Exam 3

  1. Five Core Purposes of Drugs
    • self-medicate or defend against overwhelming affect states
    • support interpersonal effectiveness
    • regulate fragile self-esteem
    • comfort or soothe oneself
    • tranquilize the harsh inner critic
  2. The Holding Environment
    • the relationship between the mother and the child
    • “the potential space between baby and mother.. can be looked upon as sacred to the individual in that it is here that the individual experiences creative living”
  3. The Good-Enough Mother
    • for the child to be happy, mother does not need to be perfect just good enough during this time
    • it is expected that she will need to turn her attention to other concerns as the infant gets older but there is a critical period where the foundation of the self is created
  4. Core Dilemma
    • the pleasurable and comforting experiences are associated with the Good Mother + the Good Self
    • the painful and uncomfortable experiences are associated with the Bad Mother + the Bad Self
  5. Traumatic Childhood
    • when things are terribly wrong, the infant is faced with a dilemma: the good experiences cannot be connected to the hateful mother
    • so they continue to have inner representations of 2 mothers (this is a survival technique)
  6. Splitting
    • common defense in Borderline patients
    • people are seen as all good or all bad
    • in relationships, people may go from being loved/idealized to being hated/despised very quickly
  7. How is drug use related to splitting?
    • drugs used for self-soothing
    • they are seen as an idealized, reassuring figure that never lets them down
    • an attempt to find a substitute for a good object
  8. Developing Object Constancy
    • the child begins to develop an internal representation of the mother
    • this allows the child to soothe himself by imagining the mother and/or experiencing her as an internal presence
    • gives them inner stability
  9. Transitional Object
    middle ground between the actual mother and a full internalized representation
  10. Failure of achieving Object Constancy
    • leaves one in a state of deep anxiety
    • makes it difficult to control one’s emotions
    • drugs can serve as a transitional object
  11. The Incorporated Bad Object
    • people incorporate the people who hurt them - they live inside of us
    • the drug is taken in hopes that it will be a good object that fights and controls the internalized bad object
    • but when the drug wears off, the bad object returns
  12. Core Needs
    • there is a deep need for: mirroring + merger & idealization
    • child can develop in a healthy manner with both or with just one or the other
  13. Mirroring
    • the mother’s joyful, empathic response to the vitality of the child (gleam in the moms eye)
    • having their specialness mirrored by significant others
    • this is about feelings and emotional atmosphere not words
    • this is how the child develops healthy narcissism + healthy grandiosity
  14. What does mirroring lead to?
    • good self-esteem
    • a drive for mastery and achievement
  15. Idealizing and Merger
    • no matter how wonderful the mirroring, the child will eventually realize they are small and helpless
    • they will have a desire to merge with the power and wisdom of those who are more powerful
  16. What is idealization followed by?
    • followed by de-idealization, which is the process of internalization
    • children create their own set of ideals and values
  17. The more severe the trauma, the…
    • the more overwhelming the affects
    • the harsher the superego/inner critic
  18. What was the purpose of drugs according to Leon Wurmser?
    • drug use is a defense/ form of self therapy
    • they modulate the affects and serve as a form of rebellion against the critic
  19. What are Adverse Childhood Experiences?
    • experiences that represent medical and social problems of national importance
    • ex. childhood abuse and neglect, growing up w domestic violence, substance abuse or mental illness in the home, parental loss or crime
  20. Finding of ACE study?
    Addiction highly correlates with characteristics intrinsic to that individual’s childhood experiences
  21. Purpose of ACE study?
    to examine the health and social effects of adverse childhood experiences over the lifespan
  22. Operant Foundations (two ways)
    • positive reinforcement — after using substance, person feels sexually aroused/euphoric/more comfortable = behavior is more likely to be repeated
    • negative reinforcement — substance use reduces anxiety, tension, stress, or depression = behavior is likely to be repeated
  23. Classical/Pavlovian Foundations + Drugs
    • stimuli that were originally neutral become triggers for alcohol/drug use
    • develops our of the repeated associated between the stimuli and the behavior
    • triggers can be external (environment, location, people) or internal (thoughts, emotions, psychological changes)
  24. Motivational Work
    • many patients are ambivalent about bringing their drug use to an end
    • the factors underlying the ambivalence can be clarified through the use of a Decisional Balance
  25. Four things to consider for Decisional Balance
    • the positive of drug use
    • the negatives of drug use
    • the positives of change/recovery
    • the negatives of change/recovery
  26. Positives of Drug Use
    • immediate physical pleasure
    • escape/feeling more there
    • feel more emotion
    • reduces social anxiety
    • shuts out critic
    • people will know “real self”
  27. Negative of Drug Use
    • feels guilty
    • others are concerned
    • not as productive
    • feels like a crutch
    • feels bad
    • health problems
  28. Positives of Recovery
    • feel a greater sense of self discipline
    • would be more productive
    • help ppl be more comfortable with self
    • greater confidence
  29. Negatives of Recovery
    • would not enjoy life as much
    • would be ignoring a part of himself
    • breaking up with something they love - a hard breakup
  30. Euphoric Recall
    • after a client has been abstinent for some period of time, fantasies about future may be influences by memories of the positive effects of past use
    • this creates a shift in attitudes and beliefs
    • positive outcome expectancies for the immediate effects of a substance — which provides a motivating forces leading to the resumption of drinking/drug use
  31. Clients are taught to attribute lapses to..
    • specific, predictable, potentially controllable events that are both internal and external
    • instead of personal failings or character flaws
  32. Slips, Lapses & Relapses
    • slips - aka the resumption of substance use is to be expected but what mattered most was not that the patient slipped but how they processed it
    • Marlatt believed that these should be seen as learning trials
    • through analysis of the situation, a framework specific to the individual for the patient could be developed
  33. Abstinence Violation Effect
    • when an individual has a slip or lapse after committing to abstinence, this can lead to a sense that they have lost control of their drug and alcohol use
    • using after committing not to creates an internal conflict
    • the inconsistency of ones efforts to abstain with the reality of just using a substance can help to push the person into a relapse
  34. Cognitive Restructuring
    • recognizing and challenging cognitions that accompany and maintain patterns of substance use
    • “i can use once and not again”
    • understanding that a part of you wants that substance, it will try to put you in situations where there is a higher risk of that happening
  35. AssertivenessjQuery1101012987095680783334_1493752020570?
    • learning assertiveness
    • drink and drug refusal skills
    • reducing exposure drugs and drug-related cues
  36. Methamphetamine and Sex
    • use leads to increases in:
    • pleasure, drive, frequency, intensity, variety, riskiness, in both men and women
    • (may lead to impotence in men over time)
  37. Men who have sex w Men - Meth Use
    • has led to an overall increase in HIV rates in this group
    • they have a 3 time higher rate of seroprevalence than among non-MA using MSM
  38. Negative Effects of Meth Use - Psychiatric
    • increased anxiety
    • insomnia
    • aggressive tendencies
    • paranoia
    • hallucinations
    • psychiatric impairment correlates with: duration of use, dosage, and method (intravenous use has a greater impact than other methods)
  39. Tweaking
    • when users become extremely irritable and paranoid because they cannot replicate the original meth high
    • physical abuse, vehicle accidents and violence often occur with tweakers
  40. Jacob Moreno, MD
    developer of psychodrama
  41. Core Paradigms of Psychodrama
    • about “acting as if” rather than “talking about”
    • enactment - show us what happened with your family
    • multiple parts of the self - show us the conflict you’re having with yourself
    • future projections - show us what you’d like to be doing in 10 years
  42. Parts of a Psychodrama
    • Stage - the special air where the work takes place, some hospitals have actual stages and balconies
    • Director - organizes and creates the drama
    • Protagonist - the hero of the drama, the one for whom the work is being done
    • Auxiliaries - other group members who play the role of important people in the Protagonists life
    • Audience - the group members that witness the drama
    • Doubling - when an auxiliary will stand behind the protagonist and say aloud what they think the protagonist is thinking and feeling but not sharing
  43. Role Reversal in Psychodrama
    • when the protagonist switches roles with an auxiliary and expresses what that person or force is thinking or feeling
    • ex. the son plays his father, the daughter plays deceased grandma
    • this is one of the central and most powerful of all the techniques
  44. Frederick “Fritz” Perls, MD
    developed chairwork into a psychotherapeutic art form
  45. Core Dichotomy of Chairwork
    • external dialogues - patient sits in one chair, speaks to an imaginal other in the opposite chair
    • internal dialogues - patient shuttles back and forth between two chairs, speaks from two different perspectives
  46. Two Basic Motivational Dialogues
    • desire to stop, reduce, or change the pattern
    • desire to continue using substances
  47. Relationship with the Substance
    • drug use can be seen as a relationship with a substance
    • a dialogue can be organized between the patient and their substance
  48. Strategic Guidelines for Motivational Dialogues
    • superego-based change says - i should, however..
    • Ego-based change says - I want…
    • patients heal and recover by strengthening the part that wants to change, not by persuading the part the wants to use to desire recovery
  49. Adolescent Substance Use - brain development
    • adolescent impulsivity and/or novelty seeking
    • a transitional behavior
    • explained in part by maturational changes in the frontal cortex
  50. Adolescent Substance Use - prevention
    • two goals:
    • delaying the initial use of the gateway drugs, cigarettes, alcohol, and marijuana
    • reducing the amount of use during ages 18-20
  51. What is Cocaine?
    • one of the oldest drugs
    • first extracted from the leaf of the Erythroxylon coca bush, which grows in Peru and Bolivia
    • in 1900s it became the main stimulant drug used in most tonics/elixirs that were used for treating various illnesses
  52. Neurobiology of Cocaine
    • cocaine attaches to the dopamine transporter and blocks the normal recycling process
    • which results in a build up of dopamine in the synapse
    • this contributes to the pleasurable effects of cocaine
    • as cocaine abuse continues, tolerance often develops
  53. During abstinence from cocaine use..
    • the memory of the euphoria associated with cocaine use or exposure to cues can trigger tremendous craving and relapse to drug use
    • even after long periods of abstinence
  54. Cocaethylene
    • cocaine + alcohol
    • cocaethylene has a longer duration of action in the brain and is more toxic than either drug alone
    • most common combo that results in drug-related deaths
  55. Seven Principles of Contingency Management
    • target behavior
    • target population
    • choice of reinforcer
    • incentive magnitude
    • frequency of distribution
    • timing of the incentive
    • duration of the intervention
  56. Target Behavior
    • typically something problematic
    • needs to be observable and measurable
    • the centerpiece of the behavioral contract
    • studies have looked at - drug use, group attendance, treatment plan goals, compliance w medical care
  57. Target Population
    • while it might be ideal to reinforce all patients, may not be feasible or necessary
    • mainly for treatment non responders, new patients, users of specific substances, or vulnerable pop. groups
  58. Choice of Reinforcer (3 basic types)
    • contingent access to privileges
    • vouches/token economy systems
    • on-site prize distribution
  59. Incentive Magnitude
    • programs could accept the limits of what they can do and change their target behavior
    • ex. group attendance requires lower levels of reinforcement than cocaine abstinence
    • more emotional difficult groups may require higher levels
    • patients may differ in their responsiveness to reinforcements
  60. Frequency of Distribution
    • this is known as the schedule for reinforcement
    • patients can be reinforced each time they exhibit the desired behavior (group attendance)
    • OR
    • only after they have exhibited the behavior several times (completing a 3-session orientation to treatment series)
  61. Timing of the Incentive
    • poor timing can undermine an otherwise well-planned intervention
    • reinforcement needs to follow the exhibition of the target behavior as closely as possible
  62. Timing of Incentive - Delay Discounting
    the longer the delay between the exhibition of the behavior and the provision of the reinforcement, the lower the perceived value of the reinforcer
  63. Duration of the Intervention
    • how long you continue to produce incentives for desirable behavior
    • prizes and vouchers are external contingencies
    • ultimately, patients will need to internalize their recovery and develop naturally occurring reinforcers that will support recovery based & non-addict identities
  64. Reward vs. Reinforcement
    • reward program - acknowledges patients for achieving a goal or accomplishing something noteworthy, most likely to give rewards to the best and most motivated patients
    • reinforcement program - breaks down each of the goals into small steps, reinforce each step along the way and distribute reinforcement with high frequency
  65. 4 Classes of Prescription Drugs
    • opioids (oxycontin, vicodin)
    • CNS depressants (benzodiazepines & barbiturates like valium and xanax)
    • stimulants (adderall and ritalin)
    • other (viagra)
  66. 5 reasons for using prescription drugs
    • pain-centered use — people in chronic pain from disease or injuries may alter their doses or supplement prescriptions w other drugs to address their pains
    • emotional self-medication group — use substances to alter dysphoric feelings / reduce anxiety
    • recreational users — interested in exploring the effects of a variety of substances, may create new mixtures to try, some refer to this as “pharming”
    • improved performance — used to improve quality of one’s experiences, performance, or ones life
    • drug dependence — state of dependence or addiction, the pills are causing great suffering
  67. History of Harm Reduction
    • developed in 1970s in the Netherlands and Liverpool as a public health approach for alcohol and heroin addiction
    • took off in the 1980s when connections between IV drug use and HIV transmission was made
  68. Nico Adriaans
    • founded and led “Rotterdamse Junkiebon” - the first drug users union
    • the junkiebond greatly influences dutch drug policy towards adopting the harm reduction model
    • also initiated the first needle exchange in Rotterdam in 1981
  69. Gradualism
    • envisioned a system where users could be gradually engaged in a process in which they went from — states of chaotic/active use to safer/reduced use to states of abstinence/moderation/nonaddictive use
    • seeks to give equal important to HIV prevention and addiction treatment
  70. Harm Reduction Classification System (3 things)
    • staying alive — keep people from dying or seriously injuring themselves, immediate time focus usually 24 hours (designated driver, naloxone)
    • maintaining health — help people protect their physical health over the long run, despite occasional or frequent use of substances (reduce risk of getting HIV, needle/syringe exchange program, safer injection info) longer time frame than staying alive group
    • getting better — looking to control and reduce use, if not eliminate it, frequently involve a therapist-patient or physician-patient aspect
  71. Harm Reduction Psychotherapy
    • no commitment to abstinence required before beginning
    • understanding that people use substances in problematic ways for reasons that may not be understood, acknowledged and sometimes treated
    • might be before the patient is willing to change their drug use
    • simultaneously engage with the underlying pain and drug use, accept small steps
    • use full array of techniques and interventions
  72. Alternative Self-Help Groups
    • SMARTRecovery
    • Moderation Management
  73. What is MDMA
    • a combination - empathogen + amphetamine
    • it releases both serotonin and oxytocin
  74. Psychotherapy with MDMA
    • at higher doses, MDMA increases the ratio of love to fear
    • the capacity to love yourself and love others triumphs over the anxiety about actually doing it
    • allowing yourself to see and accept al that you are opens the path towards healing
  75. Molly/MDMA - purity issues
    • ecstasy was relatively pure until mid 1900s
    • at a recent festival, only 16% actually took MDMA while 73% took new chemical variants
  76. Molly/MDMA - precautions
    • MDMA related deaths are not always due to overdose, bc people can die at low doses as well
    • causes of death are complex, can involve pre-existing conditions
    • frequent use of MDMA can lead to moos dysregulation
    • partying and dancing can lead to serotonin depletion = the crash
  77. Hyperthermia
    heat stroke is a major risk factor bc MDMA turns off awareness of inner thermostat, and do not drink enough water
  78. Hyponutremia
    when people die from drinking too much water
  79. History of Ibogaine
    • an african plant from Gabon and Cameroon
    • originally used during initiations of the Bwiti culture as a way to get in contact with the ancestors
    • also used for healing purposes and as a ritual when child becomes an adult
  80. What is Ibogaine?
    • an addiction interrupter, NOT a cure
    • it surpasses the painful withdrawal symptoms and stops/reduces drug cravings for weeks or months
    • which is long enough for people to get psychological help and learn to live a healthy life
  81. Noribogaine - Dr. Deborah Mash
    • the active metabolite in ibogaine, developed from the plant
    • doesnt induce the waking dream
    • there have already been Phase I trials in new zealand
  82. Neurobiology of ibogaine - Dr. Stanley Glick, MD, PhD
    • Dr. Glick and others looked at ibogaine’s performance in lab animals
    • they found evidence that it acts against the addiction to cocaine, alcohol and opioids
  83. 18-MC
    • a synthetic derivative of ibogaine that is being researched and developed
    • no waking dream - bc many found it irritating or disturbing
    • Phase I human trials are about to begin
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