SECTION II

RELEVANT BASIC SCIENCE TRAINING

Estimated Time for Delivery: 350 hours

GOAL

Participants will learn about pharmacology, epidemiology, social theories, genetic models, and behavioral conditioning models.

OBJECTIVES

Upon completion of this section, participants will be oriented about:

1. Developing an in-depth knowledge of pharmacology.

2. Understanding the role of epidemiology as it relates to substance abuse and mental disorders.

3. Understanding the social theories underlying the causes of substance abuse and its consequences and the social and support systems involved.

4. Understanding the genetic models of substance abuse and mental disorders.

5. Understanding the behavioral models of substance abuse and mental disorders.

Objective 1. Develop an in-depth knowledge of pharmacology. Trainer will provide lectures and clinical practice to orient trainees about the:

    A. Understanding of the synapse, drug effects on neurotransmission,psychopharmacologic treatment of substance abuse and major psychiatric disorders, treatment of difficult patients, and the provision of consultation to non-medical therapists.

    B. Pharmacology of and neuropharmacology of opiates, alcohol, benzodiazepines, and cocaine

TRAINER NOTE

1. Using handouts/overheads, Trainer will deliver this section presenting the most updated information possible at the time of training delivery.

2. Allow 120 hours for delivery of this section. (60 hours per semester)

3. Throughout this manual, appendices will include materials which can be used as handouts or overheads, at the Trainer's discretion. The Trainer is encouraged to add or amend handout and overheads as new information, treatment protocols, and updated materials are incorporated into the training.

CONTENT

An overview of the general principles of psychopharmacology will be presented which will include:

I. Variables affecting its administration:

    1. drug selection, prescription, and interaction with other drugs

    2. psychodynamic meaning to the patient

    3. family and environmental influences

    4. informing patient, relatives, and health providers about the reasons and theoretical basis for this treatment, its benefits and potential risks.

II. Pharmacological Actions<

    1. Pharmacokinetics

    a. absorption
    b. distribution
    c. metabolism and excretion

    2. Pharmacodynamics

    a. receptor mechanisms
    b. dose-response curve
    c. therapeutic index
    d. development of tolerance, dependence, and withdrawal phenomena

III. Clinical Guidelines

    1. Role of clinician as diagnostician and psychotherapist

    2. Using patient's history, current clinical state and treatment plan, select drug and initiate treatment

    3. Choice of drug

    4. Nonapproved dosages and uses

    5. Therapeutic trials

    6. Therapeutic failures


Drug Classification Useful in a Clinical Setting

1. General Central Nervous System (CNS) Depressants

a. structure, predominant effects, physically addictive, used to create a "high"
b. depression of excitable tissues at all levels of the brain
c. relatively few analgesic properties at the usual doses
d. includes most sleeping medications, antianxiety drugs, alcohol
e. antipsychotic drugs such as chlorpromazine or haloperidol are not CNS depressants

2. CNS Sympathomimetics or Stimulants

a. stimulation of CNS tissues through blockage of the actions of inhibitory nerve cells or by the release of transmitter substances from the cells or by direct action of the drugs themselves.
b. includes amphetamine, methylphenidate, cocaine, weight-reducing products

3. Opiate/Narcotic Analgesics

a. clinical use to decrease pain
b. include heroin, morphine, methadone, and almost all prescription analgesics.

4. Cannabinols

a. tetrahydrocannabinol(THC) as the active ingredient
b. predominant effects: euphoria, altered time sense, hallucination
c. includes marijuana and hashish ("street drugs")

5. Hallucinogens or Psychedelics

a. predominant effect: enhanced sensory perceptions, hallucinations (usually visual in nature)
b. no accepted medical use ("street drugs')
c. includes lysergic acid diethylamide(LSD), mescaline, psilocybin, ecstasy

6. Solvents

a. used as drugs of abuse to later the state of consciousness
b. produce light-headedness and confusion
c. includes aerosol sprays, glues, toluene, gasoline, paint thinner

7. Over the Counter Drugs

a. sedative and hypnotic medications, containing antihistamines, are the most frequently abused
b. produce euphoria and light-headedness
c. includes drugs that contain atropine, scopolamine, weak stimulants, antihistamines, weak analgesics

8. Others

a. includes phencyclidine (PCP)



A. Pharmacology of Opiates

CONTENT

General overview of the latest findings on the pharmacology of opiates will be delivered and will include didactic sessions on:

1. Brain Mechanisms

       a. opiate receptors: endorphins and enkephalins
       b. subtypes among opiate receptors: mu, kappa, delta
       c. pure opiate antagonists

2. Predominant effects

       a. on mental functioning, CNS, cardiac activity
       b. on autonomic nervous system

3. Tolerance and Dependence

       a. cross-tolerance


Overview of Opiate Addiction

Based on current information available at the time of training delivery, an overview of patterns of abuse and dependence will be presented. This will include discussion of substance abuser profiles broadly defined as:

       * the small percentage who misuse analgesics in a medical setting;
       * those who take opiates obtained from nonmedical sources;
       * those who get the drug methadone legally.


Pharmacological Approaches for Treating Opiate Dependence

1. Methadone

    a. most widely used pharmacological agent in opiate dependence treatment
    b. problem of motivation
    c. approximately 115,000 of the estimated 600,000 opiate dependent persons in the United States are enrolled in methadone treatment programs according to the 1997 NIH Consensus Statement #108.

2. Naltrexone

    a. using this opioid antagonist treatment as an alternative to methadone
    b. poor treatment retention and compliance suggest limited use of this therapy

3. Buprenorphine

    a. as opioid agonist-antagonist
    b. alternative to methadone maintenance, particularly within conventional, private treatment.
    c. results of controlled studies have shown that buprenorphine represents a viable alternative to methadone for both detoxification and treatment.
    d. administered by the office-based psychiatrist or physician
    e. could provide an alternative for many heroin and other opiate dependent persons currently refusing treatment in methadone programs.
    f. adequate substance abuse training for office-based clinicians administering this treatment.

4. Desipramine

EXERCISE

Trainer will present clinical vignettes to trainees who will break into small groups and assess the patients clinical needs, prescribe or modify an appropriate psychopharmacological regimen.



B. Pharmacology of Alcohol

TRAINER NOTES

1. Before considering the various uses of psychopharmacologic agents in the treatment of alcoholic patients with coexisting psychiatric disorders, the Trainer will review the protracted withdrawal symptoms (PWS) experienced by alcoholic individuals following cessation of alcohol intake and the need for the physician to prepare the patient and patient's family to be aware of and accept these symptoms as normal symptoms of withdrawal.

2. Trainer will inform participants that the delineation of primary versus secondary affective disorder in patients presenting the syndrome of alcoholism may be one of the most difficult diagnostic problems in psychiatry. A number of patients present a history of alcoholism and affective disorder starting at approximately the same age, and it is often difficult to decide if the excessive use of alcohol resulted in depression or if the patient was self-medicating for the depression.

3. The Trainer will discuss how the degree of psychopathology appears to be a predictor of treatment outcome in alcoholic patients.

Pharmacological Approaches for Reducing Alcohol Intake:

1. Disulfiram

    a. proper dosage
    b. contraindications for patients with co-morbidity diagnosis of schizophrenia
    c. used with dopamine-blocking agent( high-potency neuroleptic).
    d. possible, though rare side effects: e.g., peripheral nerve damage.

2. Lithium

    a. limited use in treatment of alcoholics, based on inconclusive studies conducted to date.

3. Anti-depressant compounds/agents for some comorbid symptoms of alcoholism

    a. serotonin-enhancing compounds.

    b. use during abstinence phase.

    c. to date, no commercially available antidepressant has been found to be more effective than other antidepressants for use in alcoholic patients presenting depressive episodes.

4. Naltrexone

    a. as a relatively safe compound without serious long-term side effects.


(TRAINER NOTE: It should be stressed that any compound that requires oxidation by the liver may have different pharmacokinetics when administered to an alcoholic patient during the early phase of the illness, when there may be an induction of the microsomal enzyme oxidation system, than when it is administered during the later phase of alcoholism, which may be associated with cirrhosis of the liver, causing a subsequent reduction of available metabolic enzymes.)

5. Anxiolytics

Used in alcoholism patients with generalized anxiety disorders, panic disorders or other anxiety related disorders. Dosage should not interfere with the patient's cognitive processes, manual dexterity, or recovery in someone who may be likely to abuse a habit-forming drug:

    a. BZs(diazepam and alprazolam) for anxiety reduction in alcoholic patients during their maintenance phase is controversial.
    b. Buspirone due to early dropout rate of alcoholic outpatients not recommended as effects are not manifested in until 12 weeks.
    c. Monoamine oxidase inhibitors (MAOIs), particularly when administered in conjunction with behavioral modification techniques are beneficial for patients with panic disorder.
    d. Phenelzine in treatment of social phobias, a frequent comorbid diagnosis in alcoholic patients.

(TRAINER NOTE: Concern about alcoholic individuals abusing drugs such as methylphenidate or amphetamines has made many clinicians hesitant to use these compounds.)

6. Neuroleptic Medications

    a. absolutely necessary for alcoholic patients with a comorbid diagnosis of schizophrenia.
    b. caution in dosage recommended for these patients.
    c. prevalence of noncompliance among schizophrenic patients who abuse alcohol compared to patients experiencing schizophrenia without substance abuse.
    d. role of group therapy in combination with these medications.
    e. problem of neuroleptic induced tardive dyskinesia.

7. Vitamins

    a. Common nutritional deficiencies of alcoholic patients : e.g., magnesium, zinc, various vitamins.
    b. Administration of supplemental thiamine to all patients with a history of chronic alcoholism and in the treatment of Wernicke's encephalopathy, alcoholic amblyopia.
    c. Multiple mega-B therapy recommended for amblyopia.

(TRAINER NOTE: Routine orders should include thiamine, 100 mg daily and a multivitamin supplement, provided patient shows no significant neurologic or hematologic problems secondary to chronic excessive alcohol intake.)

8. Pharmacotherapy of organ damage secondary to chronic excessive intake of ethanol.

    a. Fluvoxamine administration in improvement of Alcoholic Amnestic Disorder (AAD)
    b. -blocker treatment
    c. prophylactic sclerotherapy
    d. propylthiouracil

(TRAINER NOTE: Trainer will indicate that these biochemical interventions can be undertaken with complete confidentiality and without invasion of privacy and with the intent to interrupt the course of alcohol abuse or dependence before inpatient hospitalization becomes necessary.)

EXERCISE

Trainer will present clinical vignettes and trainees will break into small groups to make clinical assessments and prescribe or modify treatment protocols.

SELECTED READINGS

Backis CA, Gold MS: New concepts in cocaine addiction: The dopamine depletion hypothesis. Neuroscience and Biobehavioral Reviews 9:469-477,1985.

Emrich HM, Vogt P, Herz A, & Kissling W: Antidepressant effects of buprenorphine, Lancet, 9/25/82, p.709

Fuller, RK et al: Disulfiram treatment of alcoholism: A Veterans Administration cooperative study. J of the American Medical Association 256:1449-1455.

Gawin FH, Ellinwood EH: Cocaine and other stimulants: Actions, Abuse and Treatment, New England J of Medicine 318:1173-1182, 1988.

Jasinski GR, Pevnick JS & Griffith JD: Human Pharmacology and abuse potential of the analgesic buprenorphine. Arch Gen Psychiatry 35:501-516, 1978.

NIH Consensus Statement Online: Effective Medical Treatment of Opiate Addiction 11/97, p.17 - 19, 3/3/97; 15 (6):in press.

Volpicelli, JR, et al: Naltrexone in the treatment of alcohol dependence. Arch Gen Psychiatry 49:876-880.


Objective 2. Provide an overview of epidemiology as it relates to an understanding of the causes, treatment, and prevention of mental disorders and substance abuse. Trainer will provide lectures and/or exercises on:

    A. The role of epidemiological methods to help define and evaluate strategies to prevent and control disease and disability: neurophysiologic correlates of addictive behavior.

    B. The role of epidemiological studies in assisting in general planning and evaluation of mental health programs locally and nationally.

    C. The application of epidemiology in psychiatric research by correlating clinical findings with sociodemographic variables such as age, gender, and sociodemographic status.

TRAINER NOTE

1. Deliver training content using handouts/overheads:
2. Provide students with access to computer with internet capabilities.
3. Allow 56 hours ( approximately 1/2 day per week for 1 semester for this section.)



GENERAL OVERVIEW OF EPIDEMIOLOGY

Although for most substances, there appears to be a modest but clinically significant decrease in the proportion of individuals using the drugs and in the number of individuals having severe repetitive problems with each of these substances of abuse, substance use and substance-related problems remain the most prevalent of the clinically relevant behavioral syndromes clinicians are likely to encounter. In the United States, two out of three men and women are drinkers at some point in their lives, even higher numbers of people have consumed caffeinated beverages; at least among individuals in their 20s and 30s, 70% or more have had experience with marijuana; 20% - 40% of members of subgroups have used amphetamines or cocaine on occasion, and perhaps 10% - 20% have had experience with any variety of other drugs including hallucinogens, brain depressants other than alcohol, and solvents.

The lifetime risk for alcohol abuse or dependence is between 15% to 20% for men, with lower but still substantial figures for women. Repetitive use of alcohol and other drugs can:

      1. cause a wide range of psychiatric symptoms;
      2. contribute to problems in the workplace;
      3. contribute as a factor in many fatal accidents;
      4. exacerbate almost all major medical problems.

In general for most substances, the age period of highest prevalence as well as the highest quantity intake occurs between mid-teens and mid-twenties. Most people begin with caffeine and nicotine, move on to alcohol, and if experimentation with drugs continues, progresses on to cannabinols, then to any mixture of stimulants, depressants and/or hallucinogens, and on to opiates.

For most drugs the proportion of the population continuing to have experience with the substance and the intensity of intake decreases with each subsequent decade of life. In general, with the exception of the use of nicotine, most substances are more likely to be taken by men than women, but there are few racial differences in the probability of use or development of significant substance-related problems once socioeconomic factors are controlled for.

Some subgroups of the population appear to be more vulnerable to the development of problems with some substances especially some health care providers such as physicians, nurses, medical students.

CONTENT

Using handouts and overheads, discuss the extent of substance use, abuse, and dependence in the United States and review the strengths and weaknesses of various survey methods used:

1. The National Household Survey on Drug Abuse (Household Survey)
2. The Drug Abuse Warning Network (DAWN)
3. The Drug Use Forecasting Program (DUF)
4. The National High School Senior Survey--Monitoring the Future (High School Survey)

Discuss other data sources available on street availability and purity of illicit drugs, drug seizures, and arrests for drug offenses from the Drug Enforcement Agency and the Federal Bureau of Investigation, as well as from locally funded municipal police departments.

TRAINER NOTE

The Trainer will present current data available on pattern of use for each specific substance or group of drugs listed below:

1. Marijuana
2. Cocaine
3. Alcohol
4. Prescription Drugs
5. Nicotine
6. Caffeine

EXERCISE

Using website addresses, participants will access the four survey methods (Household Survey, DAWN, DUF, High School Survey), to obtain sample data, and discuss applicability to diagnosis and treatment of substance abuse.

SELECTED READINGS

Myers JK, et al: Six-month prevalence of psychiatric disorders in three communities: 1980-2. Arch Gen Psychiatry 41:959-967,1984.

Begleiter H, et al, Auditory brainstem potentials in sons of alcoholic fathers. Alcoholism: Clinical and Experimental Research 11:477-480,1987.

Hill TW: Ethnohistory and alcohol studies. In Recent Developments in Alcoholism, Vol.2, NY: Plenum, 1984.

O'Brien,CP, et al: Conditioned narcotic withdrawal in humans. Science 195:1000-1002, 1977.

Poulous CX & Cappell H: Conditioned tolerance to the hypothermic effect of ethyl alcohol. Science 206:1109-1110, 1979.

Siegel S, et al: Heroin "overdose" death: Contribution of drug-associated environmental cues. Science 216:436-437, 1982.


Objective 3. Provide an overview of mental health care, work, and family systems ; social psychology; social cognition and support; cultural diversity; homelessness; gay and lesbian lifestyles.

TRAINER NOTE

1. Deliver training content using appropriate overheads/handouts.
2. Allow 54 hours (18 sessions of 3 hours each) for delivery of this section.
3. Provide a list of specialists and programs in the hospital center and the community.

LEARNER OBJECTIVES

At the end of this training section, participants will:

1. have the tools to comfortably consult with, and refer patients to addiction specialists, alcohol and drug treatment programs, and mutual self-help groups;

2. understand how the addiction treatment specialist, patient, and family members can work with the physician to develop a treatment plan;

3. know when and how to make referrals;

4. understand the role of the family in substance abuse treatment and its 3 phases:(a) developing and establishing a system for developing a drug-free state (b) establishing a workable method of family therapy (c) dealing with the family's readjustment after the cessation of substance abuse.

5. learn various treatment techniques to meet the needs of different types of substance abusers based on the following factors: drug(s) abused, ethnicity, family type, stage of disease, sex of the individual.

CONTENT

The trainer will present an overview of the Mental Health System as it is established in the relevant state or city as part of a general overview to the various factors and resources that affect the diagnosis and delivery of treatment for substance abuse.

EXERCISE

Using various case studies presented by the Trainer, participants will role-play implementing the steps in referring patients to various specialists and agencies. Case studies will be provided by each Trainer based on client data as provided within individual institution where training is conducted.

CONTENT

Understanding the relationships among substance-using patients and their families is relevant for understanding the etiology of substance dependence and its treatment and for helping other family members to cope with problems associated with the substance-using behavior. Participants will review some general principles applicable to substance dependence while learning the various mediating variables that affect the patient, the patient's family, and the treatment protocol.

TRAINER NOTE

Using handouts and overheads, Trainer will:

1. present an overview of Family Systems;

2. discuss the genogram as a basic tool in many family therapy approaches used to examine relationships in extended family complex and any other members of household or significant relationships. (As therapy progresses, full but informal family genogram may be gradually developed as other important family members from past and present are discussed.)

Family Diagnosis

    a. Provide framework to look at family interactional and communication patterns and relationships.
    b. Construct a map of basic alliances and roles among family members.
    c. Examine family rules, boundaries, and adaptability; coalitions(especially, transgenerational), shifting alliance, splits, cutoffs, triangulation.
    d. Observe communication patterns, confirmation and disconfirmation, unclear messages, and conflict resolution.
    e. Note family's stage in family life cycle.
    f. Note mind-reading: predicting reactions and reacting to them before they happen, or knowing what someone thinks or wants), double binds, and fighting styles.
    g. Develop 3-generational genogram on the Index Patient (IP) for parents & progeny and spouse's.

Developing a system for establishing & maintaining abstinence:

      a. early establishment of a system for achieving abstinence;
      b. establishment of a method for maintaining abstinence;
      c. working with families with continued drug abuse;
      d. motivating the entire family to participate.

EXERCISE

Using a case study, participants will construct a genogram for a substance- dependent patient. Case study will be provided by each Trainer based on client data as provided within the institution where training is conducted.

CONTENT

It is important that treatment protocols and programs acknowledge the existence of racial, ethnic, and sexual preference differences, as well as differences along the spectrum of acculturation. Cultural values of the patients need to be respected and understood in order to develop an effective, culturally sensitive protocol.

How to Approach Cultural Diversity in Treatment

  • Whenever possible bilingual and bicultural staff should be used to provide clinical services.

  • In-service training sessions will be provided based on the needs of the community and client population served.

  • Based on patient population needs and resources available arrangements will be made with the internal staff or consultants will be hired to provide necessary training in cultural awareness and its impact on diagnosis, treatment, and relapse prevention for the substance abuser and his or her family.

EXERCISE

1. Using case studies, Trainees will roleplay application of skills and knowledge acquired during these sessions. Case studies will be provided by each Trainer based on client data as provided within the individual institution where the training is conducted.

2. As resources allow, Trainees will meet with the staff of the Bilingual Treatment Program to discuss issues related to treatment of different populations.

CONTENT

An issue facing many municipal hospitals in large cities is the problem of homelessness among patients who are substance abusers or mentally ill chemical abusers. This presents many challenges to the clinician, as well as to the hospital system. In New York City, for example, the inner city general hospital setting of the drug treatment clinic in Bellevue Hospital Center provided close proximity to allied health care services, thereby streamlining coordination of care. This will not be the case in every institution where this training might be delivered. Where institutional resources for this population are scarce or not available, it is even more important that a referral network of community shelters, outreach, and treatment programs is developed and maintained in order to provide the patients basic needs and a basic structure for conducting the treatment protocol.

Value of a Therapeutic Community or modified Therapeutic Community for the Homeless Substance Abuser or MICA:

  • Provides consistent discipline and clear behavioral guidelines.
  • Challenges social stereotypes.
  • Provides equal access to leadership roles.

Gender issues in drug treatment have received considerable attention since funding of women's demonstration projects by the National Institute on Drug Abuse began in the early 10970's, This attention escalated in the mid-1980's, in response to the epidemic of crack cocaine, which afflicted both genders in equal proportion.

Significant sex-related differences in the nature and progression of addictive disorders among men and women require gender-specific approaches to case-finding, diagnosis and treatment. These approaches will consider:

  • a. physiological factors
  • b. psychological factors
  • c. sociocultural factors


Treatment of Addicted Women Includes:

    1. Acknowledging problems of addicted women: stigma, denial, barriers to treatment

    2. Modifying traditional approaches such as treatment modalities and 12-step programs such as Alcoholics Anonymous.

    3. Assessing comorbid psychiatric disorders preceding addiction or subsequent to a prolonged period of abstinence.

    4. Assessing history of physical and sexual abuse.

EXERCISE

Trainer will present case studies of addicted women and trainees will role-play interviewing and evaluating patients. Trainees will also develop a gender specific treatment plan. Case studies will be provided by each Trainer based on client data as provided within individual institutions where training is conducted.

CONTENT

The treatment of gay and lesbian substance abusers and dually diagnosed patients is another area with which clinicians should be aware. In this section the Trainer will provide:

a. an overview of health issues which are of particular concern to this population, particularly HIV disease.
b. an overview of gay and lesbian community and health resources.

SELECTED READINGS

Blume SB, Women: Clinical aspects in substance abuse: A Comprehensive Textbk (3rd ed.) NY: Williams & Wilkins, 1997.

Buffum J: Substance abuse and high-risk sexual behavior. J of Psychoactive Drugs 20: 165-8,1988.

Kaminer, Yifrah: Adolescent Substance Abuse. Textbk of Subs Abuse Treatment. NY: AP Press, 1994.

Sterk C: Cocaine and HIV seropositivity, Lancet 1988; 5/5: 1052-3. Wikler A: Dynamics of drug dependence: Implications of a conditioning theory for research and treatment, Arch Gen Psychiatry 28:611-616, 1973.


Objective 4. Provide an overview of genetic models of mental disorder and substance abuse and related concepts such as:

    A. Single major gene model with minimal or nonexistent environmental factors.

    B. Multifactorial-polygenic model supposing that two or more genes are involved and that environmental factors (both psychological and nonpsychological are involved in the development of the final phenotype).

    C. Role of behavioral genetics methods with emphasis on "model fitting" approaches that allow for a separation of genetic and environmental influences.

TRAINER NOTE

1. Handouts/overheads will be used at Trainer's discretion.

2. Allow 60 hours for delivery of this section.

CONTENT

Genetic Factors/Vulnerability: Children of alcoholic parents are at higher risk for developing alcoholism and drug dependence than are children of nonalcoholic parents. (The evidence for genetic factors is derived from twin and adoption studies.) Alcoholism can also develop in the absence of detectable family history, and as many as one-third of alcohol-dependent persons have no family history of alcoholism. Men are more likely to develop alcoholism than women.

Biological and Behavioral Differences

Discussion will focus on studies exploring how persons with or without family histories of substance abuse might differ based on:

       1. measures of personality
       2. patterns of drug-use and alcohol-use
       3. psycho-motor and cognitive performance
       4. electrical activity of the brain
       5. endocrine responses to challenges with alcohol and other substances
       6. measures of receptor numbers/affinities and enzyme activities in peripheral tissues


EXERCISE

Using case studies, participants will make some diagnostic assessments based on information acquired during these training sessions. Case studies will be provided by each Trainer based on client data as provided within individual institutions where training is conducted.

SELECTED READINGS

Rowe, DC: Behavior genetic models of alcohol abuse in Alcohol & the Family: Research & clinical perspectives. The Guilford substance abuse series. (R.Lorraine Collins, Kenneth E. Leonard, John S. Searles, Eds.),pp.107-133, NY: Guilford Press, 1990.

Schuckit MA: Genetic aspects of alcoholism. Ann of Emergency Medicine 15:991-996, 1986.

Schuckit MA: Genetics and the risk for alcoholism, JAMA 254:2614-2617, 1985.

Cadoret RJ, et al: An adoption study of genetic and environmental factors in drug abuse. Arch Gen Psychiatry 43:1121-1136, 1986.

Cadoret RJ. et al: An adoption study of genetic and environmental factors in drug abuse. Arch Gen Psychiatry 43:1121-1136, 1986.


Objective 5. Provide an overview of behavioral models of substance abuse and mental disorder.

    A. Trainees will learn behavioral and psychoeducational theory and applications to therapy, as well as social skills therapy with the chronically mentally disturbed patients.

    B. Continued review of psychotherapeutic theory, to include short-term dynamic, cognitive, behavioral, and interpersonal models, and its application to patients with particular diagnoses.

    C. Theory and research on small group dynamics from a psychodynamic and open systems perspective; models, process, social defenses, phases of development, and the authority/member relationship; and issues relative to designing, starting, and conducting therapy.

CONTENT

Psychodynamic understanding can enhance work with individuals, groups, and the rehabilitation process. In this section trainees will explore how psychodynamic theory can be used to enhance their understanding and treatment of addicted patients.

TRAINER NOTE

1. Trainer will present an overview of behavioral theory and application.

2. Trainer will emphasize to participants that adequate preparation, interpersonal sensitivity, and experience are required for the therapeutic process, particularly for therapeutic interventions.

3. Allow 60 hours for delivery of this section.


A. Behavioral and Psychoeducational Theories and Applications

Recent developments in psychodynamic theory

     1. Distinguish between psychodynamic theory centered on developmental and structural deficits and early psychoanalytic theory centered around drives.

     2. Role of defense deficit, and affective experience in alcoholism and drug abuse.

     3. Alexithymia and the inability of addicted persons to verbalize affect states.

     4. Addiction as severe psychic trauma resulting in characteristic defensive patterns.

     5. Drug use as dispersion of affects into action.

     6. Narcissistic injury and superego regression as precipitants of substance abuse.

     7. Severity of psychopathology underlying substance abuse.

     8. Importance of specific effects of particular drugs on affect.

     9. Choice of particular substance based on specifically desired results.


Application of Psychodynamics to Treatment

  • Importance of making a clear distinction between psychodynamic principles and psychoanalysis.

  • Focus on current conflicts as they relate to the past rather than on childhood experience.

  • Therapist in dual role of actively confronting or supporting the patient.

  • Therapist-patient relationship is openly discussed in order to facilitate working through resistances without an effort to foster regression.


B. Short-term dynamic, Cognitive, Behavioral, and Interpersonal Models

Psychodynamic techniques aimed at increased self-awareness, growth and working through conflicts can be combined with cognitive approaches, suggestions, education, and providing support and reassurance where this is indicated.


C. Small Group Dynamics from a Psychodynamic and Open Systems Perspective

The addition of group psychotherapy or self-help groups, such as AA or NA, is especially needed when individual therapy alone is not working in maintaining abstinence. Group treatment helps diffuse some of the powerful negative transference that may be impossible to overcome in early treatment.

  • Group focus: self-care, self-esteem, affect regulation.

  • Homogeneous or heterogeneous membership.

  • Incorporation of aspects of 12-step programs

  • The patient-therapist relationship: problem of countertransference


SELECTED READINGS

Galanter M: Psychotherapy for alcohol and drug abuse: An approach based learning theory. J of Psychiatric Treatment & Evaluation 5:551-6, 1983.

Galanter M: Zealous self-help groups as adjuncts to psychiatric treatment: A study of Recovery, Inc. Am J Psychiatry 145:1248-53, 1988.

Galanter M, et al: Substance abuse among general psychiatric patients: Place of presentation, diagnosis and treatment. Am J Drug Abuse 14:211-235, 1988.

Emrich CD: Alcoholics Anonymous: Affiliation processes and effectiveness as treatment. Alcoholism: Clinical & Experimental Research 11:416-23, 1987.

Woody GE, et al: Individual psychotherapy: Other Drugs in Textbk on Subs Abuse Treatment, NY: AP Press, 1994.


   

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