As an adjunct to your study, review this 10-minute CrashCourse.com video that reviews the relationship between trauma and substance abuse:
You will now shift your focus from prevention strategies to that of treatment modalities. Despite the available (or lack of) resiliency factors in an individual’s environment, and the preponderance of risk variables, some individuals’ initial experimentation with drugs turns into a chronic and maladaptive pattern of abuse and dependence. For these individuals, a rigorous and highly structured program is needed to help change the highly reinforcing pattern of drug addiction. This can be quite challenging and the rate of relapse is often quite high. As you have seen previously, a multimodal approach that attempts to address as many intervening variables as possible, while also bolstering all available, naturally occurring supports, tends to work best.
What are some of the challenges in creating an effective substance-abuse treatment program?
One of the primary challenges in the development of an effective treatment program for the individual who is substance abusing or dependent is that, in many cases, they are using, abusing, or dependent or an array of drugs, both licit and illicit. This complicates the approach of intervening in that the likelihood for drug substitution and the influence of the individual’s environment particularly habits and social relationships related to multiple drug use, is particularly ingrained and strong. In fact, the Diagnostic and Statistical Manual of Mental Disorders (DSM) uses the diagnosis of Polysubstance Abuse and Dependence to designate cases of such complexity where co-occurring drugs are abused in a concurrent fashion to the detriment of the individual’s life across a variety of contexts.
Another layer of complexity that exists in the treatment of substance-abusing individuals is that approximately 30% of the sample will also be actively experiencing problems with at least one chronic mental health disorder. These dually diagnosed individuals need to be receiving co-occurring mental health treatment which has evidence-based support for the particular disorder of concern. In some instances, drug abuse by individuals who are experiencing untreated mental disorders are, in effect, trying to ameliorate their own mental health symptoms, albeit in a pathological manner. It is often advantageous for a treatment team consisting of a physician and a psychologist or counselor, at a minimum, to work together to address the individual’s concerns.
The prevailing model that attempts to effectively address many of the aforementioned complexities is the biopsychosocial model of substance-abuse treatment. As the name implies, this model acknowledges that drug abuse and treatment is both multi-dimensional and multi-factorial and requires evidence-based understanding and interventions targeted across the realms of biologic, psychological and social factors. This model advocates taking an integrated approach in the design and implementation of a treatment program. This requires a variety of professionals from several disciplines (as a multidisciplinary treatment team) and an active degree of communication and collaboration among them.
What are the stages of change as they relate to substance-abuse treatment and recovery?
The psychological theorist, Prochaska, developed a theoretical framework to help people understand the cognitive and behavioral processes of change that individuals pass through over time when often struggling to make difficult changes in their lives. This five-stage model includes the following steps. (1) The Precontemplation Stage is what occurs first and it involves the intermittent wish or desire to change, but without any well-reasoned plan of action or even awareness that an individual, in the case of substance abuse, has a problem significant enough to merit full consideration of the need to change. In the case of substance abuse and dependence, an example might be an individual who has been placed in treatment immediately following a crisis, but has yet to make any self-directed decisions about his or her own future to address future occurrences.
The Contemplation (2) Stage is distinguished by the fact that an individual does indeed acknowledge that a problem in one’s life exists, and he or she is considering how to address this problem, but have yet to make a firm commitment to an action(s) to address the problem. The individual may report feeling overwhelmed by the challenges involved in making a firm commitment, including the discomfort with withdrawal and making significant relationship changes in their lives. It is at this point that a therapist can be helpful in helping to delineate reasons for committing to lifestyle changes and the cost of not doing so.
The Preparation (3) Stage is defined as being committed to making a lifestyle change and planning to initiate action in the next 30 days after having been unsuccessful in making any substantive, positive changes over the last year. This may manifest itself as a proposed “quit date” or a date for the first day of sobriety. Again, therapists can be useful at this stage to discuss ways for the individual to inoculate himself or herself against postponing the intended change, as well as preparation for the short-term negative repercussions that will surface upon the first few steps of drug cessation and withdrawal.
The Action (4) Stage is defined by being proactive and taking actions to stop drug seeking and drug-use behaviors. As you can imagine, this is the most difficult and fragile stage because the threat of relapse becomes more poignant at this stage. Individuals need ongoing support and reinforcement for all behaviors that are incompatible with former pathological actions that related to drug use. Support networks, whether family or treatment groups, are critical at this juncture.
Finally, the Maintenance (5) Stage is entered after the individual has been drug-free for a minimum of six months. For this to occur, new changes in habits and lifestyle will have had to occur. However, treatment is far from over and continued mindfulness and proactive steps toward sobriety will need to be continued. These stages are certainly fluid and the possibility of relapse is real and moving among the various stages throughout life is quite common.
Once in treatment, what role(s) do the family play in outcome?
As has been discussed throughout this course, the role of the family is extremely significant in the origin, continuation, maintenance and discontinuation of drug use in individuals. Families can be a great source of support and resilience and, conversely, can also be a source of continued risk and the enabling of self-destructive behavior. It is important for the recovering individual, hopeful in the company of a well-trained therapist, to carefully evaluate the role that the family has played to date and what, if any, role the family can have with regards to recovery. There may be some individuals within the family system that engage in destructive, enabling behaviors such as avoiding, denial, shielding others from consequences, and rationalizing, while others who are ready to extend themselves and their resources to help ensure success for the person needing assistance.