparentscanttellmewhattodo;IstilluseandIdontseetheharminit-doyou?”MotivationalEnhancementcontinued:Stageofchange:ContemplationContemplation Ask:Howwaslifebetterbeforedruguse?Ask:Howwaslifebetterbeforedruguse? EmphasizechoicesEmphasizechoices Typicalquestionsare:

151、Typicalquestionsare:-Whatdoyougetoutofdrinking?-Whatdoyougetoutofdrinking?-Whatsthedownside?-Whatsthedownside?Resistance:n nInevitablen nMilleradvisesrollwithit“rollwithresistance”n nUsereflectivesummarizingContemplationStagecontinued: Typicaladolescentcomment: ImontopoftheworldwhenImhigh,butthenwhe

152、nIcomedown,Imreallydown.ItwasbetterbeforeIgotstartedonthesethings.PreparationStage: Settingthedate Whatdoyouthinkwillworkforyou? Adolescentcomments,“Imfeelinggoodaboutsettingadatetoquit,butwhoknows?”ActionStage:Adolescentcomment:“StayingcleanmaybeAdolescentcomment:“Stayingcleanmaybehealthy,butitsure

153、makesforadulllife.MaybeIllhealthy,butitsuremakesforadulllife.MaybeIllcheckoutoneofthosegroups.”checkoutoneofthosegroups.”“Therapist:“Whydontyoulookatwhatothers“Therapist:“Whydontyoulookatwhatothershavedoneinthissituation?”havedoneinthissituation?”Helplocateanappropriategroup.Helplocateanappropriateg

154、roup.MaintenanceStage:n nAdolescentcomment:“Itsbeenafewmonths;ImnotthereyetbutIm“Itsbeenafewmonths;ImnotthereyetbutImhangingoutwithsomenewfriends.”hangingoutwithsomenewfriends.”GenderSpecificApproachforGirls Equalitydoesnotmeansameness. Programsforgirlsdobetterwhentheyfocusonrelationships. Waterloo,

155、Iowa-grouphome-Quakerdalespecializesincareofteenagegirls. LearningoflifeskillsLearningoflifeskills GainingcompetencyasinartGainingcompetencyasinartProblemsinMiddleAdulthoodn nRelapseproblems.n nImpactofbabyboomgenerationillicitdrugusedoubled2002-2007inover50agegroup.n n6.6%useillicitdrugsoverage26;m

156、ostismarijuana.n n10.8%ofpregnantwomendrink;1in6smoke.RisktoCombatVeteransn nMostproblemsofVAclientswithsubstanceuseandMostproblemsofVAclientswithsubstanceuseandPTSDinyoungeragegroup,but11%areolder.PTSDinyoungeragegroup,but11%areolder.n nTraumaiscommon.PTSDamongfemaleveteransTraumaiscommon.PTSDamong

157、femaleveteranswhoweresexuallyvictimized(15%werevictimized).whoweresexuallyvictimized(15%werevictimized).n nNeedfortreatment;moreisbeingdonetoday.Needfortreatment;moreisbeingdonetoday.n nNeedtocontrolmarketingofalcoholandcigarettestoNeedtocontrolmarketingofalcoholandcigarettestosoldierssoldiers.Subst

158、anceAbuseamongOlderAdults 13%ofU.S.populationoverage65. Moremenwithalcoholproblems Olderadultsconsume20-25%ofallprescriptionmedications Twotypesofalcoholism:earlyandlateonset Earlyonset-moreseverelevelsofdepressionandanxietyFactsaboutLateLifeSubstanceUse Olderadultsconsumelessalcoholthantheyoung. 5.

159、2%overage50usedanillicitdruginthepastyear;9.1%smoke. Trendtowardnursinghomesforshort-termalcoholismrehabilitation Manymaleex-alcoholicsresideinnursinghomes.DrinkingPatternsn nOlderadultstendto:n n drinksmalleramountsdrinksmalleramountsatoneatonetime,misusedrugstime,misusedrugsprescribedbyprescribedb

160、ydoctors,doctors,experienceahiddenalcoholexperienceahiddenalcoholproblemproblem. . n ndrinkdrinkinconnectionwithinconnectionwithanumberanumberoflate-lifeoflate-lifestresses,includingstresses,includingbereavementbereavementandlossofandlossofoccupationaloccupationalroles.roles.SAMHSA2010TreatmentRepor

161、tn n1of8personsoverage50soughthelpforsubstanceusein2008.n nTheirshareoftreatmentadmissionsdoubledn nbetween1992and2008.n nPrimarysubstanceuseproblemswerewithalcohol,heroin,cocaine.n nManylateonsetdrugusershadproblemswithprescriptionmedications.MoreFacts ManyearlyonsetsufferfromKorsakoffssyndromeando

162、theralcohol-relatedneurologicalproblems. Medicalcomplications: Hipfracture,suicide,braindamageHipfracture,suicide,braindamage Lateonsetmorewomenhere,closefamilytiesCounselingOlderClients DWIandeffectonselfimage Agesegregatedvs.mixedagesintreatment Guidelinesforworkingroupswithelderly: -Avoidstrongla

163、nguage,rebuildsupportsystems -KeeppaceslowRelapsePrevention: TeacholderclientstolearnthewarningsignsandTeacholderclientstolearnthewarningsignsandhighriskevents;highriskevents; ReviewfeelingsthatledtorelapsesotheycanbeReviewfeelingsthatledtorelapsesotheycanbeavoided(forexample,depression);HALTavoided

164、(forexample,depression);HALT Focusoncriticalthinkingskills.Focusoncriticalthinkingskills. Helpclientsrenewtheircommitmenttosobriety;Helpclientsrenewtheircommitmenttosobriety; Findeffectivecopingstyles;Findeffectivecopingstyles; Buildsupportsystems;Buildsupportsystems; Rememberthatnon-confrontational

165、approachisbest.Rememberthatnon-confrontationalapproachisbest.CounselorPitfalls:(Beechem) Anticipatefeelingsofguiltandshameinolderclientsintroublewiththelaw; Ageism CountertransferenceCountertransference DenialinassessmentDenialinassessment SympathynotempathySympathynotempathyLossandgriefinfamilymemb

166、ersofaddictedpersons:n nTypesofGuiltn nSurvivorguiltSurvivorguiltn nHelplessnessHelplessnessn nAmbivalenceAmbivalencen nSpiritualhealingsenseofmeaning,connectednessn nStrengthfrom12StepsSpiritualHealingToday,socialworkeducationstressesimportanceofToday,socialworkeducationstressesimportanceofhelpingc

167、lientsfindspiritualmeaning.helpingclientsfindspiritualmeaning.OlderadultsoftenchangetheiroutlookastheylookOlderadultsoftenchangetheiroutlookastheylookbackontheirlives.Seekforthemeaningoflife.backontheirlives.Seekforthemeaningoflife.HigherPowerasnatureinNorway,NativeAmericanHigherPowerasnatureinNorwa

168、y,NativeAmericantraditions.traditions.Searchforforgivenessandrenewal.Searchforforgivenessandrenewal.12Stepsasguidetoselfknowledge12StepsasguidetoselfknowledgeChapter7:ScreeningandAssessmentn nChapterfocusonstrengthsperspective.n nAdvantagesofdoingassessment:getinformation,matchtocounselor,getinsuran

169、cereimbursementfordiagnosis.n nDisadvantages:maysetupfalseexpectationsforspecializedtreatment,delaysactualtreatment,maybeinappropriateformanyminoritygroups.ScreeningInstrumentsn nConsistofjustafewquestionstodeterminenatureofhelpneeded.n nInformalquestionslike,“Doyousometimesdrink?”n nEffectiveone-qu

170、estionscreenforwomen:“Howmanytimesinthepastyearhaveyouhadfourormoredrinksinaday?”CAGEn nCHaveyoueverfeltyououghttocutdownonyourdrinkingCHaveyoueverfeltyououghttocutdownonyourdrinkingordrugordrugn nuse?use?n nAHavepeopleannoyedyoubycriticizingyourdrinkingorAHavepeopleannoyedyoubycriticizingyourdrinki

171、ngordruguse?druguse?n nGHaveyoueverfeltbadorguiltyaboutyourdrinkingordrugGHaveyoueverfeltbadorguiltyaboutyourdrinkingordruguse?use?n nEHaveyoueverhadadrinkoruseddrugsfirstthinkintheEHaveyoueverhadadrinkoruseddrugsfirstthinkinthemorningmorningn ntosteadyyournervesorgetridofahangover?tosteadyyournerve

172、sorgetridofahangover?TWEAKn nTolerancen nWorriedn nEyeOpenersn nAmnesian nKutdownWorkswellwithmixedethnicpopulationsAUDITn nRecommendedbyWHOforglobaluse.n nTheAUDITincludes10itemsthatcoveramountandfrequencyofdrinking,alcoholdependencesymptoms,personalproblems,andsocialproblemsn n“Haveyouorsomeoneels

173、ebeeninjuredbecauseofyourdrinking?”AUDITcontinuedn nScoringdiscriminatesbetweendifferentlevelsofriskhazardous,harmful,andpossibledependence.n nApreventiontooltoassessfuturerisks.n nCanbegiventotheclientasaquestionnairen ntofillout,oritcanbeusedasinterviewquestions.n nAvailableforfreeontheInternet.As

174、sessmentToolsn n(CSAT)(2005)definesassessmentasthe“processfordefiningthenatureoftheproblemanddevelopingspecifictreatmentrecommendationsforaddressingtheproblem.”n nCangiveadeeperpictureofmotivationtochange.n nCanbebeginningofrelationship.GamblingAssessmentn nGamblersAnonymoushas20questionstodetermine

175、ifGamblersAnonymoushas20questionstodetermineifsomeonehasaproblem.Examples:someonehasaproblem.Examples:n nDidDidyoueverlosetimefromworkorschoolduetogambling?youeverlosetimefromworkorschoolduetogambling?n nHasHasgamblingevermadeyourhomelifeunhappy?gamblingevermadeyourhomelifeunhappy?n nDidDidgamblinga

176、ffectyourreputation?gamblingaffectyourreputation?n nHaveHaveyoueverfeltremorseaftergambling?youeverfeltremorseaftergambling?n nDidDidyouevergambletogetmoneywithwhichtopaydebtsoryouevergambletogetmoneywithwhichtopaydebtsorotherwisesolveotherwisesolvefinancialdifficulties?financialdifficulties?DRINCn

177、nTheDrinkerInventoryofConsequences(Drinc)TheDrinkerInventoryofConsequences(Drinc)originallyoriginallydesignedfordesignedforProjectMATCHProjectMATCHn nAA50-itemquestionnairethatcoversphysical,social,50-itemquestionnairethatcoversphysical,social,intrapersonal,impulseintrapersonal,impulsecontrol,andint

178、erpersonalproblemcontrol,andinterpersonalproblemareas.areas.Ofprovenreliability,validity.Ofprovenreliability,validity.n nIncludespositivequestionssuchas(“Includespositivequestionssuchas(“HowoftenhasHowoftenhasdrinkingdrinkinghelpedhelpedmetorelax?”),metorelax?”),andnegatives:“andnegatives:“Howoftenh

179、asHowoftenhasmymyabilityabilitytobeagoodparentbeenharmedbymydrinkingtobeagoodparentbeenharmedbymydrinking”. ”.TheSASSIn nTheSubstanceAbuseScreeningInventory(SASSI)(Miller&TheSubstanceAbuseScreeningInventory(SASSI)(Miller&Lazowski,1999Lazowski,1999) )n nAAdifferentapproachtoassessmentdifferentapproac

180、htoassessmentinstrumentsdoesnotaskinstrumentsdoesnotaskdirectlyaboutsubstancemisuseononesideoftheform.directlyaboutsubstancemisuseononesideoftheform.n nConsistsoftrue-falseitems.Consistsoftrue-falseitems.suchas“suchas“IamIamoftenresentful,”andoftenresentful,”and“Iliketoobeythe“Iliketoobeythelaw.”law

181、.”AssessingLevelsofCaren nEarlyEarlyInterventionInterventionn nOutpatientOutpatientTreatmentTreatmentn nIntensiveIntensiveOutpatient/PartialHospitalizationOutpatient/PartialHospitalizationTreatmentTreatmentn nResidential/InpatientResidential/InpatientTreatmentTreatmentn nMedicallyMedicallyManagedInt

182、ensiveInpatientTreatment.ManagedIntensiveInpatientTreatment.n nEachlevelofcareincludesseverallayersofintensity.Eachlevelofcareincludesseverallayersofintensity.ASSESSMENTOFPERSONSWITHCO-OCCURRINGDISORDERS(COD)n nAbasicprogramfromtheCSATprovidestreatmentforonedisorder,butscreensfortheotherdisorder;n n

183、Anintermediatelevelfocusesprimarilyononedisorderbutalsoaddressessomespecificneedsoftheother.n nAdvancedlevelprovidesservicesforbothdisorders.GuidelinesforAssessmentofCODn nBefamiliarwithlatestDSMandcriteriaforBefamiliarwithlatestDSMandcriteriafordiagnosis.diagnosis.n nKeepuptodateontherelevantpsychi

184、atricKeepuptodateontherelevantpsychiatricmedications.medications.n nHarmreductiontherapistsrecommendonlyHarmreductiontherapistsrecommendonlycontactingfamilymembersandothersifclientssocontactingfamilymembersandothersifclientssowishandwiththeclientpresent.wishandwiththeclientpresent.n nKnowthecommunit

185、yresources.Knowthecommunityresources.AssessmentofOlderClientsn nRiskfactorsRiskfactorsforgamblingproblemsare:forgamblingproblemsare:thethepresenceofcurrentposttraumaticstressdisorderpresenceofcurrentposttraumaticstressdisordersymptoms,minorityracesymptoms,minorityraceorethnicity,andbeingaVeteransAff

186、airs(VA)patientorethnicity,andbeingaVeteransAffairs(VA)patient . .n nThereforeincludequestionsaboutgambling.Thereforeincludequestionsaboutgambling.CAGEandMASTGeriatricversionarevalidatedCAGEandMASTGeriatricversionarevalidatedforusewitholderadults.forusewitholderadults.ASSESSMENTFORSTRENGTHSn nViewcl

187、ientsasinchargeoftheirowngoals.Viewclientsasinchargeoftheirowngoals.n nTakeintoaccountsocialfactorsaswellasindividualTakeintoaccountsocialfactorsaswellasindividualfactorsforacomprehensiveviewofthesituation.factorsforacomprehensiveviewofthesituation.n nMovetheassessmenttowardstrengths,bothMovetheasse

188、ssmenttowardstrengths,bothintrapersonal(intrapersonal(motivation,emotionalmotivation,emotionalstrengthsandstrengthsandabilitytothinkclearly)andinterpersonal(familyabilitytothinkclearly)andinterpersonal(familyn nnetworksnetworks,etc.,etc.n nAvoididentifyingthepersonwithalabel.Avoididentifyingtheperso

189、nwithalabel.StrengthsAssessmentcontinuedn nKeyingredients:n nEmpathy.Empathy.n nProvidehope.Providehope.n nR Reflectivelistening.eflectivelistening.EndofChapters1-7Assessmentn nNeedforassessmentformstobesensitivetogender/culturaldifferencesn nLanguagedifferences,e.g.,thewordcraving hardtotranslaten

190、nCAGEandTWEAKworkwellwithwomenCAGEn nHaveyoutriedCuttingdown?n nHavepeopleAnnoyedyou?n nHaveyoufeltGuiltyaboutyourATODuse?n nHaveyoueverusedATODasanEyeopener?OtherScreeningFormsn nAUDITdevelopedbyWHOforalcoholusen nNIAAA50iteminstrument,InventoryofDrugUseConsequences,inpublicdomainn nWHOdesignatedar

191、easofharmcausedbydrinkphysical,emotional,health,family,finances,etc.Chapter8Strengths-andEvidence-BasedHelpingStrategiesDennisSaleebey Focusonpossibilities,choicesprovidingtreatmentFocusonpossibilities,choicesprovidingtreatmentoptions.options. Resilience,healing,andwholeness.Resilience,healing,andwh

192、oleness. Contrastwithproblem-solvingapproach.Contrastwithproblem-solvingapproach.DennisSaleebey Focusonpossibilities,choicesprovidingtreatmentFocusonpossibilities,choicesprovidingtreatmentoptions.options. Resilience,healing,andwholeness.Resilience,healing,andwholeness. Contrastwithproblem-solvingapp

193、roach.Contrastwithproblem-solvingapproach. Strengths-basedStrengths-basedpracticepracticedefineddefinedbySaleebeybySaleebey as“aversatileas“aversatilepracticeapproach,relyingpracticeapproach,relyingheavilyonheavilyoningenuityandingenuityandcreativity.”creativity.”IssueofSelf-DeterminationHowdowehono

194、rclientsself-determinationwhentheclientisharminghimself-herselfwithsubstancemisuse?1.Rightofchoiceshouldbeextendedtoallsocialclasses;asitispeopleinpovertyhavefarlesschoicethanthoseathighincomelevels.2.Importanceofprovidingoptions.Abstinence-basedmodelsdonot.3.Attendtoreadinessofclienttochange.Firsto

195、fFourModelsofStrengths-BasedApproaches1.1.Harm reductionHarm reduction:publichealthmodel,prevention,:publichealthmodel,prevention,outreach.outreach.Abstinencenotpreconditiontotreatment;recoveryAbstinencenotpreconditiontotreatment;recoverycanbemeasuredthroughdegreeofimprovement.canbemeasuredthroughde

196、greeofimprovement.StagesofChangeModel:ProchaskaandStagesofChangeModel:ProchaskaandDiClementeDiClementePrecontemplationPrecontemplationContemplationContemplationPreparationPreparationActionActionMaintenanceMaintenanceRelapseRelapseHarmReductionStrategies Practitionersareadvisedtofocusonharmsotherthan

197、substanceuse,suchasunemployment,poverty,needforhousing. Gamblingproblemscanbepreventedbyremovinggamblingmachinesfromshoppingcenters,stripmalls,clubs,andhotels. Othersupportservices,suchasmentalhealthandfinancialcounselingshouldbereadilyavailable.2.MotivationalInterviewing(MI)-WilliamMiller D Defined

198、efinedasa“client-centered,directiveasa“client-centered,directive methodforenhancingintrinsicmotivationtomethodforenhancingintrinsicmotivationtochangebyexploringandchangebyexploringandresolvingambivalence.”resolvingambivalence.” Needtoasktherightquestions;“TellmeaboutaNeedtoasktherightquestions;“Tell

199、meaboutaperiodwhenyouweredoingwell?”periodwhenyouweredoingwell?” Smoking:onascaleof1-10togiveupsmoking,Smoking:onascaleof1-10togiveupsmoking,whereareyounow?whereareyounow?MIcontinuedStepstoenhancemotivation:ExpressempathyDevelopdiscrepancyAvoidargumentationRollwithresistanceSupportself-efficacyAskin

200、gopen-endedquestionshelpsclientsevokethedecisiontochange.3.SolutionfocusedtherapyFindingsolutiontoproblemviewedasmoreimportantthanfindingthecause.Strategies: Miraclequestion Thepersonalnarrative Scalingquestions Copingquestions4.Cognitive/BehavioralTherapy(CBT) AttributedtoAaronBecksworkwithdepressi

201、on.AttributedtoAaronBecksworkwithdepression. AlbertEllischallengedclientsfaultybeliefsystems.AlbertEllischallengedclientsfaultybeliefsystems. CurrentlymorefocusonpromotingpositivethoughtsCurrentlymorefocusonpromotingpositivethoughtsratherthanfocusonthenegative.ratherthanfocusonthenegative. Studiesco

202、nsistentlyStudiesconsistentlyshowCBTasthemostshowCBTasthemostempiricallyempirically supportedsupportedformofgrouptherapyforaddictionsformofgrouptherapyforaddictionsTeachingaboutDistortions Gamblingexample:conditioningusedbycasinoownerstogetGamblingexample:conditioningusedbycasinoownerstogetplayersto

203、spendmoreuseofbells,positivereinforcement.playerstospendmoreuseofbells,positivereinforcement. GamblersoftenhavedistortedbeliefsaboutluckydaysandGamblersoftenhavedistortedbeliefsaboutluckydaysandmachinesandsoforth.machinesandsoforth. SkillstrainingcanhelpclientsavoidsuccumbingtotriggersSkillstraining

204、canhelpclientsavoidsuccumbingtotriggersthatpromotegambling.thatpromotegambling. RoleplaysandreinforcementofbehaviorstoresisttemptationRoleplaysandreinforcementofbehaviorstoresisttemptationareeffectivestrategies.areeffectivestrategies.CBTforRelapsePrevention Interpersonalcopingskillshelpclientsdealwi

205、thhigh-riskrelapsesituationsandtodevelopsocialsupportfortheirrecovery. Teachingofrefusalskills. Intrapersonalcopingskillsfocusonlearninghowtocopewithonesowninternaltriggers,suchasanger,stress,andnegativemoods.GroupTherapy Mostpopularformofdeliveringsubstanceabusetreatment. Costeffective,goodsourcefo

206、rfeedback. Ofproveneffectivenessinteachingskills,helpingpeopletolearnfromothers,gettingfeedback.EarlyStagesofGroupTherapy Firststeptoestablishtrust,buildfaithintheFirststeptoestablishtrust,buildfaithinthecounselorandgroupmembers.counselorandgroupmembers. Discussrulesofagencyandgroupnorms.Discussrule

207、sofagencyandgroupnorms. Forexample,confidentialitywhatissaidintheForexample,confidentialitywhatissaidinthegroupstaysinthegroup.groupstaysinthegroup. MotivationalinterviewinggroupsforcollegestudentsMotivationalinterviewinggroupsforcollegestudentsshowntobehelpfulinreducingdrinkingproblems.showntobehel

208、pfulinreducingdrinkingproblems. Exampleofdrop-ingroupforhomelesspeople.Exampleofdrop-ingroupforhomelesspeople.TraditionalTreatmentandStrengths-BasedApproaches Detoxopportunitytointroducepatienttochoices. Outpatientprimarilygroupcounseling. Inpatientandhalfwayhouses. Aftercareonceamonth,maybe12Stepgr

209、ouporreligiousactivity.Chapter9SubstanceMisuseWithACo-OccurringDisorderOrDisabilityCo-OccurringDisorders DoublewhammysubstancedependenceandmentalDoublewhammysubstancedependenceandmentaldisorder.Bipolarfeelinghighcanimitatedruguse.disorder.Bipolarfeelinghighcanimitatedruguse. MentalHealthParityandAdd

210、ictionEquityActofMentalHealthParityandAddictionEquityActof2008ended2008endeddiscriminationagainstdiscriminationagainstconsumersofconsumersofmentalhealthandsubstanceabusetreatmentservicesmentalhealthandsubstanceabusetreatmentservicesininsurancecoverage.ininsurancecoverage. Thenumbersofpeoplewithserio

211、usmentaldisordersThenumbersofpeoplewithseriousmentaldisorderswhomisusesubstancesandwhosmokeisdoublethewhomisusesubstancesandwhosmokeisdoubletherateofthosewithoutmentalhealthdisorders.rateofthosewithoutmentalhealthdisorders. AroundhalfofpeopleintreatmentforsubstanceuseAroundhalfofpeopleintreatmentfor

212、substanceusedisorderhaveaseriousmentaldisorder.disorderhaveaseriousmentaldisorder.NeedforIntegratedTreatment IntegratedApproachfitswithharmreduction Aboutathirdofaddictiontreatmentprogramsnowincludetreatmentforpsychiatricdisorders. Only8.5%offerintegratedprogramming(2006) Anxietydisorderdiagnosedin4

213、0%ofpersonswithdrugdependency;maybeeffectofstimulantdrugs.Co-OccurringDisorderscontinued Addictioncounselorsoftenexplainpsychosisasdruginduced. Mentalhealthprofessionalstendtoseealcoholuseasselfmedication. Truthisboth/and,noteither/or. Coexistingdisorders:anxiety,compulsivegambling,eatingandmooddiso

214、rders.DisordersthatOftenCo-existwithSubstanceAbuse: Anxiety Compulsivegambling Mooddisorders Eatingdisorders Personalitydisorders PsychosisPersonalityDisorders: Borderlinepersonality Anti-socialpersonality Thesediagnosesoftenbasedonculturalbiases Integratedtreatmentneeded Needtoofferbetterhousing,ca

215、nrelyonfundingbySupplementalSecurityInsurance(SSI)PTSD Diagnosiscamein1980inresponsetoVietnamDiagnosiscamein1980inresponsetoVietnamwarveteransandfeministmovementonbehalfofwarveteransandfeministmovementonbehalfofrapevictimsrapevictims About25%exposedtoseveretraumawilldevelopAbout25%exposedtoseveretra

216、umawilldevelopsubstancerelatedproblemssubstancerelatedproblems HighrateofrelapseamongwomeninsubstanceHighrateofrelapseamongwomeninsubstanceabusetreatmentwithPTSDuponreleaseabusetreatmentwithPTSDuponrelease HighanxietyaproblemHighanxietyaproblem TraumafromnaturaldisasterssuchasHurricaneTraumafromnatu

217、raldisasterssuchasHurricaneKatrinaKatrinaPTSDafterCombat Atleast1in6veteransofwarinIraqhasPTSD Flashbackscommon ImmediateinterventionwithSSRIsrecommendedtooffsetformationoflockedmemories Womenseekinghelpforrapetrauma,someimesfromattacksbyfellowsoldiersBipolarDisorder Mostcommonlydiagnosedofthemental

218、disordersforthosewithco-occurringdisorders. Frommaniatodepression 90%withthisdisorderhavesubstance-relatedproblemsinaprisonsampleSchizophrenia About1%developschizophrenia Delusions,hallucinations,apathyandlossofpleasure,problemsconcentrating JohnNash,ABeautifulMind 48%havesubstance-relatedproblems,a

219、varietyofsubstancesused “Nowrongdoor”totreatment Pronetohomelessness;HousingFirstprogramsIntegratedTreatmentPrinciplesSAMSHA IntegratedIntegratedtreatmentspecialistsaretrainedtotreatbothtreatmentspecialistsaretrainedtotreatbothsubstanceusesubstanceusedisordersanddisordersandseriousmentalillnesses.se

220、riousmentalillnesses. Co-occurringCo-occurringdisordersaretreatedinastage-wisefashionwithdisordersaretreatedinastage-wisefashionwithdifferentservicesdifferentservicesprovidedatdifferentstages.providedatdifferentstages. MotivationalMotivationalinterventionsareusedtotreatconsumersinallinterventionsare

221、usedtotreatconsumersinallstages,stages,butespeciallybutespeciallyinthe“persuasion”stageinthe“persuasion”stage. .IntegratedPrinciplescontinued Substanceabusecounseling,usingacognitive-behavioralapproachfortheactivetreatmentandrelapsepreventionstages. Multipleformatsforservicesareavailable,includingin

222、dividual,group,self-help,andfamily.Medicationservicesareintegratedandcoordinatedwithpsychosocialservices.AssertiveCommunityTreatment(ACT) Unlikeintegratedtreatment,herethecounselorsgotoUnlikeintegratedtreatment,herethecounselorsgototheclientandareavailablearoundtheclock.Onlytheclientandareavailablea

223、roundtheclock.Onlyforthemostseverementalillness.Principles:forthemostseverementalillness.Principles: Teamapproach:ACTteamTeamapproach:ACTteammembersinterdisciplinarymembersinterdisciplinaryandactasawholetoensurebasicneedsaremet.andactasawholetoensurebasicneedsaremet. SmallSmallcaseload:Teamsof1012se

224、rve100caseload:Teamsof1012serve100consumers.consumers. TimeTimeunlimitedunlimitedservices.Noindividualservices.Noindividualcaseloadscaseloads.HousingFirst Supportivemodelforchronicallymentallyillwithsubstanceuseproblems.Incontrasttohousingprogramsrequiringtotalabstinence. Intensivecasemanagementprov

225、ided.Clientchoicesarerespected. “Wet”houses. CosteffectiveforcommunitiesNewYorkCity,Seattle,SanFrancisco,Portland,OR.PhysicalandCognitiveDisabilities1990AmericanswithDisabilitiesActforfullparticipationinservicesPersonswithheadinjuriesathighriskforsubstancemisuse;manywereintoxicatedwheninjuredHighamo

226、ngwoundedwarveteransTraumaticbraininjuryfromwarinIraqBarrierstotreatmentfewprogramswithexpertisetomeettheneed.PartIVSocialAspectsofAddictionsChapter10FamilyRisksandResilience Addictionisafamilydiseasepainandstigma.Addictionisafamilydiseasepainandstigma. Box10.1Box10.1DesMoinesRegisterDesMoinesRegist

227、er“ChildrenofAddicts”“ChildrenofAddicts”methlabs,familyfights,andchildneglectinIowamethlabs,familyfights,andchildneglectinIowa ClassicFamilyStructure:ClassicFamilyStructure: Addictassymptomofcarrier.Addictassymptomofcarrier. FaultycommunicationinfamilyanorexiaFaultycommunicationinfamilyanorexia Conf

228、usionofcauseandeffectConfusionofcauseandeffect Familytherapyfield,littleattentiontoaddictionproblemsFamilytherapyfield,littleattentiontoaddictionproblemsexceptassymptomsexceptassymptoms Littleattentiontoculturaldiversityaswell.SeeLittleattentiontoculturaldiversityaswell.SeeMcGoldricketalsMcGoldricke

229、talsEthnicityandFamilyTherapyEthnicityandFamilyTherapy(2005)(2005)HistoryofFamilyTreatment Lackofinsurancepreventsemphasisonfamilytreatment VirginiaSatir:studiedfamilyadaptationtopersonsillness. ClaudiaBlack “Itwillneverhappentome”“Itwillneverhappentome” Donttalk,trust,feelco-alcoholic,Donttalk,trus

230、t,feelco-alcoholic,codependent.codependent. Al-Anon1950sWegscheidersRoleTheory Codependentperson,chiefenablertermstookCodependentperson,chiefenablertermstookonnegativeconnotationslater.onnegativeconnotationslater. Thistextusesthemorepositiveterm,Thistextusesthemorepositiveterm,familyfamilymanagerman

231、agerinsteadofchiefenabler.insteadofchiefenabler. Wegscheiderstermsforfamilyroles:hero,Wegscheiderstermsforfamilyroles:hero,scapegoat,lostchild,mascotscapegoat,lostchild,mascot MelodyBeattie:MelodyBeattie:CodependencyNoMoreCodependencyNoMore popularizedtheterm.Wesuggestsurvivorinsteadpopularizedthete

232、rm.Wesuggestsurvivorinsteadofcodependent,atermthathastakenonalifeofofcodependent,atermthathastakenonalifeofitsown.itsown.Figure9.1FamilyFormsEnmeshedfamily:Spousesareestranged:onechildhereisenmeshedwithfather,onewithmotherFCMCIsolatedfamily:Lackofcohesionandsocialsupport.Eachmemberisprotectedbywallo

233、fdefenses.CFMCHealthyfamily:Allaretouching,buttheirboundariesarenotoverlapping.CMFCStagesofChangeandFamily: 1.Precontemplation:Counselorsdescribefamilycommunicationpatterns. 2.Contemplation:familyconcernslookforsolutions.Malepartnersmaybehardtoengage. 3.Preparation:Breakingpoint-formalintervention(s

234、eeboxedreadingbyCarrollSchutey)Familymembersmakealistoffeelingresponsestoaddictsactions.Stagescontinued 4.Action: RehearsalandtreatmentoffamilywithoutRehearsalandtreatmentoffamilywithout addictedmember.addictedmember. TherapistfeedbackExampleoftherapistresponsetofamilyTherapistfeedbackExampleofthera

235、pistresponsetofamilyargument:“Inotethatasyou,Stevesaidthatjustthen,youargument:“Inotethatasyou,Stevesaidthatjustthen,you(kid)felloutofchair.”Purposetorevealhowthefamilyroles(kid)felloutofchair.”Purposetorevealhowthefamilyrolesoperateinasystem.operateinasystem. 5. 5. Maintenance: Focusonprocessnotcon

236、tent“whattodoFocusonprocessnotcontent“whattodoif.”Transitionwithsobriety.if.”Transitionwithsobriety.CulturalConsiderationsMcGoldricketalsbookondifferentethnicities.McGoldricketalsbookondifferentethnicities.Describesworkwith:Describesworkwith: AfricanAmericanfamiliesreciprocityastrengthAfricanAmerica

237、nfamiliesreciprocityastrengthherehere LatinofamiliesavoidabusinesslikeapproachLatinofamiliesavoidabusinesslikeapproach AsianandAsianAmericanfamiliesengagemostAsianandAsianAmericanfamiliesengagemostpowerfulpersoninthefamilypowerfulpersoninthefamily AppalachianfamiliesengagethewomenwhoAppalachianfamil

238、iesengagethewomenwhowillteachhealthcarepracticeswillteachhealthcarepracticesSituationsofDomesticViolenceConnectionofsubstanceuseandviolence.Batteringinterventionprograms.Motivationalinterviewingasbridgebetweenwomensdomesticviolenceservicesandsubstanceabusetreatment.Teachingwomensafetyplansforharmred

239、uction.Riskofseriousviolenceanddeath.RulesofFightingFair Attackbehavior,notperson Keepissuesofmanageablesize,dontlabel, Dontusenegativelabels. Dontrehashthepast.ThreeRsModel RenameRename:Nolabels,shoppingaddictionas:Nolabels,shoppingaddictionasillness,notfoolishspending.illness,notfoolishspending. R

240、eframeReframe:helpclientseethingshappenfora:helpclientseethingshappenforareasonreason ReclaimReclaim:healing,we-ness,familycirclesto:healing,we-ness,familycirclestomakedecisions(fromNativeAmericans)makedecisions(fromNativeAmericans) KathyandEd:CaseStudyKathyandEd:CaseStudy ExercisesRelatedtoFamilyWo

241、rk1. 1.Drawingfamilymaps,circles2. 2.Relapsepreventionplan.3. 3.Viewingexcerptfromamovieorvideotape.Chapter11Mutual-HelpGroupsMutualAidGroups Confusion12Stepfacilitatedtreatmentand12Stepselfhelpgroups(farmoretolerantandnon-judgmental). AAspirituallybasedfellowshipisfree Voluntarytreatment:consistent

242、withharmreduction. Involuntarytreatmentforthosewhofailedatmoderation.TwelveStepsPresentedinBoxPresentedinBox11.1.Firstfive:11.1.Firstfive:1.We1.Weadmittedwewerepowerlessoveralcoholthatouradmittedwewerepowerlessoveralcoholthatourliveshadliveshadbecomeunmanageablebecomeunmanageable. .2.Cametobelieveth

243、ataPowergreaterthanourselvescould2.CametobelievethataPowergreaterthanourselvescouldrestoreustosanity.restoreustosanity.3.Madeadecisiontoturnourwillandourlivesovertothe3.MadeadecisiontoturnourwillandourlivesovertothecareofGodcareofGodasweasweunderstoodHim.understoodHim.4.Madeasearchingandfearlessmora

244、linventoryofourselves.4.Madeasearchingandfearlessmoralinventoryofourselves.5.AdmittedtoGod,toourselvesandtoanotherhumanbeing5.AdmittedtoGod,toourselvesandtoanotherhumanbeingthetheexactnatureexactnatureofourwrongsofourwrongs. .AlcoholicsAnonymous(AA) GreaterinvolvementinAAfoundtoeffective.Greaterinvo

245、lvementinAAfoundtoeffective. UseofnarrativesstoriesofpowerlessnessoverUseofnarrativesstoriesofpowerlessnessovertheaddiction,livesoutofcontroltheaddiction,livesoutofcontrol Feministobjectionsto12StepsFeministobjectionsto12Steps Metaphorofdiseasemental,physical,andMetaphorofdiseasemental,physical,ands

246、piritual,metaphorofpowerlessnessspiritual,metaphorofpowerlessness Meansofexpandingtreatment.wordsinBigMeansofexpandingtreatment.wordsinBigBookOnedayataBookOnedayatatimeHigherPower.timeHigherPower.OtherSelf-HelpGroups GAmemberstendtobeolderandhavehighrateofGAmemberstendtobeolderandhavehighrateofabsti

247、nenceafterattendingfor2months.abstinenceafterattendingfor2months. Addressesfinancialaswellasspiritualproblems.Addressesfinancialaswellasspiritualproblems. NAmultilingualmeetings.NAmultilingualmeetings. WomenforSobriety13Steps.WomenforSobriety13Steps. SMARTRecovery-cognitiveapproach.SMARTRecovery-cog

248、nitiveapproach.ModerationManagementstartsat30daysofModerationManagementstartsat30daysofabstinence,aharmreductionstrategyabstinence,aharmreductionstrategy Somesay12Stepsshouldbemodernized.SeeoneSomesay12Stepsshouldbemodernized.Seeoneattempt9Sattempt9SRecoveryCommunityCentersAnewdevelopmentinsomestate

249、s,followrecoverymanagementphilosophy.Providesservicessuchastelephonesupport(usuallybyavolunteerinrecovery),familysupportgroups,housingassistance,recoverygroupmeetings,socialevents,andrecoverycoaching.Chapter12Racial,Ethnic,CultureandClassIssuesMinorityGroupMembership Needtoknowsocialpoliticalcontext

250、ofbeingminority. Treatmentmusttakeintoaccountethnoculturenorms. TheCouncilonSocialWorkEducation(CSWE)liststheabilityto“engagediversityanddifferenceinpractice”asoneofthetencorecompetencies. Weneedtoknowsomethingaboutnormsofparticulargroupstoenhancetreatment.SocialClassImportanceofclassbellhooks-Class

251、affectsadolescentsaccesstodrugs.Druguseaffectedbyunemploymentandlowincomestatus.Oftenasacculturationincreases,sodoessubstancemisuseAsianAmericans/PacificIslanders Lowrateofsubstancemisusejustover3%.Lowrateofsubstancemisusejustover3%. JapaneseAmericansdrinkmuchmorethanChineseJapaneseAmericansdrinkmuc

252、hmorethanChineseAmericans.Americans. SuccessoftenisrelatedtotheirlevelofeducationatSuccessoftenisrelatedtotheirlevelofeducationathomeandurbanization.homeandurbanization. Cambodians-wartrauma.Cambodians-wartrauma.AsiansandHawaiians AsianAmericans-highestincomeofallethnicities,filialAsianAmericans-hig

253、hestincomeofallethnicities,filialpiety.piety. EmotionalEmotionalsharingmayleadtolossofface.sharingmayleadtolossofface. ImmigrationImmigration,amajorstress.,amajorstress. ForForNativeHawaiiansfemaleeldersprovideculturallyNativeHawaiiansfemaleeldersprovideculturallybasedtreatment.basedtreatment. Pilot

254、PilotprograminIndiausesyogaandmeditationtoreduceprograminIndiausesyogaandmeditationtoreducestress.stress.AmericanIndiansandAlaskanNatives Historical traumaHistorical traumaracismandchildrenwereonceracismandchildrenwereoncesenttoboardingschoolstodestroyculture.senttoboardingschoolstodestroyculture. N

255、ativeAmericansarelessthan.9%ofUSpopulation.NativeAmericansarelessthan.9%ofUSpopulation.Almosthalfreporttheyareofmixedrace.Almosthalfreporttheyareofmixedrace. Highrateofsubstanceabuseordependence:15.5%.Highrateofsubstanceabuseordependence:15.5%.illicitdruguse18.3%,bingedrinking22.2%,illicitdruguse18.

256、3%,bingedrinking22.2%,cigaretteuse41.8%.Highfatalaccidentrate,FAS.cigaretteuse41.8%.Highfatalaccidentrate,FAS. Highpoverty,alcoholabuse,youthinhalantuse.Highpoverty,alcoholabuse,youthinhalantuse. UseofMedicineWheelforholistic,spiritualUseofMedicineWheelforholistic,spiritualframework,talkingcircles.(

257、Box12.2)framework,talkingcircles.(Box12.2) RedRoadtoSobriety.RedRoadtoSobriety.Latinos 16%ofpopulation(California:1/3ofpopulation)16%ofpopulation(California:1/3ofpopulation) 58%ofHispanicsintheU.S.areMexicans.58%ofHispanicsintheU.S.areMexicans. SubstanceabuseordependenceforHispanics10.2%.Substanceab

258、useordependenceforHispanics10.2%.Increaseintreatmentadmissionsformethuse.Increaseintreatmentadmissionsformethuse. TreatmentneedsforalcoholmisuseamongMexicanTreatmentneedsforalcoholmisuseamongMexicanAmericans(9.2%)andPuertoRicans(6.1%).Americans(9.2%)andPuertoRicans(6.1%). InU.S.21.1%ofLatinossmoke.L

259、essamongwomenInU.S.21.1%ofLatinossmoke.Lessamongwomenbutincreasing.butincreasing. Highrateofgamblingproblems.HIV/AIDSamajorHighrateofgamblingproblems.HIV/AIDSamajorproblem.problem. Highrateofpoverty;fewhavehealthinsurance.Highrateofpoverty;fewhavehealthinsurance. Grouphasthehighesthighschooldrop-out

260、rate,Grouphasthehighesthighschooldrop-outrate,PuertoRicans,thehighestpovertyrate.PuertoRicans,thehighestpovertyrate.TreatmentIssuesforLatinos Male/femaleMale/femaleroledifferentiation.roledifferentiation. WorkWorkwithfamilyshouldsupportfamilystrengthswithfamilyshouldsupportfamilystrengths. . Needfor

261、Spanish-speakingcounselors.UnderstandthatNeedforSpanish-speakingcounselors.Understandthatwithsecondgeneration,womenhavemoreaddictionwithsecondgeneration,womenhavemoreaddictionproblems.problems. CasemanagementservicesneededtogetclientsintoGEDCasemanagementservicesneededtogetclientsintoGEDprogramswher

262、eneededandjobtrainingprograms.programswhereneededandjobtrainingprograms.AfricanAmericans Arejustover12%ofpopulation.Arejustover12%ofpopulation. Substanceabuseandaddictionrateis8.8%.24%Substanceabuseandaddictionrateis8.8%.24%reportbingedrinking.Illicitdrugabuse9.6%.Aboutreportbingedrinking.Illicitdru

263、gabuse9.6%.About24%oftreatmentpopulationbutdruguseisnotmuch24%oftreatmentpopulationbutdruguseisnotmuchmorethanthatofgeneralpopulation.morethanthatofgeneralpopulation. Inprisonare44%ofinmatessentencedforillicitdrugInprisonare44%ofinmatessentencedforillicitdruginvolvement.involvement. Ofthosewhogamble

264、,highaddictionrate.Ofthosewhogamble,highaddictionrate. 45%ofallnewHIVcasesareAfricanAmerican.45%ofallnewHIVcasesareAfricanAmerican.AfricanAmericanscontinued HigherHighersocialclassandchurchattendanceareprotectivesocialclassandchurchattendanceareprotectivefactorsfactors. . OlderAfricanAmericanwomenov

265、er85%abstain.OlderAfricanAmericanwomenover85%abstain. Twiceasmanyareinpovertyaswhites.HighersocialclassTwiceasmanyareinpovertyaswhites.Highersocialclassaprotectivefactor.aprotectivefactor. Almosthalfofadvertisingbudgettargetsblacks.Almosthalfofadvertisingbudgettargetsblacks. Recoveryrelatestospiritu

266、alityandfamilysupport.Recoveryrelatestospiritualityandfamilysupport. DavidGoodsonquote:“dealswithculturalpain.”HarmDavidGoodsonquote:“dealswithculturalpain.”Harmreductiontechniquesrecommendedreductiontechniquesrecommended. . TreatmentbarrierspaperworkforMedicaid,waitingTreatmentbarrierspaperworkforM

267、edicaid,waitingperiod,wantingtoconcealproblem,waitingperiod.period,wantingtoconcealproblem,waitingperiod.WorkwithSomalis Traumafromwarandrefugeeexperiences. Needfortranslationservices. Gamblingmaybeaproblemamongtheyoungimmigrantsalthoughforbiddenintheculture. Immigrantswillseekspiritualcounselingatt

268、hemosque.Chapter13PublicPolicyPolicyIssues Only11%ofthosewhoneedtreatmentgetit,butmaynotwantit. War on Drugs is not harm reduction, butharmmaximization SSI(SupplementalSecurityIncome)foralcohol/drugsdisabilitieshasbeendiscontinued Managedcare,reducedinpatientcoverage,reductionsinMedicarereimbursemen

269、tPromisingDevelopmentsDrugcourts,mentalhealthcourts.Baltimoreuniquelyhasahugenumberoftreatmentslotsavailable.ReductionindrugoverdosedeathsinWashingtonDCthankstomoretreatmentfunding.WelfareReform FederalgovernmentdeniesbenefitstoneedypeopleFederalgovernmentdeniesbenefitstoneedypeoplewithalcoholanddru

270、gproblems.withalcoholanddrugproblems. TANFdrugtestinginsomestates.TANFdrugtestinginsomestates. RemovalofcoverageforsubstancerelateddisabilitiesRemovalofcoverageforsubstancerelateddisabilitiessuchasalcoholismfromSSI(SupplementalSecuritysuchasalcoholismfromSSI(SupplementalSecurityIncome),lossofMedicai

271、deligibilitythroughthisIncome),lossofMedicaideligibilitythroughthisprogramfortreatment.programfortreatment. GovernmentencouragesdrugtestingforwelfareGovernmentencouragesdrugtestingforwelfarerecipients;newlawsinstatesnowdoingthis.recipients;newlawsinstatesnowdoingthis.ManagedCareRestrictionsoncareare

272、familiartoalltreatmentproviders.Costcontainmentandaccountabilityarestressed.Focusonbrief,outpatientvisits.Cutsinmentalhealthcarebythestates.FederalConfidentialityLaws “ConfidentialityofAlcoholandDrugAbuse“ConfidentialityofAlcoholandDrugAbuse PatientRecords”(2011)applytoallagenciesthatprovidePatientR

273、ecords”(2011)applytoallagenciesthatprovidesubstanceabusetreatmentorprevention.substanceabusetreatmentorprevention. TherulesarefarmorestringentthanforanyothercategoryofTherulesarefarmorestringentthanforanyothercategoryoftreatment.treatment. NodisclosureofcontentthatwouldbeharmfultothepatientNodisclos

274、ureofcontentthatwouldbeharmfultothepatientwithorwithoutthepatientssignedconsent.withorwithoutthepatientssignedconsent. Thisistrueevenwithacourtsubpoena.Thisistrueevenwithacourtsubpoena. ThislawisprotectclientswhoseektreatmentfromfactsaboutThislawisprotectclientswhoseektreatmentfromfactsabouttheirpri

275、ordruguseordealing.theirpriordruguseordealing.OtherLegalMatters TreatmentTreatmentoptionsoptionstotoAASupremeAASupremeCourtCourtrulingrulingrelatedtoseparationofchurchandstate.relatedtoseparationofchurchandstate. WaronDrugsfailedpolicy,mostagreeinWaronDrugsfailedpolicy,mostagreeinsurvey:injustice,ra

276、cialoppression,hugeexpense.survey:injustice,racialoppression,hugeexpense. Mediahypeaboutdrugcrime,mandatoryMediahypeaboutdrugcrime,mandatoryminimumsentencing.minimumsentencing. Mostinmatesinfederalprisonareminorities.Mostinmatesinfederalprisonareminorities. Mothersofcrackbabiesgivenpunitivetreatment

277、.Mothersofcrackbabiesgivenpunitivetreatment.EthicalMattersMentalhealthprofessionalshavetheircodesofethicsasMentalhealthprofessionalshavetheircodesofethicsasdosubstanceabusecounselorsthatrequire:dosubstanceabusecounselorsthatrequire: NondiscriminationofNondiscriminationofclientsonthebasisofclientsont

278、hebasisofrace,race,colorcolor,gender,sexualorientation,age,disability,gender,sexualorientation,age,disability, C Continuingprofessionalandontinuingprofessionalandeducationaleducationalgrowth;growth; N Nototexploitingclientssexuallyorexploitingclientssexuallyorfinancially;financially; R Reportingepor

279、tingprofessionalmisconductofcolleagues,professionalmisconductofcolleagues,suchassuchasviolationsofviolationsofclientconfidentialityclientconfidentiality. . Avoiddualrelationships.Avoiddualrelationships.WaronDrugsOver40,000killedinMexicanwarondrugswarofcartels.GlobalCommissiononDrugPolicy(2011)ledbyf

280、ormerpresidentsfromLatinAmericacalledforendtodrugwars.Needtorethinkzerotolerancepolicies.Two-thirdsofAmericansagree;aslightmajorityofAmericansfavorlegalizationofmarijuana.MandatorySentencing WomenhavethefastestgrowingprisonpopulationWomenhavethefastestgrowingprisonpopulationrate,especiallyinfederalp

281、risons.rate,especiallyinfederalprisons. 1986,federalmandatoryminimumsentencinglaws1986,federalmandatoryminimumsentencinglawsenacted.enacted. Hysteriaover“crackbabies”harmtofetusactuallyHysteriaover“crackbabies”harmtofetusactuallywasfromthealcoholused.wasfromthealcoholused. USSupremeCourtin2007ruledt

282、helawsshouldUSSupremeCourtin2007ruledthelawsshouldserveasguidelinesonly.serveasguidelinesonly. DrugconspiracylawscausewomentobearrestedasDrugconspiracylawscausewomentobearrestedastheirpartnersturntheminasapartoftheirpleatheirpartnersturntheminasapartoftheirpleabargainingagreementstogettheirsentences

283、reduced.bargainingagreementstogettheirsentencesreduced.TheNewJimCrowMichelleAlexander(2010):The New Jim Crow: Mass Incarceration in the Age of Color-Blindness1in9youngblackmenbehindbars.Manychildrenwithoutfathersorbothparents.CivilAssetForfeitures Policeseizeproperty(cars,houses)relatedtocrimescommi

284、ttedbasedon“amerepreponderanceofevidence.” Oregonrequiresaconvictionfirst. Partnersofdrugdealersoftenpaytheprice. Informantsawardedpartofthevalueofthegoodsseized.HarmReductionStrategies Needleexchangeservesonly15%ofdruginjectors.Needleexchangeservesonly15%ofdruginjectors. Methadoneandbuprenorphinema

285、intenanceMethadoneandbuprenorphinemaintenance HeroinprescribedtoaddictsinsomeEuropeanHeroinprescribedtoaddictsinsomeEuropeancountriescountries Drugcourts:apromisingstrategy,costeffectiveforDrugcourts:apromisingstrategy,costeffectiveforcommunitiescommunities Thistextarguesnotlegalizationbutformiddleo

286、ftheThistextarguesnotlegalizationbutformiddleoftheroadpoliciesdecriminalizationtoreduceharm.roadpoliciesdecriminalizationtoreduceharm.RecommendationsConcerningGambling Restrictallgamblingtothosewhoareatleast21yearsofage Removeslotmachinesfromneighborhoodstores,banningbettingoncollegiateandamateurathleticevents. Banaggressiveadvertisingthattargetsimpoverishedneighborhoodsandyouth, Prohibitcreditcardmachinesincasinos.TheEndAddictionTreatment:AStrengthsPerspective,3rded.