Addictions Exam Review

014 Ageism

2010-12-22T08:54:00.000-08:00

Ageism

Originating in the 1960’s, ageism is a term that refers to the negative stereotypes society places on older adults that justify their problems as ramifications of their old age, instead of as actual medical, social, or psychological problems. An example of this is the tendency for older adults to be categorized as senile, when instead the adult actually has some type of treatable comorbid condition, like Alzheimer’s disease, depression mult-infarct dementia, and alcoholism. Ageism is the reflection of AMERICA’S DISLIKE OF ADVANCING IN YEARS, BECOMING WEAK, AND EVENTUALLY DYING. THESE STEREOTYPES ARE INTERNALIZED BY ELDERLY PEOPLE VERY OFTEN AND MANY TIMES THE ADULT WILL NOT ASK FOR MENTAL HEALTH AND SUSBTANCE ABUSE TREATMENT. Ageism has negative effects in that it causes health care providers to simply attribute old age to symptoms instead of looking deeper for the real problem. Older adults are frequently misdiagnosed because of this. Another reason older adults are misdiagnosed is because their health care providers will mistakenly think that even if the older adult is treated for substance abuse their quality of life will still be low. It is commonly thought that it would be a waste of time to treat older adults because they will die soon anyway. This low level of expectations is called “therapeutic nihilism”. Another reason older adults are not treated is because of the lack of awareness of the people around them. Society has placed a stigma on substance abuse in the older generation because of religion, gender, or culture. Thus, many older adults deny a problem with substance abuse to avoid this stigma.

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013 Adolescent Recovery

2010-12-16T07:20:00.001-08:00

Adolescent Recovery

Recovery for adolescents in the developmental model is a gradual process that is made up of various emotional, psychological, and socially associated recovery tasks that become increasingly complex. The term recovery refers to the abstinence from mood-altering chemicals while advancing the area of functioning in the individual.

The pretreatment phase (which typically takes place when the individual begins treatment) of the developmental model is where the adolescent will see view his or her unpleasant experiences as consequences of the inability to hold control over their life because of use. They will also change their perspectives regarding how their abuse is related to their problems. Additionally, they will feel emotional pain that stimulates them, and they will consciously decide to become involved in the treatment procedure.

The next phase is the initial stabilization that will take place in the first two weeks of treatment. In it, patterns of use are disrupted, withdrawal recovery occurs during the period of abstinence, and there is a detoxification from impulsive behaviors.

The next phase is the early recovery phase I, where struggles with acceptance and understanding of addiction occurs, along with the adolescent’s ability to recognize triggers and to learn of skills that encourage personal development. He or she will also take personal responsibility for choices, decisions, and actions as well as identifying and voicing feelings.

The next phase is the early recovery phase II, where the adolescent will manage triggers, manage drug craving, and accept recovery. The last phases are the middle, the advanced, and the maintenance phase (which continues throughout the adolescent’s life).

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012 Developmental Model of Adolescent Recovery

2010-12-08T07:47:00.000-08:00

Developmental Model of Adolescent Recovery

The developmental model recovery is viewed as a gradual procedure that involves mastering undertakings that are emotional, psychological, social, and recovery associated. These undertakings may begin at an easy level and gradually become harder, eventually leading to recovery.

The first phase is the pretreatment phase, which takes place when the adolescent’s enters treatment. In this phase, the adolescent will face results from their drug use that may be disagreeable or controlling over their life. They will also begin to see that the problems in their lives are caused by their substance use and feel a certain amount of emotional pain, which allows them to decide how much effort they will put into the treatment procedure.

The next phase is the initial stabilization phase, which will take place within the first couple weeks of the treatment process. In this stage, the methods of use will alter; the adolescent will recover as a result of abstinence, and other impulsive behaviors will detox.

Next is the early recovery phase, or phase I. In this phase, the adolescent will begin to be aware of triggers, emotional struggles, and verbalize feelings as well as learn how to behave in self-improving ways.

The early recovery phase II is an extension and development of phase I, followed by the middle phase and then the advanced phase, where the adolescent resolves old detrimental behaviors and habits and begins to develop spiritually and emotionally. Lastly, is the maintenance phase, which is a pattern of growing that continues throughout the adolescent’s life.

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011 The Influence of Chemical Dependency on Adolescent Development

2010-12-06T08:11:00.001-08:00

The Influence of Chemical Dependency on Adolescent Development

When an adolescent is chemically dependent, he will experience effects cognitively, in language areas, in physical development, in the role of the family, and in social development.

Cognitively, the adolescent will experience the extension of personal fable thinking, warped cognitions because of adolescent delusional system, blocked growth in the development of abstract thinking, illusions of adolescent accomplishment as a result of drug use, and less life experience, causing interference in the growth of reasoning and thinking skills.

Effects of adolescent language skills will be impediments in recall, retrieval, and short-term memory. If there is a weakening in academic performance, then language skills may also be influenced, and this scarcity of language skills may cause interference in academic and interpersonal functioning. If the adolescent has limited language skills, then treatment may not benefit him or her.

Physical development effects may include discomfort in sexual areas. If the individual uses marijuana at an early age, then sexual development may be impaired due to inaccurate sexual information and inappropriate outlets for sexual energies.

Social development may be affected by the individual, viewing drugs as his primary relationship as apposed to other people. Dependence on chemicals is used to ease social discomfort (inhibiting the growth of basic social skills for individuals of that age). Frequently, these individuals will be in peer groups that are narcissistic and disregard the feelings of other people. Additionally, the adolescent may ignore the realities of society, such as rules, values, and morals.

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010 Adjuncts

2010-11-30T07:34:00.001-08:00

Adjuncts

When selecting a referral or an adjunct, several factors should be taken into account, including: the qualifications of an agency to help the client, issues that would prevent the client from profiting from the referral, whether or not the client’s response to being referred would be positive, whether or not there are legal considerations to take into account (because of confidentiality), and clinical considerations (will the referral affect the client’s treatment plan?). The counselor has the option of providing the client with a couple of referral options or only one if the counselor believes that one particular referral will best help the client. The counselor’s selection of the referral should be based on the cost of the referral, the competence of the therapist, the clinical orientation of the therapist, when working with the therapist any professional responsibilities, and if the therapist is culturally similar to the therapist. All in all, for the counselor to make an effective choice when choosing a referral, he or she should be aware of the options in the community. The most commonly used referrals in communities are: ambulances and paramedics, battered women’s shelters, Bureau of Public Assistance, the Department of Public Welfare, Human Services, Social Services (economic help), Child Help USA Service Office (they provide 24 hour information, referral and crisis counseling services), Department of Social Services, Emergency Rooms, Employment Offices (for unemployment insurance), Hotlines for Rape, Suicide, Child Abuse, or Runaways, PET (the Psychiatric Emergency Team), Police, Sheriff, and the Veterans Administration.

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009 Additional Factors Crucial in Counseling

2010-11-29T07:41:00.001-08:00

Additional Factors Crucial in Counseling

For a successful counseling procedure, the counselor must possess certain qualities, including interpersonal skills that work effectively, little or no confrontation, fervent concern for curing the client’s problems, adaptability, no discomfort in discussing most topics, self-awareness, comprehension, sound mental health, sensitivity, a non-judgmental attitude, objectivity, reliability, competence, honesty, and empathy towards clients. The counselor and client’s personal relationship is extremely important in the counseling process. Both the client and the counselor should be actively involved in the relationship; however, the client should be the focus of it and not the counselor. Yet, some boundaries should be decided on in the relationship as well. Important factors in the client-counselor relationship are a strong bond, collaboration, pre-determined goals and objectives, competence on the part of the counselor in determining the client’s ideas and meanings, multi-cultural empathy on the part of the counselor in understanding the client’s world-view, noticing what the client values, and empathy. The counselor needs to also be genuine, not phony, or acting in a way different from internal feelings. Within the professional relationship, the counselor needs to be able to continually share what is occurring, stay focused, and remain accountable to goals. Other qualities for the counselor are warmth (acting humanely, accepting the client, and keeping the treatment friendly), congruence (acting the way that he speaks), positive regard and respect (respectful attitude, acting respectful, acting in a committed manner towards the client, demonstrating empathy, behaving warmly), and overall making sure that the client views the counselor as warm and friendly.

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008 The Addiction Process

2010-11-24T09:22:00.001-08:00

The Addiction Process

The disease model of addictions is made up of the following components: addictions are not a symptom of a hidden psychiatric disorder but a primary disease; addiction is Multidimensional Biopsychosocial Disease; and the disease is not biogenetically predisposed. Other facts in the disease concept, are that there is twice the possibility of children of alcoholics becoming alcoholic, an alcoholic twin is twice as more likely to become alcoholic than an fraternal twin, young men with alcoholic relatives metabolize alcohol in a different way than men without alcoholic relatives (that after ingesting three drinks they had lower alcohol levels and lower impairment in behavior), daughters adopted by alcoholic mothers had three times as much risk of becoming alcoholic, and some studies suggest that there is a connection between biochemistry and alcoholism increased Tetrahydropaveroline, (also called THP) that is present in clients in treatment, these are similar to opiates, and studies suggest that opiates instill the wish to consume ethanol.

Physical components are present in addictions, because the more an individual consumes a drug, the higher the individual’s tolerance and need for more becomes. The components of drug and alcohol addictions affect culture, society, and family. Many studies suggest that families with alcoholics experience alcoholism symptomatology, academic problems, antisocial behavior, social problems, unbalanced careers, and severe physical symptoms. The psychological components to addictions can possibly appear before an addiction begins and persist after detoxification. Psychological addictions are made up of psychological primary, self-doubt, abstinence, and a connection to the drug.

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007 Action Responses

2010-11-22T07:27:00.000-08:00

Action Responses

Another type of therapeutic response is action responses, where the client’s structured reference has more data and perceptions from the counselor. Timing is important in these responses, and they should be used once the client and the counselor have a firm and trusting relationship. Action responses ask questions only with a specific purpose in mind, using open-ended questions (beginning with either what, how, where, or who) to gain more information from the client, focusing with probes on the problems of the client, waiting a moment after questioning the client to give him time to think and answer, limiting questions to one at a time, not using belligerent or blame-oriented questions, not using too many probes at one time (so that the client will feel at ease), using open-ended probes only at the start of the treatment, making sure that questions presented to the client are legitimate and therapeutic, and effectively using these questions to achieve your intended effect.

Sometimes the counselor must confront the client if his messages are unclear or mixed. The purposes of confrontation are to help the client to understand the way that they see themselves, to reveal discrepancies, and to show the client an important point. Before using confrontation, however, there must be strong and trusting relationship between the counselor and the client. Even after the rapport is achieved, the counselor must present the confrontation in a timely manner that is an expressive and tangible thought, behavior, or feeling.

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006 Culturally Diverse Intervention: Acculturated and Bi-cultural

2010-11-18T07:54:00.000-08:00

Culturally Diverse Intervention: Acculturated and Bi-cultural

Diversity in intervention adds difficulty to the already complicated planning in an intervention. Introducing diversity means to be especially sensitive to populations that vary in values, life styles, or situations. The first two components of the interpersonal styles that are in our society are acculturation and bi-cultural individuals.

Acculturated individuals mostly identify with the white society class. Examples of acculturated individuals are African Americans and Latinos, who typically fit in with the white middle class in America. These African Americans and Latinos would live in white neighborhoods, be friends with white adults, and have mainly white colleagues. However, the spouse of the acculturated individual may not identify or describe his or her spouse as having acculturated into white society to the extent that is correct. Also, involving the extended family into the treatment plan is not as important with an acculturated individual.

Bi-cultural is the next component of intervention with diverse individuals. The bi-cultural individual is slightly more immersed in his or her own culture than the acculturated individual. However, he or she will still be easy interacting with white society. The life of the bi-cultural individual will be integrated in all areas including work, living environment, and entertainment. Their friends will integrate with them as well, mixing between white to Latino to African-American to Native Americans. When treating these individuals, involving the extended family in the process becomes more significant. In fact, it is beneficial for the entire treatment to be integrated in many areas to ensure the individual’s maximum comfort.

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005 MSE-Attention, Concentration and Memory

2010-11-16T08:11:00.000-08:00

MSE- Attention, Concentration and Memory

The initial interview with a client is critical, not only for information gathering but for rapport building. A skillfully done interview should help the professional: diagnose, estimate severity of problems, decide on a course of action, gain a dynamic understanding of the client, and engage the client in psychotherapy. Supportive, attentive, and nonjudgmental attitude can help pave the way toward a productive interview. As previously indicated, the MSE is a critical component of the initial diagnostic interview. The MSE serves not only to gauge a persons current level of functioning but also aids in diagnosis and can serve as a baseline for future reference. We will look at other areas of the initial interview in later segments. For now, let us finish with the MSE.

When focusing on attention, two general areas are under consideration. The first is the individual’s ability to “attend”, or the ability to pay attention for short periods of time without being distracted. The second is the ability to attend for long periods (concentrate). The ability to concentrate is primary in testing higher levels of functioning.

Attention can be tested in several ways. One is to simply observe the interviewee’s ability to stay focused and attend to the interview. A more structured assessment of attention may be gleaned with digit span or a nonnumeric test. Digit span is simply listing a series of numbers (write them down as you say them), starting with three numbers. They should be spoken in a monotone voice, with one spoken every second in cadence. On the last number in the series, your voice should drop, indicating the end of the series. Start with three numbers (e.g. 3-7-1). Do two sets of three numbers. If at least one of the two series is repeated back, go to four numbers- until the client fails both trials. Then do the same in reverse. The average is five numbers remembered. The nonnumeric test consists of reading a list of random letters and asking the client to tap his finger when certain letters are stated. In this test, it is best to have a prepared list of letters.

Concentration can be assessed using serial number counting (subtracting 7, 5 or 3 from 100 consecutively). This may be hard for some people with lower educational levels, so days of the week or months said backward may be substituted. Simple multiplication problems may be useful but have the same limitations on premorbid intellectual functioning and general education level, as do the serial counting tests. Asking a person to draw a picture or do some math problems on paper will also give information as to their concentration ability.

There are several different types of memory and ways of referring to them. In Psychology, the terms short term and long term memory are used. The medical tradition refers to immediate, recent and remote. Some also break this up to recent past and remote past. (See the MSE content sheet for one example). Unless you want to do a very comprehensive memory assessment (in that case use a memory assessment instrument), the immediate, recent and remote memory should be assessed. Immediate memory assessments are the digit span (described above), asking the client to remember three objects (dog, house, ball) to be recalled after a 5 minute delay. A counting test where one asks the client to count to a number (e.g. 27) stop for 1 minute, continue counting where they leave off, stop at a specific number for 1 minute (do this three times), is also useful. Recent memory is events of the last 24 hours and remote is assessed with early memories or dates of employment, etc.

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004 MSE-Orientation-intellectual ability

2010-11-11T07:29:00.000-08:00

MSE-Orientation-intellectual ability

Orientation is central to the mental status exam. A person's awareness of their surroundings, their location temporally, and their own identity is primary to general functioning. Of course, everyone occasionally loses track of the date, but when an individual that you are interviewing believes it is 1983- or that it is summer, when the coat rack in the corner is full, this is a significant finding that must be explored further. Assessment of orientation always includes person, place and time (Oriented x 3). Questions of person generally include the identity of the patient and who you are (Dr or counselor, etc.). Orientation to place may include the city, state, or town- where he lives and where he is now. For some patients, it may be appropriate to ask "what planet is this". If they say Jupiter, then you may have an alien (or a psychotic individual) on your hands. Time orientation include day of the week, date, month, year, etc. (The interviewer may also ask about the current situation, why a person is in your office, etc. This would be oriented x 4.) As a rule, confusion about person is more significant than is confusion about time, place, or situation. If the patient says he is the boogieman and you are Jethro Tull, the patient is exhibiting significant problems (since Jethro Tull was not an individual, but the name of a group). Problems in orientation are often the result of organicity. However, some very depressed individuals may lose tack of time, by several days or even weeks. Further, there is a difference between confusion and delusion about person, place and time. Both schizophrenic and dementia patients may exhibit either delusions or confusion in their orientation.

It is often important to quickly evaluate a person's intelligence. This can be difficult (as well as unimportant) if other more acute issues are primary (prominent suicide ideation with a plan, acute psychosis, or the person is very distressed and tearful). However, in a routine MSE, intelligence is an important aspect of treatment planning.

Quick and easy intellectual capacity can be obtained through asking the person to perform some simple calculations in their head (serial 7s, multiplication word problems). It is also important to know if an individual is able to reason abstractly. Proverbs are one of the simplest and best ways of getting information about concrete versus abstract reasoning ability. The responses may be literal, concrete, personalized, or bizarre. An example of proverbs that may be used is: "still waters run deep"; "a rolling stone gathers no moss".

Orientation and Intellectual functioning is extremely important in the hospital setting. Delirious patients will often be quite disoriented. The MSE can be used for baseline functioning and tracking of the symptom pattern. In delirium, there is often a fluctuation of consciousness throughout the day. In this case, the MSE can quite useful. Further, it can be used to narrow down medications that might be negatively or positively affecting a patient's mental status.

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003 Content of Metal Status Exam

2010-11-09T07:41:00.000-08:00

Content of Mental Status Exam

1. General Presentation.

A. Appearance-apparent age, grooming, state of health, hygiene/cleanliness, physical characteristic {build/weight, physical abnormalities, deformities, etc.), state of health, distress, pain, appropriateness of attire. pride, dignity, Note unilateral neglect of dress, description of appearance should be enough detail for identification. take into consideration the individual’s age, race, sex, educational background, cultural background, socioeconomic status, etc.

B. Motor Activity-posture {slouched, erect), gait {staggering, shuffling, rigid), coordination, speed-activity level, gestures, tremors, tics/grimacing, relaxed, restless, pacing, threatening, hyperactive or under active, disorganized, purposeful, stereotyped movements, repetitive.

C. Interpersonal-rapport with the interviewer. Engaged, interested, cooperative, opposition/resistant, submissive, defensive, fearful, note how they greet examiner.

D. Facial Expression-relaxed, tense, happy, sad, alert, day-dreamy, angry, smiling, distrustful/suspicious, tearful.

E. Behavior-distant, indifferent, evasive, negative, irritable, labile, depressive, anxious, sullen, angry, assaultive, exhibitionistic, seductive, frightened, alert, agitated, lethargic, somnolent.

2. State of Consciousness-alert, hyperalert, lethargic -reasons for lethargy often organic.

3. Speech.

A. Form-conversational, distractible, rambling, circumstantial, tangential.

B. Quantity-mute, overtalkative, can’t be interupted.

C. Rate-rapid, accelerated, pressured, slow, blocked.

D. Quality-dramatic, histrionic, sarcastic, humorous.

F. Expressive Language-normal, circumstantial, anomia, paraphasia, clanging, echolalia, incoherent, blocking, neologisms, perseveration, flight of ideas, mutism.

G. Receptive Language-normal, comprehends, abnormal.

H. Dysprodia-Flat monotone speech-no emotional expression.

4. Mood and Affect.

A. Mood-a symptom as reported by the individual describing how they feel emotionally, such as: normal, euphoric, elevated, depressed, irritable, anxious, angry.

B. Affect-observed reaction or expressions. Range of affect includes: broad, restricted, blunted, flat, inappropriate, labile, mood congruent, mood incongruent.

5. Orientation and Intellectual Ability.

A. Orientation-time, person, place, and self. The individual should be asked questions such as the day of the week, month, the date, where he lives, where he is now, if he knows who he is.

B. Intellectual Ability-above average, average, below average.

        a. General information-the last four presidents, governor, the capitol, what direction does the sun rise, etc.

        b. Calculation-serially subtracting 7 from 100 (at least six times). Simple multiplication word problems such as, “if a pencil costs 5 cents, how many pencils can you buy with 45 cents?”.

        c. Abstract Reasoning-proverbs. This is the ability to make valid generalizations. Responses may be literal, concrete, personalized, or bizarre. Example, “Still waters run deep”, “ A rolling stone gather no moss”.

        d. Opposites-slow/fast, big/small, hard/soft.

6. Attention & Concentration-.

A Concentration-Days of the week backward-serial sevens-serial threes, serial fives.

B. Attention-Non-numeric test-read series of random letters-have patient tap finger or say yes every time hear chosen letter. Numeric-string of digits forward and backward-starting with three digits. Stop when patient misses two of each. Average is 7 digits.

7. Memory-immediate (10 to 30 sec) short term (up to 1hour) recent (2 hours to 4 days) recent past (past few months) remote past (6 months to lifetime).

8. Thought Processes/Content-deals with organization and composition of thought. Examples include: normal, blocking, loose associations, confabulation, flight of ideas, ideas of reference, illogical thinking, grandiosity, magical thinking, obsessions, perseveration, delusions, depersonalization, suicidal ideation, homicidal ideation.

9. Hallucination-none, auditory, visual,olfactory, gustatory.

10. Insight-good, fair, poor. Understanding, thought,feeling, behavior.

11. Impulse Control-good, fair, poor. The ability/tendency to resist or act on impulses.

*This is not exhaustive-mental status questions could go on interminably.

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002 MSE- Consciousness, Speech, Mood and Affect

2010-11-04T12:53:00.000-07:00

MSE- Consciousness, Speech, Mood and Affect

The mental status exam can cover a myriad of areas and each mental health professional
will need to decide what is important. Professionals from different disciplines are likely
to be interested in areas relevant to their specialty and area of expertise. For example,
a neuropsychologist will be interested in neurological processes as they relate to
behavior. Hence, a the MSE conducted by a neuropsychologist might be detailed in assessment
of attention, concentration, language, memory, etc. A psychiatrist on the other hand, may
focus more on issues related to thought processes, mood and anxiety level. Of course, this
is not clearly defined, as many areas of mental health treatment are cross-disciplined.
The point is, one "good" MSE does not necessarily look like another. It can be adapted to
one's theoretical orientation as well as the specific information that is required at the
particular time. As a rule, the interviewer must adapt to the situation based on
information and observation. He must think on his feet, so to speak. Below is a brief case
example.

A 25-year-old Hispanic female is brought into your office by her mother. The mother
reports that her daughter is depressed. You speak to the girl alone and find that she is
indeed depressed. In the course of the interview, you note that she uses an occasional
word that you have never heard before. Since she is Hispanic, and you do not speak Spanish,
you assume she is substituting occasional Spanish for English words. However, these words
do not "sound" Spanish, so (in passing) you ask about them. After discovering that these
are made up words- you decide to pursue more detailed inquiry into language, thought
processes and thought content.

Along the way, you must follow the clues brought up in the interview. In the above case,
the client may have been exhibiting neologisms (made up words- often related to thought
disorder and psychosis) or she could have been creating her own private language (for a
variety of non-pathological reasons), or she might simply have some articulation problems
related to organic brain damage. The interviewer should be "curious" about everything that
comes up in the interview.

Some areas of inquiry are easily identified. If the interviewee is clearly drowsy,
somnolent, or stuporous, this becomes primary to other areas of inquiry. However, if a
person is alert and responsive, it is not necessary to conduct a Glasgow Coma Scale.

Mood and Affect are areas commonly evaluated in almost all mental status examinations.
Mood is a "sustained" emotional state, such as: depressed, euphoric, elevated, anxious,
angry, and irritable. Affect is more the observable emotional state at the time of the
interview. These include descriptors such as: flat, blunted, restricted, and
inappropriate.

In inquiry about mood, affective clues are important. Facial expression, quality of voice
(timber pitch, intensity), eye contact and muscular tension (among others) all give clues
as to mood. Of course, self-report is one of the best ways to evaluated mood. One
interesting and useful bit of information for clarifying the difference between anxiety
and depression is to use Brenner's Definitions. A pervasive feeling that something bad
"has happened" is indicative of depression. If one has a pervasive feeling that something
bad is "going to happen," this indicates anxiety.

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Stages of Alcoholism

2010-10-11T11:45:00.000-07:00

Stages of Alcoholism

Some early warning sins that an individual is an alcoholic are that the
individual exhibits an increased tolerance for alcohol, the individual shows
discomfort when he or she is without alcohol, when the individual has more
confidence when drinking, the individual hides his use, the individual
experiences memory loss, the individual becomes distressed when drinking is
discussed, the individual changes his drug or drink use, the individual
experiences morning after reactions, the individual has school, work, or family
problems, the individual is not able to cease or control use, the individual
drinks for fast results, the individual is jailed or has legal problems, the
individual changes his or her priorities, the individual is challenged by
friends or family, the individual has financial difficulties, and the
individual is hospitalized.

Beyond the initial signs of alcohol use there two more stages of alcoholism.
The middle stage is where the user will experience blackouts, indistinct
feelings of guilt and regret, drinking solitarily, a growing inability to stay
in control, an alibi system, family withdrawal, financial loss, ‘and
antisocial behavior. In the late stages of alcoholism the alcoholic will have
moved on from vague to extreme feelings of guilt and regret, to morning
drinking and overprotection of drinks, and to indistinct fears and resentment.
The individuals drinking pattern will also change, followed by a failure of
the alibi system. The individuals financial gains will also often turn into
real poverty.

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

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◆ 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

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⋅ 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

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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

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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