Psychological dimensions

The Psychological Dimensions of the Drug Problem &

Treatment and Rehabilitation of Drug Dependents

Rey M. Mollenido, MD

A Brief Look at the Drug Problem

Dangerous Drug Board (DDB)—1999

1.8 Million regular users of dangerous drugs

1.6 Million occasional users of dangerous drugs

Prevalence of Drug Abuse: Thailand (5.6%)

Philippines (2.8%) --PDEA Annual

Report 2006

A Brief Look at the Drug Problem

Rehabilitation Centers

Admissions 4,703 (2005—5,783)

Mean Age: 28 yrs

Sex (Male:Female)= 9:1

Civil Status: Single (57.77%) --PDEA Annual

Report 2006

A Brief Look at the Drug Problem

Rehabilitation Centers

Occupation: Unemployed (35.81%)

Educational Attainment: High School (29.79%)

Economic Status (Ave. Monthly Family Income) = P13,706.43

--PDEA Annual Report 2006

A Brief Look at the Drug Problem

Rehabilitation Centers

Choice of Drug Abused:

Methamphetamine: 69.23%

Marijuana : 38.42

Contact Cement: 11.97%

--PDEA Annual Report 2006

A Brief Look at the Drug Problem

Rehabilitation Centers

Admissions 4,278

Mean Age: 20-29 yrs

Sex (Male:Female)= 9:1

Civil Status: Single (57.77%) --PDEA Annual

Report 2007

More people trying

More people trying again and again

The abuser doesn’t get totally cured

Must cover the BIO-PSYCHO-SOCIAL aspect of each person

Why Examine the Psychological Dimension of the Drug Problem?

Discontinuation of substance use

Detoxification

Rehabilitation

Treatment of co-morbid conditions

Environmental manipulation

Family therapy

Behavioral modification

The Treatment Process

Discontinuation of substance use

Detoxification

Rehabilitation

Treatment of co-morbid conditions

Environmental manipulation

Family therapy

Behavioral modification

The Treatment Process

Discontinuation of substance use

Detoxification

Rehabilitation

Treatment of co-morbid conditions

Environmental manipulation

Family therapy

Behavioral modification

The Treatment Process

Discontinuation of substance use

Detoxification

Rehabilitation

Treatment of co-morbid conditions

Environmental manipulation

Family therapy

Behavioral modification

The Treatment Process

Discontinuation of substance use

Detoxification

Rehabilitation

Treatment of co-morbid conditions

Environmental manipulation

Family therapy

Behavioral modification

The Treatment Process

Discontinuation of substance use

Detoxification

Rehabilitation

Treatment of co-morbid conditions

Environmental manipulation

Family therapy

Behavioral modification

The Treatment Process

Discontinuation of substance use

Detoxification

Rehabilitation

Treatment of co-morbid conditions

Environmental manipulation

Family therapy

Behavioral modification

The Treatment Process

Discontinuation of substance use

Detoxification

Rehabilitation

Treatment of co-morbid conditions

Environmental manipulation

Family therapy

Behavioral modification

The Treatment Process

Curiosity

Boredom

Peer group pressure

Temporary relief from problems

Security feelings

Like Adam and Eve

Why People Try Drugs

Etiology: Psychological Theories

Addictive Personalityneed to feel self-worth

need to have control over the environment

need to feel intimate contact

need to accomplish something

need to eliminate pain or negative feelings

Etiology: Psychological Theories

Behavioral Theories

conduct problems of childhood

relationship between conduct problems, hyperactivity, impulsivity, and future substance abuse

Psychodynamics

• Freudian

– infantile desires

• regressive pleasurable adaptation

• Neo-Freudian

– adaptive effort to survive

• Progressive responses to psychological suffering and deficient self-regulation

Behavioral Models

• Drug self-administration model

– Skinner

– Operant reinforcement

– Pleasure with drug

• Conditioned place-preference model

– Kumar from Pavlov

– Place conducive to addiction

Age of anxiety

Age of Depression

Personal inadequacies, failures and conflicts cause tension

Predisposing personality, emotional and behavioral disturbances.

Why People Continue to Use Drugs

Primer Receptor sites

Cravings Compelling urge Urgent and overpowering desire Irresistible impulse

WHO : desire to experience the effect(s) of a previously experienced psychoactive substance

Why People Continue to Use Drugs

Factors Peer Pressure

Coping Mechanism to Stress Anxiety Disorders Depression Feel Good

Why People Continue to Use Drugs

Drug use starts early and peaks in the teen years

Firs

t D

rug

Use

(nu

mbe

r of

in

itiat

es)

Infant Teen Adult Older Adult

Child

Evidence from surveys

Drug use starts early and peaks in the teen years

One of the serious concerns regarding today’s youth

About 25% of adolescents 12-17 years of age have illicit drug use

Drug use starts early and peaks in the teen years

Risk factors include high levels of family conflict, academic difficulties,

Co-morbid psychiatric disorders, parental and peer substance use, impulsivity, & early onset of cigarette smoking

Drug use starts early and peaks in the teen years

Drug use starts early and peaks in the teen years

Lack of connectedness to parents and family

Poor training in delaying gratification

Much due to ignorance

“Adult-sized CHILD”

Drug use starts early and peaks in the teen years

Lack of ability to plan for future

Pubertal intensities Physical challenges – “new found power”

Lack emotional stability – identity struggles

Need for belonging (gang formations) Insecurities

Independence struggles

Use of Multiple Drugs

• Cigarettes

• Beer or wine or other forms of alcohol

• Marijuana

• Problem drinking

• Downers or uppers

• Shabu/Ecstasy/Cocaine/Heroin

Presence of Co-morbid Disorders

Attention Deficit Hyperactivity Disorder

Conduct Disorder

Affective/Mood Disorders

Tends not to resolve after a few weeks of abstinence

Adults = depressive disorders usually resolve

Anxiety Disorders

The good news is…The good news is…

Drug Abuse is aDrug Abuse is apreventablepreventable behavior behavior

and and

Drug Addiction isDrug Addiction isa a treatabletreatable disease disease

Treatment Goals

• Abstinence

• Physical, psychiatric and psychosocial well-being of the patient

Matching Patients to Matching Patients to Individual NeedsIndividual Needs

No single treatment is appropriate for all individuals

Effective treatment attends to multiple needs of the individual, not just his/her drug use

Treatment must address medical, psychological, social, vocational, and legal problems

www.drugabuse.gov

Management

As Outpatient

As Rehabilitation Patient In-housed

Slightly different setting & approach

Treated as Out-patient after

Management as Outpatient

Biological therapy

Psychosocial therapies

– Behavior modification

• home

• school

– Structuring of activities

Management as Outpatient

Psychosocial therapies Sports activity

Psychotherapy – individual

Support group – to be organized

Prayers

Working with the family

Coordination with the school

Outpatient Treatment: Key Elements

Explicit structure and expectations

Positive and collaborative relationship with the client

Teaching information and cognitive-behavioral concepts

Positively reinforcing desired behavioral change

Outpatient Treatment: Key Elements

• Positive and collaborative relationship with the client

client must be engaged (stages of change) in the process

client must return for the next session

Outpatient Treatment: Key Elements (cont’d)

Corrective feedback using a motivational interaction style

Educating family members on the expected course of recovery

Periodic urine testing

Introducing/encouraging self-help participation

Outpatient Treatment: Key Elements (cont’d)

Periodic urine testing

not presented as a monitoring measure

a way to help discontinue drug use

a useful therapeutic opportunity for insight into client’s behavior

Treatment Considerations

Cognitive behavioral approach

current treatment of choice

focuses on “unlearning” maladaptive behavior and on learning more adaptive responses

most closely linked with existing scientific knowledge

Cognitive Behavioral Outpatient Therapy

Focus on abstinence

Focus on behavior vs feelings

Focus is behavior vs reason behind it

Transference is encouraged and utilized

Goal is stability vs emotional catharsis

Self-Help and DrugSelf-Help and DrugAddiction TreatmentAddiction Treatment

Complements and extends treatment efforts

Most commonly used models include 12-Step (AA, NA) and Smart Recovery

Most treatment programs encourage self-help participation during/after treatment

www.drugabuse.gov

Motivation for Change

• Key predictor of whether an individual will change their substance abuse

• Involves recognizing problem, searching for a way to change, and then changing

Motivation for Change

• Motivational interviewing seeks to elicit self-motivational statement from

patients,

supports behavioral change, and

creates a discrepancy between the patient’s goals and continued alcohol and other drug use.

Guidelines for Therapeutic Relationship

• Encourage honest expression of feelings

• Listen and express caring

• Hold individual responsible for behavior

• Provide consequences for negative behavior and talk about specific, objectionable actions

• Do not compromise own values, monitor reaction

• Communicate to team

Assessing an Adolescent

Trust in necessary for a therapeutic alliance.

Effective ways to prevent a trusting relationship from developing: To test without the young person’s knowledge

To test in spite of the adolescent’s objections

To test on parents’ demand

Rehabilitation

Not prison, nor punishmentNot prison, nor punishment

Therapeutic environmentTherapeutic environment

More protective for the clientMore protective for the client

May be a form of group therapyMay be a form of group therapy

Not merely a place, but a process as wellNot merely a place, but a process as well

Rehabilitation Involves

Personal developmentPersonal development

Parental concerns and knowledgeParental concerns and knowledge

School environment and educationSchool environment and education

Community education & program participationCommunity education & program participation

Rehabilitation Involves

Program in a workplaceProgram in a workplace

Mass media education & program involvementMass media education & program involvement

Law enforcementLaw enforcement

LegislationLegislation

Duration of TreatmentDuration of Treatment Depends on patient problems/needsDepends on patient problems/needs

Less than 90 days is of limited/no effectiveness Less than 90 days is of limited/no effectiveness for residential/outpatient settingfor residential/outpatient setting

A minimum of 12 months is required for A minimum of 12 months is required for methadone maintenancemethadone maintenance

Longer treatment is often indicatedLonger treatment is often indicated

www.drugabuse.gov

Treatment Outcome Measures

Substance Use

Medical and Physical Health

Psychosocial Functioning

Employment stability

Criminal Justice Involvement

Relapse Prevention

Treatment Centers in Iloilo

WVMC-Substance Abuse Treatment & Rehabilitation Center

WVSUMC for detoxification

New Life Therapeutic Center

DelaLlana Detention Center

Dalayunan Home for Boys

Prevention Strategies

• Always the best approach

• A group effort

STRATEGIES FOR DRUG ABUSE STRATEGIES FOR DRUG ABUSE PREVENTION IN THE WORKPLACEPREVENTION IN THE WORKPLACE

Company Policies and Procedures on alcoholism and drug abuse.

Example:Example:

-Tardiness and absenteeism guidelines;

- Establishing an alcohol /drug-free workplace

STRATEGIES FOR DRUG ABUSE STRATEGIES FOR DRUG ABUSE PREVENTION IN THE WORKPLACEPREVENTION IN THE WORKPLACE

Information on harmful effects of drugs and alcohol utilizing the following media:

- - Posters, Comics, Seminars, Newsletter, Leaflets, Posters, Comics, Seminars, Newsletter, Leaflets, Paging System, Stage Presentation, Skits, Exhibitions Paging System, Stage Presentation, Skits, Exhibitions and Film Showingand Film Showing

Example:Example:

STRATEGIES FOR DRUG ABUSE STRATEGIES FOR DRUG ABUSE PREVENTION IN THE WORKPLACEPREVENTION IN THE WORKPLACE

Education

Example:Example:

Employee Education ProgramEmployee Education Program Training of Staff/Supervisors for Training of Staff/Supervisors for EAPEAP

Training on ParentingTraining on Parenting

STRATEGIES FOR DRUG ABUSE STRATEGIES FOR DRUG ABUSE PREVENTION IN THE WORKPLACEPREVENTION IN THE WORKPLACE

Positive alternatives - opportunities for wholesome recreation and self-expression.

- Sports, Cultural Activities and Livelihood Activities

Example:Example:

ineffective parentingineffective parenting

chaotic home environmentchaotic home environment

lack of mutual attachments/nurturinglack of mutual attachments/nurturing

inappropriate behavior in the classroominappropriate behavior in the classroom

failure in school performancefailure in school performance

Prevention Programs Should . . . .Prevention Programs Should . . . .Reduce Risk FactorsReduce Risk Factors

www.drugabuse.gov

poor social coping skillspoor social coping skills

affiliations with deviant peersaffiliations with deviant peers

perceptions of approval of drug-using behaviors perceptions of approval of drug-using behaviors in the school, peer, and community environmentsin the school, peer, and community environments

Prevention Programs Should . . . .Prevention Programs Should . . . .Reduce Risk FactorsReduce Risk Factors

www.drugabuse.gov

Prevention Programs Should . . . .Prevention Programs Should . . . .

strong family bonds parental monitoring parental involvement success in school performance prosocial institutions (e.g. such as family,

school, and religious organizations) conventional norms about drug use

www.drugabuse.gov

Enhance Protective FactorsEnhance Protective Factors

Resist drugs

Strengthen personal commitments against drug use

Increase social competency

Reinforce attitudes against drug use

Prevention Programs Should . . . .Prevention Programs Should . . . .

www.drugabuse.gov

Include Interactive Skills-Based Training

Involve Communities and SchoolsInvolve Communities and Schools

Media campaigns and policy changes

Strengthen norms against drug use

Address specific nature of local drug problem

www.drugabuse.gov

Prevention Programs Should . . . .Prevention Programs Should . . . .

Provides greater impact than parent-only or child-only programs

Include at each stage of development

Involve effective parenting skills

Prevention Programs Should be. . . .Prevention Programs Should be. . . .

www.drugabuse.gov

Family-FocusedFamily-Focused

Have you changed your mind?Have you changed your mind?