HUBERT KAIRUKI MEMORIAL UNIVERSITY FACULTY OF MEDICINE

1. HUBERT KAIRUKI MEMORIAL UNIVERSITY FACULTY OF MEDICINE DEPARTMENT OF BEHAVIOURAL SCIENCE AND ETHICS SUBJECT: THERAPEUTIC COUNSELLING 300 • TOPIC:UNDERSTANDING AND COUNSELLING ALCOHOLICS AND DRUG DEPENDANTS. FACILITATOR: Mr.Liwa PRESENTER: GROUP 16

2. Group 16 members. • Ally MsigitiSalimu • Danielle Dann • Elizabeth Joseph • FirdausNassour Ali • Irene Frank Shirima • JuvenaliusKirango Anselm • Shadrack EliaMakundi • Hiltruda Julius Kimario • SifaRajabu • AlphonceCosmasNtobi

3. Contents • Introduction • Objectives • Definition of terms • Main presentation • Summary • Conclusions • References

4. OBJECTIVES • To understand what addiction and dependency is in regards to alcohol and drug abuse • To understand the role that a counsellor plays in helping someone break the cycle of dependency. • To understand the types of counselling available for use. • To understand that not all types of counselling apply to each individual and that counselling must be tailored for the patient. • To understand the risk factors associated with drug abuse and alcoholism.

6. Introduction • Addiction is shown by a behavioural change caused by the biochemical changes in the brain due to continuous substance abuse. • It becomes the main priority of the addict, with out any care of the harm they do to them selves or others. • It causes people to act irrationally if they do not have the substance in their system. • Dependence is a physical dependence on a substance. Its symptoms are tolerance and withdrawal. • It normally leads to addiction.

7. Introduction continued… • Addiction and dependency can lead to health conditions, mental health problems and social problems. • When considering counselling someone with a substance abuse problem, its good to look at the Biopsychosocial effect it is having and treating each problem rather than focusing on just one. • Dependency as mentioned before is a step before Addiction and patients at this stage can often respond to counselling better than those with addiction. • The tried and tested methods shown in this power point will show the health professional a range counselling techniques that they can use for patients with these problems. (www.addictioncenter.com)

8. DEFINITION OF TERMS • Dependency: overreliance by a person on another person or on a drug, etc(www.dictionary.com) • Addiction: the state of being enslaved to a habit or practice or to something that is psychologically or physically habit-forming, as narcotics, to such an extent that its cessation causes severe trauma.(www.dictionary.com) • Drug abuse: the habitual taking of addictive or illegal drugs or alcohol. • Counselling: Is a type of talking therapy that allows a person to talk about their problems and feelings in a confidential and dependable environment. (www.nhs.gov.uk) • Therapy: A therapy that helps people feel better, grow stronger and cope better especially after an illness (cambridge dictionary)

9. Definition of terms continued… • Drug: A medicine or other substance which has a physiological effect when ingested or otherwise introduced into the body. ( inhaled, injected, consumed, absorbed via the skin etc) • Drug misuse/abuse: the continuous use of a drug or alcohol with negative consequences. This is not associated with regular use of a drug to treat a condition. • Tolerance: a persons diminished response to a drug which occurs when the drug is used repeatedly and the body adapts to the continued presence of the drug. • Withdrawal: abnormal physical or psychological features that follow the abrupt discontinuation of a drug that has the capability of producing physical dependence. An example is of withdrawal from opiates, which symptoms include sweating, goosebumps, vomiting anxiety and pain.

10. Main Presentation • Drug Dependancy or alcohol dependancy may have many different underlying route causes but one thing is true for all dependants, their need for their drug is triggered by stressful circumstances. • When counselling people who have addiction, its important to enable them to develop coping methods for these cues alongside treating the problem to avoid relapse at a later stage.

11. Alcohol and Drug Dependency Risk Factors and health related problems: • Social • Isolation from friends and family • Personality changes • Fighting, behavioural problems • Economic: • Loss of earnings through loss of job • Homelessness • Health: • Infectious diseases related to drug use, eg HIV, HEP, etc • Liver Damage • Cardiac problems- arrhythmias, peripheral artery disease • GIT – gastroenteritis

13. Causes/theories of Dependency • High stress levels • Having parents with a history of addiction • Severe trauma or injury • Exposure to substance abuse at a young age • Mental health conditions- mood disorders and chronic anxiety and depression • Psychological trauma including loss of a love one or chronic loneliness

14. How to recognise drug abuse… • Symptoms: • Sudden loss of interest in family and friends • A loss of interest in hobbies and activities they once found fulfilling • Bloodshot eyes or dilated pupils • Stealing money to support drug habit • Borrowing money from friends and family • Unexplained absences from home • Lying about whereabouts • Irritability or sudden mood swings • Types of drug abuse • Heroine • Cocaine • Crack • Meth • Hallucinogens • Amphetamines • Marijuana • Alcohol • Inhalants • Prescription drugs

15. How to recognisealcohol abuse… CAGE • Cutting down: A patient admits that they have tried to cut down but have failed in the past • Annoyed: the patient feels annoyed when their drinking is mentioned. • Guilty: the patient feels feeling of guilt associated with their drinking habits. • Eye opening: This is when a patient needs to drink when they wake up • If a patient scores 2 or more in this check list, then they are considered to be dependent on alcohol. NB THIS IS NOT APPLICABLE TO DRUG USERS.

16. Functional Analysis and Orientation phases • Is a step in CBT. It helps alcoholics identify factors that lead to alcohol abuse. If used as part of a comprehensive treatment regimen, functional anaylsis can help an acoholic avoid relapse and replace negative behaviours with positive habits. • Steps: • The alcoholic sits down with the counsellor. • They work together to identify feelings, thoughts and behaviours that are associated with the client’s drinking habits. • The examination is systematic of the consequences of addictive behaviour. • This gives way to highly targeted treatment plans. • www.alcoholrehab.com

17. Functional analysis continued… • This is a list of questions often asked when using functional analysis to treat alcohol abuse: • When was the last time you drank alcohol? • What happened before you started drinking? • Where were you at the time? • How were you feeling on that day? • At what moment did you realize that you wanted to drink? • What sort of feelings did you experience while you were drinking? What about after the incident was over? • What consequences (positive and negative) arose because of the drinking?

18. Types of Counselling for Addiction • The types of counselling recommended for addiction/dependancy can depend on the substance that is being abused and also the patient who is using them. As with all counselling techniques, what works for one may not work for another. These are the methods that are used and will be explained in more detail through out the talk.

19. Types of Therapy (NIH, National Institue on Drug Abuse, 2012) • Cognitive-Behavioural Therapy • Contingency Management interventions/Motivational incentives • Motivational enhancement therapy • 12 step Facillitation Therapy • Family Behaviour Therapy • Behavioural Therapies for Adolescents

20. Cognitive Behavioural Therapy. CBT (Carroll,K.M 2005) • Developed as method to prevent relapse for alcohol abuse, later adapted for addictions to cocaine. • Based on theory that in the development of maladaptive behavioural patterns, how you learn plays an important role. • CBT teaches the client how to identify and correct problem behaviours by applying different skills. • This helps stop drug abuse and sometimes other problems that can co-exist with it.

21. CBT continued • CBT helps clients in self control by delevoping coping strategies. • For example, looking at positive and negative consequences of dependency, monitoring cravings early and working out situations that put the clients at risk of re-using. • It helps patients cope with cravings and avoiding high risk situations.

22. Contingency Management Interventions/Motivational Incentives • This involves giving patients tangible rewards to reinforce positive behaviours, ie abstinence. • Studies have shown (Methadone programs) that incentive based help is effective in increasing patients in treatment and avoidance of drugs. • The process works by a patient receiving a reward for every drug –free urine sample provided. This can be exchanged for food, cinema tickets etc. • The value of the reward increases as the more drug free urine samples are given. • This could be a problematic method in poorer communities where the opportunity to set up an incentive scheme is not affordable. (Petry N.M. 2005)

23. Motivational Enhancement Therapy (MET) • This helps clients become motivated to treat their dependancy. • It aims to produce a rapid and internally motivated change, rather than a step by step approach. • It starts with an initial assessment, leading to 2-4 sessions with a therapist. • The first treatment session involves the counsellor giving feedback on the initial assessment, causing discussion about the clients personal use and trying to encourage some self motivational statements. • This process intends to help improve motivation and create a future plan for change.

24. MET continued • The patient discusses coping strategies with the counsellor. • Further sessions require the counsellor to notice change in the patient and then encourages more commitment to change. • Often patients are encouraged to bring a loved one with them to sessions to help with the motivation. • Success has been seen with alcohol dependents • This method is recommended in conjunction with other treatment, such as CBT. (Baker, A. (2002)

25. 12- Step Facilitation Therapy • This is a therapy commonly used in Alcoholics Anonymous, Drug Addicts Annonymous, Gambling Annonymous etc. • It involves self help groups, encouraging support from peers and the ability to relate to those around you, going through the same problems. • It works from the premise that the patient accepts 3 key ideas: • 1. Acceptance. – the realisation that drug addiction is chronic, that one has no control over it, and that willpower alone is insufficient to overcome the problem. That abstinance is the only answer. • 2. Surrender- Involves giving oneself over to a higher power. The need to follow the program and rely on the help of others.

26. 12 steps continued… • 3. active involvement in meetings and activities. In these sessions, dependents must admit to themselves they have a problem. They must accept a sponsor, someone they can speak to when they feel tempted and acknowledge that the only way to beat the dependency is through abstinence entirely. Chappel, JN (1999)

27. 12 steps: • We admitted we were powerless over alcohol • We came to believe that a power greater than ourselves could restore us to sanity • We made a decision to turn our will and our lives over to the care of God as we understood Him • We made a searching and fearless moral inventory of ourselves • You admit to God, yourself and to another human being the exact nature of our wrongs • Were entirely ready to have God remove all these defects in character • We humbly asked Him to remove our shortcomings • Make a list of persons we have harmed and are willing to make amends to them all • Made direct amends to such people wherever possible, except when to do so would injure them or others • Continued to take personal inventory and when we were wrong, promptly admitted it • Sought through prayer and meditation to improve our conscious contact with God as we understood Hum, praying only for knowledge of His will for us and the power to carry that out • Having had a spiritual awakening as the result of the steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.

28. Family Behaviour Therapy FBT • This addresses both substance abuse and other problems as well. • It is useful in adolescents and Adults and focuses on child mistreatment, depression, family conflict, unemployment, behavioural disorders. • Counsellors conduct sessions with loved ones, encouraging behaviouralstragegies to improve the home environment. • It also focuses on contingency management, ie, preventing substance use and reducing HIV infections. • Parents are encouraged to set goals to improve parenting behaviours, this is reinforced by incentives by loved ones when goals are met.

29. FBT continued… • Patients take part in the treatment planning. • They can choose specific interventions from a list of evidence based treatment options. • This treatment was found to be more effective than supportive counselling for adolescents with behavioural problems. • Carroll, K. M (2005)

30. Behavioural Therapies for Adolescents • Treating adults and adolescents requires completely different strategies. Adults have a perception of risk which adolescents do not. Studies have shown that family involvement is important for helping youth. • Multisystemic Therapy: • This is used in teenagers with antisocial behaviour and substance abuse. • It targets the factors that are associated with the above issues, such as poor family discipline, peers positive attitude to drug abuse, school, eg drop out rates, and neighbourhood, eg gang culture.

31. MST continued • Intensive treatment at home, school or neighbourhood settings enables youth and family to complete a full course of treatment. • Studies have shown it is effective for at least 6 months after treatment.

32. Many issues surrounding drug and alcohol dependency stem from what caused the misuse in the first place. • If a client lives in a neighborhood where their drug dealer lives, or has no friends or family other than the people he drinks with in the bar, it is very hard to stop some behaviors by simply looking at the issue of dependency. • In order to fully treat a patient, support is required beyond the counselors room, hence why the 12-step program is the most commonly used method as it surrounds the user with a support group and a new family.

33. Summary • Drug abuse and alcoholism require different counseling techniques depending on how the individual responds • Candidates do not respond the same, hence the counseling approaches are also different depending on the individual • It is the counselors responsibility to assess which method is working and adjust accordingly to suit the needs of the patient.

34. Conclusions. • Drug abuse is an enormous public health problem with consequences not only for individuals using drugs but also for families, communities and society. • Among risk factors such as biological predisposition factors, personality trait that reflect lack of social binding, family life style, history of being abused or neglected, low socio-economic status, emotional or psychiatric problems, inadequate social skills like history of associating with drug using peers, are complex path towards drug and alcohol addiction. • Thus, it is clear that the path to drug abuse is complex, so simple solutions to the problems are unlikely to be effective.

35. References • https://www.addictioncenter.com/addiction/addiction-vs-dependence/ • https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/evidence-based-approaches-to-drug-addiction-treatment • Carroll, K.M.; and Onken, L.S. Behavioral therapies for drug abuse. The American Journal of Psychiatry 168(8):1452–1460, 2005. • http://alcoholrehab.com/drug-addiction-treatment/functional-analysis-in-alcohol-rehab/

36. REFERENCES. • Petry, N.M.; Peirce, J.M.; Stitzer, M.L.; Blaine, J.; Roll, J.M.; Cohen, A.; Obert, J.; Killeen, T.; Saladin, M.E.; Cowell, M.; Kirby, K.C.; Sterling, R.; Royer-Malvestuto, C.; Hamilton, J.; Booth, R.E.; Macdonald, M.; Liebert, M.; Rader, L.; Burns, R; DiMaria, J.; Copersino, M.; Stabile, P.Q.; Kolodner, K.; and Li, R. Effect of prizebased incentives on outcomes in stimulant abusers in outpatient psychosocial treatment programs: A National Drug Abuse Treatment Clinical Trials Network study. Archives of General Psychiatry  62(10):1148–1156, 2005. • Baker, A.; Lewin, T.; Reichler, H.; Clancy, R.; Carr, V.; Garrett, R.; Sly, K.; Devir, H.; and Terry, M. Evaluation of a motivational interview for substance use with psychiatric in-patient services. Addiction 97(10):1329-1337, 2002. • Chappel, JN; Dupont, RL (1999). "Twelve-Step and Mutual-Help Programs for Addictive Disorders". Psychiatric Clinics of North America.  • Philip Burnard counseling skills for health proffesionsals 2nd edition.