Introduction to Psychopathology

Substance Use

Drug Culture

• for some, college = drinking
• cultural embrace of Prozac
• using drugs for non-illnesses: Rogaine for baldness

Use vs. Abuse

Terms

Defining Terms

• Tolerance = increasing amounts for effects

• suffer withdrawal when substance is withdrawn

Demographics

• 18-30 years: prime age for drug use

• part of youth culture ("live fast, die young")

• socially sanctioned (turning a blind eye)

Why do drugs?

• Give you a feeling you like
• Remove feelings you don�t like

Good vs. Bad Drugs

Strong Biases

• Example: 15 y-o kid wrecks the family car, caught stealing money, bad grades

• Therapist: "Your daughter�s an alcoholic"

• Parents: "Thank God. We were worried it was drugs"

• monkeys trained in an operant conditioning paradigm to bar press for a reward

• 10 for nicotine; 100 for heroin; 10,000 for cocaine

Substance Abuse Assessment

• Requirement: Be clear about your biases (countertransferences)

Understanding Substance Abuse

• Biochemical

• Socio-cultural

• Psychodynamics

Biology

• inherit a predisposition that affects how the body responds to substances
• + stress & psychosocial factors = abuse

Clinical example:

Addiction Equation

Implications

• Can�t change underlying biology

• Re-orient your psychology towards biological facts

• If vulnerable to addiction, don�t put drugs into the equation

Substance Abuse Assessment

• Focus on the relationship the person has with the drug

• Drug = object (psychodynamic sense)

Drug Relationships

• casual use: substance = an acquaintance
• addiction = drug is my only friend

Obtaining a clinical picture

• compulsive use

• loss of control

• "reality testing" (continued use despite negative consequences)

Compulsive use

• substance use as an integral part of one�s life style

Loss of control

• person can not engage in controlled drinking
• develop tolerance (more alcohol to produce same result)
• will say "I�ll stop at 3 drinks" but can�t

Reality Testing

• Person has every reason to abstain but fails to do so

• not an index of their true capacities

• "true" depression, decompensation or delusional thinking?

• disturbance due to the drug�s effects and/or the user�s defensive structure

Addiction

• not frequency or amount
• but a matter of function
• life is too narrowly focused on relationship with drug

Assessing Addiction

• problems with self report

• "I only had 2 drinks" (but what if it�s a 24 oz. glass!)

Alternative to self-report

• What do you do for fun? To deal with stress? When you are on a date?
• Would you go to a restaurant w/o a liquor license?
• Range of substances you use?
• How use them? Alone? W/ someone else?

Clinical techniques

• Michigan Alcohol Screening Test (like MMPI can detect deception)
• Urine screens (to test compliance)

Drug Treatment

• produces violent GI distress
• requires compliance
• reduces impulse drinking

Issue of trust in the therapy relationship

• Assumption: addict can�t be trusted

• Control is taken out of the addict�s hands

Potential for receiving help

Immediate Goal

• if not addicted, controlled use possible (e.g. U of M�s Drinkwise program)
• if addicted, biology rules out use for virtually all

• Management of behavior
• abstinence
• reasonable limits
• understand triggers for relapse prevention

• Psychotherapy

• Self-help or 12 step groups

Group Treatments

• help with guilt & shame

• paradoxical: succeed by admitting failure

• addict can better identify with peers than a non-using authority

Groups

• harness user�s defenses

• teach them to rationalize in a different way ("at least, I�m sober")

• shift dependence (construct of a "higher power" & use of a sponsor in AA)

Objections to AA and 12 step programs

• spiritual, religious focus

• possible to get around this

• one patient: higher power is the cops; another: my kids

Treating users of illegal drugs

• With controlled use of illegal substances, therapist violates the law