Lesson 15: Review and Summation

Attention

doctor holding an alcoholic drink with stehascope held agains the drink

Click HERE to read an article on Physicians who become Addicted

Learning Outcomes

Upon completion of this lesson's material, students will be able

  • State the case for SUDs as mental disorders
  • Enumerate the characteristics of a mental disorder
  • List the things that an MHRT/C can do to help their clients who have co-occurring disorders
  • Compare and contrast different approaches to helping with SUDs

Teaching

By now, when you read the article on physician drinking problems in the Attention section, you may feel dismay at the misunderstandings of these highly educated professionals. They seem to think that substance use related to stress should not afflict physicians or that if it does, it reflects character flaws. They see AUD rates of 10-15% as abnormally high although they are in the general range that we would expect for all occupational groups because the population-wide base rate (which we now believe is largely connected to genetic predisposition) is in this range. What we do not see in this article is an understanding that physicians who develop this problem have a chronic, progressive neurophysiologically based disorder that requires compassionate treatment the same as any other chronic progressive (medical) disorder.

Hopefully, by now everyone in the class can state the case for SUDs as mental disorders like schizophrenic and bipolar disorders.

Remember how DSM V defines mental disorders:

  1. a behavioral or psychological syndrome or pattern that occurs in an individual
  2. the consequences of which are clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning)
  3. must not be merely an expectable response to common stressors and losses (for example, the loss of a loved one) or a culturally sanctioned response to a particular event (for example, trance states in religious rituals)
  4. that reflects an underlying psychobiological dysfunction
  5. that is not solely a result of social deviance or conflicts with society
  6. that has diagnostic validity using one or more sets of diagnostic validators (e.g., prognostic significance, psychobiological disruption, response to treatment)
  7. that has clinical utility (for example, contributes to better conceptualization of diagnoses, or to better assessment and treatment)

SUDs meet the 1-7 criteria although we did discuss in our Lesson on hallucinogens religious use of hallucinogens that is culturally sanctioned. But even with peyote use by Native Americans, a person may suffer psychotic symptoms that require psychiatric care if the symptoms persist past the time of the ritual.

Historical Viewpoint

Historically SUDs have been seen to reflect character flaws that lead the person to abuse a substance like alcohol that others can keep under control. Hopefully by now we all understand that although choice plays a role with these disorders as it does with most disorders, bad choices do not define SUDs. Like Type II diabetes, where obesity and lack of exercise and poor diet play a role but which cannot occur without the genetic predisposition, SUDs may occur in the context of lifestyle decisions ( heavy drinking, poor stress management, poor use of social supports) but cannot exist without changes in neurophysiology that meet criterion D for mental disorders. These neurophysiological changes may not always be related to genetic predisposition but based on current research that is the most likely explanation.

Advantages of the Scientific Appraoch

The advantage to following the science here is that in our culture medical problems are generally seen as a focus for compassionate care rather than condemnation or invocation of shame.

The genetic theory and the disease theory of SUDs may be modified or understood differently in future times. But for now they comprise the result of a long hard battle to take substances and the problems associated with them out of the realm of blame and shame and into the realm of the scientific and humanistic understanding of human behavior.

You have learned that substances are generally desired by humans (and indeed other species) because they cause an enhanced response n the reward center of the brain.

Substances differ in chemical effects, but generally have a final common pathway causing increased presence of dopamine in the reward center.

Both the final common pathway and the earlier differences in chemical effects are important in treating the substance disorder and so we have labored to understand how stimulants differ from sedatives and from cannabis and other substances.

We have also tried to understand how people come to be aware of a need for change and how to enhance motivation and to acquire successful tools for change.

We understand that compassion and valuing the other as inherently worthful and worthy of self-actualization is at the heart of helping worthy of the name.

MHRT/Cs as community support/case managers help clients with co-occurring disorders to:

  • Sort out what they want and need.
  • Figure out how to achieve their goals in fulfilling their wants and needs.
  • Learn to accept and live with the parts of their lives that they cannot change.
  • Develop the skills that accomplish the first three objectives.
  • Deal with handicaps and barriers associated with their disorders.
  • Find and acquire the resources they need to accomplish all of the above.

Different Approaches

Finally, we now know that there are different approaches that recognize SUDs as a disease but differ in how they treat the disease. The 12 Step approach seen in AA and other self-help groups emphasizes a spiritual approach to the disease including recognition of powerlessness, turning our life and will over to a higher power, making moral changes with the help of our higher power and helping other people with the disease.

Psychiatrists by in large prescribe medications that help control cravings and reduce the stress associated with reducing or stopping use of the substance. They may also prescribe medications that help with co-occurring mental illnesses that exacerbate or otherwise contribute to SUDs,

Therapists help clients change thoughts, feelings and behaviors so that they can live successfully without the substance and deal with lapses so that they don't become relapses.

Harm Reduction

Harm reduction and abstinence are possible goals for SUDs.

Harm reduction with clients is taking a look with them at their patterns of drinking and figuring out which patterns cause trouble and then making changes. For example, if a client figures out that they can't resist social pressure to binge (e.g. at a party with their friends), they may decide not to go to parties and only to drink at home. Or they may ask their doctor to prescribe naltrexone and take that before they go to the party so that alcohol doesn't give them the same pleasure and so that they aren't tempted to drink too much.

Harm reduction recognizes that use may continue but tries to ameliorate the negative impact by political, social and personal interventions.

Abstinence is a strategy that recognizes that the person can't control their use of the substance and that aims at zero use, usually for the rest of their life. For the most part, people don't want this strategy until they have become convinced through reason and their life experiences that it is warranted. Following a harm reduction approach at first may help the client arrive at this conclusion. Or if the harm reduction works it may save the client from the hardships of making the big changes generally associated with abstinence.

In any case, it's another instance of both/and rather than either/or. We use the strategy that works with this client at this time.

Social Policy Interventions

Examples with alcohol of political and social interventions are use of taxes to reduce use,
ad campaigns to reduce drunken driving, education about safe drinking, etc. etc.

Assessment

Lesson 15 Quiz

  1. Make the case with someone who says that an alcoholic "just needs willpower!" Tell them what are the problems with this approach. List and describe at least three and up to five problems.
  2. The Lesson says that MHRT/Cs do (at least) six things to help people with co-occurring disorders. List the six and give examples of each.
  3. List the A through G characteristics of a mental disorder and give examples of each.

Special Assignment

Complete the Critical Thinking Special Assignment available in the Special Assignments folder in the course.

Remember, you mist post TWICE in EVERY discussion board. Your first post should address the topic of the discussion (like the one above) and your second post must be a reply to ANOTHER students' post...your reply should be MORE than just a "I agree!" or "Very cool!" It should be "substantive" by expanding on the students post, asking a questions, adding your own thoughts to what they have said, etc.