Part III

1. Part III Psychology Of Addiction Chapter 6 Addiction across the life span

2. Erik Erikson’s Stages Birth to old age Stage 1: Trust vs. Mistrust Stage 2: Autonomy vs. Shame and Doubt Stage 3: Initiative vs. Guilt Stage 4: Industry vs. Inferiority Stage 5: Identity vs. Role Confusion 12-17 years old Stage 6: Intimacy vs. Isolation Stage 7: Generativity vs. Stagnation Stage 8: Ego Integrity vs. Despair Must resolve each crisis before going to next stage Carol Gilligan’s criticism.

3. Adolescent Brain • Prefrontal cortex matures until mid-20s • Evidence of brain immaturity during the teen years comes from MRI scans of the adolescent brain

4. Teenage Drinking Use • Identity vs role diffusion • Alcohol is the drug of choice by American teens aged 12-17 • Less smoking by teens in the US then previously

5. Argentina • 16 year old exchange student found: • No drinking age • Wine or beer with supper • Drinking to be social not to get drunk • What the U.S. can learn from Argentina • Focus on moderation and adult supervision

6. SAMHSA Household survey reported • Cigarette use 10.8% with 12 to 17 year olds (2006) • Binge drinking by almost 20% of youths aged 16 and 17 • Rates of current illicit drug use for ages 12-17 for major social/ethnic groups: • Whites 8.1% • Hispanic 7.6% • African American 9.7% • American Indian/Alaska Native 12.8% • Persons reporting multiple race 12.2% (high rates of drinking and smoking as well) • Asian Americans 3.1%

7. 2006 School Surveys Reported: • Use of alcohol, the most dangerous drug—car crashes, drownings, etc., one-third of high school seniors get drunk once a month or more; same in Canada • Almost all current smokers also drank alcohol • School surveys show African Americans and Latinos have rates of illicit drug use lower than that of whites • Rise in use of painkilling drugs—OxyContin used by 4% • in recent survey; 9.5% used Vicodin.

8. In Europe WHO survey : • European kids: 16% tried marijuana, 6% another illicit drug, 37% smoke regularly • vs. 41% in US tried marijuana, 16% amphetamines • Smoking age 13—10% Europe vs. 4% US • Alcohol used regularly 24% Europe compared to 16% US • Drunkenness in European teens highest in Denmark, Ireland, UK; lowest in Mediterranean countries

9. College Students •   40 % binged on alcohol in past two weeks •   Rivera Live: $10 billion alcohol consumed by under 21 •   Beer and liquor companies most well funded lobbies •  $1 billion White House advertising campaign anti-drug ads. •   Proposal to include alcohol in ads, measures failed. • New law promises to change this, 2007.

10. Risk Factors for Later Problems: • Turbulent teen-father relationship • Child abuse and other trauma • Kids who start smoking early • Smoking can be considered a gateway drug; as many girls as boys smoking, low rate among African American girls. • Media-generated weight obsession, a major problem among girls of European American ethnicity. • Obsession leads to major problems with eating, such as anorexia and bulimia.

11. Tobacco companies targeting kids; Field andStream—ads for smokeless tobacco  Children learn gambling on the Internet; Video poker, slot machines, and the lottery Strenuous exercise programs reduce smoking. Smoking may be considered a gateway drug. Society’s Influences

12. Predictions from Scandinavia: • High risk: girls who cry easily when teased are anxious and shy. •  Male aggression at age 8 predicted alcoholism 18 to 20 years later. Evaluations at ages 10 and 27 showed: –   High novelty seeking –   Low harm avoidance (dare devil behavior) Both traits predicted early-onset alcoholism. For both sexes, poor school success predicted later drinking problems

13. Child Abuse • Alcohol and other drug abuse are factors in 7 out of 10 cases of child abuse or neglect. Treatment for parents is scarce. • According to one study, children who are spanked and slapped are twice as likely to develop alcohol and other drug abuse problems. •  Traumatized children often are unable to cope with psychological stress later. Depression, a key factor; trauma > changes in the brain. •  Animal studies show stress and alcohol consumption levels are highly correlated. • Sexual abuse is correlated with earlier onset of alcohol and illicit drug use.

14. Child Abuse continued •  Girls who are sexually abused are three times more likely than other girls to develop drinking problems later •  Boys who were sexually abused more likely to be diagnosed with conduct disorder, dysthymia (mild depression), and ADHD •  Abused girls are more likely to be diagnosed with post-traumatic stress disorder and major depression.

15. Risks for Girls • Daughters of alcoholics at increased risk for alcoholism. •  Teenage girls who are heavy drinkers are: • five times more likely to engage in sexual intercourse. • a third less likely to use condoms • which can result in pregnancy and contraction of sexually transmitted diseases including HIV/AIDS

16. Risks for Boys: •  Biggest threat to life and health for adolescent boys is alcohol-related accidents •  Male counterpart to anorexia in females is muscle dysmorphia. •  Dysmorphia-- newly identified psychiatric disorder in DSM IV.

17. DSM-IV-TR discusses body dysmorphic disorder—muscledysmorphia only briefly Obsessive body building major problem for young males Revealed in popularity of anabolic steroids Steroids used by 2.7 % of all male high school students. Health hazards: stunted growth, acne, and shrinking testicles. More Risks for Boys

18. Binge Drinking: College •  U.S. government imposed nationwide minimum drinking age of 21 in the 1980s, the attempt to curtail drunken driving by youth. • Fewer drink today, but those who do drink more. •  44.8% of college students report binge drinking; about half of them under age 21 • “Party till you puke!” signs were posted on one university campus

19. •  Critics argue students are driven to partying underground and away from faculty supervision. •   New campaigns for moderate drinking encouraged by University of Washington (Alan Marlatt) research. •   Social norms campaign with messages of moderation were unsuccessful. Modern Form of Prohibition

20. College newspaper slow to restrict enticing beer ads. Most binge drinkers mature out of wild drinking days of early adulthood. But 1,700 college students die each year from alcohol-related injuries. Cigarettes--abstinence probably works better than moderation here. Two paths to drug use by youths: –  Striving to be cool –  Using drugs to escape Messages about long-term damage are apt to have little impact. Need for Harm Reduction

21. Harm Reduction: • Need for drug courts--important for family preservation and closely supervised treatment • Forbid “happy hours,” free drinks on 21st birthdays at bars. • Lower drinking age laws; discourage drinking hard liquor • Encourage adult supervision with kids who are drinking. Encourage moderate drinking as with meals. • Serve food with alcoholic beverages.

22. Motivational Principles from Social Psychology From Elliot Aronson, The Social Animal • If you state a position, you will be wedded to it. • A small commitment to take action goes a long way. • People with high self esteem can easier resist temptation. • Working toward a goal might pay off eventually. • Change of attitude might help. • People desire to reduce dissonance.

23. They list the following traps to avoid:– Premature focus, such as on client’s addictive behavior – Confrontational round between therapist and client over denial – Labeling trap--forcing the individual to accept a label alcoholic or addict – Blaming trap, fallacy that is especially pronounced in couples’ counseling Miller and Rollnick: MI Strategies

24. Primary Prevention to Reduce Risks: • Child abuse, early-prevention education and treatment programs • Smoking education to keep youths from ever starting to smoke • Health and skill education at schools • Reducing ads promoting addictive behavior • Advocacy for the hiring of more school counselors and social workers

25. Stage-Specific Motivational Statements: Stage of Change: Precontemplation –   Goals are to establish rapport –   Counselor reinforces discrepancies Adolescent comment: “My parents can’t tell me what to do; I still use and I don’t see the harm in it- do you?”

26. Motivational Enhancement continued: Stage of change: Contemplation • Ask: How was life better before drug use? • Emphasize choices • Typical questions are: -What do you get out of drinking? -What’s the down side?

27. Contemplation Stage continued: • • Typical adolescent comment: • I’m on top of the world when I’m high, but then when I come down, I’m really down. It was better before I got started on these things.

28. Preparation Stage: • Setting the date • What do you think will work for you? • Adolescent comments, “I’m feeling good about setting a date to quit, but who knows?”

29. Action Stage: Adolescent comment: “Staying clean may be healthy, but it sure makes for a dull life. Maybe I’ll check out one of those groups.” “Therapist: “Why don’t you look at what others have done in this situation?” Help locate an appropriate group.

30. Maintenance Stage: • Adolescent comment: “It’s been a few months; I’m not there yet but I’m hanging out with some new friends...”

31. Resistance: • Inevitable • Miller advises roll with it— “roll with resistance” • Use reflective summarizing

32. Gender Specific Approach for Girls • Equality does not mean sameness. • Programs for girls do better when they focus on relationships. • Waterloo,Iowa --group home-- Quakerdale specializes in care of teenage girls. • Learning of life skills • Gaining competency as in art

33. Elderly Substance Abusers • 13% of U.S. population over age 65 • More men with alcohol problems • Elderly consume 20-25% of all prescription medications • Two types of elderly alcoholics: early and late onset • Early onset- - more severe levels of depression and anxiety

34. Elderly consume less alcohol than the young. Trend toward nursing homes for short-term alcoholism rehabilitation Many male ex-alcoholics reside in nursing homes Facts about Elderly Drinking

35. Many early onset suffer from Korsakoff’s syndrome and other alcohol-related neurological problems. Medical complications: Hip fracture, suicide, brain damage Late onset…more women here, close family ties More Facts

36. DWI and effect on self image Age segregated vs. mixed ages in treatment Guidelines for work in groups with elderly: -Avoid strong language, rebuild support systems -Keep pace slow Counseling Older Clients

37. Relapse Prevention: • Teach elderly clients to learn the warning signs and high risk events; • Review feelings that led to relapse so they can be avoided (for example, depression); HALT • Focus on critical thinking skills. • Help clients renew their commitment to sobriety; • Find effective coping styles; • Build support systems; • Remember that non-confrontational approach is best.

38. Counselor Pitfalls: (Beechem, 2002) • Anticipate feelings of guilt and shame in elderly clients in trouble with the law; • Ageism • Countertransference • Denial in assessment • Sympathy not empathy

39. Loss and grief in family members of addicted persons: • Types of Guilt • Survivor guilt • Helplessness • Ambivalence • Spiritual healing—sense of meaning, connectedness • Strength from 12 Steps

40. Spiritual Healing If there be grief, then let it be but rain, And this but silver grief for grieving’s sake. William Faulkner Today, social work education stresses importance of helping clients find spiritual meaning. Higher Power as nature in Norway, Native American traditions. Search for forgiveness and renewal 12 Steps as guide to self knowledge

41. Chapter 7 Eating Disorders, Gambling, Shopping, and Other Behavioral Addictions

42. Eating Disorders • The only one in this chapter related to a substance – food addiction. All others, for example, Internet addiction are behavioral…often clients in treatment for another disorder • Headline: “Eating disorders start in brain” • 90% of anorexia and bulimia is found in females. • Begins in adolescence • .5% of girls and women are anorexic, 1-3% bulimic.

43. Anorexia • Less than 89% of normal body weight and fine body hair. • 10% mortality rate, often by suicide, correlated with perfectionism, ritualism, high anxiety • Related to obsessive compulsive disorder (OCD): • obsessive--recurrent and persistent thoughts; • compulsions—ritualistic practices.

44. Bulimia • Gay men at risk. • Bulimia with alcohol misuse--30-70% • 35% of bulimics experienced childhood sexual abuse and use food as a drug • Little information on compulsive overeating. • New studies show lack of dopamine receptors in the brains of morbidly obese • Some after gastric bypass surgery turn to heavy drinking

45. Study in the British medical journal, Lancet—findings from twin studies showed that a strong craving for sweets predicted alcohol abuse problems, perhaps caused by a lack of dopamine. Bulimia—cognitive treatments; avoid strict dieting Anorexia—Prozac is effective in reducing compulsive behavior but only when weight has been gained. Men—muscle dysmorphia, antidepressants may help here too;. Interventions

46. Treatment • Overeaters anonymous (OA) for compulsive eating; • Group treatment.. teach moderation—CBT • Theme of neuroplasticity—brain neurons can form new connections; “brain lock” can be corrected (Schwartz) • Box 7.1 compares two treatment programs; the second one in Kansas City included trauma work

47. Gambling Addiction • Gambling, has become socially acceptable • Criteria of pathological gambling---preoccupation, increasing amounts, etc. 3-7% of gamblers have problems, suicide high in gamblers • Cost to economy is $54 billion—bankruptcies, lost work time, crime, etc. Very high among Native Americans—over 14% have gambling problems • Research shows counties with gambling casinos have higher crime rates and bankruptcies than others

48. Gambling continued • Problems among the elderly • Internet gambling is the fastest growing form. • 2-4% in Gamblers Anonymous (GA) are women. But many helpline calls. • Women gamble to escape; men for action. • Associated with other problems • Box 7.1 Reflections of a Male Compulsive Gambler. Geographical relocation helped him break his habit.

49. Questions for Screening • Have you ever borrowed money in order to gamble or cover lost money? • Have you ever thought you might have a gambling problem or been told that you might? • Have you ever been untruthful about the extent of your gambling or hidden it from others? • Have you ever tried to stop or cut back on how much or how often you gamble?

50. Treatment: cognitive work and motivational therapy Irrational thinking about winning: “I put so much money in this machine, I’m bound to win.” High profile winners Lucky machine and dates States’ spending on treatment--$36 million is small compared to $20 billion in tax revenues from gambling Treatment Issues