Conceptual Models of Substance Use

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1 Conceptual Models of Substance Use Different causal factors emphasized Different interventions based on conceptual models 1

2 Developing a Conceptual Model What is the nature of the disorder? Why causes it? Is it permanent/irreversible? How much responsibility does the individual bear? How much responsibility lies outside the individual? What is the solution or best approach to the problem? 2

3 Moral Model Individual is personally responsible for addiction. The person has complete self-control, and can choose to do the right thing. The right thing = maintaining control over substance use. Treatment : Individual needs to be persuaded that s/he is making wrong choices. Social, religious, and legal sanctions are threatened or applied 3

4 Temperance Model Often confused with moral approaches. Belief system predominated late 19th centuryrepeal of Prohibition in Historic pressure on congress to prohibit the manufacture, sale, transportation, and importation of alcoholic beverages. 1919: 18 th amendment to the Constitution (Volstead Act) ratified Belief = Not possible for anyone to drink in moderation Abstinence only viable alternative 4

5 Temperance Model Alcohol s addictive and destructive power strong The problem is substance, not person. Take away the substance and the problem will disappear Treatment = consists of just say no, and control of the supply. Prohibition unpopular and impossible to enforce Repealed in 1933 by the 21 st amendment. 5

6 Temperance Model Prohibition unpopular and impossible to enforce Repealed in 1933 by the 21 st amendment 6

7 Spiritual Model Problem results from a lack of spiritual connection. The treatment consists of replacing the spiritual deficit through: Participation in faith-based activities Prayer Spiritual education Support Program of personal growth and development. 7

8 American Disease Model After prohibition repealed, new way of looking at alcohol problems needed Model emerged in 1935, same year Alcoholics Anonymous began Primary assertion is that addiction is a unique, progressive condition, or disease. Addiction caused by irreversible, constitutional abnormality of an individual Much like an allergy Problem is within the individual, not the substance 8

9 American Disease Model Users are not responsible for their condition, and are deserving of humane treatment Chemically dependent individual is incapable of using a mood altering substance in moderation. Treatment is effective and necessary Treatment consists of Identifying the disease Confronting the person Lifelong abstinence from the substance. 9

10 Biological Basis of Addiction Adoption Studies Sons of Alcoholic Fathers Animal Studies Neurochemical Studies 10

11 Genetics of Alcoholism First degree relatives have significantly greater risk for developing addiction Male-limited alcoholism Milieu-limited alcoholism 11

12 Educational Model Addiction results from a lack of knowledge Lack can be corrected by providing sufficient awareness and information to enable people to make the appropriate decisions. Drug education approach 12

13 Characterological Addiction results from an addictive personality Destruction and self-destruction Addiction is an attempt to protect the ego. Treatment is psychodynamic psychotherapy. 13

14 Characterological or Personality Model Focus on behavior Problems with substances are associated with low levels of emotional intelligence Personality disorders (Cluster B): Antisocial, narcissistic, borderline, histrionic) Clients often have: Inadequate communication skills Poor stress management Low frustration tolerance Impaired impulse control antisocial attitudes 14

15 Emotional Intelligence Self awareness (Understanding yourself and your emotions) Self-regulation (Managing emotions) Self-motivation (Moving ahead) Empathy (Understanding how other people feel without being told in words) Social skills (The art of social relationships) 15

16 Characterological or Personality Model Focus on behavior Problems with substances are associated with low levels of emotional intelligence Personality disorders (Cluster B): Antisocial, narcissistic, borderline, histrionic Clients often have: Inadequate communication skills Poor stress management Low frustration tolerance Impaired impulse control antisocial attitudes 16

17 Characterological or Personality Model low self esteem sex-role conflicts Clinical presentation may include: Manipulative, demanding behaviors Pathological need for power and control Treatment components Abstinence if possible Treatment of co-occurring mental health issues Enhancing emotional intelligence knowledge and skills Reconstruction of personality 17

18 Characterological Typical barriers to successful treatment: Refusal to acknowledge problem Refusal to attempt change Inability to change? (ASPD) Lack of support from family and significant others 18

19 Conditioning Addiction is result of learned behaviors. Individual has acquired entrenched behaviors of using substances to solve problems and cope with life. Treatment consists of: Counter-conditioning Extinguishing unwanted behaviors Changing rewards and punishments. 19

20 Social Learning Addiction has a cultural basis Addiction results from observing and emulating poor role models. Addiction reinforced by using AOD to cope with life stressors. Treatment consists of: Skills training Changing cultural influences Substitution of appropriate role models (successful, sober persons) 20

21 Social Learning Theory Responds to a Cognitive Behavioral Approach The Fundamental Principle is self regulation Addiction is not an attempt at self regulation, it is an attempt to regulate one s life around the substance. 21

22 Cognitive Model Addiction results from unrealistic expectations and inaccurate beliefs about reality. Treatment consists of: Correcting thinking errors Restructuring inaccurate beliefs, values, and expectations. 22

23 Sociocultural Addiction is caused by environmental factors that influence and govern behaviors. Addicts are the victims of cultural norms. Treatment consists in changing social policy: Make substances unavailable by raising price and distribution controls 23

24 General Systems Model Addiction results from dysfunction of family boundaries and rules. Treatment consists of family therapy. 24

25 Public Health Model HOST AGENT ENVIRONMENT 26

26 Public Health Model Agent Host Environment Host = the person or population in which symptoms are visible Agent = the substance that enters the host, producing symptoms. 27

27 Environment: Public Health Model Factors present in the immediate physical, emotional, social and spiritual environment that contribute to the problem. Treatment consists of interdisciplinary, multiple levels of simultaneous intervention (including primary prevention and harm reduction). 28

28 Psychiatric Model Substance use disorders are caused by underlying psychological problems Depression Bi-polar disorder Anxiety PTSD Trauma (often in childhood) 29

29 Psychiatric Model Treat the psychological condition and the substance use disorder will go away Often involves the use of medication If addiction treatment is necessary, it should be offered after the psychological problem is resolved (sequential treatment) 30

30 Other Models of Treating Dual Diagnosis (Co-Occurring disorders) Parallel: Psychiatric treatment and addiction treatment are provided at the same time, but by different providers who may not coordinate the case Integrated: Psychiatric treatment and addiction treatment are provided at the same time, by the same provider, or at least in a coordinated manner 31

31 Biopsychosocial Model Addiction involves multiple areas of the client s life All aspects of the client s life should be investigated and assessed Incidence (Did it happen) Severity/breadth (How serious was the problem or disorder) Recency (When was the last time the problem occurred) Service utilization (Has the problem been treated? When? By Who?) 32

32 Biopsychosocial Model Assessment follows ASAM criteria Acute Intoxication and Withdrawal Bio-Medical Conditions and Complications Cognitive, Behavioral, and Emotional Conditions Readiness to change Relapse, continued use or continued problem potential Recovery/Living Environment 33

33 Analysis of ASAM Criteria Information Leads to treatment plan, including level of care (LOC) 0.5 Early intervention I: Low intensity outpatient II: Intensive outpatient (IOP)/Patial hospitalization III: Residential/inpatient V: Medically-managed/intensive inpatient 34

34 Recovery Management 90 days of engagement with a qualified professional or program is gold standard for good outcomes (continued sobriety and recovery) Continuing care (1-4 times a week) can extend treatment to the 90 day timeline AA: 90 meetings in 90 days What happens after treatment? 35

35 Recovery Management Acute illness/condition: Broken leg Examination Diagnosis Treatment Physical therapy Professional care ended Chronic condition: Coronary artery disease (CAD) Examination Diagnosis Treatment Check-ups Individual takes significant personal responsibility for recovery and health maintenance 36

36 The Current System of Care for Addiction as an Acute Illness Completion of care, discharged, passive referrals to self-help meetings, community support and case is closed. Detox Residential Outpatient Continuing Care The traditional addiction treatment models stop short of facilitating recovery management an essential element in treating chronic conditions

37 Recovery Management Acute illness/condition: Broken leg Examination Diagnosis Treatment Physical therapy Professional care ended Chronic condition: Coronary artery disease (CAD) Examination Diagnosis Treatment Check-ups Individual takes significant personal responsibility for recovery and health maintenance 38

38 Treatment Intensity Toward A System of Care for Addiction as a Chronic Illness As personal responsibility increases, treatment intensity decreases Continuing Care Services (CCS): Frequency of contact determined at each post-treatment session Detox Residential Outpatient Brief Transitional Community intervention housing support Via telephone E-counseling, or Face-to-face From CCS risk assessment: Education Brief intervention Brief counseling Readmission

39 Toward A System of Care for Addiction as a Chronic Illness Continuing Care Services (CCS) Detox Residential Outpatient Community Support Brief Intervention PRN

40 Continuing Care Services Approach: Post-Treatment Check Ups Follow-up visits focus on incremental behavioral changes & addressing recovery issues Once acute treatment issues have been stabilized, client moves to continuous care services with instructions for recovery management Client responsible for monitoring and maintaining sobriety and recovery client always welcome to return

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