SOC8385 - Motivating Substance Abusers through the Stages of Change: A Comprehensive Overview for Mental Health Professionals
by Ron Fagan, M.A., Ph.D.
Ron Fagan, M.A., Ph.D. is formerly a Professor of Sociology at Pepperdine University in Malibu, California. Dr. Fagan currently works as a licensed Marriage and Family Therapist in private practice and as a Clinical Care Manager, Employer Solutions, Magellan Health Services.
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This course is designed to provide the mental health clinician with a comprehensive overview of the topic of motivating substance abusers through the stages of change in treatment. Upon completing this course, the trainee will understand the following:
- American attitudes toward alcohol and other drugs
- The nature and extent of alcohol use and the use of other drugs
- The different types of alcohol and other drug users
- Factors that affect the drug experience, including those that contribute to drug dependence
- Factors that influence people’s motivation for change
- Motivation and the five stage model of change
- Ways to increase people’s motivation for change
- The techniques of motivational interviewing
- Learn about harm reduction
- Techniques for working more successfully with substance abusers
This intermediate level course is primarily designed for clinicians in the middle stages of their career, or for clinicians reviewing basic concepts in this treatment area.
5 contact hours: Core clinical
IF THE TRAINEE WISHES TO USE THIS COURSE TO MEET HIS/HER CONTINUING EDUCATION REQUIREMENTS FOR LICENSURE, HE/SHE MUST AGREE TO THE FOLLOWING:
- to complete this course in its entirety
- to complete all exercises contained in this course
- to complete the course post-test
- to complete the evaluation form after taking this course
Your decision to continue at this time constitutes acceptance of this agreement.
Section One: Introduction - Alcohol and Other Drug Use
American Attitudes toward Alcohol and Other Drugs
Throughout our history, Americans have always had ambivalent feelings, policies, and practices about alcohol and other drugs (AOD). On the one hand, many types of drugs provide benefits for people. You may know someone who has been plagued by chronic depression, but who is now living a better life as a result of antidepressant drugs. There is research that shows that moderate alcohol consumption can have many health benefits including decreasing cardiovascular disease.
On the other hand, other types of drugs and drug use have caused significant harm to individuals and the people around them. This includes not only people who abuse illegal drugs such as heroin or cocaine, but also people who abuse legal drugs such as alcohol and prescription medications. You might know someone who was prescribed a prescription drug only to become addicted to it with continued use. You probably know people who started out as moderate drinkers, but who progressed to alcohol abuse.
Why some drugs are legal and other drugs are illegal is a complicated question which often has more to do with history and politics than to the harm the substance causes. Why some people use drugs and some do not and why some people abuse drugs and some do not is also a complicated question. It has been said that there are four primary human drives: hunger, thirst, sex, and the desire to alter our consciousness. Drugs have been used throughout human history to alter consciousness.
Two dimensions distinguish types of drug use: legal status and goal or purpose of use (Goode, 2005). With respect to legal status, the use, the possession, and sale of some drugs are criminal acts. The legal status of a drug’s use is determined by factors such as age (i.e., 18 years of age for alcohol consumption), source of the drugs (i.e., prescription from a doctor), and place of use (i.e., driving while under the influence of drugs). With respect to goal or purpose, the same drug can be used for a variety of different reasons by different users and even the same person may use the same drug for different reasons at different times and in different situations.
It is also useful to distinguish between instrumental use (using a drug as a means to an end) and recreational use (using a drug to achieve a pleasurable effect). Each of these types of drug use will attract different users whose patterns and frequencies are significantly different.
Legal instrumental use: taking prescribed drugs and over-the-counter (OTC) drugs to relieve or treat mental or physical symptoms
Legal recreational use: using such licit drugs as tobacco, alcohol, and caffeine to achieve a certain pleasurable mental or psychic state (i.e., to get high)
Illegal instrumental use: taking drugs without a prescription or using illicit drugs to accomplish a society approved task or goal (i.e., taking nonprescription amphetamines to drive through the night or relying excessively on barbiturates to get through the day)
Illegal recreational use: taking illicit drugs to achieve a certain pleasurable mental or psychic state (i.e., to get high)
Patterns of Alcohol and Other Drug Use
About 119 millions Americans, or about 30% of the American population 12 years of age or older, report current use of a tobacco product (cigarettes, cigars, smokeless tobacco, and pipes). About 40% of young adults aged 18 to 25 report current use of a tobacco product. About 15% of the American population could be classified as nicotine dependent because of the frequency and pattern of their cigarette use.
About one-half of Americans aged 12 or older are current drinkers of alcohol. About one-quarter of drinkers participated in binge drinking at least once in the last thirty days and almost 7% are heavy drinkers. The highest prevalence of binge and heaving drinking is for young adults aged 18 to 25, with the peak rate of both measures occurring at age 21. The rate of binge drinking is about 42% for young adults aged 18 to 25 and about 48% at age 21. Heavy alcohol use is reported by about 15% of persons aged 18 to 25 and by about 19% of persons aged 21. About 13% of persons aged 12 or older drove under the influence of alcohol at least once in the past year.
Almost 20 million Americans, or about 8% of the population aged 12 or older, are current illicit drug users. The rate of current illicit drug use by youth aged 12 to 17 is about 11%. Marijuana is the most commonly used illicit with a rate of about 6% followed by cocaine with a rate of about 1%. Almost one in three Americans currently use psychotherapeutic drugs taken non-medically.
Illicit drug use rates are highest for American Indians and Alaskan Natives (12%), followed by persons reporting two or more races (12%), Native Hawaiians or Other Pacific Islanders (11%), Blacks (8.7%), Whites (8.3%), Hispanics (8%), and Asians (3.8%). Almost 19% of unemployed adults aged 18 or older were current illicit drug users, compared with almost 8% of those employed full-time, and about 11% of those employed part time. Almost three-quarters of illicit drug users are employed either full- or part-time.
Almost one in ten American have serious mental illness. Adults who use illicit drugs are more than twice as likely to have serious mental illness than are adults who did not use an illicit drug. Among adults with serious mental illness, about 21% were dependent on, or abused, alcohol or illicit drugs, while the rate among adults without serious mental illness was only about 8%. About 13% of adults are currently receiving treatment for mental health problems.
The most commonly reported reasons for not receiving treatment were cost of insurance issues (45 %), not feeling a need for treatment at the time or thinking the problems could be handled without treatment (41%), not knowing where to go for services (30%), perceived stigma associated with receiving treatment (23%), and did not have time (18.%).
Almost one in ten Americans could be classified as being substance dependent or abusers. About three-quarters of adults with substance dependence or abuse were employed either full- or part-time. It is estimated that about 22% of Americans need treatment for alcohol or illicit drug problems, but only less than 2% of the population received some kind of treatment for a problem related to the use of alcohol or illicit drugs in the past year. About 26% of the people who felt they needed treatment reported that they made an effort, but were unable to get treatment, while about 74% reported making no effort to get treatment.
Among those people who reported they needed treatment but did not receive treatment, the most often reported reasons for not receiving treatment were not ready to stop using (41%), cost or insurance barriers (33%), stigma of being in treatment (20%), and did not feel the need for treatment at the time or could handle the problem without treatment (17%)(www.whitehousedrugpolicy.gov).
Types of Drug Users
Drug users vary according to the reasons for their drug use, frequency of use, and types and amounts of the drugs they consume. It is possible to identify three basic types of drug users:
Experimenters begin using drug largely because of peer pressure and curiosity and they confine their use to recreational settings. Generally, they more often enjoy peers who also use drugs recreationally. Alcohol, tobacco, marijuana, hallucinogens, and many of the major stimulants comprise most of the drugs they are likely to use. They are usually able to set limits on when these drugs are taken (often preferred in social settings) and they are more likely to know the difference between light, moderate, and chronic use.
Compulsive users, in contrast, devote considerable time and energy to getting high. For compulsive users, recreational fun is impossible without getting high. Other characteristics of these users include the need to escape or postpone personal problems, to avoid stress and anxiety, and to enjoy the sensation of the drug’s euphoric effects. Often, they have difficulty assuming personal responsibility, suffer from low self-esteem, and have an inability to cope with issues without drugs.
Floaters or Chippers focus more on using other people’s drugs without maintaining a steady supply of drugs. Nonetheless, floaters or chippers, like experimenters, are generally light to moderate consumers of drugs. Chippers vacillate between the need for pleasure seeking and the desire to relieve moderate to serious psychological problems. As a result, most are on the path to drug dependence. They often drift between experimental drug-using peers to chronic drug-using peers. In a sense, these drug users are marginal individuals who do not strongly identify with experimenters or compulsive users (Hanson, Venturelli, & Fleckenstein, 2004).
Factors Affecting the Drug Experience
Basically, people use drugs because they like the way drugs make them feel. Addiction does begin with drug use, when an individual makes a conscious choice to use drugs, but addiction is not just "a lot of drug use." There are four principal factors that affect how an AOD user will experience a drug: pharmacological, cultural, social, and contextual factors.
- Pharmacological factors refer to the ingredients of a particular drug that affect the functions of the body and the nervous system and in turn affect social behavior.
- Cultural factors are society’s views of drug use, as determined by custom and tradition, and these affect the initial approach and use of a particular drug.
- Social factors refers to the belief that attitudes about drug use develop from the values and attitudes of other drug users, the norms in the community, subcultures, peer groups, friends, and families, as well as the drug user’s need for, and personal experiences with, using drugs.
- Contextual factors are the physical surroundings where drug use takes place and these contexts influence the attitudes toward drug use and the types and amount of drug use.
Becoming Drug Dependent
Three concepts are important in understanding drug dependence: tolerance, physical dependence, and psychological dependence. Tolerance describes the need to progressively increase the dose of the drug to produce the effect originally achieved with smaller doses. Physical dependence involves becoming physically dependent on the drug including experiencing withdraw symptoms when the drug is not taken.
If a drug does not cause physical dependence, discontinuing the drug does not cause major withdrawal symptoms. However, most drugs cause tolerance, and in some cases, reactions after discontinuing use can resemble withdrawal symptoms. Psychological dependence is the feeling of satisfaction and a desire to repeat the drug experience or to avoid the discontent of not having it. This anticipation of effect is a powerful factor in the chronic use of psychoactive drugs and, with some drugs, may be the only obvious factor associated with intensive craving and compulsive use.
AOD users are a very heterogeneous group; they use drugs for a wide variety of reasons, and their drug use affects them in many different ways. Research indicates that there is no single cause of AOD abuse or addiction. While pharmacological and biological factors are very important, other psychological and social factors are of equal or greater importance in the initiation and maintenance of an AOD problem.
The initial use of drugs is most often adaptive, that is, the person perceives the drug as beneficial in some way, whether it is the pleasant feeling or euphoria that drugs can produce, or the desire to be accepted by one’s peers. Drug use or abuse crosses the line into drug addiction when the person feels they have to have the drug, and they will increase the amount and frequency of the drug they take.
Most of these AOD users are using drugs as a way to deal with life’s problems or with dysphoric moods. Often these users are clinically depressed or they evidence signs of some other type of psychiatric disorder. Most of these people are using AOD not simply to feel good, but they are using AOD in an attempt to counteract negative mood states. They are trying to “self-medicate” their feelings.
While the onset of their AOD use begins with the voluntary act of using AOD, their continued use changes into a compulsive craving behavior. However, few drug users become drug dependent. Most AOD users will experiment or use drugs during their young adulthood and either stop using some drugs or reduce the amounts of some of the drugs they use when they start assuming adult roles and responsibilities. Some people will continue their AOD use into adulthood and some of them will become AOD dependent.
Various factors, such as the person’s personality, genetic makeup, peer pressure, and/or life situation will affect a person’s likelihood of becoming addicted to a drug. In addition, some drugs, such as heroin and cocaine, produce a physical addiction more quickly for many people than do other drugs. Physical addiction appears to occur when repeated use of a drug alters reward pathways in the brain.
The addicting drug causes physical changes to some nerve cells (neurons) in your brain. Neurons use chemicals called neurotransmitters to communicate. Neurons release neurotransmitters into the gaps (synapses) between nerve cells and are received by receptors on other neurons and on their own cell bodies. The changes that occur in this communication process vary with the type of drug to which you're addicted, though researchers have discovered that addictive drugs, such as cocaine and morphine, all affect some nerve endings in the brain in the same manner (www.mayoclinic.com).
Recent research provides evidence that not only do drugs interfere with normal brain functioning, creating powerful feelings of pleasure, but they also have long-term effects on brain metabolism and activity. At some point, changes occur in the brain that can turn drug abuse into addiction, a chronic, relapsing illness. Those addicted to drugs suffer from a compulsive drug craving and usage, and most people find that they have a difficult time quitting by themselves. Treatment is usually necessary to end this compulsive behavior (Hanson, Venturelli, & Fleckenstein, 2004).
In conclusion, how people develop drug problems is very complex. The process is influenced by the pharmacological properties of the various drugs, the user’s predisposing physical characteristics including genetic predisposition and family history, gender factors, personality factors, social and cultural factors, socioeconomic factors, and the availability of AOD.
While many people have AOD use problems, a majority of them never get any formal treatment for their problems or, once they are in treatment, their drop out rate is very high. People do not get or go into treatment for a wide variety of reasons, including: they do not feel they have a significant problem, they feel they can address the problem on their own or at least without being in a formal treatment program, they have tried to address their problem in the past without success, they fear being stigmatized or labeled as an alcoholic or drug addict, they cannot afford treatment, and/or there are no attractive treatment options in their area.
The key is to design interventions and programs that target a person’s AOD problem and his/her level of motivation for change. This is the topic of our next section.