Addictions Exam Review

Family Therapy for Substance Abuse Disorders

2007-07-27T09:35:00.000-07:00

■ Family Risk and Protective Factors for Substance Abuse
        o Relationship factors such as parent-adolescent attachment consistently predict adolescent drug use across cultures.
        o Parenting practices such as low monitoring, ineffective discipline, and poor communication are also implicated in substance problems among youth.

■ Family based interventions for adolescent substance abuse
        o Family based interventions have been found to have superior treatment effects on levels of adolescent drug use compared to individual therapy.

■ Family based interventions for adult substance abuse
        o It has been concluded from meta analysis of family therapy for drug abuse that family interventions work equally well for adults and adolescents and that family therapy studies with adults and adolescents tend to be of good design quality, show better results than non-family approaches, and with adult narcotic addicts, are cost effective components of methadone maintenance.

■ Family based interventions with adult alcoholics
        o Behavioral family therapy techniques have also been adapted in designing interventions aimed at increasing engagement of substance abusers into treatment by mobilizing family support,

■ Family based interventions with adult drug abusers
        o Family based engagement interventions for adult drug abusers are also gaining empirical support.
        o Preliminary evidence for the success of engagement interventions with family members and significant others suggest that interventions hold promise for enlisting these natural supports to motivate drug abusers into treatment.

Potential Ethical Violations

2007-07-02T07:54:00.000-07:00

■ YAVIS- Counselors tend to prefer clients who are young, attractive, verbal, intelligent, and successful, but the most influencing factor is similar cultural backgrounds and experiences.

■ Viewing clients from the counselors perspective
        o The following can be misinterpreted as “problems” in counseling, causing the therapist to see the client as resistant or non-responsive
                ■ Silence
                ■ Lack of eye contact
                ■ Deference to authority
        o Client defensiveness or non-disclosure may be termed “healthy cultural paranoia”
                ■ For many clients the majority cultural environment is hostile and therefore a defensive stance is a                 rational response.
                ■ The counselor must acknowledge that the problem may not lie in the client but rather the                 environment in which the client lives as a minority member

■ Stereotyping clients by group
        o May be unintentional in that the counselor researches the “group” and what the group beliefs are according to research but in so doing generalizes and may miss something about the individual sitting in front of them.

■ Inappropriate Selection of techniques
        o Counselors often depend on high level of verbal exchange to achieve therapeutic progress.

■ Inappropriate Selection of Tests and Measurements
        o Many test reviews have only been done on the majority population type and may not be applicable to all cultures, skewing “normal” results.
        o There should be an investigation of possible differences in validity for ethnicity, sex, or other sub-samples that can be identified when test is given.
        o What is considered an objective assessment instrument within a majority culture may not be so within a minority culture or a different cultural orientation.
        o It is an ethical duty to be aware of this research prior to administering assessments.

Ethical Practices with Culturally Diverse Clients

2007-07-02T07:52:00.000-07:00

■ Current ethical codes are based on individualism which is a Western characteristic.

■ There is significantly less focus on the role of family, group identity, lifestyle and religious beliefs which have equal importance to individuality in other cultures.

■ The AAMFT code of ethics states “therapists do not discriminate against or refuse professional service to anyone on the basis of race, sex, religion, or national origin.”

■ It is ethical for counselors to know their own biases and how they may impact service delivery.

■ Cultural Competence
        o Recognize cultural diversity
        o Understand the role that culture and ethnicity play in the sociopsychological and economic development of diverse populations
        o Understand that socioeconomic and political factors significantly impact the psychosocial, political, and economic development of ethnic and culturally diverse groups
        o Help clients to understand, maintain, or resolve their own cultural identification
        o Understand the interaction of culture, gender, and sexual orientation on behavior and needs

■ Implications for Clinicians
        o Many ethical codes have not yet adequately dealt with some cultural issues related to technology and assessment or the counseling relationship with culturally diverse clients.
        o Ethnic minorities will continue to underutilize services, prematurely terminate, or fail to show positive treatment outcomes if remedies are not applied and enforced.
        o Goal is to learn how to identify, understand, and accommodate the needs of differing clients.

Anticipatory Trauma

2007-07-02T07:16:00.000-07:00

◆ Reactions to anticipatory trauma:
        o Emotional
                ■ Fear
                ■ Anger
                ■ Confusion
                ■ Hopelessness
                ■ Loss of control
                ■ Numbness
                ■ Moodiness
                ■ Irritability
                ■ Guilt
        o Behavioral
                ■ Social withdrawal
                ■ Disruption of daily activities
                ■ Easily startled or jumpy
                ■ Easily cry
        o Cognitive
                ■ Thoughts preoccupied with anticipation of trauma
                ■ Difficulty concentrating
                ■ Low self esteem
                ■ Indecisiveness
                ■ Poor memory recall
        o Somatic
                ■ Muscle tension
                ■ Headaches
                ■ Gastric problems
                ■ Irregular sleep and appetite
                ■ Fatigue

◆ Treatment Techniques
        o Social support:
        o Physical self-care
                ■ Exercise
                ■ Eating healthy
                ■ Regular sleep
        o Spirituality
        o Meditation or Guided Relaxation
        o Positive self talk
        o Humor

Effects of addictive behaviors on individual and family system

2007-06-22T13:06:00.000-07:00

⋅ Any activity, substance, object, or behavior that has become the major focus of a person's life to the exclusion of other activities, or that has begun to harm the individual or others physically, mentally, or socially is considered an addictive behavior.

⋅ There is similar impact on the family between physical addiction to various chemicals in drugs and alcohol, and psychological dependence to behaviors including: gambling, sex, work, and eating disorders.
o These behaviors may produce the endorphins in the brain, producing a “high” sensation.
o When addicted, people continue these behaviors in order to get that endorphin rush, despite the detrimental effects on their work and family.

⋅ Addicts may still crave their addiction behavior even after remaining abstinent for long periods of time. Some therapeutic modalities believe this craving will be a lifelong challenge and a continual stress on the addict’s support system.

⋅ Withdrawal symptoms when behavior is ceased can cause feelings of irritability, agitation, and depression which affect the entire family system.

⋅ During active addiction many clients live in denial and hurt their families so building trust back and healing wounds caused in the family is important to keep in mind during therapy.

Addiction treatment modalities

2007-06-20T08:45:00.000-07:00

Outpatient Care

⋄ Techniques vary by clinician but typically include :
        o cognitive-behavioral therapy
        o problem-solving groups
⋄ Low success rate with heavily addicted individuals.
⋄ Moderate addicts may find that this level of treatment is enough to end their drug abuse problems.

12 Step Programs

⋄ Clients attend meetings.
⋄ Preferable after or in conjunction with some other form of drug treatment
⋄ There is the belief that they will never "recover" from their drug addiction.
⋄ This type of program may leave many feeling powerless (one of 12 steps is to accept powerlessness) over ever ending their battle with drug addiction.
⋄ This type of program may work for some, but has low success rate.

Inpatient Short-Term Rehabilitation

⋄ Substance abuse treatment that lasts typically for 30 days.
⋄ Overseen by medical professionals and trained counselors, often Certified Drug Addiction Specialist.
⋄ Goals are primarily physical stabilization, abstinence from all use, and lifestyle changes.
⋄ Primarily founded in a modified 12-step approach.

Inpatient Long-Term Rehabilitation

⋄ Inpatient long-term residential program is a 24 hour a day 7 days a week treatment.
⋄ Duration can be from several months to a year or more.
⋄ Residential treatment is conducted in non-clinical settings known as therapeutic communities.
⋄ May also include additional treatment strategies such as social education.

Methadone Maintenance Treatment

⋄ For clients with a dependence on heroin or other morphine like drugs.
⋄ Methadone decreases the feeling of pain and reduces emotional responses to withdrawal symptoms.
⋄ A dose typically suppresses an addict's symptoms for 24 hours.
⋄ Downside:
        o Clients are physically dependent on
        o They may find themselves using it for many years after they start treatment.
        o Methadone may be more difficult to withdrawal from than heroin.
        o Maintenance involves more time, pain, and expense than heroin withdrawal.

Effect of substance abuse & dependence on individual and family functioning

2007-06-20T08:42:00.000-07:00

⋄ Chronic substance abusers tend to be isolated from their families after a long period of damaging relationships.
⋄ Substance abuse affects more than the immediate family.
⋄ Extended family members often report feeling abandoned, embarrassed by, ashamed of, and withdrawn from the substance abusing family member, often choosing to break relational ties.
⋄ Different family structures in which abuse affects the family relationship:
        o Client who lives alone or with a partner.
⋄ Both partners need treatment.
⋄ Groups are offered both for addicts and for non-addict partners of addicts.
⋄ The treatment of either partner will affect both.
⋄ Often, codependence is an issue.
⋄ Enabling may have to be explored
        o Client who lives with a spouse (or partner) and minor children.
⋄ Parental substance abuse has a detrimental affect on children.
⋄ There may be triangulation or enmeshment issues if children are either placed in the middle or if non-using parent is overly protective and bonded with children due to the substance abuser’s lack of responsibility.
⋄ Issues of neglect or trauma may be present if both parents are abusing drugs.
        o Client who is part of a blended family.
⋄ Substance abuse can intensify already shaky ground of newly blended families and become an impediment to integration and stability.
        o An older client who has grown children.
⋄ As with child abuse and neglect, elder maltreatment can be subject to statutory reporting requirements for local authorities.
        o Client is an adolescent and lives with family of origin.
⋄ Non-using children may find themselves neglected or ignored emotionally due to the focus of parents on the using child.
⋄ Often, at least one of the parents uses as well..
        o Someone not identified as the client is abusing substances.
⋄ Issues of blame, responsibility, and causation will arise.
⋄ Scapegoating may be an issue.
⋄ Therapist must work towards uncovering the underlying motivations for substance abuse and other behavioral issues that bring the family into counseling.

Crisis Intervention Models

2007-06-20T08:19:00.000-07:00

Crisis intervention with date rape, school violence, substance abuse, adolescent suicide, marital abuse, HIV positive, and hospital intensive care clients.

Step #1: Listen
- Establish therapeutic relationship.
- Identify precipitating problems.
- Explore emotions.

Step #2: Assessment
- Determine the severity of the crisis.
- Assess potential lethality or physical harm to the person or others.
- Identify past coping skills, strengths and supportive resources.
- Suicide/Homicide assessment
- Determine client’s perception of reality.
- Discuss cultural beliefs about handling trauma.
- Find out if family and social resources are potential resources. Are the resources positive or negative?

Step #3: Treatment Plan
- Selectively choose and use appropriate approaches to action planning.
- Modify or eliminate past coping skills.
- Create a contract or have client sign treatment plan.
- Identify useful referral resources.
- Use three basic approaches:
        i. Start by being non-directive.
        ii. Be collaborative by working together on a joint plan.
        iii. Be directive if the person does not or will not make a plan.
- During crisis, have only short term objectives.

Step #4: Termination
- Review progress on treatment plan.
- Plan for expanding resources and support system.
- Schedule a follow up session.

Risk factors and relational patterns of endangerment

2007-06-20T08:10:00.000-07:00

Risk factors for Victimization

o Being female
o Young age
o Being a minority
o Drug and alcohol use
o High-risk sexual behavior
o Exposure to victimization as a child
o Low education level
o Unemployment
o Low SES
o Little or no support system
o Low self esteem
o Adolescence or developmental transition period
o Having a verbally abusive, jealous, or possessive partner
o Couples with income, educational, or job status disparities
o Dominance and control of the relationship by the male
o Weak community sanctions against victimization (e.g., police unwilling to intervene)
o Traditional gender norms (e.g., women should stay at home and not enter workforce, should be submissive)

Risk Factors for Perpetration

o Low self-esteem
o Low income
o Low academic achievement
o History of delinquency in youth
o Drug and alcohol use and abuse
o Depression or other psychological diagnosis
o Anger management issues
o Axis II disorders
o Past history of abuse
o Social isolation
o Unemployment
o Emotional dependence or codependence
o Belief in strict gender roles
o Abuse of power and control
o Past history of victimization
o Marital conflictfights, tension, and other struggles
o Marital instabilitydivorces and separations
o Unhealthy family enmeshment or blurred boundaries

Diagnostic interviewing techniques

2007-06-06T07:26:00.000-07:00

Questioning:
o Client asked direct questions in areas determined by interviewer
o Questioning may be open or closed.
Open= unlimited answer options
Closed= Yes, No, or one word questions

Reflection:
o Restate the clients cognitive or emotional material
o Demonstrate empathic understanding
o Rogerian Client-Centered Therapists rely heavily on reflection
o Overuse is counterproductive - important areas are left unaddressed

Restatement (Paraphrasing):
o Rephrase what client says.
o Demonstrates active listening.
o Reflection is type of intervention, clarifies and joins themes.

Clarification:
o Accompanied by utilizing other techniques such as questioning, paraphrasing, restating
o Shows understanding of client in the interview
o If done from a not knowing stance, should not invoke defensive response.

Confrontation:
o May be used to call client out on discrepancies
o Is often used with substance abusers in order to break denial and/or rigid defenses
o This may increase anxiety and avoidance but is necessary and can be constructive.

Self-disclosure
o The sharing of personal experiences by the therapist to the client relative to the session with the purpose of helping.
o Intended to facilitate client disclosure.
o Should be used minimally
o Must be careful not to cross boundaries.

Silence:
o While this may occur unintentionally there are many benefits if used correctly.
o Provides both client and therapist time to process what is being understood.
o Timing is essential
o Promotes introspection

Exploration:
o Therapist test the limits of what client is willing to process.
o May be used to determine clients level of insight.

Reframing (Cognitive reframing):
o This allows for a different perspective
o Used to challenge negative self concepts and harmful thinking patterns.
o The purpose is to lead to behavioral change.

Statutes, case law and regulations

2007-06-04T07:20:00.000-07:00

Professional disclosure statement tells clients about:
o the education and qualifications of the therapist
o the nature of the therapeutic process
o Informed Consent
o Document that the client reads about the specifics of therapy treatment
o Client consents to treatment by signing the form
o Procedures and goals of therapy
o Potential harms or risks to client
o Reasonable benefits of therapy
o Qualifications and policies of therapist
o Theoretical orientation of therapist
o Ability to terminate treatment at any time
o Reassurance of referral sources for treatment (3 is standard)
o Fee disclosure

Confidentiality
o Ethical obligation of therapist to keep communications between themselves and client private.
o May be charged in contempt of court if therapist refuses to testify about a client.

Exceptions:
o Child abuse reporting laws: mandated to report the suspicion of child abuse or neglect. (in some states this is required of all citizens not just counselors)
o Duty to warn: if therapist establishes there is a likelihood that client will cause harm to him/herself or to someone else and the therapist knows who that victim may be.

Privilege- Legal right, owned by the client, which is an exception to the general rule that the public has a right to relevant knowledge in court proceedings. This means information revealed in session is not permitted in court.

Appropriate standard of care- how most therapists would treat a case under similar circumstances. Those who do not follow this are at risk for malpractice.

Dual relationship- occur when therapist does not keep appropriate boundaries and thereby blends personal or business relationships with the therapeutic relationship.

Secret policies- written statements about how information shared privately will be handled by the therapist. Must be signed by both parties.

Risk factors for and patterns of abuse

2007-06-04T07:17:00.000-07:00

Recognizing sings of abuse

In the child:
o Sudden changes in behavior or school performance
o Not medical attention for problems brought to parents attention.
o Learning problems, difficulty concentrating, that cannot be attributed to specific disabilities.
o Tends to be watchful, expecting something to happen.
o Lacks adult supervision.
o Overly compliant, passive, or withdrawn.
o Comes to school or other activities early, stays late, does not want to go home.

The Parent:
o Shows little concern.
o Denise existence of, or blames the child, for problems at school or home.
o Asks teachers to use physical discipline.
o Describes child as bad or burdensome.
o Demanding high levels of academic and physical performance.
o Relies on child for care, attention, emotional needs.

Parent and Child:
o Do not look or touch each other.
o View of relationship is only negative.
o State they do not like each other.

Pattern of Abuse

Tension building
o Anger builds.
o Poor communication.
o Victim feels the need to keep the abuser calm.
o Tension mounts.
o Victim constantly feels weary of abuser.
o Abuse (physical, emotional, or sexual) takes place.
Making up:
o Apology may be made.
o Promise of the last time.
o Victim blaming.
o Denial of abuse.
o Calm
o Abuser acts as if nothing has happened.
o Some promises may be met, during this time.
o Victim may believe the abuse is truly over.
o Abuser may give gifts to victim.

Risk factors, stages and patterns of grief response

2007-05-23T20:59:00.000-07:00

•        DSM Diagnosis under Other Conditions That May be Focus of Clinical Attention, V62.82, Bereavement- used for death of a loved one.
•        Depression in this case is considered “normal” but individual my be seeking treatment to relieve symptoms such as insomnia or anorexia.
•        Expression of “normal” bereavement time is relative to different cultures.
•        Major Depressive disorder is not diagnosed unless symptoms last longer than two months after loss.

Stages of Grief:
•        Denial
•        Anger
•        Bargaining
•        Depression
•        Acceptance

Reactions commonly seen in children:
        o        Disbelief- children may act as if it did not happen.
        o        Complain of headaches, stomachaches, or fear of their own death.
        o        Anger- concern over own needs and about being alone, or with God.
        o        Guilt- feelings of causing death, or not having been “better”
        o        Anxiety/Fear: may become clingy and need validation of love.
        o        Regression: revert to bed wetting or thumb sucking
        o        Sadness: lethargy and isolation

Short Term Treatment Goals
•        Express fear and anger, grieve in a healthy way.
•        Loss and Grief Counseling Group
•        Recall fond memories
•        Create a phone list of supportive people to call
•        New coping techniques
•        Find a “safe place” to spend limited time thinking about deceased
•        Exercise regiment
•        Relaxation techniques- progressive muscle relaxation, guided imagery

Long Term Treatment Goals
•        Reach a point of coping without being overcome with grief.
•        Regain normal activity.
•        Reduce feelings of guilt and anger towards self, others, and God.
•        Re-mature over regressed behaviors
•        Understanding of death and life.

Therapeutic Interventions
•        Writing Activities
        o        Letter to deceased for closure
        o        Journal of thoughts (may be shared in counseling, in group, or with family members)
•        Art therapy:
        o        Finger paints are useful in expressing feelings
        o        Draw pictures of activities enjoyed with deceased (useful with children).
        o        Collage on a theme
        o        Splatter room: area where (particularly children) are free to throw violent splotches of paint to get anger out.
•        Play Therapy:
        o        Model clay or dough to vent anger or create ritual objects
        o        Puppetry- to express feelings
        o        Sand tray to play out themes, “burry” deceased for closure, or rake sand for relaxation or meditation.
•        Bibliotherapy:
        o        Appropriate self help books
        o        Books related to symptoms client is displaying
•        Loss Graph or Timeline:
        o        Used to discuss types of loss
        o        Used to recall fond memories and celebrate life
•        Storytelling:
        o        Fantasy monologues
        o        Mutual storytelling
•        Therapeutic Metaphors
        o        Helpful in understanding concept of death
•        Empty Chair
        o        Gestalt technique
        o        Imagine deceased in chair and speak to them for closure