Both in recognizing, assessing, and referring patients with ATOD problems, and in educating patients at risk for ATOD problems, it is important to recognize and understand problematic/addictive patterns and behaviors. In this module, the process and stages related to ATOD problems are presented including a self-assessment on dependent behaviors of all kinds.
(Any of the prepared newsprint items above can be used as
a transparency if desired. The hard copy is appropriate for development
of transparencies. It is best to leave in newsprint form those
things you may want to leave posted, such as the objectives and
the exercise instructions.)
Both in recognizing, assessing, and referring patients with
ATOD problems, and in educating patients at risk for ATOD problems,
it is important to recognize and understand problematic/addictive
patterns and behaviors.
Being able to explain the progressive nature of alcohol and
other drug abuse and the typical behavior patterns associated
with each stage is an important part of educating and advising
patients at risk or experiencing problems.
In this module, the process and stages related to ATOD problems
are presented, including a self-assessment on dependent behaviors
of all kinds.
A. Introduce the exercise by stating that each of us has something
that is difficult to stop or give up. Explain that in this exercise,
everyone will have an opportunity to examine some of the implications
of feeling or being dependent on something or someone. This exercise
will help in identifying with patients who are having ATOD problems
and becoming more effective in interacting with and motivating
these patients to seek help.
B. Distribute the handout on dependent behaviors (HO-4.1).
Post the instructions (Prepared Newsprint-4.2) and review:
Each participant fills out the "Dependency Questionnaire"
(5 minutes).
Small groups discuss their responses to the questions (10
to 15 minutes).
Be prepared to report to the large group one thing you learned
from each question.
C. In the large group, process the exercise by having each
group report out something they learned from each question on
the handout. Stimulate the discussion by asking questions such
as "What would you do to keep this dependency?"
D. Ask the group member how they can relate what they learned
to improving their interactions with their patients.
(Adapted from ANHCA member, Mitchell Young, unpublished dissertation, "Training Counselors to work with Addicted Populations: A Comparative Study," 1992).
A. Patterns, Habits, Compulsions, & Addiction (Prepared
Newsprint-4.2)
A continuum of behavior
Clinicians need to know the difference between a pattern,
a habit, a compulsion, and an addiction.
These four behaviors represent a continuum of behavior
ranging from that which helps us to organize our lives to be more
effective and efficient to behavior that is dysfunctional and
disrupts our lives.
As in any continuum, sometimes the demarcations are not
absolute and a behavior can start out on one part of the continuum
and move to another part.
(Note: You can ask the group to discuss the differences between
patterns, habits, compulsions, and addictions. Put their ideas
under each category on Prepared Newsprint-4.3. Fill in gaps or
misconceptions using the material below. Summarize by covering
the four behaviors with one example (e.g., smoking, overeating).
Pattern
Helps us organize our lives so they are not chaotic.
Sleep at the same time-eat regularly.
A pattern is typically a cultural norm:
Monogamy and dating patterns.
Business hours and dress.
Habits
More specific and individual than patterns.
The words usually and always are associated
with habits:
I always have coffee for breakfast.
I always take a shower in the morning.
I usually eat popcorn at the movies.
Habits can be broken with effort and a bit of will.
Compulsions
Compulsive behavior is rooted in a need to reduce tension,
often caused by inner feelings a person wants to avoid or control.
The reward is not from the activity itself, but from the
reduction or release of tension, little real pleasure is involved.
Can't, must, and I've got to are words associated
with compulsion. For example:
I can't go for more than a week without sex.
I've got to be with Maryann tonight.
I've got to clean the house.
If I don't, I can't relax.
If I don't, I go nuts.
A compulsion may be ritualized with the time of day,
certain objects, or a way of doing something. For example
Reaching for cigarettes when the phone rings.
May be compulsive about having coffee in the morning.
Aunt Rosie must have her knitting along so she can relax.
There is often a frantic feeling involved, and, if unable
to carry out a compulsion, there may be feelings of agitation
and distress which may last hours until the compulsive urge is
met (Kasl, 1989).
It often takes insight into underlying unconscious conflicts
or buried feelings to change compulsions.
People may not like their compulsions, but typically they
don't hide them, deny them, or feel too bad about them.
Compulsions may not escalate or change over time; they can
remain fixed and stable. This is especially true of compulsions
which serve a useful function.
Compulsions may have harmful consequences; they may
Limit emotional life.
Be physically harmful.
Restrict activities.
Intrude upon and limit relationships (e.g., Aunt Rosie won't
go anywhere that she can't take her knitting.)
Addictions
In some models or approaches, addiction and compulsion are
thought to be one and the same. In this model, addiction is a
compulsion that progresses on the continuum to dysfunction and
rigidity.
Person experiences a split in thinking, such that there is
addicted thinking (obsessions) and normal thinking. Addictive
behavior (compulsions) progresses, increases in oddness, and typically
becomes more consequential. There are two components to addictions;
the obsessions (thinking or fantasy) and the compulsions (behavior).
Addictions involve such terms as unmanageability, powerlessness,
and being out of control.
Addiction and addictive behavior become the central part of
the addict's life. Typically, only those people who support the
addiction are involved in the addict's life, and activities and
behaviors increasingly revolve around addictive ritual, ceremony,
and planning.
The addictive behavior begets problems in most areas of the
addict's life, such as career, financial, marriage, and other
interpersonal relationships.
Addicts use denial; in fact, addiction is a disease of denial.
The compulsive does not deny his or her behavior; the addict
goes to great lengths to deny his or her addiction.
B. Impaired thinking of addicts
Part of the denial system-along with the obsessive thinking
that accompanies addictions, addicts have impaired thinking processes.
Addicts tend to use several defenses.
Rationalization: In the face of overwhelming evidence, addicts
will deny that they have a problem, using rationalization. For
example
"If the boss had not gotten on my case at work today,
I would not have gotten drunk."
"If my husband (wife) had not nagged at me all day, I
would not have bought the drugs."
Minimize: Addicts will minimize whatever problem is created,
because of their addiction. For example
"Sure I wrecked the car, but it was getting old, and
anyway I think the transmission was going out on it."
Projection: Addicts tend to blame others for their problems.
For example
"You know my wife is so angry at the world that she is
always angry; why doesn't she just have a drink and take it easy?"
C. Five Basic Criteria Used to Determine Addictions (Kasl,
1989) (T-4.1):
Powerlessness to stop at will:
Addicts are out of control.
Overeat till it hurts.
Have sex till it hurts.
Place themselves in jeopardy with drugs and tainted needles.
Unable to form close personal relationships or maintain
a good marriage.
Escalation of use: Need more and more of the substance or
behavior that is their addiction.
Withdrawal upon quitting: Body will readjust chemistry upon
quitting addictive behavior whether this is ATOD addiction, behavioral
addiction, or process addiction.
For most addicts, quitting is terrifying. . .why?
Now have to cope with life.
Face emotions. . .face reality.
They don't know how to face life. . .to cope.
That is, they don't know how to live within and maintain a
social support system.
Terms used in the description of ATOD problems include the following:
Addiction-Compulsive craving for something; over-dependence
on the intake of certain substances, such as alcohol and other
drugs, or the performance of certain acts such as smoking, etc.;
inability to overcome a habit or behavioral pattern.
Dependence-physical-A physical state or condition wherein
an individual's system has made a cellular adaptation to the repeated
intake of a chemical substance and is now subject to disturbing
or life-threatening symptoms if the substance is withheld.
Dependence-psychological-Refers to the user's attitude that the effects produced by the drug, or the conditions associated with its use, are necessary to maintain well being; can become a craving or compulsion.
Withdrawal-Physiologic processes that occur when
a drug is withheld from a physically dependent person. Processes
that are suppressed during the presence of the drug are hyperactivated
in its absence.
Acute withdrawal-The first stage of withdrawal-usually 2 to 7 days. Most pronounced withdrawal symptoms are present during this period.
Prolonged withdrawal-The second stage. Can last for weeks or months. Less intense than the acute stage.
Intoxication-The state of being poisoned; usually
interpreted as being due to ethyl alcohol but may be caused by
numerous drugs and various diseases.
Tolerance-The physiological adaptation to the presence
of a drug, so that the drug must be taken in larger doses or more
frequently to achieve the same effect.
Cross-tolerance-The development of tolerance to
all drugs within a class. For example, the heroin addict will
demonstrate tolerance to morphine and other opiates.
Use liability-The capacity of a drug to reinforce
continued use. Drugs with the highest use liability produce intense
euphoria and have a rapid onset of action.
B. The Addiction Process (T-4.2)
The road to addiction for alcohol and other drugs occurs in stages which can progress in varying time frames depending upon the individual, the substance, and the risk factors involved. This model outlines the addiction process in four main stages:
Contact-The first use of a substance. This can
occur in a social or medical setting. There may be more contacts
and either the process comes to a halt or the use is more habitual.
Experimental-This stage varies in length of time
and intensity. The person may use the drug only in a social context
and only when it is available. After a period of time, this stage
may end or the person moves on to the next stage.
Excessive use-This stage is marked by an increase
in use that produces damage or the risk of damage to social, psychological,
or physical functioning. At this point the person may return
to occasional use, stop use, or progress to the last stage.
Addiction-In this stage, use is damaging to the
person. Social, psychological, and/or physical functioning is
impaired. Physical and/or psychological dependence is present
and life revolves around substance taking behaviors. The person
may be able to reverse this process, but it is rare that this
can be accomplished without outside help.
In addition to the general models developed to explain the
addiction process, models for alcohol and other drugs exist which
outline more specific behaviors associated with the progression.
We will look at one for cocaine and one for alcohol.
C. Cocaine and alcohol progression and recovery
Review of chart handout on cocaine use (HO-4.3).
Review behaviors for each stage of progression and recovery
of cocaine use: experimental use; compulsive use; dysfunctional
use; rehabilitation process; recovery process.
Stop after each state and discuss the behaviors. Solicit
questions, comments, or illustrations from participants about
each stage.
Review of chart handout on alcoholism (HO-4.4).
Review behaviors for each stage of progression and recovery
for alcoholism: early stage, middle stage, late stage, and recovery.
Stop after each stage and discuss the behaviors. Solicit
questions, comments, or illustrations from participants about
each stage.
Comparison of two charts and discussion of behavioral indicators.
Discussion points can include similarities between charts;
and differences between charts; relationship between stages.
Point out the difference in time of progression from initial
use to full-blown addiction:
- 3 to 4 months for cocaine
- Up to 20 years for alcohol (for some susceptible people
it is a lot less).
There is no clear line between stages. There is overlap,
but the clusters of behavioral indicators give a good sense of
where the patient is in the progression.
A. Using the Trainer Information Sheets for ideas (TSI-4.1,
TSI-4.2), demonstrate (using a recovering person if possible)
the various stages with a series of preplanned role-plays done
by the recovering person as the patient and the trainer as the
clinician.
B. Stop after each stage is demonstrated and (HO-4.3, HO-4.4)
have the participants identify the stage and accompanying verbal
and nonverbal behaviors.
C. Discuss the importance of understanding the concept of
stages of progression in making assessments and presenting the
diagnosis.
(Options: The demonstration can be done with two trainers. The exercise can also be done as a case study, using the scenarios in the Training Information Sheet.)
Experimental: A well-dressed, 32-year-old female requests support from her physician in the form of a letter to the court stating that she is not a cocaine addict and has never been a cocaine addict. She was the passenger in the car stopped because the driver was driving erratically and cocaine was found in the car. She reports occasional coke use at parties and likes the way it makes her feel, but she doesn't buy it it for herself. She admits to a previous alcohol problem when in her late 20s, "but it's ok now."
Compulsive: A 22-year-old man is referred for depression. He has recently (in the past 4 months) experienced problems with sleep, appetite, and work performance. The intake nurse at the clinic was concerned over possible suicidal ideation. Although he initially denied any drug or alcohol use, he eventually reports occasional (about every 2 weeks) episodes of coke use. Each episode starts on Friday evening and ends on Sunday morning.
Dysfunctional: Because of extreme weight loss, the nurse practitioner in the general medical screening clinic refers a 22-year-old woman for evaluation for anorexia nervosa. On exam, she is hypertensive (BP 130/100), tachycardic (pulse 110), and diaphoretic with a fine tremor. She is anxious, and the tone and direction of her questions suggest that she is somewhat paranoid. Until recently, she was employed as a bartender but lost her job due to excessive quarrels with her fellow employees. There was some question raised about some possible financial mismanagement at her job. She denies the charges, stating, "They were harassing me on my tips." She reports daily cocaine use, "but only to get my energy up so I can get out and look for a job."
Rehabilitation: A 44-year-old man asks for a physical exam that will clear him for work at the town's homeless shelter. He reports being clean from cocaine and alcohol for 4 months. He had been a patient at an outpatient drug treatment program in a nearby city for 2 months, was attending NA meetings three times a week, and was a sponsor for a newly recovering addict. Now on disability, he plans to return to a job as a bus driver in 2 months. He has recently been visiting with his wife and four children from whom he has been estranged the previous 2 years.
ALCOHOL ADDICTION: STAGES
Early: A 36-year-old man was brought in by his concerned wife because of a recent domestic quarrel in which she claims that he hit her. He denies her version of the story, saying, "I never hit her." He reports drinking "a few beers to unwind after work." He believes that this wife is prone to nagging him "about everything," especially drinking. His favorite activity is Monday night football and playing pool, both of which he does with his coworkers after work each night. He sometimes does not remember arguments he gets into with his wife when he gets home. He says she makes them up.
Middle: A 29-year-old secretary at the clinic asked to see the doctor "for help with my drinking." She had been reprimanded for excessive work absence. She reported at least one blackout. She was remorseful and tearful over her repeated ineffective attempts to stop. She refuses to attend AA ("I know too many people").
Late: A 19-year-old man comes in to have his bandages changed from a wound sustained in an auto accident the previous week. This is not his first auto accident. He is jobless and his family has kicked him out of the house because of his drinking. He is sleeping in his car.
Recovery: A 41-year-old woman comes in for a follow-up appointment at the clinic for a "lumpectomy" for a metastatic breast cancer. She has 7 years of sobriety through daily attendance at AA. For the past month, her attendance at AA has fallen off because of her preoccupation with her marital problems and the fact that her son was recently injured in an automobile accident and lost his job. Her twin sister, a using alcoholic, is visiting from Des Moines.
