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Al rarely uses cocaine at home, and never in the presence of his wife or children. Occasionally, he snorts a line or two on weekday evenings or weekends at home when everyone else is out of the house. Al denies current use of any other illicit drug but reports taking 10–20 mg of an antianxiety drug, Valium (diazepam) (prescribed by a physician friend), at bedtime on days when cocaine leaves him feeling restless, irritable, and unable to fall asleep. When Valium is unavailable, he drinks two or three beers instead.
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During the interview, Al remarks several times that although he thinks that his cocaine use "might be a problem," he does not consider himself to be "addicted" to it and is still not sure that he really requires treatment. In support of this view, he lists the following evidence: 1) his current level of cocaine use is not causing him any financial problems or affecting his standard of living; 2) he is experiencing no significant drug-related health problems that he is aware of, with the possible exception of feeling lethargic the next day after a day of heavy use; 3) on many occasions, he has been able to stop using cocaine on his own, for several days at a time; and 4) when he stops using the drug, he experiences no withdrawal syndrome and no continuous drug cravings. On the other hand, he does admit the following: 1) he often uses much more cocaine than intended on certain days; 2) the drug use is impairing his functioning at work because of negative effects on his memory, attention span, and attitude toward employees and customers; 3) even when he is not actively intoxicated with cocaine, the aftereffects of the drug cause him to be short-tempered, irritable, and argumentative with his wife and children, leading to numerous family problems, including a possible breakup of his marriage; 4) although he seems able to stop using cocaine for a few days at a time, somehow he always goes back to it; and 5) as soon as he starts to use cocaine again, the craving and the preoccupation with the drug are immediately as intense as before he stopped using it.. ?. z0 o/ o5 P) ~0 m

At the end of the interview, Al agrees that although he came for the evaluation largely under pressure from his wife, he can see the potential benefits of trying to stop using cocaine on a more permanent basis. With a saddened expression, he explains how troubled and frightened he feels about the problems with his wife and children. He says that although marital problems existed before he started snorting cocaine, his continuing drug use has made them worse, and he now fears that his wife might leave him. He also feels extremely guilty about not being a "good father." He spends very little time with his children and often is distracted and irritable with them because of his cocaine use.+ V9 d+ y$ G4 d' k( E$ l2 ^

DSM-IV-TR Casebook Diagnosis of "Cocaine"/ s3 |8 v' N4 S

Al's case also illustrates the valuable effects that family members or concerned significant others can have on a treatment course for substance-dependent patients. The fact that Al's wife took a stand that she would leave him if he would not seek treatment for his cocaine use was clearly instrumental in his motivation and was a critical first step in his treatment. Often, one or several people in a patient's life can exert this kind of "leverage," and patients such as Al should be encouraged to allow them to participate in the treatment. The clinician will want to avoid the appearance of taking sides with the significant others—ganging up on the patient—but instead should help the patient listen to the concerns of the people he or she is close to and decide how to respond to them. Several family or couple therapy techniques have been tested for treatment of substance-dependent patients in controlled trials and have been found to demonstrate solid evidence of efficacy (Liddle et al. 2001; Stanton and Shadish 1997; Szapocznik and Williams 2000). Such techniques are based on family systems theory—examining the disruptions in family systems brought about by a substance-abusing family member. From this perspective, Al's cocaine habit can be viewed as having caused him to abdicate his parental role, becoming instead like a difficult, angry child who his wife is left to manage by herself. Their children's school problems are further evidence of the disrupted family system—a response to the loss of the positive discipline and role modeling exerted by their "good father" before he became addicted. An effective family therapy or couples therapy can address not only the drug problem but also the larger couple or family problems because the drug use is viewed as one component of the disrupted family system. Thus, it is notable that Al's treatment program included ongoing marital counseling. k* k" D: H* j9 G5 f
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In the treatment of cocaine or other substance dependencies, it is important to identify and treat other co-occurring psychopathology. Having a drug or alcohol problem increases the risk of a range of disorders, including Mood Disorders, both unipolar and bipolar, Anxiety Disorders, Attention-Deficit/Hyperactivity Disorder (ADHD), Eating Disorders, and Personality Disorders, especially Borderline and Antisocial, not to mention other substance use disorders. ADHD often goes unrecognized in adults, and the stimulant properties of cocaine may attract such patients. Impatience and anger are frequent adult symptoms of ADHD, particularly in response to being frustrated or kept waiting. If Al's anger had not resolved so thoroughly after he quit using cocaine, it would have been important to examine whether the irritability might have been related, at least in part, to a Mood Disorder or ADHD and treated accordingly. Placebo-controlled trials of antidepressant medication for treatment of co-occurring depression among alcoholics and opiate addicts have yielded mixed results but on balance support efficacy of such treatment. Few such studies have been conducted among cocaine abusers, but results also appear encouraging (Nunes and Quitkin 1997). Few studies have examined treatment of co-occurring disorders other than depression, but it seems a safe general principle to treat other disorders when they are present. Such treatment will not cure the addiction by itself, but it may contribute to the success of a larger treatment plan.

Al enters a treatment program that includes individual and group therapy, marital counseling, urine screening, and self-help group participation, and he does beautifully. What makes a good treatment program? Does the therapeutic orientation or the various components matter? Would Al have been just as well off being seen in an individual therapist's office? Programs vary in quality, and it is important to pick good ones. Urine screening for cocaine and other drugs is essential; a good program should collect urines routinely and have procedures to supervise the collection (i.e., a staff member watches the patient urinate) if there is concern that the patient is hiding drug use by substituting fake urine. Most patients are frank about their use to clinicians if the clinician's stance is nonjudgmental and negative consequences are not tied to admissions of use. Patients are more likely to obfuscate if they fear consequences (e.g., disapproval by staff, anger or retaliation by spouse or family member, legal or employment issues). In general, it is best to create a trusting atmosphere. It is also important to be aware that some substances, such as alcohol or the high-potency benzodiazepines (e.g., Xanax [alprazolam]) or narcotics (e.g., fentanyl), are often not detected in urine., C' j3 Y6 s; p# F; R3 v6 T
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Most substance abuse treatment programs in the United States today are oriented toward "12-step" self-help groups, such as Alcoholics Anonymous or Cocaine Anonymous, in which Al was encouraged to participate. The emphasis of self-help groups is on complete abstinence (note that Al was pressured to quit drinking alcohol, too), concrete strategies for maintaining abstinence, and following the 12 steps. Many patients do not feel comfortable in such groups, but those who take to them often do very well, as Al did. It is thus important, as a clinician, to continue to encourage patients to attend the group sessions and work through their resistance. This "traditional" approach found support in the largest controlled study of outpatient therapy for Cocaine Dependence to date—the National Institute on Drug Abuse's Collaborative Study (Crits-Christoph 1999)—which sought to embody such standard drug counseling interventions in treatment manuals. The study found that the combination of individual drug counseling and group drug counseling conducted by experienced counselors was more effective in reducing cocaine use at follow-up compared to group drug counseling alone or group drug counseling plus either of two psychotherapeutic techniques (cognitive therapy or supportive-expressive therapy). In fact, drug counseling can be viewed as having contained many of the essential components of both of the psychotherapies, including an empathic stance, building of the treatment alliance, and concrete advice on how to cope with various challenges of abstinence, and it may have been delivered by clinicians who were more experienced treating Cocaine Dependence.5 Y$ u2 [! Z0 Q: r, B' p
; q1 e6 a( L) H2 q5 u$ f sGet Rich Bang Bitch Child Custody Attorney Singlewomenadultservice H Q Single Hentai Sk 1 Single Women Adult Service Cases From DSM-IV-TR® Casebook and Its Treatment Companion - 诊断标准（DSM-IV & CCMD-3 & ICD-10） - 临床、咨询与健康心理学 - 心理搜普 ♡ 致力于中国最专业的心理学会所让心理学真正改变人类生活 - Powered by Discuz!v Single Women Adult Service Single Women Adult Service hGet Rich Bang Bitch Child Custody Attorney Singlewomenadultservice H Q Single Hentai Sk 1 Single Women Adult Service Cases From DSM-IV-TR® Casebook and Its Treatment Companion - 诊断标准（DSM-IV & CCMD-3 & ICD-10） - 临床、咨询与健康心理学 - 心理搜普 ♡ 致力于中国最专业的心理学会所让心理学真正改变人类生活 - Powered by Discuz!z p m Single Women Adult Service Single Single Women Adult Service