Daily Archives: September 7, 2010

A Look At The Counseling Side


It seems the Mental Health profession is still in its infancy and has been developing since 1979.  While mental health counseling was being practiced before 1979, it was at this time that members of the AMHCA, the American Mental Health Counselors Association, decided that Mental Health Counselors should be recognized as a core profession in the field.  This decision caused the members to select several steps that they felt would need to take place in order to make this happen.  The AMHCA spear headed this development piece by piece in order to ensure the continuation of each process.  They decided a membership association would be needed, they felt standards should be built on a national level so members who successfully passed would hold national certification, they had a vision that the education these members received would be accredited and training programs would be readily available.  These members also felt that licensure should be available in all 50 states and that the competencies in order to gain the licensure should be standard.

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These visions started to become reality in 1980 when certifications became available nationally and shortly after that the National Board for Certified Counselors which is now known as the Clinical Academy of NBCC or “The Academy”.  The certifications offered by this organization are completely voluntary and in 1999 around 2,000 counselors were Certified Clinical Mental Health Counselors or CCMHC’s, to date that number is over 1,000. We have gotten as far as to have license recognition in every state.  In 1999, only a handful of states had licensing or certification requirements, by 2004 licensure was recognized by 48 states, as well as in the District of Columbia, and Puerto Rico.  In 2007 Nevada recognized licensure and by January 2012 California counselors, both grandfathered and new will have their licenses recognized.  Getting the Mental Health Counselor recognized as an actual profession has taken over 30 years and is as of now an ongoing procedure.  The movement by the states to recognize licensure is a great one, but the titles of the professionals are varied by state and national certification by the NBCC is voluntary and does not provide the counselor a license to practice.

National licensure either in lieu of or required in addition to the state requirements would be a step in the right direction because the requirements would be more stringent and a counselor would be able to move states without having to find out and adhere to new state requirements.

In 1986 and 1987, comprehensive training standards were set for Clinical Mental Health Counselors in order to help them gain creditability and clinical skills.  A Clinical Counselor would need to have a minimum of 60 semester credit hours and a minimum of 1,000 clock hours of clinical supervision. There are literally hundreds of programs that will train counselors but most are not accredited by the Council for Accreditation of Counseling and Related Educational Programs, or, CACREP.  The standards set for a Clinical Counselor will not help them qualify for payment from a third-party payer such as private insurance or Medicare.  The standards for this privilege are much higher.  Third party payment wasn’t even a reality for the Mental Health Counselor until 1993 and was a strong concern until that time.  The standards were developed by the AMHCA and include having at least 3,000 hours of clinical experience, a minimum of 100 hours completed face-to-face supervision, a counselor must adhere to their appropriate association’s code of ethics, they have to achieve a passing score on the clinical exam, and submit an actual counseling session as well as have the appropriate licensing.  The certifications, education and licensing requirements have helped to make the Mental Health Counseling field strong but there are some concerns that we will need to address sooner or later.

In the world today, online counseling is gaining strength, which could be a threat to the traditional counselor.  If online counseling grows into something that is more acceptable or used more often than traditional services, counselors with state licensing would be forced to adjust and begin practicing this way, causing even more competition than before.  At this time in our lives, through this media anyone can be a counselor, the qualifications can range anywhere from a Dear Abby wannabe to a highly licensed and trained counselor.  The only proof generally offered is on the “About” page.  This type of counseling claims to be faster, but is it really?

Is sending an email about a problem you are having and then waiting for an answer completely comforting?  Of course, it is faster than having to research counselors and then wait for an appointment.  The draw would be that it is useful for people who are comfortable writing out their feelings and they would rather have the anonymity that comes with the internet.  If you have difficulty getting out of your house or have physical limitations or if you are uncomfortable with traditional counseling this would be a good solution.   Some concerns would be, first and foremost is the fact that a person’s non-verbal cues are not visible, this would include body language, facial expressions, hand gestures, and sitting positions, not to mention tone and inflection in a person’s voice cannot be heard.  How many times have you sent an email and then had to explain because the receiving party misinterpreted what you were trying to say?  This could be a big deal because this is at least half of how you learn about the person you are counseling.  Another concern would be the ability to understand what the counselor’s background is.  In order to be sure you are getting what is posted on a counselor’s website the minimal you would need to do would be to check with the Better Business Bureau, which is recommended no matter who you choose to help you.  You could also go as far as to check the counselor’s credentials with their respective schools or perform a background check which would cost even more money than what you are already spending on counseling.  In reality, most people will not check the credentials of the counselor, they will take what is given and run with it.

Lastly, since each state has their own regulations for licensing, if you get a counselor online who is not licensed in your state, they could be considered to be practicing illegally, so there is no recourse if you feel that you should be able to file a law suit for any reason.  The most logical solution to this would be that online counselors should be regulated and licensed as well, this will take a lot of legislation as well as time to make this happen, but it will be a reality in the years to come.

Salary seems to be another threat in the mental health field.  Once licensed, an entry-level salary is in the low $30,000 level.  This seems to be due to employment mainly in non-profit organizations where individuals are responsible for payment, which calls for a lower, more competitive fee.  It does seem like there is more movement into specialty areas of counseling which could be a solution to this problem.  Areas such as developmental disabilities, addiction disorders, chronic or fatal health conditions, and sex abuse victims, but at the same time this carries a threat of its own.  The risk of this would be that the counselor could end up in a niche that doesn’t suit him or her.  They may have a hard time getting into another specialty which could cause them to leave the field all together.  This is a double edged sword and it seems like to succeed in this field it would be a good idea while you are still in school to work or volunteer closely with counselors who are already in the profession you think would be a good fit.  This could enable a counselor starting out to begin at a higher level of salary.

It is very evident that the face of mental health is not a positive one. This is a threat not only for the counselors because it is considered taboo for a person to seek help, but also for the clients because they are easily labeled abnormal or crazy.  It seems that in order to try to move past the stigma we face as a mental health community, we need to focus more on awareness and sensitivity so that the people who aren’t currently undergoing any kind of treatment will understand why others feel the need to find ways to help themselves. We could accomplish this by speaking publicly in middle schools or high schools and definitely in colleges and participating more on a community level.  The more we can make people aware that the services we offer do not necessarily mean that our clients are insane, the better the communities around our clients will feel, and the better our clients will feel about what they are doing to help themselves.

With issues like these it is easy to tell the counseling field is still in the beginning stages of development where Mental Health Counselors are concerned.  Even though the mental health counseling field still has a long way to go it has made great strides in the recent past.

We have gained recognition in each state with licensure; we have come to a point where we can get paid through third-party payers, albeit with some pretty lengthy requirements, we have even entered the technological world with online counseling.  Will the salary ever catch up with the other advancements we have made?  Will public opinion ever move past the stereo type that because you have chosen to seek help, instead of go it alone, there must be something drastically wrong with you?  We will make these advancements as well, but only with hard work and persistence and it will definitely take longer than it should.

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References:

Mental Health Counseling: Past, Present, and Future. Journal of Counseling & Development; Current Issues Medicare Coverage of Licensed Professional Counselors. www.counseling.org;

Defining the mental health counseling profession: Embracing historical and contemporary perspectives at the interface of theory, practice, research, and professional exchange.  Journal of Mental Health Counseling;

What’s Next for the Profession of Mental Health Counseling?. Journal of Mental Health Counseling;

The American Mental Health Counselors Association: Reflection on 30 Historic Years. Journal of Counseling and Development : JCD

Substance Abuse: Etiological Considerations


Over the course of the last few decades prevalence of substance abuse has increased on a global scale.  The lifetime prevalence of a substance use disorder in the general population is approximately 24%.  The lifetime prevalence of any mental disorder (excluding substance abuse/dependence) is approximately 22.5%.  (McDowell & Clodfelter Jr., 2001)  Despite the increase, no single etiological path has been identified as a precipitating cause.  “Many interrelated factors influence a person’s decision to use substances.  These include psychological (intrapersonal and interpersonal), biological, environmental, and cultural factors.”  (Netherton, Holmes, & Walker, 1999, p. 245)  This essay will attempt to address some of the more predominant etiologies as related to substance abuse, with the express understanding that no single explanation is solely plausible due to the interactional and interdependent natures of the etiologies themselves.

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Individualized personality traits have been inexorably linked to problem drug behavior.  The “addictive personality” has come to represent individuals whom demonstrate significant levels of neuroticism; disinhibitory tendencies; anti-sociality; novelty seeking; negative affect; low self-esteem; anxiety sensitivity; hopelessness; sensation seeking; and impulsivity.  All of these individualized variables and personality traits can be employed to predict both nature and course of substance use.  (Blaney & Millon, 2009, p. 271, p. 260)  “Drug abusers show deficits in impulsive choice and inhibition, although it is impossible to know whether difference in impulsivity caused or were caused by drug abuse.”  (Perry & Carroll, 2008, p. 19)  Reyno and associates (2006) found that anxiety sensitivity was strongly related to alcohol consumption in certain high risk situations.

Genetically speaking, “having a biological parent who was or is alcoholic increases one’s risk for alcoholism about 2.5 times, regardless of whether one was raised by that parent.”  (Blaney & Millon, 2009, p. 261)  Drug availability, when coupled with permission parental attitudes (up to and including parental drug use), has been shown to facilitate adolescent initiation and use of substances.  (Blaney & Millon, 2009, p. 258)  Parental smoking has been shown to increase risk for substance use in adolescent offspring.  (Keyes, Legrand, Iacono, & McGue, 2008)  As severity of substance abuse in the family increases, the negative consequences on adolescent development increase and are manifested in physical symptoms and negative mood.  (Gance-Cleveland, Mays, & Steffen, 2008)  It has been suggested that removal of the child from the substance abusing household can result in significant gains in child cognitive functioning.  McNichol & Tash (2001) found that children placed in forster care presented with low to average cognitive skills, but that they made disproportionate and significant improvement during placement.  Furthermore, they found that children with prenatal exposure to drugs scored significantly lower at the beginning of the placement, but made significantly more progress than the other children during placement.  This research seems to suggest that prenatal exposure to drugs, while regrettable, is not a “life sentence” for children.

Since adolescents place great value on peer opinions and struggle to fit in, peers contribute to the onset of drug use first by providing access to the substance by contributing to developing attitudes regarding expectancy.  (Blaney & Millon, 2009, p. 258; Netherton et al., 1999, p. 247)  Early expectancies of personal response to drug use have been shown to predict later use.  (Blaney & Millon, 2009, p. 268)  Research suggests that doing things in order to be popular with others is strongly related to feeling pressured by others, and that peer pressure is a far stronger predictor of risk behaviors and potential psychosocial difficulties than popularity.  (Santor, Messervey, & Kusumakar, 2000)

There is considerable evidence that severe trauma (e.g., disaster, assault, combat) greatly increase the risk for drug use and abuse.  (Blaney & Millon, 2009, p. 260)  In an exemplary study, Brave Heart (2003) leveraged the Lacota population to demonstrate that historical trauma (HT) has substance abuse ramifications, deemed to be a historical trauma response (HTR).  HT represents the cumulative emotional and psychological wounding over the lifespan and across generations.  HTR manifests in traumatized populations as depression, self-destructive behavior, suicidal thoughts and gestures, anxiety, low self-esteem, anger, difficulty recognizing and expressing emotions, and substance abuse.  (Brave Heart, 2003)  There is also evidence to the contrary, with research that suggests that among homeless men, trauma experiences are strong indicators of mental health problems, but are not indicators of either physical health or substance abuse problems.  (Kim, Ford, Howard, & Bradford, 2010)

The weight of cultural influences is colossal, as demonstrated by relative conformity of subcultures within a specific society, and by the wide comparative variability between and among cultures and subcultures.  (Blaney & Millon, 2009, p. 255)  For example, “the holocaust experienced by American Indian and Alaska Native (AI/AN) peoples during the past five centuries includes ravaged communities, destroyed families, the brutal murder of hundreds of thousands of AI/AN people, organized attempts to erase rich cultures and beautiful languages, and trans-generational scars that affect AI/ANs to this day.”  The subsequent introduction of alcohol and other substances have resulted in high rates of sexual and physical trauma, high death rates from physical complications of substance abuse, suicide, homicide, depression, grief, poor school performance, and low employment rates.  (Gray & Nye, 2001)

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References

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Brave Heart, M. Y. (2003, Jan-Mar). The historical trauma response among natives and its relationship with substance abuse: A Lakota illustration. Journal of Psychoactive Drugs, 35(1), 7-13. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=338232111&sid=18&Fmt=3&clientId=4683&RQT=309&VName=PQD

Gance-Cleveland, B., Mays, M. Z., & Steffen, A. (2008, Jan). Association of adolescent physical and emotional health with perceived severity of parental substance abuse. Journal for Specialists in Pediatric Nursing, 13(1), 15-25. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1418986821&sid=20&Fmt=3&clientId=4683&RQT=309&VName=PQD

Gray, N., & Nye, P. S. (2001). American indian and alaska native substance abuse: Co-morbidity and cultural issues. American Indian and Alaska Native Mental Health Research (Online), 10(2), 67-84. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1077011111&sid=19&Fmt=3&clientId=4683&RQT=309&VName=PQD

Keyes, M., Legrand, L. N., Iacono, W. G., & McGue, M. (2008, Oct). Parental smoking and adolescent problem behavior: An adoption study of general and specific effects. The American Journal of Psychiatry, 165(10), 1338-1344. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1567487491&sid=7&Fmt=4&clientId=4683&RQT=309&VName=PQD

Kim, M. M., Ford, J. D., Howard, D. L., & Bradford, D. W. (2010, Feb). Assessing trauma, substance abuse, and mental health in a sample of homeless men. Health & Social Work, 35(1), 39-48. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1969768361&sid=18&Fmt=3&clientId=4683&RQT=309&VName=PQD

McDowell, D. M., & Clodfelter Jr., R. C. (2001, Apr). Depression and substance abuse: Considerations of etiology, comorbidity, evaluation, and treatment. Psychiatric Annals, 31(4), 244-251. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=71687723&sid=22&Fmt=4&clientId=4683&RQT=309&VName=PQD

McNichol, T., & Tash, C. (2001, Mar/Apr). Parental substance abuse and the development of children in family foster care. Child Welfare, 80(2), 239-256. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=70552258&sid=20&Fmt=4&clientId=4683&RQT=309&VName=PQD

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

Perry, J. L., & Carroll, M. E. (2008, Sep). The role of impulsive behavior in drug abuse. Psychopharmacology, 200(1), 1-26. doi: 10.1007/s00213-008-1173-0

Reyno, S. M., Stewart, S. H., Brown, C. G., Horvath, P., & Wiens, J. (2006, Aug). Anxiety sensitivity and situation-specific drinking in women with alcohol problems. Brief Treatment and Crisis Intervention, 6(3), 268-282. doi: 10.1093/brief-treatment/mhl007

Santor, D. A., Messervey, D., & Kusumakar, V. (2000, Apr). Measuring peer pressure, popularity, and conformity in adolescent boys and girls: Predicting school performance, sexual attitudes, and substance abuse. Journal of Youth and Adolescence, 29(2), 163-182. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=53959633&sid=17&Fmt=4&clientId=4683&RQT=309&VName=PQD

Comorbidity: Substance Abuse Disorders (SUDs)


Comorbid, or comorbidity, is literally defined as “recurring together.”  (Shiel, Jr. & Stoppler, 2008, p. 94)  For our purposes, comorbidity will refer to cases where two or more psychiatric conditions coexist, and where one of the conditions is a substance abuse disorder (SUD).  “There are 11 groups of substances specifically discussed in the DSM-IV: alcohol; amphetamines and related sympathomimetics; caffeine; cannabis; cocaine; hallucinogens; inhalants; nicotine; opiates; phencyclidine and related drugs (PCP); and sedatives, hypnotics, and anxiolytics.”  (Colman, 2009, p. 741)  Any one of the above substances, or combination of the above substances, can contribute to and be related this discussion of comorbidity with SUDs.

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Although this list is by no means exhaustive, “long-term substance use is related to psychiatric conditions such as suicide and depression, affective disorders, eating disorders (ED), and personality disorders (PD).”  (Netherton, Holmes, & Walker, 1999, p. 248)  Increased risk of mood disorders has been documented across all substance categories and across all mood related diagnoses.  (Blaney & Millon, 2009, p. 287)  Substance-Related Disorders are commonly comorbid with many mental disorders, including Conduct Disorder in adolescents; Antisocial and Borderline Personality Disorders, Schizophrenia, Bipolar Disorder.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 204)   Schneier et al. (2010) also concluded that alcohol use disorders and social anxiety disorder (SAD) is a prevalent dual diagnosis, associated with substantial rates of additional co-morbidity.

ADHD represents a risk factor for substance abuse.  ADHD patients with a high degree of nicotine consumption may be consuming large quantities as a form of self-medication.  Nicotine and alcohol, when combined, pose a markedly greater risk for the development of other addictions.  (Ohlmeier et al., 2007, p. 542)  There is “high comorbidity between heavy drinking and heavy smoking.”  (Blaney & Millon, 2009, p. 266)  These admissions seem to support the premise that alcohol and nicotine continue to serve as “gateway drugs” for people whom suffer from ADHD.

“In terms of clinical presentation, a concurrent Personality Disorder (PD) diagnosis is associated with an earlier age of onset of alcohol-related problems, increased addiction severity, more secondary drug use, more psychological distress, and greater impairment in social functioning.  As for course in addiction treatment, a concurrent PD diagnosis has been associated with premature discontinuation of treatment, earlier relapse, poorer treatment response, and worse long-term outcome.”  (Zikos, Gill, & Charney, 2010, p. 66)  Cluster B (Antisocial, Borderline, Histrionic, and Narcissistic) Personality Disorders (PDs) appear to be particularly prevalent, perhaps because the link between substance dependency and antisocial behavior can be found genetically.  (Blaney & Millon, 2009, p. 263)

“Among individuals with schizophrenia, between 40% and 50% also meet criteria for one or more substance use disorders.”  (Blaney & Millon, 2009, p. 288)  Comorbid substance use complicates adherence to sometimes complex schizophrenia treatment regimens.  Poor adherence to treatment results in worsening of schizophrenia symptoms, relapse, worsening of overall condition, increased utilization of health care facilities, re-hospitalization, reduced quality of life, social alienation, increased substance abuse, unemployment, violence, high rates of victimization, incarceration, and death.  (Hardeman, Harding, & Narasimhan, 2010, p. 405-406)  The compounding effect of substance abuse on the quality of life for individuals with schizophrenia can’t be understated.  Substance abuse is particularly common and also worsens the course of schizophrenia.  (Buckley, Miller, Lehrer, & Castle, 2009, p. 396)

Differential diagnosis and treatment can sometimes be a troublesome proposition.  Comorbidity complicates the diagnosis, treatment, and clinical course of Substance Abuse Disorders (SUDs).  (Blaney & Millon, 2009, p. 287)  “If symptoms precede the onset of substance use or persist during extended periods of abstinence from the substance, it is likely that the symptoms are not substance induced.”  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 210)  Carbaugh and Sias (2010) concluded that successful outcomes can be increased through proper diagnosis and early intervention, at least in the case of comorbid Bulimia Nervosa and substance abuse.  Prevention of substance use disorders can help alleviate or decrease much impairment in psychiatric patients in particular.  (Powers, 2007, p. 357)  Furthermore, a review of treatments for patients with severe mental illness and comorbid substance use disorders concluded that mental health treatment combined with substance abuse treatment is more effective than treatment occurring alone for either disorder or occurring concurrently without articulation between treatments.  (Hoblyn, Balt, Woodard, & Brooks, 2009, p. 54)

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Buckley, P. F., Miller, B. J., Lehrer, D. S., & Castle, D. J. (2009, Mar). Psychiatric comorbidities and schizophrenia. Schizophrenia Bulletin, 35(2), 383-402. doi: 10.1093/schbul/sbn135

Carbaugh, R. J., & Sias, S. M. (2010, Apr). Comorbidity of bulimia nervosa and substance abuse: Etiologies, treatment issues, and treatment approaches. Journal of Mental Health Counseling, 32(2), 125-138. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=2026599321&sid=2&Fmt=3&clientId=4683&RQT=309&VName=PQD

Colman, A. M. (2009). Oxford dictionary of psychology (3rd ed.). Oxford, NY: Oxford University Press.

Hardeman, S. M., Harding, R. K., & Narasimhan, M. (2010, Apr). Simplifying adherence in schizophrenia. Psychiatric Services, 61(4), 405-408. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=2006767471&sid=3&Fmt=3&clientId=4683&RQT=309&VName=PQD

Hoblyn, J. C., Balt, S. L., Woodard, S. A., & Brooks, J. O. (2009, Jan). Substance use disorders as risk factors for psychiatric hospitalization in bipolar disorder. Psychiatric Services, 60(1), 50-55. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1654365811&sid=6&Fmt=3&clientId=4683&RQT=309&VName=PQD

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

Ohlmeier, M. D., Peters, K., Kordon, A., Seifert, J., Wildt, B. T., Weise, B., … Schneider, U. (2007, Aug). Nicotine and alcohol dependence in patients with comorbid attention-deficit/hyperactivity disorder (ADHD). Alcohol and Alcoholism : International Journal of the Medical Council on Alcoholism, 42(6), 539-543. doi: 10.1093/alcalc/agm069

Powers, R. A. (2007, May). Alcohol and drug abuse prevention. Psychiatric Annals, 37(5), 349-358. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1275282831&sid=5&Fmt=3&clientId=4683&RQT=309&VName=PQD

Schneier, F. R., Foose, T. E., Hasin, D. S., & Heimberg, R. G. (2010, Jun). Social anxiety disorder and alcohol use disorder co-morbidity in the National Epidemiologic Survey on Alcohol and Related Conditions. Psychological Medicine, 40(6), 977-988. doi: 10.1017/S0033291709991231

Shiel, W. C., Jr., & Stoppler, M. C. (Eds.). (2008). Webster’s new world  medical dictionary (3rd ed.). Hoboken, NJ: Wiley Publishing.

Zikos, E., Gill, K. J., & Charney, D. A. (2010, Feb). Personality disorders among alcoholic outpatients: Prevalence and course in treatment. Canadian Journal of Psychiatry, 55(2), 65-73. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1986429431&sid=1&Fmt=3&clientId=4683&RQT=309&VName=PQD

Substance Abuse Grab-bag


On the subject of terminology, I thought it was rather odd that NHW made the statement that “the phrases ‘chemical dependency, addiction, and habit’ are still in use but less so than ‘substance abuse, use, or misuse;’” and then later citing “changes in the thinking in the field of chemical dependency.”  (Netherton, Holmes, & Walker, 1999, p. 241)  Perhaps that’s an indication that old habits are not easily broken.

The text again acknowledges that “the use of substances to cope, alter moods, or reach another level of consciousness has been an acceptable form of communication and expression for most of humankind.”  (Netherton et al., 1999, p. 242)  This statement alone suffices to encapsulate the difficulty of the task at hand.  Quite simply, there is a significant portion of the population that doesn’t recognize there is a problem.  “Substance use has become less stigmatizing among adolescents and is fiend less as a problem among their peers.”  (Netherton et al., 1999, p. 242)  Check and checkmate.

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I have trouble “getting behind” the disease model for substance use and abuse.  To my eyes, substance use appears more like a behavior than a disease.  In my experience, alcoholism is typically a secondary symptom stemming from another underlying physical cause or emotional disorder.  The degree and the prevalence of comorbidity would appear to support this position.  While I don’t disagree that the behavior needs to be recognized and addressed, I believe that addressing the underlying emotional disorder is critical to the long term success of these individuals.

Other substance-related models include the developmental model, the gateway model, problem behavior theory, cognitive models, the social learning model, and finally… the addictive behavior model.  I believe that social learning weighs heavily on the adolescent mind, and I wholly support the statement that “adolescents place great value on peer opinions and struggle to fit in.”  (Netherton et al., 1999, p. 247)  This serves as an entry point for the behavior, which then sets the tone for the addictive behavior model, which subsequently suggests that behaviors are a series of bad habits that have been over-conditioned to the extent that they become detrimental.

“Long-term substance use is related to psychiatric conditions such as suicide and depression, affective disorders, eating disorders, and personality disorders.”  (Netherton et al., 1999, p. 248)  This is only the second time in this class where we have listed entire categories as being comorbid with a specific disorder.  Is this the first mention of dual diagnosis in this class, or have we previously addressed that?

Addressing treatment, the treatment options range from pretreatment services, through outpatient treatment, to intensive inpatient treatment and/or residential care.  “Some of the fundamental treatment services include structure, dual diagnosis capabilities, pharmacological interventions, arrangements with medical care, role modeling, client participation in the therapeutic milieu, family groups, individual and group therapy, school/vocational training, recreational programs, relapse prevention, and 12-step support.”  (Netherton et al., 1999, p. 255)

Of the specific treatment approaches and interventions, I most identified with the harm reduction approach.  “Harm reduction, harm minimization, and risk reduction are terms that describe methods based on the assumption that habits can be placed along a continuum ranging from lowest risk to highest amount of risk.”  (Netherton et al., 1999, p. 258)  The object, or the goal, is the transition the individual along the continuum to a behavior that is less harmful.  It seems to be more progressive in its approach, with its intent to “normalize rather than marginalize substance abusers.”  I don’t think this is necessarily the ideal treatment for all people who suffer from alcohol-related problems, but I think it would be a less invasive and potentially better received option than some of the more stringent measures.

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Reference

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.