Substance Disorders

Article written by Zentai in the "Beyond the 12 Steps" series

PSYCHOACTIVE SUBSTANCE USE DISORDERS
Psychoactive substance use disorders deal with symptoms and maladaptive behavioral changes associated with more or less regular use of psychoactive substances that affect the central nervous system. There are ten classes of psychoactive substances that often are used in maladaptive ways: alcohol, amphetamines or similarly acting sympathomimetics; cannabis; cocaine; hallucinogens; inhalants; nicotine, opioids; phencyclidine (PCP) or similarly acting arylcyclohexylamines; and sedatives, hypnotics, or anxiolytics.

Substance use disorders come in two varieties: abuse (the milder of the two) and dependence. Substance abuse is diagnosed in clients who do not meet the criteria for dependence (on the same substance) and who have demonstrated a pattern of continued use despite knowledge of having a persistent or recurrent social, occupational, psychological, or physical problem that is caused or exacerbated by the use of the psychoactive substance or recurrent use in situations in which use is physically hazardous (e.g., driving while intoxicated), for at least one month (or repeatedly for a longer period of time).

Dependence is diagnosed if the client has met at least three of the following criteria for at least one month (or repeatedly for a longer period of time): (1) using the substance more than intended; (2) persistently wanting the substance or making unsuccessful efforts to control substance use; (3) spending a great deal of time related to the substance (for example, recovering from intoxication); (4) manifesting intoxification or withdrawal that interferes with normal activities, or intoxication that involves physically hazardous use; (5) limiting activities as a result of the substance use; (6) continuing to use the substance despite awareness that it is causing difficulties; (7) showing clear signs of tolerance; (8) having withdrawal symptoms; (9) using the substance to relieve or avoid withdrawal.

In diagnosing a psychoactive substance use disorder, the clinician would specify the substance involved and indicate whether there is abuse or dependence and, if there is dependence, the severity of the condition (for example, "alcohol dependence, moderate). Substance use disorders, then, do not necessarily entail longstanding and pervasive impairments; in fact, most people who abuse drugs or alcohol are employed and have families. Nevertheless, the substance use has a powerful negative impact on the users as well as on the people who are close to them. The problem is particularly prevalent among young adults. Many causes have been suggested to explain substance use disorders: biological, cultural, environmental, interpersonal (social, familial), and intrapersonal (developmental, cognitive, affective), but no conclusive explanation has been found yet for these disorders.

The search for an addictive personality has not been a particularly fruitful one, although some researchers believe there are personality patterns that predispose people toward substance abuse. I suggest that people with problems of substance abuse have been hurt by significant others and that those who are orally addicted had particular problems with their families (considerable evidence indicates that this is particularly so if they had problems with their mothers.) People who abuse substances experience lifelong anxiety, seek a sense of identity, and are depressed and dependent. I believe they engage in avoidant behavior and are often suspicious and guilt ridden. To some extent, these behaviors may stem from their efforts to conceal their substance abuse from others and to defend their use of drugs and alcohol. People who use drugs or alcohol to excess may have learned to cope by lying to others or by placating or abusing others; and these patterns may be carried into recovery.

Approximately two-thirds of those with substance use disorders have another coexisting disorder, most commonly depression. Some of the coexisting disorders are preexisting conditions; others were initiated or worsened by the substance use. People with a family history of alcohol abuse are particularly likely to have coexisting disorders. This pattern is difficult to treat because it becomes a vicious cycle: the substance abuse worsens the coexisting disorder, which, in turn, increases the client's tendency to use drugs or alcohol as a form of self-medication for the coexisting disorder. Also, the substance use often masks the symptoms of the underlying disorder, further complicating the treatment/recovery picture.
Suicide and suicidal ideation are frequent in people who abuse substances and seem to increase as the abuse increases. The possibility of suicide is of particular concern because substance abusers have an available lethal weapon, drugs and alcohol, and the combination of intoxication and depression may lead them to turn a binge into a suicide attempt. With multiple substance abuse becoming increasingly the norm, suicide becomes easier via a mixture of drugs (such as alcohol and tranquilizers). Often suicidal "attempts" are actually a cry for help - but the "attempt" can, by mistake, turn into an actual suicide.

Therapist who treat these disorders take an active role in the therapy and avoid the more traditional analytical models initially, which do not seem effective in treating substance abuse (at least until the person becomes stabilized). Most therapists are caring yet firm and realistic with substance abusing clients. I think therapists must also be comfortable with limit setting and confrontation. Life and death situations presented by many substance abusers requires the therapist to exert external control and even coercion, breaking confidentiality if necessary when the client's life is in danger.

Therapists who work with substance-abusing clients must be prepared to deal with resistance, hostility, manipulativeness, and deception. They also need to handle appropriately their own reactions to client's reluctance to change, continuing to communicate empathy and acceptance to even the most hostile and resistant clients. While these behaviors are certainly not descriptive of all clients seeking help for substance use, they are common among these clients. One of the challenges facing the therapist is the reversal of these patterns and the development of an honest relationship even when a part of you wants to kick them in the ass.

An important difference between drug abuse and alcohol abuse is that most abused drugs are illegal. Consequently, although alcohol clients also may have legal difficulties if they are arrested for driving while intoxicated, drug abusers often are involved in serious crimes and devote extensive time and energy to obtaining the funds needed to purchase drugs. Many clients with drug abuse problems come to therapy involuntarily on a court referral and may be suspicious, guarded, and resentful.

Many of those who abuse drugs have problems with impulse control in other areas and resemble clients with impulse control disorders. Adolescent drug users, in particular, seem to have a high susceptibility to boredom along with a high need to take risks and seek excitement. Men are more likely to abuse illicit drugs; women are more likely to abuse prescription drugs. Those who abuse prescription drugs tend to be dependent, shy, anxious, and socially isolated or obesity precipitated the drug use.

There may be an association between personality traits and preferred drug. Heroin addicts tend to be childlike yet distant and to have one parent who is punitive or distant and one who is over involved. Opioid users tend to be apathetic, egocentric, narcissistic, easily bored and frustrated, and have difficulty with authority. I've found that most opiate addicts have at least one coexisting emotional disorder, most often major depression, alcoholism, antisocial personality disorder, dysthymia, or an anxiety disorder. They are also likely to come from lower socio-economic groups. Female heroin addicts often have a history of incest. Those who abuse amphetamines are also often coping with underlying depression. Amphetamine users may be depressed and suicidal when they are not on drugs; when they are on drugs, they may have symptoms resembling a paranoid psychosis. In addition, people who abuse amphetamines tend to be agitated and suspicious, and frequently have little sense of direction. Some studies have found a correlation between cocaine abuse and a high incidence of depressive and bipolar disorders. Cocaine use, itself, can cause anxiety and suspiciousness as well as temporary energy and self-confidence; and some people may use cocaine to relieve depression. Barbiturates tend to be abused by people who feel tense, anxious, and inadequate. Barbituates are highly addictive and are probably the most frequent cause of drug-related deaths. Chronic marijuana users tend to be passive, lacking in ambition, and prone to depression, suspiciousness, and panic or anxiety attacks. Polydrug abusers tend to be young, venturesome, apathetic, and depressed; to have social problems; and to engage in antisocial behavior. They are often dependent and have confused values and poor problem-solving skills. They seem to be particularly troubled.

Although there is not the clear pattern of genetic transmission that is seen in alcoholism, families of drug abusers have a high incidence of impulse control problems, are conflict ridden and enmeshed, have particularly strong mother-child connections, and are troubled with issues of death and loss. Antisocial behavior and alcoholism are often found in these families, as are high levels of marital disruption, inconsistency, and emotional disorder. The drug abuser was often the favorite child and had an important role in maintaining the family.

Therapy with substance-abusing clients usually will be structured and behaviorally oriented, with abstinence being the goal. Contracts can be useful in affirming that goal and in specifying steps clients can take when they feel the desire for drugs or alcohol. For many clients, substance use is reinforced by a peer group; group counseling as well as self-help groups can counteract the influence of these peer groups. I use an eclectic approach to treatment. This approach emphasizes behavioral therapy, abstinence, and self-help groups. It also includes "genetic reconstruction," to help clients come to terms with the past, accept reality, and modify defenses. Finally, this approach makes use of interpretation and insight to help clients understand and manage feelings. I have also used aversive conditioning. I incorporate assertiveness training to develop social skills, cognitive therapy, and, in the later stages, existential therapy to promote a decision to establish a different lifestyle. In summary this approach results in: Admission, submission, restoration, and construction.

One common approach to treating substance abuse is "attack therapy" and is most commonly conducted in therapeutic communities staffed by paraprofessionals who are themselves recovering substance abusers. I believe that approach can promote insularity (a sort of closed community) and can increase clients' hostility, leading them to change in order to placate others rather than out of internal motivation. There are those who apparently react well to this kind of treatment. Most do not.

Self-help groups such as Alcoholics Anonymous and Narcotics Anonymous are almost always part of the treatment plan for substance abuse and become the central ingredient of most aftercare programs. Auxiliary groups, such as Al-Anon and Adult Children of Alcoholics, help family members deal with the impact of the substance use on them and also show them how to encourage the recovery of the substance abuser.

Substance abuse, as well as relapse, is associated with stressful life events. To prevent a setback when things do not go well in client's lives, therapy should help them look realistically at their lives; make needed changes; and develop coping mechanisms, so that they are better prepared to deal with future stress. In addition, therapy should focus on any developmental or lifestyle deficits that may have resulted from prolonged substance abuse. Many clients need assistance with career development and job seeking, socialization and communication, parenting; developing drug-free leisure activities, and improving family relationships. (Much of the Discussion Topic message boards are dedicated to these subjects.) I have done and do a structural-strategic model of family counseling with substance-abusing clients and their families and suggest that multiple family therapy (including other families with similar difficulties) can be particularly helpful. If there is a coexisting disorder, in addition to the substance use disorder, treatment seems to be most effective in both problem areas when they are addressed through the treatment.

This recovery/support site, Dynamics Of Recovery, has gone to great lengths to include a largess of information and guidelines to help those in their sincere efforts to gain whole-person health. An enormous amount of work has gone into this endeavor, expecting absolutely nothing in return. Our hope is that our members use it as intended to improve their lives. The one thing I have little patience for or compassion with is "crap". If you have smoke to blow - blow it somewhere else. I have no need to impress you and I don't need you to impress me. I want you to actualize. I want you to become all you can be.

I have found on the MMPI that people who abuse alcohol tend to receive high scores on introversion, depression, and somatization; on the California Psychological Inventory, these people score high in imagination, intellectual ability, extroversion, passivity, instability, anxiety, and interpersonal undependability. Also, they tend to have little information on the physiological and interpersonal effects of their substance abuse. I have found that those who abuse alcohol tend to be immature, impulsive, and antisocial, and have poor coping skills and low self-esteem.

Males with alcohol problems often manifest antisocial behaviors and attitudes while women are often depressed and phobic. For women, the pathology seems to precede the alcoholism; the reverse is more common with men, except for those with antisocial personality disorder and panic disorder; about half of those who abuse alcohol are significantly depressed. They tend to be anxious, self-centered, and sensitive to stress; have interpersonal difficulties and poor ego strength; perceive themselves as having little control and few options; and overreact to failure. The alcohol abuser's personality is similar to that of the client with a borderline personality disorder. Many studies suggest that people who abuse alcohol have a range of associated difficulties - especially depression, low self-esteem, poor coping mechanisms, and interpersonal concerns. Whether these traits preceded or were consequence to the alcohol abuse is unclear, but what is clear is that therapy should go beyond establishing abstinence in clients who abuse alcohol or other drugs.