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The Psychological Dimensions of the Drug Problem &
Treatment and Rehabilitation of Drug Dependents
Rey M. Mollenido, MD
A Brief Look at the Drug Problem
Dangerous Drug Board (DDB)—1999
1.8 Million regular users of dangerous drugs
1.6 Million occasional users of dangerous drugs
Prevalence of Drug Abuse: Thailand (5.6%)
Philippines (2.8%) --PDEA Annual
Report 2006
A Brief Look at the Drug Problem
Rehabilitation Centers
Admissions 4,703 (2005—5,783)
Mean Age: 28 yrs
Sex (Male:Female)= 9:1
Civil Status: Single (57.77%) --PDEA Annual
Report 2006
A Brief Look at the Drug Problem
Rehabilitation Centers
Occupation: Unemployed (35.81%)
Educational Attainment: High School (29.79%)
Economic Status (Ave. Monthly Family Income) = P13,706.43
--PDEA Annual Report 2006
A Brief Look at the Drug Problem
Rehabilitation Centers
Choice of Drug Abused:
Methamphetamine: 69.23%
Marijuana : 38.42
Contact Cement: 11.97%
--PDEA Annual Report 2006
A Brief Look at the Drug Problem
Rehabilitation Centers
Admissions 4,278
Mean Age: 20-29 yrs
Sex (Male:Female)= 9:1
Civil Status: Single (57.77%) --PDEA Annual
Report 2007
More people trying
More people trying again and again
The abuser doesn’t get totally cured
Must cover the BIO-PSYCHO-SOCIAL aspect of each person
Why Examine the Psychological Dimension of the Drug Problem?
Discontinuation of substance use
Detoxification
Rehabilitation
Treatment of co-morbid conditions
Environmental manipulation
Family therapy
Behavioral modification
The Treatment Process
Discontinuation of substance use
Detoxification
Rehabilitation
Treatment of co-morbid conditions
Environmental manipulation
Family therapy
Behavioral modification
The Treatment Process
Discontinuation of substance use
Detoxification
Rehabilitation
Treatment of co-morbid conditions
Environmental manipulation
Family therapy
Behavioral modification
The Treatment Process
Discontinuation of substance use
Detoxification
Rehabilitation
Treatment of co-morbid conditions
Environmental manipulation
Family therapy
Behavioral modification
The Treatment Process
Discontinuation of substance use
Detoxification
Rehabilitation
Treatment of co-morbid conditions
Environmental manipulation
Family therapy
Behavioral modification
The Treatment Process
Discontinuation of substance use
Detoxification
Rehabilitation
Treatment of co-morbid conditions
Environmental manipulation
Family therapy
Behavioral modification
The Treatment Process
Discontinuation of substance use
Detoxification
Rehabilitation
Treatment of co-morbid conditions
Environmental manipulation
Family therapy
Behavioral modification
The Treatment Process
Discontinuation of substance use
Detoxification
Rehabilitation
Treatment of co-morbid conditions
Environmental manipulation
Family therapy
Behavioral modification
The Treatment Process
Curiosity
Boredom
Peer group pressure
Temporary relief from problems
Security feelings
Like Adam and Eve
Why People Try Drugs
Etiology: Psychological Theories
Addictive Personalityneed to feel self-worth
need to have control over the environment
need to feel intimate contact
need to accomplish something
need to eliminate pain or negative feelings
Etiology: Psychological Theories
Behavioral Theories
conduct problems of childhood
relationship between conduct problems, hyperactivity, impulsivity, and future substance abuse
Psychodynamics
• Freudian
– infantile desires
• regressive pleasurable adaptation
• Neo-Freudian
– adaptive effort to survive
• Progressive responses to psychological suffering and deficient self-regulation
Behavioral Models
• Drug self-administration model
– Skinner
– Operant reinforcement
– Pleasure with drug
• Conditioned place-preference model
– Kumar from Pavlov
– Place conducive to addiction
Age of anxiety
Age of Depression
Personal inadequacies, failures and conflicts cause tension
Predisposing personality, emotional and behavioral disturbances.
Why People Continue to Use Drugs
Primer Receptor sites
Cravings Compelling urge Urgent and overpowering desire Irresistible impulse
WHO : desire to experience the effect(s) of a previously experienced psychoactive substance
Why People Continue to Use Drugs
Factors Peer Pressure
Coping Mechanism to Stress Anxiety Disorders Depression Feel Good
Why People Continue to Use Drugs
Drug use starts early and peaks in the teen years
Firs
t D
rug
Use
(nu
mbe
r of
in
itiat
es)
Infant Teen Adult Older Adult
Child
Evidence from surveys
Drug use starts early and peaks in the teen years
One of the serious concerns regarding today’s youth
About 25% of adolescents 12-17 years of age have illicit drug use
Drug use starts early and peaks in the teen years
Risk factors include high levels of family conflict, academic difficulties,
Co-morbid psychiatric disorders, parental and peer substance use, impulsivity, & early onset of cigarette smoking
Drug use starts early and peaks in the teen years
Drug use starts early and peaks in the teen years
Lack of connectedness to parents and family
Poor training in delaying gratification
Much due to ignorance
“Adult-sized CHILD”
Drug use starts early and peaks in the teen years
Lack of ability to plan for future
Pubertal intensities Physical challenges – “new found power”
Lack emotional stability – identity struggles
Need for belonging (gang formations) Insecurities
Independence struggles
Use of Multiple Drugs
• Cigarettes
• Beer or wine or other forms of alcohol
• Marijuana
• Problem drinking
• Downers or uppers
• Shabu/Ecstasy/Cocaine/Heroin
Presence of Co-morbid Disorders
Attention Deficit Hyperactivity Disorder
Conduct Disorder
Affective/Mood Disorders
Tends not to resolve after a few weeks of abstinence
Adults = depressive disorders usually resolve
Anxiety Disorders
The good news is…The good news is…
Drug Abuse is aDrug Abuse is apreventablepreventable behavior behavior
and and
Drug Addiction isDrug Addiction isa a treatabletreatable disease disease
Treatment Goals
• Abstinence
• Physical, psychiatric and psychosocial well-being of the patient
Matching Patients to Matching Patients to Individual NeedsIndividual Needs
No single treatment is appropriate for all individuals
Effective treatment attends to multiple needs of the individual, not just his/her drug use
Treatment must address medical, psychological, social, vocational, and legal problems
www.drugabuse.gov
Management
As Outpatient
As Rehabilitation Patient In-housed
Slightly different setting & approach
Treated as Out-patient after
Management as Outpatient
Biological therapy
Psychosocial therapies
– Behavior modification
• home
• school
– Structuring of activities
Management as Outpatient
Psychosocial therapies Sports activity
Psychotherapy – individual
Support group – to be organized
Prayers
Working with the family
Coordination with the school
Outpatient Treatment: Key Elements
Explicit structure and expectations
Positive and collaborative relationship with the client
Teaching information and cognitive-behavioral concepts
Positively reinforcing desired behavioral change
Outpatient Treatment: Key Elements
• Positive and collaborative relationship with the client
client must be engaged (stages of change) in the process
client must return for the next session
Outpatient Treatment: Key Elements (cont’d)
Corrective feedback using a motivational interaction style
Educating family members on the expected course of recovery
Periodic urine testing
Introducing/encouraging self-help participation
Outpatient Treatment: Key Elements (cont’d)
Periodic urine testing
not presented as a monitoring measure
a way to help discontinue drug use
a useful therapeutic opportunity for insight into client’s behavior
Treatment Considerations
Cognitive behavioral approach
current treatment of choice
focuses on “unlearning” maladaptive behavior and on learning more adaptive responses
most closely linked with existing scientific knowledge
Cognitive Behavioral Outpatient Therapy
Focus on abstinence
Focus on behavior vs feelings
Focus is behavior vs reason behind it
Transference is encouraged and utilized
Goal is stability vs emotional catharsis
Self-Help and DrugSelf-Help and DrugAddiction TreatmentAddiction Treatment
Complements and extends treatment efforts
Most commonly used models include 12-Step (AA, NA) and Smart Recovery
Most treatment programs encourage self-help participation during/after treatment
www.drugabuse.gov
Motivation for Change
• Key predictor of whether an individual will change their substance abuse
• Involves recognizing problem, searching for a way to change, and then changing
Motivation for Change
• Motivational interviewing seeks to elicit self-motivational statement from
patients,
supports behavioral change, and
creates a discrepancy between the patient’s goals and continued alcohol and other drug use.
Guidelines for Therapeutic Relationship
• Encourage honest expression of feelings
• Listen and express caring
• Hold individual responsible for behavior
• Provide consequences for negative behavior and talk about specific, objectionable actions
• Do not compromise own values, monitor reaction
• Communicate to team
Assessing an Adolescent
Trust in necessary for a therapeutic alliance.
Effective ways to prevent a trusting relationship from developing: To test without the young person’s knowledge
To test in spite of the adolescent’s objections
To test on parents’ demand
Rehabilitation
Not prison, nor punishmentNot prison, nor punishment
Therapeutic environmentTherapeutic environment
More protective for the clientMore protective for the client
May be a form of group therapyMay be a form of group therapy
Not merely a place, but a process as wellNot merely a place, but a process as well
Rehabilitation Involves
Personal developmentPersonal development
Parental concerns and knowledgeParental concerns and knowledge
School environment and educationSchool environment and education
Community education & program participationCommunity education & program participation
Rehabilitation Involves
Program in a workplaceProgram in a workplace
Mass media education & program involvementMass media education & program involvement
Law enforcementLaw enforcement
LegislationLegislation
Duration of TreatmentDuration of Treatment Depends on patient problems/needsDepends on patient problems/needs
Less than 90 days is of limited/no effectiveness Less than 90 days is of limited/no effectiveness for residential/outpatient settingfor residential/outpatient setting
A minimum of 12 months is required for A minimum of 12 months is required for methadone maintenancemethadone maintenance
Longer treatment is often indicatedLonger treatment is often indicated
www.drugabuse.gov
Treatment Outcome Measures
Substance Use
Medical and Physical Health
Psychosocial Functioning
Employment stability
Criminal Justice Involvement
Relapse Prevention
Treatment Centers in Iloilo
WVMC-Substance Abuse Treatment & Rehabilitation Center
WVSUMC for detoxification
New Life Therapeutic Center
DelaLlana Detention Center
Dalayunan Home for Boys
Prevention Strategies
• Always the best approach
• A group effort
STRATEGIES FOR DRUG ABUSE STRATEGIES FOR DRUG ABUSE PREVENTION IN THE WORKPLACEPREVENTION IN THE WORKPLACE
Company Policies and Procedures on alcoholism and drug abuse.
Example:Example:
-Tardiness and absenteeism guidelines;
- Establishing an alcohol /drug-free workplace
STRATEGIES FOR DRUG ABUSE STRATEGIES FOR DRUG ABUSE PREVENTION IN THE WORKPLACEPREVENTION IN THE WORKPLACE
Information on harmful effects of drugs and alcohol utilizing the following media:
- - Posters, Comics, Seminars, Newsletter, Leaflets, Posters, Comics, Seminars, Newsletter, Leaflets, Paging System, Stage Presentation, Skits, Exhibitions Paging System, Stage Presentation, Skits, Exhibitions and Film Showingand Film Showing
Example:Example:
STRATEGIES FOR DRUG ABUSE STRATEGIES FOR DRUG ABUSE PREVENTION IN THE WORKPLACEPREVENTION IN THE WORKPLACE
Education
Example:Example:
Employee Education ProgramEmployee Education Program Training of Staff/Supervisors for Training of Staff/Supervisors for EAPEAP
Training on ParentingTraining on Parenting
STRATEGIES FOR DRUG ABUSE STRATEGIES FOR DRUG ABUSE PREVENTION IN THE WORKPLACEPREVENTION IN THE WORKPLACE
Positive alternatives - opportunities for wholesome recreation and self-expression.
- Sports, Cultural Activities and Livelihood Activities
Example:Example:
ineffective parentingineffective parenting
chaotic home environmentchaotic home environment
lack of mutual attachments/nurturinglack of mutual attachments/nurturing
inappropriate behavior in the classroominappropriate behavior in the classroom
failure in school performancefailure in school performance
Prevention Programs Should . . . .Prevention Programs Should . . . .Reduce Risk FactorsReduce Risk Factors
www.drugabuse.gov
poor social coping skillspoor social coping skills
affiliations with deviant peersaffiliations with deviant peers
perceptions of approval of drug-using behaviors perceptions of approval of drug-using behaviors in the school, peer, and community environmentsin the school, peer, and community environments
Prevention Programs Should . . . .Prevention Programs Should . . . .Reduce Risk FactorsReduce Risk Factors
www.drugabuse.gov
Prevention Programs Should . . . .Prevention Programs Should . . . .
strong family bonds parental monitoring parental involvement success in school performance prosocial institutions (e.g. such as family,
school, and religious organizations) conventional norms about drug use
www.drugabuse.gov
Enhance Protective FactorsEnhance Protective Factors
Resist drugs
Strengthen personal commitments against drug use
Increase social competency
Reinforce attitudes against drug use
Prevention Programs Should . . . .Prevention Programs Should . . . .
www.drugabuse.gov
Include Interactive Skills-Based Training
Involve Communities and SchoolsInvolve Communities and Schools
Media campaigns and policy changes
Strengthen norms against drug use
Address specific nature of local drug problem
www.drugabuse.gov
Prevention Programs Should . . . .Prevention Programs Should . . . .
Provides greater impact than parent-only or child-only programs
Include at each stage of development
Involve effective parenting skills
Prevention Programs Should be. . . .Prevention Programs Should be. . . .
www.drugabuse.gov
Family-FocusedFamily-Focused
Have you changed your mind?Have you changed your mind?