Serous effects of Substance abuse and Alcohol abuse all over the world including India is now an important problem.
Addiction in not a new phenomenon. Man has used opium and its derivatives for over five thousand years. Opium is a mixture of a number of alkaloids of which Morphine, Pethidine are important and used as sedative and pain killer. Following the discovery of Heroin (Diamorphine) from Morphine, it was widely prescribed as pain reliever in place of Morphine. But Heroin was found to be an addictive agent and its medical use was stopped because of an elicit drug. During the last few years there is remarkable increase in the use of psychoactive (mind altering) drugs in our society. The most commonly used substance for addiction are heroin or brown sugar (adulterated from of heroin), cannabis (Ganja, Bhang, Charas, Marijuana etc) barbiturates, cocaine, sedative and some socially approved substances like Alcohol and Nicotine.
Substance abuse and Alcoholism has increased after 1970’s and younger, people are becoming the victims and exposed themselves at risk of serious physical, psychological and social harm. Adolescents are the most vulnerable age group for developing substance abuse problem.
Now regarding management of Substance Related Disorder and Disorders associated with alcohol, multidisciplinary approach is essential, here the role psychosocial therapy, such as psychotherapy and counseling is important.
Counselling is an act of assistance. It is a particular form of brief Psychotherapy and the term is used in specific sense to refer to methods developed by Carl Roger. By counseling an individual is assisted to become self-sufficient, self-dependent, self-directed and to adjust efficiently to the demands of a better and meaningful life.
Let’s discuss here why, when and how Counselling is helpful in the management of substance-related disorders and disorders associated with Alcohol.
In the management of substance abusing persons early detection and evaluation is essential which is followed by pre-detoxification couselling, detoxification and After Care (Which includes Post-detoxification couselling, Occupational Therapy, Rehabilitation etc.)
The outline of management of Alcohol abuse as follows:
- Aversion therapy, done in some selected cases.
- Long term Institutional care, indicated in some cases.
- Occupation therapy.
- Hostels for some Young alcoholics
- Other useful resources or organizational support for changing the life style such as Alcohol Anonymous (AA)
Limited drinking,
One has to remember that substance abusing patients are often difficult for detection and evaluation, because they are prone to use denial, usually unreliable. Substance abuse frequently coexist with other psychiatric conditions, such as personality disorder, anxiety disorder and Mood disorder. Alcohol dependence and abuse may have co-morbidity with other mental disorders, such as anxiety, depression and insomnia.
In both substance abuse and disorders associated with alcohol dependence and tolerance are important to consider.
Dependence on a drug may be physical, psychological or both. Physical (Physiological) dependence is characterized by tolerance, a craving or need to take the drug to prevent the occurrence of a withdrawal or abstinence syndrome.
Psychological dependence referred to as habituation, characterized by a continuous or intermittent craving for the substance or alcohol.
Tolerance is the need for more substances or alcohol to produce desired effect. The development of tolerance, especially marked tolerance usually indicates dependence.
In the management of substance abuse or alcohol abuse initial treatment requires detoxification (as outpatient or institutional) and treatment of any withdrawal symptoms. Coexisting mental disorders also need medical and psychiatric treatment. But a patient must acknowledge that he or she has a substance abuse or drinking problem. The role of counseling here is important. By couselling insight to the problem is to develop, severe denial may have to be overcome and patient will cooperate in treatment. Family couselling with family members and group couselling will help in family and social rehabilitation. Psychosocial interventions in the form of couselling is effective and particularly family therapy should focus or describing the effects of substances or alcohol use on other family members.
Counselling, a brief form of psychotherapy is a specialized function. Psychotherapy and couselling indicated for substance abusers may be done by psychiatrist and/or psychologist who are members of the multidisciplinary team for the treatment and care. But couselling may be done by cousellors, psychiatric social workers and general practitioner with adequate knowledge and training in couselling. As in psychiatry, a number of different theories are used to explain human behavior, each theory has corresponding techniques. These techniques are based on the different underlying explanatory models of behavior. Certain clinical problems such as substance abuse or alcohol dependence may respond to more to one therapy than to another. Hence along with simple couselling other therapeutics techniques such as psychoanalytically oriented psychotherapy, behavior therapy, cognitive therapy and Interpersonal therapy (IPT) are also using for substance abusers and alcohol dependence patents.
Substance abusers with personality disorders or symptomatic and character logical problem can be benefitted by couselling along with psychoanalytically-oriented psychotherapy. In this less intense form of classical psychoanalysis greater emphasis is given on day-to-day reality issue. It may be insight-oriented and supportive or relationship psychotherapy. In supportive therapy, the essential element is support rather than the development of insight (insight-oriented therapy). Support can take the form of limit setting, reassurance, increasing reality testing and advice with developing social skills.
Behaviors therapy is based on that maladaptive behavior can change without insight into its underlying causes and is based on learning theory, including operant and classical conditioning.
Operant conditioning is based on principle that behavior is shaped by its consequences, that is, if behavior is positively reinforced it will increase, when punished it will decrease. If it elicits no response It will be extinguished. Classical conditioning is based on the premise that behaviors is shaped by coupled or uncoupled fro anxiety proving stimuli. Token economy, Aversion therapy, systemic desensitization, flooding are different types of behaviors therapy.
Cognitive therapy is useful to substance abusers or alcoholics with depression. It is based on the theory that behavior is secondary to the way in which person think about themselves and their role in society. Ingrained, stereotyped thoughts can lead to cognitive distortions or error in thinking.
Interpersonal therapy (IPT) usually helps a substance abusers with depression to improve interpersonal life. In this short term therapy the therapist is very active in helping to formulate the patient’s predominant interpersonal problem areas. It focus on interpersonal stress related to current psychosocial problem. In this therapy intrapsychic conflicts are not addressed or stressed and emphasis is given on current interpersonal relationship.
The different approaches to couselling are based on the varying conceptions of human personality structure and dynamics. Couselling, a client centred therapy of Carl Roger has been by far the most widely used humanistic approach to therapy. Humanistic-Existential therapies are based on assumption that man has freedom to control his won behavior. One can reflect upon his won problems, make choices and take positive actions. It is assumed in this therapy that the individual himself must take most responsibilities in the course of therapy with the therapist serving as cousellor, guide and facilitator.
Counselling therapies can broadly be divided into
i) Supportive therapy – it may involve persuasion, reassurance, pressure and prestige suggestion. It is used to help a person. (likesubstance abuser) through a time limited crises caused either by social problems or by physical illness. In this method patient is encouraged to talk freely about his problem while counselor listens sympathetically. The Cousellor offers advice and may use deliberate suggestion in order to help the client through a shortlived worsening of the symptoms. Listening and Reassurance are important and prestige suggestion (such as patient is encouraged to take responsibility for his own actions and to work out solution of his own problem) is valuable.
ii) Insight therapies – it may be (a) re-educative and (b) reconstructive.
Re-educative approaches to therapy are directed towards producing more harmonious self-structure Roger’s client centered approach is an outstanding example of insight therapy with re-educative goal.
The re-constructive approach to therapy has for its objective the gaining of insight into an individual’s unconscious conflicts. It brings about extensive alteration in the individual’s character structure and release of energies for the development of new adaptive capacities.
Insight therapies instead of removing the anxiety producing sources or factors in the life of the individual, reduce or remove, if possible, anxiety of the patient by altering the perception of the individual.
No doubt, couselling for the drug victims or alcohol abuser need some special attention during couselling, Drop out, relapse are inevitable problem.
Relapse is a very controversial and critical issue in counseling and management of substance abusers including alcohol, dependence. Relapse is the breakdown or failure in a patient’s attempt to change or modify any target behavior. Normally it means as the act of taking alcohol or substance (drug)after a period of abstinence. During conselling one has to remember the possible reasons of relapse-
Readjustment problem : fails to adjust in family and work place. Poor rehabilitation.
Emotional problem : Sense of inferiority, shame depressed mood.
Lack of motivation : unwillingness for treatment and follow up.
Abnormal though process : fear, loneliness, co-morbid mental disorder, like depression, schizophrenia.
Peer group pressure : teasing by friends, temptation by peddlers.
Social rejection : aloofness and apathetic family members and community
Excess pressure of family members
Adequate and proper relapse prevention strategies are to be considered during counseling of substance abusers.
Treatment approach including couselling for substance abuse particularly poly-substance dependence vary according to chemical nature of substances, patterns of abuse, patient’s physical and psychological features and available psychosocial support systems. Counseling and Psychotherapy may induce beneficial effects to substance abusers and Alcohol dependence along with family and community support and care.
References:
- Anthony, J. Drug Dependence and Illicit Drug Use, Curr. Opinion Psy. 4 1991
- Beck A, A. cognitive therapy. Int. University Press New York, 1976.
- Gray D. counselors in Gen Practice J. R. Coll. Gen. Prac. 38, 1988.
- Ghodse, H. Drugs and Addictive Behavior: A Guide to treatment Blackwell Scientific Pub. Oxford 1989.
- Kaplan & Sadock. Synopsis of Psychiatry, 8th Ed.
- Kaplan & Compressive group Psychotherapy 3rd Ed. 1983.
Merikanga et al. (1998) Arch. Gen. Psychiatry 55, 973-979.
– Dr. Vinod Gajghate
