Addiction and Recovery
Addiction to substances is considered as a major threat to Individual, family and society. It damages homeostasis of physical, psychological and social functioning. Family members are pushed to myriad of problems including regular conflicts, financial problems, and decaying of social respect and acceptance. Clinically it has been observed most of the families take persons with addiction disorders for only when they are burnt out of care taking. It is always better to give treatment at early stages. World health organization has identified six cardinal symptoms of addiction disorders. Those are craving, withdrawal symptoms, tolerance, loss of control, salience and continued use despite of harmful effects. Three or more symptoms are signs for addiction. Craving is an individual’s intense urge to use substance, withdrawal symptoms are difficulties such as shivering of hands, seizure, difficulty to get sleep and body aches, which are experienced when people stop use, tolerance is understood as difficulty to get satisfaction with usual amount, and salience is a stage where drug use would be the main priority than other responsibilities of daily life.
Bio psycho social factors or interaction of these three factors can cause addiction. Biological factors such as genetical vulnerability, temperament and brain adaptations, psychological factors such as mood status, anxiety, and emotional conflicts, social reasons such as learning habits from faulty role models, peer socialization and adverse social situations like poverty and social exclusions are found consistently as causal factors in addiction related researches.
Addiction causing substances, behaviors and situations are as follows. Substances are nicotine, alcohol, cannabis, opioids like pain killers’ tablets and injunctions and cough syrups, sleeping tablets, heroin, and inhalants like whitener diluter, thinner and petrol. These are most common addiction causing substances seen in India. Playing cards, betting on race horses, or taking lotteries can also become addiction. This type of addiction is known as pathological gambling. Internet addiction, addiction to sexual activities and mobile are being reported for professional help.
Treatment for addiction can be divided into three stages. Motivating persons to seek help or stop, giving help to adjust with withdrawal symptoms, and stabilizing abstinence behavior with the support of medicines and psycho social training are these stages. Holistic and long term professional help from psychiatrist, psychologist, psychiatric social workers and trained nurses as a team and self help groups (alcohol anonymous groups and family support groups) can help persons to stop or reduce the consumption of substances or frequency of addiction causing behavior.
Specialized care for persons with addiction is available in all medical colleges in India as part of the department of Psychiatry. De addiction Centre, National Institute of Mental Health and Neuro Sciences, Bangalore is one of the leading centers in Asia.
Author
Mr. Sojan Antony (Ph.D Scholar in Department of Psychiatric Social Work & Psychiatric Social worker in De addiction Centre, NIMHANS, Bangalore-29). He is the gold Medalist of MPhil in Psychiatric Social Work.
sojan47@gmail.com
Thursday, August 19, 2010
Poly Substance Use and Temperamental Risks Among Children
Poly Substance Use and Temperamental Risks Among Children
Substance abuse has been threat to human growth and well being. Bio psycho social factors play vital role as cause of the problem and elements of treatment. Recent researches focus more on temperamental issues and substance use. Study findings would help practitioners to frame early school based prevention. School is one of the prominent socializing agents of human behavior. Nature and nurture are two predictors of human behavior. Nature means biologically what we are and nurture means our socialization process. Socialization process is the process of transforming a biological being into social being. Both of these predictors influence a child to use or not to use substances. Certain temperamental traits are prone to develop substance use in unsafe environment.
Poly substance use has been recognized as use of more than two substances. Children usually start with tobacco products like beedi, cigarette, panparag, gutka (nicotine) etc. Then they initiate alcohol use. Curiosity and urge to experience more pleasure usually lead to other drug. They would try other substance like cough syrup (opioids), whitener (solvent) sleeping tablets (benzodiazepines) ganja joints (cannabis), brown sugar (opioids), pain killers (opioids). When a person starts using more than two substances regularly, they would be called as persons with poly substance use.
Temperamental traits are understood as a set of consistent response to environment till he/she reaches adulthood. Later in adulthood those traits would be defining personality. Children with Attention deficit and hyperactive disorders have mainly three types of difficult temperaments like hyperactivity, inattention and impulsivity. These temperaments lead them to poor academic performances and clashes with parents, siblings, peer group and school teachers. Such conflicts, non stimulating environment and relationships along with impulsivity lead to multiple asocial activities. Another cluster of temperaments are characterized as difficulty to follow social norms, rules and regulations; though they break such social control rarely they feel guilt or repentance. This set of behavior known as conduct disorders in children, might lead them to experiment with various stimulating substances. Yet another set of temperamental traits where they constantly have clashes with near and familiar authority figures. This is known as oppositional defiant disorders and it might lead to labeling of such children as “gone case” or “disobedient” or “bad boy”. Sometimes authority figures use harsh punishments as remedy to solve these high risk behaviors. It yields undesirable results. Above mentioned temperamental traits can be called as externalizing spectrum. Certain internalizing spectrum of traits such as anxiety, fear, dependence to near one, social phobia and obsession also might lead to substance use.
Children usually have high curiosity to know different things. That curiosity naturally leads to various experiments. If they are able derive pleasure in that experiment they are highly prone to continue the same behavior. Children with externalizing or internalizing spectrum of traits are likely to reward with pleasure by using substance. Regular substance use may lead them to form gangs or gang activities where they can easily procure and use. Poly substance use may be also a part of socialization in such gangs. Children with externalizing traits are accepted well in such gangs as “leader” or “hero”. Peer acceptance and stimulating experiences and environment would fix such children in those gangs. Children with internalizing spectrum traits may find poly substance use as a way of coping with internal crisis. Better social interaction after the use of substances reinforces them to continue use. Quite often later group may land up in above mentioned group as followers or dependents. It is also noticed that later group members turn as silent and lonely users. Another key factor in poly substance use is undesirable effect of one substance use is dealt by other substance. For example depressing effect of alcohol is tried to alter by smoking or chewing nicotine. The impulsive nature and less risk perception tempt them to use or experiment with various pleasure giving sources. So they are prone to all range of substances and other high risk behaviors like drug injecting or unprotected sex. Clinical experience shows that children with externalizing traits and family history of addiction are more vulnerable to develop dependence before the age of 25 years. Genetic reasons and social learning factors such as modeling are major reasons to this early dependence. Poly substance use is widely seen among adolescents who are out of school.
Early intervention would save children from grave crisis. Parents and teachers have duty to identify these risky traits as early as possible. This identification and talent based differential reinforcement help child to turn as pro social being . Following school centered social work interventions are the need for hour.
1. Life skill training
2. Awareness creation
3. Training for parents on parenting skills
4. Alternative pleasure activities e.g. Pleasure trips, games
5. Pro social group activities
6. Anti drug campaign for ban and policies
Temperamental traits have to be considered while training children at school or home. World famous swimming star had Attention deficit and hyperactive problem in childhood. His father identified this problem and diverted him to swimming pool. That helped him to become unbeaten sports man with number of world records in swimming. Careful assessment of child’s nature and talents and appropriate reinforcement strategies would prevent drug use among children.
Sojan Antony *Ph.D Scholar in Psychiatric Social Work department and Psychiatric social worker of De-addiction Centre, NIMHANS, Bangalore, sojan47@gmail.com.
Substance abuse has been threat to human growth and well being. Bio psycho social factors play vital role as cause of the problem and elements of treatment. Recent researches focus more on temperamental issues and substance use. Study findings would help practitioners to frame early school based prevention. School is one of the prominent socializing agents of human behavior. Nature and nurture are two predictors of human behavior. Nature means biologically what we are and nurture means our socialization process. Socialization process is the process of transforming a biological being into social being. Both of these predictors influence a child to use or not to use substances. Certain temperamental traits are prone to develop substance use in unsafe environment.
Poly substance use has been recognized as use of more than two substances. Children usually start with tobacco products like beedi, cigarette, panparag, gutka (nicotine) etc. Then they initiate alcohol use. Curiosity and urge to experience more pleasure usually lead to other drug. They would try other substance like cough syrup (opioids), whitener (solvent) sleeping tablets (benzodiazepines) ganja joints (cannabis), brown sugar (opioids), pain killers (opioids). When a person starts using more than two substances regularly, they would be called as persons with poly substance use.
Temperamental traits are understood as a set of consistent response to environment till he/she reaches adulthood. Later in adulthood those traits would be defining personality. Children with Attention deficit and hyperactive disorders have mainly three types of difficult temperaments like hyperactivity, inattention and impulsivity. These temperaments lead them to poor academic performances and clashes with parents, siblings, peer group and school teachers. Such conflicts, non stimulating environment and relationships along with impulsivity lead to multiple asocial activities. Another cluster of temperaments are characterized as difficulty to follow social norms, rules and regulations; though they break such social control rarely they feel guilt or repentance. This set of behavior known as conduct disorders in children, might lead them to experiment with various stimulating substances. Yet another set of temperamental traits where they constantly have clashes with near and familiar authority figures. This is known as oppositional defiant disorders and it might lead to labeling of such children as “gone case” or “disobedient” or “bad boy”. Sometimes authority figures use harsh punishments as remedy to solve these high risk behaviors. It yields undesirable results. Above mentioned temperamental traits can be called as externalizing spectrum. Certain internalizing spectrum of traits such as anxiety, fear, dependence to near one, social phobia and obsession also might lead to substance use.
Children usually have high curiosity to know different things. That curiosity naturally leads to various experiments. If they are able derive pleasure in that experiment they are highly prone to continue the same behavior. Children with externalizing or internalizing spectrum of traits are likely to reward with pleasure by using substance. Regular substance use may lead them to form gangs or gang activities where they can easily procure and use. Poly substance use may be also a part of socialization in such gangs. Children with externalizing traits are accepted well in such gangs as “leader” or “hero”. Peer acceptance and stimulating experiences and environment would fix such children in those gangs. Children with internalizing spectrum traits may find poly substance use as a way of coping with internal crisis. Better social interaction after the use of substances reinforces them to continue use. Quite often later group may land up in above mentioned group as followers or dependents. It is also noticed that later group members turn as silent and lonely users. Another key factor in poly substance use is undesirable effect of one substance use is dealt by other substance. For example depressing effect of alcohol is tried to alter by smoking or chewing nicotine. The impulsive nature and less risk perception tempt them to use or experiment with various pleasure giving sources. So they are prone to all range of substances and other high risk behaviors like drug injecting or unprotected sex. Clinical experience shows that children with externalizing traits and family history of addiction are more vulnerable to develop dependence before the age of 25 years. Genetic reasons and social learning factors such as modeling are major reasons to this early dependence. Poly substance use is widely seen among adolescents who are out of school.
Early intervention would save children from grave crisis. Parents and teachers have duty to identify these risky traits as early as possible. This identification and talent based differential reinforcement help child to turn as pro social being . Following school centered social work interventions are the need for hour.
1. Life skill training
2. Awareness creation
3. Training for parents on parenting skills
4. Alternative pleasure activities e.g. Pleasure trips, games
5. Pro social group activities
6. Anti drug campaign for ban and policies
Temperamental traits have to be considered while training children at school or home. World famous swimming star had Attention deficit and hyperactive problem in childhood. His father identified this problem and diverted him to swimming pool. That helped him to become unbeaten sports man with number of world records in swimming. Careful assessment of child’s nature and talents and appropriate reinforcement strategies would prevent drug use among children.
Sojan Antony *Ph.D Scholar in Psychiatric Social Work department and Psychiatric social worker of De-addiction Centre, NIMHANS, Bangalore, sojan47@gmail.com.
Social Interventions for Addiction Disorders
Social Interventions for Addiction Disorders
Sojan Antony
Introduction
Human beings like to have pleasure. They tried various ways to experience that exciting mood altering substances. That enquiry led to the discovery of various addictive substances. Behavioral and learning theories analysis show pleasurable activities would be repeated. Modern human brain related science adds that changes in the brain structure and chemistry do not allow few among users to stop, though they face harmful effect. Socialization process by family, peer, school, religion and work environment do play a vital role in the life of persons to develop against or supportive attitude towards addiction. Relearning or change in attitude would make constructive move in the life of a person with addiction. Individual, family and group based structured social interventions were found to be an effective element in addiction treatment.
Gravity of problem
Addiction has been identified as a social problem in
Social aspects of addiction
Society perceives addiction as a source of pleasure as well as a cause of physical and psychological problem. This situation induces ambiguity in the mind of individual members of every society. A part of society through their socialization process develops anti drug use attitude and save themselves. Other part of society due to curiosity and peer pressure experiments the use. Last part of society accepts drug use as part of their culture and resumes their use. Society has been defined as a web of relationships. The same relationship chain help few of them to lead a drug free life and for another few same kind of relationships chain them in regular pattern of use.
Social Interventions
Major social interventions are divided based on target groups.
Individual based interventions
Family based interventions
Group based interventions
Community based interventions
Structured Contents for group and individual sessions
Individual based interventions would help to specific and confidential issues. Group based interventions (Karen & Murthy 1998) have been seen as a source of support, information and stage for attitude change and skill training (Moos.R.H. et.al, (2008)). Following contents would be dealt in both individual and group sessions.
Psychoeducation
Individuals and family who seek treatment are not aware fully about nature of problem, process of treatment, stages of change and prognosis. This might lead to early drop out from treatment. Psycho education from mental health professionals would motivate persons to continue treatment which has been shown better out come in clinical experience.
Motivational interview
It is a style of interviewing individuals with addiction with out raising resistance or denial of problem to enhance motivation to stop. Precisely motivational interview do two kind of work creating a discrepancy in the thought and assisting them to move ahead till maintains abstinence or treatment goal. Though motivational interview is sophisticated psychological intervention, this style of interaction would guide all professional to help individual with addiction.
Myths and misconceptions
Drug use is associated with certain myths and misconceptions. Few of them are “it relaxes me” “creativity can be enhanced” “I get confidence to do things, I wont get fear if I use and do” “I can do work much more time with high concentration” “Night for sleep it is helpful” “drinking is good for heart” “little drug use is a booster in sexuality” and “for my bad mood this is a solution”. These are few sample conversation which have been shared by patients in group. Current understanding of addiction show that chronic drug use would give adverse effect in all most all above mentioned expectations of use. Peer interaction based learning and experience of abstinence may change these misconceptions.
High risk situations
Peer group interaction (Martino, et.al, (2006)) has been reported as a main precipitating and maintaining factor of addiction. Even after the treatment old drug use friends may force the individual to use again. Individual gets environmental cues related feeling to use. It may be during the celebration of festivals, family gathering or in the occasion of major life events like marriage, child birth or death. Problems or difficult life situation are being identified as a risk situations of restarting use. Identifying various high risk situations along with individual, family and group would help individuals to prepare themselves to prevent post treatment relapse.
Craving management
Craving has psychological and social dimension though it is defined as an intense urge to use substance. Social cues are one among reasons of craving. Avoiding such cues would reduce risk of relapse. Usually patients are helped to identify the flagging thoughts of craving such as “only for today, let me take my last drink” “now I am Ok, I can manage with one drink” “I have stopped for 2 years so let me” “I wont take let me just sit with my friends while they are having” “beer is a soft drink, it is not harmful”. Individual must see the psychological and physical cues. Then they can use 4-D distraction techniques with the awareness of sea wave nature of craving. Like a wave in sea side craving would come and go and they need balance in that time. Distraction, Deep breathing, Drinking water and Delay (4-D techniques) would help individual to manage craving.
Drink refusal skills
Role plays are used to train drink refusal skills. It is basically training of assertive skills. This would empower individual to say “No” when friend, relative or others force him to use. Tone of voice and nonverbal expressions are vital part off assertive skills. These would be trained in a role through enacting a party scene or road side scene. Individuals are encouraged to leave that place as early as possible while others force to use.
Coping skills
Coping skills are trained in two aspects, emotion based coping and problem based coping. In emotion based coping individuals are taught temporary nature of emotion, how it can be reduced using relaxation techniques. Individuals are educated not to take any hasty decisions or to negotiate with others while they are in emotions. The need of waiting while they are emotionally up would be discussed with life examples. Problem solving techniques has been used in problem based coping.
Problem solving structure
Addiction has been a cause and result of problems. So it is important to teach problem solving pattern to break this vicious cycle. Problem solving is a process, which includes identifying the main problem, understanding the problem, identifying the resources, identifying solutions, implementing the best possible solution considering personal resources and social support, evaluating the result, and if problem is not solved try again or attempt next best solution. This training can be done with analyzing their any one of the problems. It would help individuals not to resort drugs as a solution in their difficult situations.
Positive addiction and life style change
Lifestyle change need to be promoted through diverting individuals attention to positive addiction such as sports and games, exercises, yoga, meditation, social activities, spiritual activities, and hobbies like watching T.V.. Positive addiction would give alternative pleasure as well as keep individual engaged in some sort of activities. In turn it reduces the risk of relapse.
Sleep, money, and time management
Difficulty in sleep, money and excessive free time are some of the factors for relapse. So it is necessary to teach sleep hygiene and money management skills in terms of saving. Free time needs to be planned in advance to avoid boredom which has been reported as a primary reason of restart of use.
Relapse management and follow up
Relapse is a possibility in addiction treatment. Anticipating relapse in advance and be prepared to deal in a supportive medical model as early as possible would ensure recovery. Long term follow up has been rated as major factor in the success of treatment. Family should be trained to help individual in non critical manner during relapse.
Family based interventions
Family dynamics and related factors are important in addiction treatment. As a victim of addiction they ought to be helped to ventilate their suppressed emotions in the absence of individual. Proper training and supportive psycho-education can change the attitude of family. Quality of marital and family life (Pandian, 1999) and family rituals (Shankaran 2007) are found to be positive factors in family dynamics of recovered or resilient individuals. This would promote the quality of social support to individual. It has been documented social support is a crucial factor in recovery (Gifford, et.al, 2006).
Community based interventions
Community based interventions (Pandian & Sinu, 2007) are found to be effective in ensuring the long term abstinence. Training of PHC doctors, NGO staff, volunteers, counselors, College, school and preprimary teachers, strengthening self help groups like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) and having an effective network with various service organizations in the community can be useful in addressing substance use disorders in case identification, diagnosis, referral to treatment, providing long term care and rehabilitation services.
Evidence
Social support system (Ashok, 2008, Kiran & Muralidhar, 2004), self motivation (Lilly, 2001), healthy family interaction (Shankaran, 2007, Pandian, 1999, Thirumoorthy, 1995, Veela, 1994) and regular treatment follow up (Rajaram, 1990) are found to be the major protective factors of abstinence after treatment.
Practice implication
Bio psycho social aspects of addiction support the need for multidisciplinary treatment efforts. Psychiatric nurses play a vital role to reduce the risk of relapse due to social factors through empowering patient to face social and environmental risks.
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