Addiction psychology mostly comprises the clinical psychology and abnormal psychology
disciplines and fosters the application of information obtained from
research in an effort to appropriately diagnose, evaluate, treat, and
support clients dealing with addiction. Throughout the treatment process
addiction psychologists encourage behaviors that build wellness and emotional resilience to their physical, mental and emotional problems.
The basis of addiction is controversial. Professionals view it as a disease or a choice. One model is referred to as the Disease model of addiction.
The second model is the Choice model of addiction. Researches argue
that the addiction process is like the disease model with a target organ
being the brain, some type of defect, and symptoms of the disease. The
addiction is like the choice model with a disorder of genes, a reward,
memory, stress, and choice. Both models result in compulsive
behavior.
Cognitive Behavioral Therapy, Dialectal Behavior Therapy and
Behaviorism are widely used approaches for addressing Process Addictions
and Substance Addictions. Less common approaches are Eclectic,
Psychodynamic, Humanistic, and Expressive therapies. Substance
addictions relate to drugs, alcohol, and smoking. Process addictions
relate to non-substance related behaviors such as gambling, spending,
sexual activity, gaming, internet, and food.
Psychologists oldest definition of addiction is that the addict
has a lack of self-control. The addicted party wants to abstain, but
they can't resist the temptation. Addicts lose control over their
actions. It is viewed that an addict battles with their addiction and
wanting abstinence and gain control over their actions.
History
The
word 'addiction' has successfully been traced to the 17th century.
During this time period, addiction was defined as being compelled to act
out any number of bad habits. Persons abusing narcotics were called
opium and morphine 'eaters.' 'Drunkard' referred to abusers of alcohol.
Medical textbooks categorized these 'bad habits' as dipsomania or
alcoholism However, it wasn't until the 19th century when the diagnosis was first printed in medical literature. In the 1880s, Sigmund Freud and William Halsted
began experimenting with users of cocaine. Unaware of the drug's
powerful addictive qualities, they inadvertently became guinea pigs in
their own research and, as a result, their contributions to psychology
and medicine changed the world.
While working in Vienna General Hospital
(Vienna Krankenhaus), in Austria, cocaine took possession over Freud's
life when he found cocaine to relieve his migraine. When the effect of
cocaine decreased, the amount of cocaine Freud consumed increased. With
information about the pain suppressing properties of cocaine, physicians
began prescribing cocaine to their patients who required pain relief.
Unaware of Freud and Halsted's experiments with cocaine, American
Physician W.H. Bentley was conducting his own similar experiments. The
Index Medicus published his article describing how he successfully
treated patients with cocaine who were addicted to opium and alcohol. In
the late 1800s the use of cocaine as a recreational drug spread like a
worldwide epidemic.
As cocaine continued to spread physicians began looking for ways
to treat patients with opium, cocaine, and alcohol addictions.
Physicians debated the existence of the label 'addictive personality'
but believed the qualities Freud possessed (bold risk taking, emotional
scar tissue, and psychic turmoil) were of those that fostered the
'addictive personality'.
Important contributors
Physician Sigmund Freud,
born on May 6, 1856, in Freiberg, Moravia (an area now known as Pribor
in the Czech Republic), was instrumental in the field of psychology.
Dream interpretation and psychoanalysis (also known as talk therapy) are
two of his well-known contributions. Psychoanalysis is used to treat a
multitude of conditions including addictions.
As one of the most influential thinkers in the 20th century, he altered
the way we perceive ourselves and communicate about our perceptions as a
number of his theories have been popularized and terms he created have
entered into general language.
Theories on mental health, personality development and illness
that Freud developed are considered highly controversial. According to
Freud, people are endowed with three levels of awareness: conscious,
preconscious, and unconscious, where conscious level refers to what we
are fully appreciative of, preconscious is what people could be aware of
if they became more attentive, and unconscious level includes facts
that humans cannot be aware of. The aim of the therapy is to turn
unconscious into conscious.
William Halsted,
born on September 23, 1852, in New York City, received his degree in
medicine in 1877. Throughout his medical career as a surgeon he
contributed surgical techniques that ultimately led to improvement of
the patient's outcome following surgery. During Halsted's professional
career, he (along with Freud) conducted experiments with the drug
cocaine. While their research was in process they became guinea pigs for
their own experiments when they became addicted to cocaine. In 1884 he
became the first to describe how cocaine could be utilized as a
localized anesthetic when injecting into the trunk of a sensory nerve,
and how the localized ischemia prolonged the anesthetic properties of
the drug.
G. Alan Marlatt
was a pioneer in the field of addiction psychology. Born in Vancouver,
British Columbia, in 1941, he spent his professional career as an
addiction psychologist, researcher, and director of the University of
Washington's Addictive Behaviors Research Center and professor in the
Department of Psychology. Marlatt adopted the theory of harm reduction,
and developed and scientifically tested ways to prevent an addict's slip
from becoming a relapse. He understood that expecting immediate and
complete abstinence from addicts often deterred addicts from seeking the
help they needed and deserved. Marlatt died on March 14, 2011.
A. Thomas McLellan
was born in 1949 in Staten Island, New York. He is a professor at the
University of Pennsylvania School of Medicine at the Center for Studies
of Addiction. McLellan serves or has served on editorial boards as a
reviewer of medical and scientific journals, and as an advisor to
government and non-profit organizations including the National Practice
Laboratory of the American Psychiatric Association, and the World Health
Organization. He is co-founder and chief executive officer of the
Treatment Research Institute located in Philadelphia, Pennsylvania.
McLellan has conducted decades of research for the efficacy of treatment
for substance abuse patients, and is recognized both at the national
and international level as an addiction psychologist. He is also known
for the development of the Addiction Severity Index or ASI and serves as
editor-in-chief of the Journal of Substance Abuse Treatment and the deputy officer of National Drug Control Policy, Research and Evaluation.
Arnold Washton has specialized in addiction since 1975 and is an
addiction psychologist known for his work in the development of
therapeutic approaches to the treatment of drug and alcohol abuse. He is
the author of many books and professional journal articles on treatment
and addiction. He is a lecturer, clinician, researcher, and has served
on the advisory committee for the US Food and Drug Administration.
Washton is the founder and executive director of Recovery Options, a
private addiction treatment practice located in New York City and
Princeton, New Jersey.
William L. White
is a Senior Research Consultant at Chestnut Health Systems, an
addiction counselor, researcher and writer in the field of addiction for
over 45 years. He wrote over 400 papers and 18 books. He received
awards from the National Association of Addiction Treatment Providers
(NAATP), the National Council on Alcoholism and Drug Dependence,
(NAADAC), the Association of Addiction Professionals and the American
Society of Addiction Medicine (ASAM).
Addiction
Addiction is a progressive disease and psychiatric disorder that is defined by the American Society of Addiction Medicine
as "a primary, chronic disease of brain reward, motivation, memory and
related circuitry. It is characterized by the inability to control
behavior, it creates a dysfunctional emotional response, and it affects
the users ability to abstain from the substance or behavior
consistently. Psychology Today
defines addiction as "a state that can occur when a person either
consumes a substance such as nicotine, cocaine, or, alcohol or engages
in an activity such as gambling or shopping/spending."
When a non-addict takes a drug or performs a behavior for the
first time he/she does not automatically become an addict. Over time the
non-addict chooses to continue to engage in a behavior or ingest a
substance because of the pleasure the non-addict receives. The now
addict has lost the ability to choose or forego the behavior or
substance and the behavior becomes a compulsive action. The change from
non-addict to addict occurs largely from the effects of prolonged
substance use and behavior activities on brain functioning. Addiction
affects the brain circuits of reward and motivation, learning and
memory, and the inhibitory control over behavior.
There are different schools of thought regarding the terms
dependence and addiction when referring to drugs and behaviors. One
adopted belief is that "drug dependence" equals "addiction." The second
belief is that the two terms do not equal each other. According to the
DSM, the clinical criteria for "drug dependence" (or what we refer to as
addiction) include compulsive drug use despite harmful consequences;
inability to stop using a drug; failure to meet work, social, or family
obligations; and, sometimes (depending on the drug), tolerance and withdrawal.
The latter reflects physical dependence in which the body adapts
to the drug, requiring more of it to achieve a certain effect
(tolerance) and eliciting drug-specific physical or mental symptoms if
drug use is abruptly ceased (withdrawal). Physical dependence can happen
with the chronic use of many drugs—including even appropriate,
medically instructed use. Thus, physical dependence
in and of itself does not constitute addiction, but often accompanies
addiction. This distinction can be difficult to discern, particularly
with prescribed pain medications, where the need for increasing dosages
can represent tolerance or a worsening underlying problem, as opposed to
the beginning of abuse or addiction.
There are some characteristics of addiction that regardless of
the type share commonalities. The behavior provides a rapid and potent
means of altering mood, thoughts, and sensations of a person which occur
because of physiology and learned expectations. The immediate
precipitating factors of the relapse, the timing of the relapse and the
rate of relapse following treatment is high.
American Psychological Association
The American Psychological Association
(APA) is a professional psychological organization and is the largest
association of psychologists in the United States. Over 100,000
researchers, educators, clinicians and students support the association
through their membership. Their mission "is to advance the creation,
communication and application of psychological knowledge to benefit
society and improve people's lives."
APA supports 54 divisions, two of which pertain to addictions.
Division 50, Society of Addiction Psychology promotes advances in
research, professional training, and clinical practice within the range
of addictive behaviors. Addictive behaviors include problematic use of
alcohol, nicotine, and other drugs as well as disorders involving
gambling, eating, spending, and sexual behavior. Division 28, Psychopharmacology and Substance Abuse promotes teaching, research, and dissemination of information regarding the effects of drugs on behavior.
The College of Professional Psychology (CPP), hosted by the
American Psychological Association Practice Organization, previously
offered a certificate to psychologists whom demonstrated proficiency in
the psychological treatment of alcohol and other substance-related
disorders. The CPP maintains the certificate of proficiency for persons
who acquired it prior to 2011. The Society of Addiction Psychology
certificate will be re-instated while the Society examines other avenues
for credentialing professionals in addiction treatment.
Addiction as a Disease
It seems that wherever one finds intoxication, one likely will find addiction.
Recently researchers have argued that the addiction process is like the
disease model, with a target organ, a defect, and symptoms of the
disease. In other accounts, addiction is a disorder of genes, reward,
memory, stress, and choice.
The Disease Model in Addiction
According to the new disease model, rather than being a disease
in the conventional sense, addiction is a disease of choice. That is, it
is a disorder of the parts of the brain necessary to make proper
decisions. As one becomes addicted to cocaine, the ventral tegmentum nucleus accumbens in the brain is the organ. The defect is stress-induced hedonic regulation.
Understanding the impact that genes, reward, memory, stress, and
choice have on an individual will begin to explain the Disease Model of
Addiction
Genetic
The genetic makeup of an individual determines how they respond
to alcohol. What causes an individual to be more prone to addiction is
their genetic makeup. For example, there are genetic differences in how
people respond to methylphenidate (Ritalin) injections.
Reward
Increased dopamine is correlated with increased pleasure. For
that reason, dopamine plays a significant role in reinforcing
experiences. It tells the brain the drug is better than expected. When
an individual uses a drug, there may be a surge of dopamine in the
midbrain, which can result in the shifting of that individual's pleasure
“threshold” (see figures one and two).
Memory
The neurochemical, glutamate is the most abundant neurochemical
in the brain. It is critical in memory consolidation. When an addict
discovers an addicting behavior, glutamate plays a role by creating the
drug cues. It is the neurochemical in motivation which initiates the
drug seeking, thus creating the addiction.
Stress
When under stress the brain is unable to achieve homeostasis. As a
result, the brain reverts to allostasis, which in turn alters the
brains ability to process pleasure, which is experienced at the hedonic
“set point” (see figures one).
Thus, previous pleasures may become no longer pleasurable. This is also
known as anhedonia, or “pleasure deafness.” When stressed, the addict
may experience extreme craving—an intense, emotional, obsessive
experience.
Choice
An addict may incur damage to the orbitofrontal cortex (OFC), the
anterior cingulate cortex (ACC), and the prefrontal cortex (PFC). This
damage causes a tendency to choose small and immediate rewards over
larger but delayed rewards, deficits in social responding due to
decreased awareness of social cues, and a failure of executive function
such as sensitivity to consequences.
Licensed Practitioners
Many
degrees provide space for the treatment of addictions. The educational
background that each professional obtains will contain similarities but
the philosophy and the viewpoint from which the material is delivered
may vary. The required amount of education prior to earning a
certificate or degree also varies. A few of the more commonly recognized
fields of study are included.
- Psychologist
- Psychiatrist
- Licensed Counselor Social Worker
- Licensed Social Worker
- Licensed Professional Counselor
- Paraprofessional
Recognized Certifications in the Field of Addiction Psychology
Many certifications are recognized in the field of addiction psychology. Each have their own requirements.
- Certification for Alcohol and Drug Counselor Candidate.
- Credentialed Alcoholism and Substance Abuse Counselor.
- A Certified Chemical Dependency Counselor.
- Substance Abuse Counselor/Certified Addiction Counselor.
- The Certified Addiction Professional.
- Certified Addiction Treatment Counselors.
- Combined Certifications With Other Degrees.
Treatment
Both
process addiction and behavioral addiction have many dimensions causing
disarray in many aspects of the addicts' life. Treatment programs are
not a one size fits all phenomenon, hence there are different modalities
or levels of care. Effective treatment programs incorporate many
components to address each dimension. The addict suffers from
psychological dependence and some may suffer from physical dependence.
Helping an individual stop using drugs is not enough. Addiction
treatment must also help the individual maintain a drug-free lifestyle,
and achieve productive functioning in the family, at work, and in
society. Addiction is a disease which alters the structure and function
of the brain. The brain circuitry may take months or years to recover
after the addict has recovered.
This may explain why drug abusers are at risk for relapse even
after long periods of abstinence and despite the potentially devastating
consequences. Research shows that most addicted individuals need a
minimum of 3 months in treatment to significantly reduce or stop their
drug use, however treatment in excess of 3 months has a greater success
rate. Recovery from addiction is a longterm process.
Modalities of Care
The
modality or level of care needed for a patient is decided by the
treating professional in conjunction with the patient when feasible. As
expected the patient receiving treatment will likely take steps forward
and backward the level of care will likely to fluctuate. Common
modalities are explained.
Detoxification and Medically Managed Withdrawal
The
process when the body rids itself of drugs is referred to as
detoxification, and is usually concurrent with the side effects of
withdrawal which vary depending on the substance(s) and are often
unpleasant and even fatal. Physicians may prescribe a medication that
will help decrease the withdrawal symptoms while the addict is receiving
care in an inpatient or outpatient setting. Detoxification is generally
considered a precursor to or a first stage of treatment because it is
designed to manage the acute and potentially dangerous physiological
effects of stopping drug use.
Long-term Residential
Treatment
is structured and operates 24 hours a day. Residents will remain in
treatment from usually 6 to 12 months while developing accountability,
responsibility and socialization skills. Activities are designed to help
addicts recover from destructive behavior patterns while adopting
positive behavioral patterns. Constructive methods of interacting with
others and improving self-esteem are other areas of focus. The
therapeutic community model is an example of one treatment approach.
Many therapeutic communities provide a more comprehensive approach to
include employment training and other support services.
Short-term Residential
Short-term
residential programs are on average 3–6 weeks in a residential setting.
The program is intensive followed by more extended outpatient treatment
to include individual and/or group therapy, 12-step Anonymous programs,
or other forms of support. Because of the short duration of this
modality it is even more important for individuals to remain active in
outpatient treatment programs to help decrease the risk of relapse
following residential treatment.
Outpatient-treatment Programs
Outpatient
treatment program vary regarding the services offered and the
intensity. It's more affordable and may be more suitable for patients
who are employed full-time and/or who have secured multiple social
supports. Outpatient programs may include group and/or individual
therapy, intensive outpatient program,
and partial hospitalization. Some outpatient programs are also designed
to treat patients with medical or other mental health problems in
addition to their drug disorders.
Individualized Drug Counseling
Individualized
drug counseling not only focuses on reducing or stopping illicit drug
or alcohol use; it also addresses related areas of impaired functioning
such as employment status, illegal activity, and family/social relations
as well as the content and structure of the patient's recovery program.
Through its emphasis on short-term behavioral goals, individualized
counseling helps the patient develop coping strategies and tools to
abstain from drug use and maintain abstinence. The addiction counselor
encourages 12-step participation (at least one or two times per week)
and makes referrals for needed supplemental medical, psychiatric,
employment, and other services.
Group Counseling
An
outpatient treatment option facilitated by a treatment provider and
used to expand on the support system the patient already has. Groups
foster a non-judgmental environment allowing patients to meet and
discuss difficulties and successes of their addiction while providing
on-going support that is needed to be successful with recovery.
Intensive Outpatient Program (IOP)
As
the name implies this is an outpatient treatment option designed for
addicts who for various reasons do not have the opportunity to attend an
inpatient treatment program, yet who otherwise would not be able to
receive the level of support needed to recover from their addiction.
Programs vary in duration based on the patients need. Because of the
lower level of support offered IOP is frequently used as a step down
approach from patients leaving inpatient treatment but who are still in
need of intensive therapy.
Prevention, Relapse & Recovery
Therapeutic Orientations & Approaches
In
1878 the Index Medicus published research conducted and written by
American physician W.H. Bentley. Bentley's research described his
success in treating patients addicted to the ‘opium habit’ w/cocaine.
Two years later he reported success in treating both opium and alcohol
abusers w/cocaine. Today, the swapping one addiction for another is referred to as crossover addiction.
A variety of treatment approaches are utilized by health
professionals in order to provide their clients the highest possible
level of success to overcome their addictions. There is no one specific
approach and often therapists will use multiple techniques.
- Behaviorism.
- Humanistic Therapy.
- Cognitive Behavioral Therapy (CBT).
- Dialectical Behavioral Therapy (DBT).
- Psychodynamic.
- Expressive.
- Integrative.
- Harm Reduction.
- Eclectic.
- Animal Assisted Therapy.
Further reading
- Integrative Therapy: 100 Key Points and Techniques; Maria Gilbert, Vanja Orlans books listed here that may be of interest but don't incl if they were already cited in article
- Hubbard, R.L.; Craddock, S.G.; Flynn, P.M.; Anderson, J.; and Etheridge, R.M. Overview of 1-year follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors 11(4) 291-298, 1998.
- Miller, M.M. Traditional approaches to the treatment of addiction. In: A.W. Graham and T.K. Schultz (eds.), Principles of Addiction Medicine (2nd ed.). Washington, D.C.: American Society of Addiction Medicine, 1998.
- Simpson, D.D., and Brown, B.S. Treatment retention and follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors 11(4) 294-307, 1998.
- Institute of Medicine. Treating Drug Problems. Washington, D.C.: National Academy Press, 1990.
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