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SpeedyCEUS
Substance Abuse
Chapter 6, Part A: Treatment Models and Approaches
VI. Treatment Models and Approaches
There are various models of treatment for substance abuse, as there are for other counseling needs. The models used may depend on various factors, including the training orientation of the provider, the severity of the use and or addiction, any dual diagnostic factors, age of the user and circumstances under which the use occurs (i.e.: alone or with friends).
There are also different settings and adjunctive support groups that may be part of treatment. These may include hospitalization and residential rehabilitation, and groups such as Narcotics Anonymous and Alcoholics Anonymous. In addition, they include private individual, group and family counseling. Each of these settings will be addressed along with the circumstances in which they may be most beneficial. Treatment approaches are not usually exclusive but rather used in conjunction with others to have the greatest potential for success.
In providing substance abuse treatment it is beneficial to consider the following researched principles from the National Institute of Drug Abuse (2005):
A. NIDA's Principles of Drug Addiction Treatment
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Nearly three decades of scientific research has yielded 13 fundamental principles that characterize effective drug abuse treatment. These principles are detailed in NIDA's Principles of Drug Addiction Treatment: A Research-Based Guide.
1. No single treatment is appropriate for all individuals. Matching treatment settings, interventions, and services to each patient's problems and needs is critical.
2. Treatment needs to be readily available. Treatment applicants can be lost if treatment is not immediately available or readily accessible.
3. Effective treatment attends to multiple needs of the individual, not just his or her drug use. Treatment must address the individual's drug use and associated medical, psychological, social, vocational, and legal problems.
4. At different times during treatment, a patient may develop a need for medical services, family therapy, vocational rehabilitation, and social and legal services.
5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness. The time depends on an individual's needs. For most patients, the threshold of significant improvement is reached at about 3 months in treatment. Additional treatment can produce further progress. Programs should include strategies to prevent patients from leaving treatment prematurely.
6. Individual and/or group counseling and other behavioral therapies are critical components of effective treatment for addiction. In therapy, patients address motivation, build skills to resist drug use, replace drug-using activities with constructive and rewarding nondrug-using activities, and improve problem-solving abilities. Behavioral therapy also facilitates interpersonal relationships.
7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. Methadone and levo-alpha-acetylmethodol (LAAM) help persons addicted to opiates stabilize their lives and reduce their drug use. Naltrexone is effective for some opiate addicts and some patients with co-occurring alcohol dependence. Nicotine patches or gum, or an oral medication, such as buproprion, can help persons addicted to nicotine.
8. Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way.
9. Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use. Medical detoxification manages the acute physical symptoms of withdrawal. For some individuals it is a precursor to effective drug addiction treatment.
10. Treatment does not need to be voluntary to be effective. Sanctions or enticements in the family, employment setting, or criminal justice system can significantly increase treatment entry, retention, and success.
11. Possible drug use during treatment must be monitored continuously. Monitoring a patient's drug and alcohol use during treatment, such as through urinalysis, can help the patient withstand urges to use drugs. Such monitoring also can provide early evidence of drug use so that treatment can be adjusted.
12. Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases, and counseling to help patients modify or change behaviors that place them or others at risk of infection. Counseling can help patients avoid high-risk behavior and help people who are already infected manage their illness.
13. Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug use can occur during or after successful treatment episodes. Participation in self-help support programs during and following treatment often helps maintain abstinence.
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B. Specific Treatment Approaches to Substance Abuse/Dependence
Peter Bohm suggests the following possible combinations of Drug Addiction Treatment Units and Methods:
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TREATMENT UNITS
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Treatment Methods
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Individual
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Family
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Group
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Network
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Social System
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Behavioral
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X
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X
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X
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X
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Cognitive
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X
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X
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X
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X
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Medical
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X
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X
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X
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Psychodynamic
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X
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X
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X
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Psychosocial
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X
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X
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X
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X
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X
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Therapeutic community*
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X
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X**
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X
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*Therapeutic community refers to situations of group living where the focus of the group program is to reduce drug dependency. The program involves combinations of individual and group treatment.
** Added by me (Parks) being aware of such treatment.
Individual treatment is not typically effective in and of itself, but important in giving the drug user a specific therapeutic relationship to rely on. The role of the therapist can also be valuable in coordinating all of the other interventions and counseling activities involved with the substance abuse. The therapist can serve as a support and help with social skills training, job placement, relaxation etc. Individual counseling can help minimize environmental factors that have supported the substance abuse of the client. Research has also shown that client characteristics account most for how treatment comes out, so working with the clients strengths in overcoming the substance abuse can be invaluable.
As mentioned, families can develop patterns where their functioning becomes dependent on the substance abuse habit of the family member. As a result, family intervention can be useful. There are different family approaches that can be used based on who is in treatment and group. They can include al-anon/alateen and Narc-Anon (alcohol anonymous programs for families and friends of alcoholics and drug addicts), parent-groups, family sessions, sibling oriented groups and multiple family groups.
Expanding the treatment to those of the client's social network may also be helpful. These include people from work, clubs, teams, school, friends and neighbors, etc. Needless to say, it would be difficult to involve such a large group of people in treatment, but the more people being aware of the problem and knowing how to help, the greater the support to the client.
Small group settings can have an especially strong effect on behaviors. As the small group tends to be a microcosm of the clients world, but much more manageable, it creates an opportunity for intense reality checks. A group made up of peers knows the struggles and also the games played. They can most often tell, better than a therapist, when somebody is being straight, or just speaking to sound good--or doing time to fulfill a court-ordered treatment requirement. In addition, clients are more likely to listen to peers. This is especially true for adolescents, where acceptance issues and peer pressure probably contributed to their use in the first place. (Bohm, 1984)
C. Specific Approaches to Marijuana, Cocaine and Methamphetamine Users
The following provides treatment approaches for three of the more common illicit drugs abused. The first focuses on adolescent marijuana abuse. Next, the treatment of more addictive drugs, cocaine and methamphetamines are addressed.
Treatment of Adolescent Cannabis Abuse
The following is from The U.S. Department of Health and Human Service, Substance Abuse and Mental Health Services Administration. In this series regarding adolescent cannabis use, Susan Sampl, Ph.D. and Ronald Kadden, Ph.D. of the University of Connecticut School of Medicine provide a treatment approach for adolescents using marijuana. At http://kap.samhsa.gov/products/manuals/cyt/text/cyt1.txt is the complete manual: Motivational Enhancement Therapy and Cognitive Behavioral Therapy for Adolescent Cannabis Users: 5 Sessions (2005).
The following are some researched facts regarding adolescent substance abuse found the in the series mentioned above (Sampl and Kadden):
- Marijuana use is the most widely used and most readily available illicit psychoactive substance in the United States. (Office of Applied Studies, 2000).
- The rate of the daily use of marijuana is higher than the daily rate of alcohol (Monitoring the Future, 1999).
- Adolescents continue to use higher rates of marijuana as they think the risks and negative effects are minimal. (Johnson, Hoffman & Gerstein, 1996)
This last perception is inaccurate. Adolescents who use marijuana weekly are 3 to 47 times more likely to have a host of problems including symptoms of dependence, emergency admissions, dropping out of school, behavioral problems, fighting, non-drug-related legal problems, other legal problems, and being arrested. Unfortunately, fewer than 1 in 10 adolescents with past-year symptoms of dependence received treatment (Dennis & McGeary, 1999; Dennis, Godley & Titus, 1999).
When parents are looking for treatment for their child, it is important for them to shop around for the program that will meet their needs. The following questions, developed by the American Academy of Children and Adolescent Academy (2004), provide questions that parents should ask professional regarding treatment. A provider can ask these questions as a self-assessment of the service they provide, but also in assessing treatment sources they might refer clients to.
SUBSTANCE ABUSE TREATMENT FOR CHILDREN AND ADOLESCENTS: QUESTIONS TO ASK
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Many children and adolescents use alcohol and other drugs. Some develop serious problems which require professional help to control. Such as inpatient treatment, outpatient treatment, twelve step programs, and dual diagnosis units for individuals with emotional and substance abuse problems.
There are a variety of substance abuse treatment programs. The decision to get treatment for a child or adolescent is difficult, and parents are encouraged to seek consultation from a child and adolescent psychiatrist when making decisions about substance abuse treatment. Other psychiatric disorders often co-exist with substance abuse problems and need assessment and treatment.
When substance abuse treatment is recommended, parents can obtain the information they need by asking the following questions from professionals:
- Why do you believe this treatment in this program is indicated for my child? How does it compare to other programs or services which are available?
- What are the credentials and experience of the members of the treatment team, and will the team include a child and adolescent psychiatrist with knowledge and skills in substance abuse treatment?
- What treatment approaches does this program use regarding chemical dependency; detoxification; abstinence; individual, family, and group therapy; use of medications; a twelve-step program; mutual-help groups; relapse prevention; and a continuing recovery process?
- Based on your evaluation, does my child have other psychiatric problems in addition to the substance abuse problem? If so, will these be addressed in the treatment process?
- How will our family be involved in our child's substance abuse treatment -- including the decision for discharge and the after-care?
- What will treatment cost? Are the costs covered by my insurance or health plan?
- How will my child continue education while in treatment?
- If this treatment is provided in a hospital or residential program, is it approved by the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO)? Is this substance abuse treatment program a separate unit accredited for youngsters of our child's age?
- How will the issue of confidentiality be handled during and after treatment?
- How long will this phase of the treatment process continue? Will we reach our insurance limit before treatment in this phase is completed?
- When my child is discharged from this phase of treatment, how will it be decided what types of ongoing treatment will be necessary, how often, and for how long?
- As my child's problem improves, does this program provide less intensive/step-down treatment services?
Severe substance abuse and chemical dependence in adolescence may be a chronic relapsing disorder. Parents should ask what treatment services are available for continued or future treatment.
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While some adolescent users mature out of their period of abuse on their own without treatment, for others, some type of treatment is not only preferred but necessary. One of the difficulties in treating adolescents is to convince them to come to accept treatment. Not only is there a denial of a problem, but the typical sense of invincibility.
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