https://phoenix.vitalsource.com/#/books/97814833420478 Substance Abuse Counseling and Co-occurring Disorders CHAPTER OBJECTIVES After reading this chapter, you will be able to:
1. Recognize substance dependence and substance abuse.
2. Know key diagnoses and definitions from the DSM-IV-TR.
3. Be aware of the various co-occurring disorders that are common to substance abusers.
4. Understand the various screening and assessment tools that are used in the treatment of substance abuse disorders.
5. Know the 12 core functions associated with substance abuse treatment.
6. Be aware of the impact that denial has on the addicted population’s prognosis.
7. Understand the dynamics of relapse prevention.
INTRODUCTION The prevalence of offenders suffering from substance use and abuse problems currently in the American Criminal Justice System is staggering. The massive increase in the number of convicted offenders suffering from substance abuse began in the 1980s and continues through the present. As Hanser (2006) points out, any informed discussion of drug offenders in the United States must begin with the war declared on drugs by the U.S. Government. As crack cocaine began to sweep through the nation in the early to mid-1980s an outcry shivered through the fabric of our society. Not only was the drug trade burgeoning and access to illegal substances becoming easier than ever, the violent crime rate was also increasing. A connection was quickly made between the expanding drug culture and the often violent incidents that occurred within its realm. This connection, along with societal upheaval, forced the government to take action in an attempt to rid ourselves from the evils and perils commonly associated with substance abuse and criminal behavior. The resulting action taken by federal and state lawmakers has been to draft laws aimed at corralling illegal substance–using offenders. And, law enforcement efforts have been somewhat successful—successful at least in its ability to arrest a sufficient amount of drug-related offenders so that nearly every correctional agency in America is at or beyond capacity. Once drafted these laws are enforced. In order to be enforced assets must be well equipped and mobilized. What is the primary ingredient for equipping and mobilizing assets? Money. As a country we have spent enormous amounts of money in attempt to halt the flow and usage of illegal substances. The money has primarily gone to two components of the criminal justice system: enforcement and corrections. Enforcement efforts are usually aimed at stopping the flow of illegal substances from entering our country; arresting those transporting and distributing illegal substances after they have entered the country; as well as, arresting those found to be using illegal substances. Enforcement efforts are carried out by a multitude of law enforcement agencies ranging from federal to state and local jurisdictions. Once arrested these offenders then become the responsibility of correctional agencies, also operating at local, state, and federal levels. In essence, we have filled every space available within the correctional component of criminal justice with a human inmate. Closely related to substance use and abuse problems are co-occurring disorders. Co-occurring disorder is a phenomenon whereby individuals are not only suffering from substance abuse issues but they are also afflicted with psychological or emotional impairments that affect their overall health and well-being. For example, co-occurring disorder would be the appropriate concept used to describe an offender suffering from substance use or abuse in conjunction with some other ailment such as anxiety or depression. In fact, it is very rare to observe an offender with substance abuse issues but not also suffering from other psychological or emotional disorders. This is because, in general, substance use and abuse is a method of relieving or adapting to life circumstances that are experienced as unpleasant and troublesome. Psychologically and emotionally healthy human beings are generally not involved with the abuse of illegal substances because of their limiting effects. Humans function best in natural states of existence free of foreign substances. The ingestion of illegal substances by mostly psychologically and emotionally healthy individuals has a tendency to “gum things up” keeping them from functioning at their highest levels. What we do know is that our correctional system is at full capacity. We also know that our correctional system is filled mostly with offenders suffering from co-occurring disorders. It would be difficult at best to refute these facts. The question then becomes, What do we do? How do we deal with our inmate population that is largely made up of offenders suffering from a multitude of psychological and emotional disorders coupled with the use and abuse of illegal substances? First, it is important to point out that there are no simple answers or solutions. Our democratic style of government ensures checks and balances that work to limit one ideology from completely dominating policy and procedure. Conservatives may argue that the answer lies in building more prisons. The problems with this approach, however, are robust. How many more prisons would we need to build? Who would assume responsibility for the massive costs? On the other hand, liberals may argue that we need to decriminalize all forms of substance use. In relation to this postulate, the reality is that our society is not yet ready to seriously consider this approach as viable. Therefore, we are left to function somewhere between these two extremes. Our contention is that we need a strong presence on different fronts. We need law enforcement to work diligently because many offenses, often violent, occur in conjunction with substance use and abuse. In addition, we need to create innovative approaches to address both the substance abuse issue among offenders as well as mental health issues that confront them. Among the innovations that have been incorporated, it is the use of both drug courts and mental health courts that has received widespread support and popularity within the criminal justice system. Students may recall the mention of these types of interventions from Chapter 1, noting again that drug courts synthesize therapeutic treatment and judicial processes to optimize outcomes with the drug-addicted offender population (Watson, Hanrahan, Luchins, & Lurigio, 2001), while mental health courts consist of specialized dockets for defendants with mental illnesses (Bureau of Justice Assistance, 2004). Over the past two decades, there has been fervent support for drug courts and, upon the common realization that substances induce and correlate with other disorders, mental health course as well. As can be seen, the trend is, and should be, to bear public resources on treating offenders who suffer from co-occurring disorders while in custody. Recidivism rates speak loudly and aggressively to this last postulate. As Hanser (2006) points out, recidivism rates are closely related to substance abuse. When considering co-occurring disorders recidivism rates are even higher. However, the complexities in providing the actual intervention for offenders who present with these multiple challenges are great. Therefore, the remaining portions of this chapter are aimed at identifying, describing, and treating those offenders suffering from substance use and abuse as well as co-occurring disorders. To begin, it is useful to define some of the concepts commonly used within the parameters of treating offenders suffering from substance abuse and co-occurring disorders. Many of these terms are commonly used interchangeably but as will be pointed out there are subtle differences that need to be illuminated. PART ONE: RECOGNIZING SUBSTANCE DEPENDENCE AND SUBSTANCE ABUSE Important Concepts Defined The document most relied on to provide official definitions for most psychological and emotional concepts is the Diagnostic Statistical Manual (DSM-IV-TR) published by the American Psychological Association (APA). The latest version being the fourth edition published in 2000. First, substance-related disorders are divided into substance use disorders and substance-induced disorders (CSAT, 2006). Substance use disorders are further divided into substance abuse and substance dependence. Substance use disorders are characterized by 11 categories provided by the APA (2000, p. 191): 1. Alcohol 2. Amphetamine or similarly acting sympathomimetics 3. Caffeine 4. Cannabis 5. Cocaine 6. Hallucinogens 7. Inhalants 8. Nicotine 9. Opioids 10. Phencyclidine (PCP) or similarly acting arylcyclohexylamines 11. Sedatives, hypnotics, or anxiolytics. These 11 categories are separated by criteria into abuse and dependence. Substance abuse is often used to refer to both abuse and dependence. Also, substance dependence and addiction are often used interchangeably although there is strong debate as to whether this is appropriate (CSAT, 2006). Finally, the system of care responsible for treating substance-related disorders is commonly referred to as the substance abuse treatment system. Substance Abuse—the DSM-IV-TR defines substance abuse as a “maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances” (APA, 2000, p. 198). Individuals who abuse substances are likely to experience harmful consequences such as, but not limited to, the following: 1. Repeated failure to fulfill roles for which they are responsible 2. Use in situations that are physically hazardous 3. Legal difficulties 4. Social and interpersonal problems. Substance Dependence—is defined by the APA (2000) as “a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems” (p. 192). This harmful pattern of behavior includes all of the features of substance abuse as well as such features as: 1. “Increased tolerance for the drug, resulting in the need for ever-greater amounts of the substance to achieve the intended effect 2. An obsession with securing the drug and with its use 3. Persistence in using the drug in the face of serious physical or psychological problems” (CSAT, 2006, p. 1). Substance-Induced Disorders—are characterized by three main facets which include substance intoxication, substance withdrawal, and group of symptoms that are “in excess of those usually associated with the intoxication or withdrawal that is characteristic of the particular substance and are sufficiently severe to warrant independent clinical attention” (APA, 2000, p. 210). Further exacerbating the problem of substance-induced disorders is the fact that individuals suffering from this ailment often present with a wide variety of symptoms characteristic of various mental disorders including delirium, dementia, amnesia, psychosis, mood disturbance, anxiety, sleep disorders, and sexual dysfunction (CSAT, 2006). Co-occurring Disorders—a condition where individuals suffer from substance-related and mental disorders. Offenders suffering from co-occurring disorders will likely have one or more substance-related disorders operating in conjunction with one or more mental disorders (CSAT, 2006). The Center for Substance Abuse Treatment (CSAT) further defines co-occurring disorders, at the individual level, as a phenomenon where “at least one disorder of each type can be established independent of the other and is not simply a cluster of symptoms resulting from a single disorder” (CSAT, 2006, p. 3). An important distinction noted by CSAT (2006) is that some offenders at particular points in time may present with symptoms that do not neatly fit the criteria for diagnoses found in the DSMIV-TR categories. From a practical standpoint, however, these offenders are suffering from symptoms that are best addressed from a framework which assumes the presence of a co-occurring disorder. To address this distinction CSAT (2006) created a “service definition of co-occurring disorder.” The definition consists of three postulates: 1. “Individuals who are ‘prediagnosis’ in that an established diagnosis in one domain is matched with signs or symptoms of an evolving disorder in the other 2. Individuals who are ‘postdiagnosis’ in that either one or both of their substance-related or mental disorders may have resolved for a substantial period of time 3. Individuals with a ‘unitary disorder and acute signs and/or symptoms of a co-occurring condition’ who present for services. Suicidal ideation in the context of a diagnosed substance use disorder is an excellent example of a mental health symptom that creates a severity problem, but itself does not necessarily meet criteria for a formal DSM-IV-TR diagnosis. Substance-related suicidal ideation can produce catastrophic consequences. Consequently, some individuals may exhibit symptoms that suggest the existence of co-occurring disorder but could be transitory (e.g., substance-induced mood disorders). While the intoxicated person in the emergency room with a diagnosis of a serious mental illness will not necessarily meet abuse or dependence criteria, he or she will still require co-occurring disorder assessment and treatment services” (p. 3). How Substance Abuse Starts First, it is important to state clearly that it is impossible to articulate a clear path to substance abuse to capture the path taken by all people. The paths are as complex and varied as human beings themselves. In addition, there has been much debate that still continues to try and place substance abuse within a particular domain. For example, in past years it was believed that substance abuse was primarily a moral issue. Addicts were viewed as morally deficient and corrupt (Dimoff, 2001). More recently, debate has shifted to consider substance abuse as a disease. This ideology places the enigma into the medical profession. Today, it is mostly accepted that the issue of substance abuse is primarily grounded on at least two main components: heredity and environment, and/or a combination of the two. There is strong evidence that heredity is a major factor with powerful influence on the likelihood of some individuals engaging in substance abuse. Some reports claim individuals reared by parents who are substance users and abusers are four times more likely to be involved with substance abuse (Dimoff, 2001). Environmentally, the United States comprises of approximately 5–6 % of the world’s population. Americans consume, however, three-quarters of all illegal drugs produced in the world making us the leading consumers of alcohol and prescription drugs. Important to this discussion is one environmental factor that highlights current emphasis on “feeling good.” With medical advances we now have a variety of medications aimed at soothing almost any ailment. If we do not feel good we turn to substances as a solution. And, this ideology has become big business for drug makers and pharmaceutical companies. This fact is quickly observed by the constant flow of media outlets telling us there is medication for whatever adverse feelings we may experience. Closely related to this phenomenon is the media-advanced depiction of what we should physically look like in order to be accepted and successful. In essence, if you are not thin and attractive you are relegated to the outer fringes of society. This ideology creates enormous social and environmental pressures which are impossible to achieve. There is a constant drive toward perfection. The problem with perfection, however, is that it is a very elusive concept that is usually characterized by such statements as, “If I were only able to be a little more … then I would be perfect.” We mentally create scenarios that are impossible to achieve. And when we are unable to measure up to the impossible circumstances we create the result which is usually a feeling of shame or defectiveness. In order to alleviate the painful feelings of these emotions some turn to substances to dull the effects. A vicious circular cycle is created and rigidly adhered too and unfortunately this cycle is one that is incapable of producing the feelings we truly desire. An additional component that may be most salient in the origins of substance abuse is the role or influence of parents or guardians. A strong consensus now exists that indicates much of a child’s personality is formed by the age of eight. This includes values, morals, work ethic, and attitude. In most cases, parents will have the greatest influence on their children’s psychological and emotional well-being. Ideally, children need to be given sufficient freedom to explore and learn their ever-expanding world. This freedom needs to be balanced with guidance and support aimed at showing the child what is right and wrong and also what is safe and dangerous. If children are not given sufficient freedom to learn and grow it is likely that deep emotional problems will result such as stress, low self-worth, depression, anxiety, and nervousness. These psychological and emotional disorders often contain negative feelings that are powerful influences on behavior. As children grow to adolescence and early adulthood it becomes very difficult to function in a normal and healthy manner. Not surprisingly, many will turn to substances to relieve the powerful pangs of anxiety, depression, shame, anger, and fear. External pressures also contribute to the origins of substance use and abuse. External difficulties are commonly characterized by such issues as school problems, work difficulties, family problems, peer pressure, and relationship issues. All of these circumstances or environments are strong causal factors for individuals to experience feelings such as shame and defectiveness, which are described as being at the heart of addiction. As will be covered later in the chapter, substance abuse is really a symptom of psychological and emotional dysfunction. The issue is not so much treating substance abuse as it is treating repressed emotion and the psychological dys-function that accompanies it. Progressive Stages of Substance Abuse It is important to recognize the different stages that usually lead to substance abuse. Obviously, these stages may vary for some individuals depending on particular circumstances. However, there is usually observable behavior that would fit the following five categories: 1. Compulsion to acquire and use substances and a preoccupation with their acquisition and use 2. Loss of control over substance use or substance-induced behavior 3. Continued substance use despite adverse consequences 4. A tendency toward relapse following periods of abstinence 5. Tolerance and or withdrawal symptoms (LASACT, 2004). Compulsive behaviors usually result from users learning that good feelings can be produced by using substances. The individual may start out using substances at parties or on weekends to “take the edge off.” Initially, powerful feelings of euphoria are experienced because of a lack of tolerance. And, generally there are no adverse behavioral effects because the substance has not yet begun to interfere with the user’s lifestyle or obligations. In essence, there is a powerful feeling of euphoria with few consequences (Dimoff, 2001). Due to the euphoric effects and initial lack of consequences, compulsive behaviors become more pronounced as users begin to actively plan both attainment and use of the substance(s). At this point use may still be controlled. For example, the individual may use only at “appropriate” times and places such as, not at work, not before 5:00 P.M. and certainly not in the mornings. Nonetheless, a very important and powerful process is now underway; tolerance is beginning to be developed. Loss of control over substance use or substance-induced behavior usually becomes evident as the individual becomes more preoccupied with euphoric mood swings. There is generally an increase in the frequency of substance use and some of the self-imposed rules begin to be broken. The individual may engage in solitary use as opposed to only at parties or on the weekends with friends. In addition, more of the substance may be used than originally planned. At this point, the user is quickly approaching the realm of chemical dependency. This is where the individual’s lifestyle begins to change. In fact, individuals who have become chemically dependent on a substance will usually arrange their life so that the substance and its obtainment and use are paramount. Everything else becomes secondary to the substance.
