SECTION V HANDOUT/OVERHEAD: Basic Science: Section II, Objective 1.
Key areas for regular updates on the pharmacotherapy of psychiatric disorders:
1. emergence of new agents
2. demonstration of new indications for existing agents
3. clinical usefulness of plasma concentrations
4. identification and treatment of drug-related adverse effects
HANDOUT/OVERHEAD: Basic Science: Section II, Objective 1.Biographical and Clinical data helpful to the clinician in making the diagnosis of a primary major depression disorder (bipolar disorder):
1. affective disorder preceding the onset of alcoholism or a history of an affective disorder occurring during sustained periods of abstinence;
2. early childhood history of separation anxiety, phobic behavior, or neurasthenia;
3. occurrence of a hypomanic reaction to anti-depressant medication;
4. family history of bipolar illness;
5. family history of affective illness in two or more consecutive generations;
6. a positive dexamethasone suppression test after the patient has been abstinent for 4 or more weeks.
HANDOUT/OVERHEAD: Basic Science: Section II, Objective 3.HOW TO ACCESS ALCOHOL AND DRUG ABUSE SPECIALISTS IN THE COMMUNITY
1. Ask a colleague for names of treatment programs or individual providers they have found to be successful.
2. Contact an alcohol treatment specialist or program, Mental Health center, or hospital for consultation.
3. Call the state alcohol and drug abuse agency for a list of publicly and privately funded treatment programs in the state.
4. Consult an employee assistance program in the area.
5. Provide a list of publicly funded community programs for those with limited insurance or resources.
6. Call directors of local treatment programs to determine the range of services provided by those programs.
HANDOUT/OVERHEAD: Basic Science: Section II, Objective 3.What the physician can do if a patient refuses to see an addiction specialist or does not have the financial resources to follow through.
1. Identify recovering alcoholics in the community who are willing to discuss methods for changing drinking behavior.
2. Refer patient to local Alcoholics Anonymous.
3. Direct patients to specific programs that will meet their needs: e.g., women's groups.
4. Alternative Meetings: Rationale Recovery and Women for Sobriety.
HANDOUT/OVERHEAD: Basic Science: Section II, Objective 3.ELEMENTS OF PSYCHODYNAMIC THERAPY
1. Countertransference: Therapists must be aware of how families will replay their problems in therapy by attempting to detour or triangulate their problems onto the therapist who must be sensitive about becoming an enabler who, like the family, protects or rejects the substance abusing patient.
2. The role in interpretation: Repetitive patterns and their maladaptive aspects to each family member can be pointed out, and tasks can be given to help them change these patterns. Some families need interpretations before they can fulfill tasks. Emphasis on mutual response when making any interpret is example of a beneficial fusion of structural and psychodynamic therapy.
3. Overcoming resistance: This is defined as behaviors, feelings, patterns, or styles that prevent change. In substance abusing families, key resistance behaviors that must be dealt with involve the failure to perform functions that enable the substance abuser to stay"clean." It is important to recognize, emphasize and interpret the circumstances that arouse resistance patterns. Early on the therapist must avoid labeling the behavior as resistant or directly confronting it because this increases hostility and resistance. Reciprocal family interactions that lead to resistant behaviors should be pointed out. Resistance (blaming, scapegoating) can be directly discouraged by the therapist by joining techniques , including minimizing demands on the family to change so that the family moves more slowly, but in the desired direction.
4. Working through: This important concept, derived from psychoanalysis, is similar to structural concept of isomorphic transactions. It underscores the need to work repeatedly on many different overt issues all of which stem from the same dysfunctional core.(TSA 338).
5. Family of Origin Technique. In this technique the family-of-origin of substance abusing adults is worked with to understand how past difficulties are being replayed in the present and to begin to shift these transferential problems.
HANDOUT/OVERHEAD: Supervised Clinical Experience: Section III, Objective 1.GENERAL GUIDELINES FOR REHABILITATION EFFORTS WITH SUBSTANCE ABUSERS
1. Justify your action.
2. Know the natural course of the disorder.
3. Guard against the overzealous acceptance of new treatments.
4. Keep it simple.
5. Apply objective diagnostic criteria.
6. Establish realistic goals.
7. Know the goals of your patient.
8. Attempt to match your patient's goals and characteristics with the specific treatment.
9. Make a long-term commitment.
10. Use all available resources.
11. When appropriate, notify all involved physicians and pharmacists.
12. Do not take final responsibility for the patient's actions.
HANDOUT/OVERHEAD: Supervised Clinical Experience: Section III, Objective 3
AN OVERVIEW OF FAMILY TREATMENT TECHNIQUES STRUCTURAL-STRATEGIC THERAPY TECHNIQUES
1. Use tasks with the therapist responsible for planning a strategy to solve the family's problems.
2. Put the problem in solvable form.
3. Place considerable emphasis on change outside the sessions.
4. Learn to take the path of least resistance so the family's existing behaviors are used positively.
5. Use paradox, including restraining change and exaggerating family roles.
6. Allow the change to occur in stages. The therapist may create a new problem so the solving it leads to solving the original problem. The family hierarchy may be shifted to a different, abnormal one before reorganizing it into a new functional hierarchy.
7. Using metaphorical directives in which the family members do not know they have received a directive.
HANDOUT/OVERHEAD: Supervised Clinical Experience: Section III, Objective 3.
AN EXAMPLE OF BOWEN'S SYSTEMS FAMILY THERAPY 7 STEPS IN THE THERAPY OF ALCOHOLIC COUPLES (339)*
1. Functional analysis
Families are taught to understand the interactions that maintain drug abuse.
2. Stimulus control
Drug use is viewed as a habit triggered by certain antecedents and maintained by certain consequences. The family is taught to avoid or change these triggers.
3. Rearranging contingencies
The family learns techniques providing reinforcement for efforts to achieving a drug-free state by frequent reviewing of positive and negative consequences of drug use and self-contracting for goals and specific rewards to achieving these goals. Covert reinforcement is done by role-playing a scene in which the patient resists a strong urge to use drugs.
4. Cognitive restructuring
Patients are taught to modify self-derogatory, retaliatory, guilt-related thoughts.
5. Planning alternatives to drug use
Patients are taught techniques for refusing drugs though role-play and covert reinforcement.
6. Problem-solving and assertion
Patient and family are helped to decide if a situation calls for an assertive response and then, through role-play, develop effective assertion techniques which are then performed by the patient twice daily. These techniques are also used in difficult situations that would have previously triggered urge to use drugs.
7. Maintaining planning
The entire course of therapy is reviewed, and the new armamentarium of skills is emphasized. Patients are encouraged to practice these skills regularly, as well as to re-read handout materials that explain and reinforce these skills.
*Noel NE, McCrady, BS:"Behavioral treatment of an alcohol abuser with spouse present," in Power to Change: Family Case Studies in the Treatment of Alcoholism. Edited by Gurman AS, NY, Brunner Mazel, 1981
HANDOUT/OVERHEAD: Supervised Clinical Experience: Section III, Objective 3.
PRINCIPLES OF LEADERSHIP IN GROUPS WITH DUAL DIAGNOSIS MEMBERS
Area of Concern Principle Environment Arrange seating to maximize group interaction
Minimize distractionsPersonal Style Exhibit genuine warmth and caring
Instill motivation and hope
Set realistic expectations in group for members and yourself
Modeling open to feedback
Respond to constructive feedbackStructure Establish structure; but keep it flexible (i.e. allow for trips to restroom and water fountain)
Increase structure as needed for decreased attention spans
Vary method of presentation to sustain attention
Use handouts to solidify themes of session
Maintain a single-session framework
Request verbal/written evaluations about sessionsProcess Assist members in setting realistic personal goals
Allow for wide variability
HANDOUT/OVERHEAD: Supervised Clinical Experience: Section III, Objective 3.CONDUCTING AN EARLY INTERVENTION FOR THE ALCOHOLIC PATIENT
1. Alcoholic patient's spouse calls upset that patient refuses to see the problem and the need for help.
2. The initial interview is arranged with the spouse to obtain a history of the problem and to identify the key people in the environment who have the most influence on the patient.
3. The therapist explains to the spouse that he or she is the patient, thus maintaining the confidentiality of the alcoholic spouse. The patient has affected the emotional state of the spouse and the spouse's chart includes the history of the patient's drinking behavior and its effects upon family and friends.
4. The next meeting should include the teenage or adult children, if available, and possibly one or two close friends whose attendance is requested to validate the spouse's history. At that time they are also educated about the disease of alcoholism. If appropriate, all of these people become members of the intervention team. They are asked to make a list of three to five painful or embarrassing events, avoiding labels and name-calling, associated with the behavior demonstrated by the patient while intoxicated.
5. Individuals involved must be nonjudgmental as well as honest and have genuine concern for the patient.
6. Spouse is told to inform the patient about each meeting and to invite the patient to attend because the specific goal of the intervention is to have the chemically dependent person visit the therapist at least once.
7. It is then the therapist's job to convince the patient to begin treatment.
8. The above steps help contain the patient's anger during the final confrontation intervention meeting because he or she has been informed about the previous meeting with the spouse and other important people in the patient's environment.
9. The spouse should explain how the children and friends were included at the request of therapist, to deflect anger away from the spouse and avoid additional anger in the household.
10. This method is less likely to precipitate sincere or manipulative suicide attempts.
11. The intervention team is requested to prepare a list of significant events that frightened, embarrassed them, or intimidated them by an explosion of anger.
12. Members of the team rehearse the confrontation with the physician during the 4th or 5th meeting to present a united approach, explore resistance, and identify expected problems.
13. Members agree to discontinue all communication with patient upon his or her refusal to see the clinician for even one meeting.
This is based on a modification of the classical interpersonal intervention technique originally described in 1973 (Johnson 1973) as described in the Textbook of Substance Abuse (Gallant 1994).
HANDOUT/OVERHEAD: Basic Science: Section II, Objective 3.POTENTIAL MARKERS FOR GENETIC VULNERABILITY TO ALCOHOLISM
Electrophysiological Markers
• excess beta activity (fast electroencephalographic activity)
• energy in fast-frequency alpha range of EEG
• reduced amplitude of P300 waveform of event-related potentialsBiochemical Markers
• platelet monomine oxidase activity
• platelet adenylate cyclase activity
• rate of platelet serotonin uptakeDifferences in Reactions to Alcohol
• alcohol-induced increase in baseline heart rate
• alcohol-induced decreases in plasma prolactin and cortisol
(parallels reduced subjective level of intoxication)
