Substance Abuse and the Family

Assessment and Treatment

Michael D. Reiter

• Publisher: Routledge
• Year: 2019
• ISBN:
  9780429861116
• Edition: 2
• Topic: Política y relaciones internacionales
• Subtopic: Política social

In this updated edition of Substance Abuse and the Family, Michael D.Reiter examines addiction through a family systems lens which considers a range of interconnected contexts, such as biology and genetics, family relationships, and larger systems.

Chapters are organized around two sections: Assessment and Treatment. Examining how the family system organizes around substance use and abuse, the first section includes contributions on the neurobiology and genetics of addiction, as well as chapters on family diversity, issues in substance-using families, and working in a culturally sensitive way. The second half of the book explores various treatment options for individuals and families presenting with substance abuse issues, providing an overview of the major family therapy theories, and chapters on self-help groups and the process of family recovery.

The second edition has many useful additions including a revision of the family diversity chapter to consider sexual and gender minorities, brand new chapters on behavioral addictions such as sex and gambling, and a chapter on ethical implications in substance abuse work with families. Additional sections include information on Multisystemic Therapy, Behavioral Couples Therapy, Motivational Interviewing, and Twelve-Step Facilitation. Each chapter now contains a case application to help demonstrate treatment strategies in practice.

Intended for undergraduate and graduate students, as well as beginning practitioners, Substance Abuse and the Family, 2nd Ed. remains one of the most penetrating and in-depth examinations on the topic available.

__________PART I__________

ASSESSMENT

ONE

Conceptualizing Addictions

On Monday morning you enter your agency, ready for another day of providing counseling to your clients. Mondays at your agency are always intriguing since this is the day that you conduct new client intakes. Today you have several new clients on your schedule. You do not know anything about them or what the issues are that bring them to see you.

At the appointed time you walk to the waiting room and greet your first client. As you introduce yourself, you look him over, making initial impressions based on his age, height, weight, clothing choices, and hygiene. Walking with him back to your office, you make small talk about the current weather, finding the office, or something that recently happened in the news. Upon sitting down, you talk with the client about informed consent and make sure all the proper paperwork is signed. Then you let him know that you will need to gather a lot of information from him, as is required from the agency, since the first meeting is designed for you to develop a biopsychosocial assessment. You start to talk with him about his history and current situation, all the while trying to figure out how you will understand what is happening for him and, most importantly, what you will be able to do to help him, regardless of what the “problem” may be.

After a few minutes of small talk and joining, you ask the client the all-important question, “What brings you in to therapy?” (or “How can I help you,” “What would you like different in your life,” “etc.”). The client responds that he has been addicted to alcohol and drugs for the last two years and that he wants to stop.

You now have a dilemma. Based on how you conceptualize problems, you will not only ask different questions, but will pay attention to some material more than others, leading you to develop a theory of problem formation and an associated theory of problem resolution (Reiter, 2014, 2019). When the client says that he is abusing drugs, how do you view this? Do you see this as strictly a biological problem? Do you believe that there is something mentally wrong with your client—that he has a psychological disorder? Do you think that the addiction is housed within a web of relationships and view it from a systemic perspective? Or do you expand a systemic view to see that biology, psychology, and social factors all contribute to the client’s experience?

Your answer to these questions is anything but insignificant. How you answer each question informs how you conceptualize why the client developed the problem, how it is currently maintained, and what you might do in therapy to help him. Your view of why people develop addictions and how they continue to use guides the whole of the treatment.

While there is validity to many different conceptualizations, this book attempts to help therapists view substance abuse problems from a systemic perspective. This includes an understanding of how the individual is impacted by the drug compounds, their susceptibility based on their genetics, as well as how past and current family and relational functioning impacts use of the substance. This systemic orientation can help individuals to move beyond their abuse of drugs. We will come back to our client later in this chapter, but first we should focus on knowing some of the most prominent terms in the substance abuse arena so that we are clear on what we are talking about.

Defining Addiction

Perhaps we should start our exploration of the field of substance abuse and the family through defining some of the key concepts. It is important, especially when interacting with other mental health professionals, to be on the same page when we are discussing what is occurring for our clients. While various substance abuse professionals may have differing views on the etiology of addiction or the most efficacious treatment, we can usually agree on the basic terms that we use when we are explaining the situations clients find themselves in.

In the field of mental health the definitive source for criteria of mental disorders is the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is currently in its fifth edition (American Psychiatric Association, 2013). The DSM does not provide a definition of addiction but does provide criteria for which various types of substance (and primarily mental health) issues can be categorized. What might be viewed as addiction-related issues are housed under the title of substance-related disorders, which encompass 10 classes of drugs: alcohol; caffeine; cannabis; hallucinogens; inhalants; opioids; sedatives, hypnotics, and anxiolytics; stimulants; tobacco; and other (or unknown) substances.

These 10 classes of drugs were chosen because they all have very similar processes in how they impact people physiologically. The primary process focuses on a direct activation of the brain reward system (which we will talk about more in Chapter 2). This activation impacts the reinforcement of the drug use behavior. While these drugs will show differential effects on people—for instance, it may take more or less of the drug to produce the same effects in two different individuals—they each demonstrate some type of impact on brain functioning.

Within the category of substance-related disorders the DSM-V makes a distinction between substance use disorders and substance-induced disorders. Substance use disorders are a cluster of cognitive, behavioral, and physiological symptoms, which impact the individual’s functioning, even after problems develop. What this means is that once the person’s use of drugs begins to impair their functioning in a variety of areas (i.e., perhaps they are not able to maintain a job or they find that they need much more of the drug to attain the effects) the person continues to use. Criteria include impaired control, social impairment, risky use, and pharmacological criteria (including tolerance and withdrawal).

Figure 1.1 The severity classification for substance use disorders according to the Diagnostic and Statistical Manual-V

Substance use disorders are viewed on a continuum from mild to severe. This designation depends on how many symptoms are present. Mild substance use disorder is based upon the presence of two or three symptoms, the moderate designation has four or five symptoms and the severe criteria is determined by six or more symptoms (see Figure 1.1).

Substance-induced disorders are secondary disorders that occur from the use of the drugs. Some examples of these include intoxication, sleep disorders, sexual dysfunctions, and anxiety disorders. The symptoms from substance-induced disorders are reversible, coinciding with a reduction or abstinence from the specific drug being used. A key component here is that the symptoms cannot be associated with a medical condition or other mental disorder. As an example, substance-induced disorders may demonstrate themselves in a relationship where the male may not be able to get or maintain an erection—not because of physiological problems, but because of the use of a specific drug. Once they stop using the drug, they are able to have erections again.

In the substance abuse field, there are many overlapping concepts and terms. Perhaps the most prominent one is the notion of addiction. What is addiction? What comprises someone who is addicted? The answer to this is highly debated, as part of the answer to this question relates to the hypothesized etiology of drug abuse. While there may be alternative definitions to the terms/concepts that are presented here, we will use these definitions throughout the book to help us develop a common language.

Addiction: The American Society of Addiction Medicine (ASAM, 2014) defined addiction as “a primary, chronic disease of brain reward, motivation, memory and related circuitry.” The ASAM holds that it is the dysfunction of brain circuitry which leads to problems in the biological, psychological, social, and spiritual realms. They promote an A-B-C-D-E acronym for the characteristics of addiction:

a. Inability to consistently Abstain;

b. Impairment in Behavioral control;

c. Craving; or increased “hunger” for drugs or rewarding experiences;

d. Diminished recognition of significant problems with one’s behaviors and interpersonal relationships; and

e. A dysfunctional Emotional response.

This definition provides a medical perspective to addiction where the action occurs within the individual but also has external consequences.

While this is one of many definitions and criteria, overall, definitions of addiction and substance-related concepts have been changing over time. As more information about drug science and brain functioning comes forth, newer and more accurate understandings of addiction can be developed. Given this, the definition of dependence in the DSM and International Statistical Classification of Diseases and Related Health Problems (ICD) has changed over time (Nielsen, Hansen, & Gotzsche, 2012).

The following are many of the primary terms in the substance abuse and addiction field.

Abstinence: Abstinence is the complete disuse of a substance. The person does not put in their body the drug that they were using. If someone were addicted to alcohol and consumed 20 beers per week, but cut down to 10, they would not be abstinent. They would need to not ingest any type of alcohol for us to be able to utilize this term.

Craving: Craving is an intense or heightened desire for a substance. While almost all of us have had what we might call a “craving” at some point (for instance, on Thursday I was really craving peanut butter and chocolate ice cream), in the substance abuse field craving refers to a desire for the substance, which becomes a primary motivating factor to obtain that substance.

Drugs: Drugs are usually considered to be a substance (outside of things such as food) that impacts the physiology of the body. While foods, nutrients, and vitamins do have physiological results, they are necessary for survival. Drugs, as used in substance abuse, are not. A person can easily live a healthy life never having consumed alcohol, nicotine, cocaine, heroin, etc.

Drug of choice: Drug of choice is the preferred drug that a person uses. While they may use multiple drugs, such as alcohol, tobacco, and cocaine, the drug of choice is the one the person would use if given the choice.

Dual diagnosis: Dual diagnosis is a term used when a person has more than one recognized diagnosis (as determined by fitting the criteria of either the DSM-V or the ICD-11). Usually this term is in reference to having a psychological diagnosis in conjunction with a substance abuse diagnosis. Other terms for this condition are co-occurring disorders or co-morbid disorders.

Psychotropic drugs: Psychotropic drugs are those that are prescribed by medical professionals usually for the purpose of treating mental disorders. Although these are prescribed and are legal, they can be misused by the person (i.e., taking more of the pill than prescribed) or may even become addictive for the individual. For instance, a woman who was prescribed Xanax for anxiety episodes begins to take a pill every day rather than as necessitated by the occasional onslaught of a panic attack. After some time, her behavior becomes organized around the daily taking of the Xanax rather than being able to function without the drug.

Recovery: Recovery is the process of a person reducing or abstaining from a drug that they were dependent on. Usually, recovery is more connected with the notion of abstinence, where the recovery process is focused on the person not using the substance. However, recovery can also refer to a moderated management of use. In this instance, instead of drinking and getting inebriated, which was the normal pattern, the person is able to drink only one or two drinks and not experience becoming drunk.

Relapse: Relapse is a worsening of the problem after some time of improvement. The use of the substance does not have to go back to when it was at its worst to be considered a relapse, but it is usually a movement back into problematic actions and patterns. Relapses might be a one-time occurrence or can last many years.

Slip: A slip is similar to a relapse but not as severe. It is a brief use of the substance after a period of reduction or abstinence from the drug. However, there is usually a quick return to a more functional state. For instance, if someone who had smoked two packs of cigarettes per day for three years had completely stopped smoking, but then found themselves smoking one cigarette and then did not smoke again after that, this would be considered a slip. The main difference between a slip and a relapse is that a slip is just use of the substance while relapse involves a return to negative patterns of behavior.

Substance abuse: Substance abuse occurs when a person uses a drug beyond its normal purpose or when they develop a pattern of use that necessitates further use and/or difficulties in various areas of their life. Prescription medications can be abused when they are used for symptoms for which they were not intended or in amounts not prescribed. An estimated 54 million people (more than 20% of those aged 12 and older) have used prescription medications for nonmedical reasons at least once in their lifetime. The most misused prescription drugs are pain relievers, followed by tranquilizers, stimulants, and then sedatives (Center for Behavioral Health Statistics and Quality, 2016). For instance, a doctor may have prescribed Vicodin for someone who was recovering from an accident. If the person began to take more pills each day than the recommended dosage then they would be abusing the substance. This has been a growing trend, with opioids, central nervous system depressants, and stimulants being the three classes of medications that are most misused.

Substance dependence: Substance dependence occurs when a person needs an increased amount of the drug to feel the effects of that drug. This process is known as tolerance. Further, dependence happens when the person experiences withdrawal symptoms when they do not use that substance. We might see this in someone who uses cocaine, where each time they use, they need just a little more of the drug to achieve their normal high. When they do not use cocaine they may experience cravings for it, fatigue, and tremors or chills, among other possible withdrawal symptoms.

Substance use: Substance use is when a person comes into contact with a substance that is deemed a drug. There are many instances when someone uses a substance and it is legal and not problematic for the individual. Going to a pub with friends and having one or two beers once a week (drinking within recommended limits) can be a physiologically (Mukamal, 2010) and socially beneficial endeavor. It is when the use of the substance begins to impair the person that substance use shifts to abuse or dependence.

Tolerance: Tolerance is the diminishing physiological impact of a substance upon repeated usage. In essence, we need to use more of the drug to obtain previous results. As an example, one year ago it might have taken three vodka tonics for the person to feel inebriated, but, having consumed much alcohol over the past year, today it takes five vodka tonics to have the same feeling.

Withdrawal: Withdrawal is the physiological and psychological reactions when the person reduces usage of the drug. Each drug has its own physiological consequence when a person begins to lessen their connection to the substance. For some drugs, such as marijuana, the obvious withdrawal symptoms are minimal. For other drugs, such as heroin, the body’s physiological reactions are severely debilitating to the individual. There are even some drugs that if a person attempts to stop using by going “cold turkey” (stopping...