UNDERSTANDING THE IMPACTS OF FINANCIAL AND OTHER STRESS ON ADDICTIVE BEHAVIOUR AND MENTAL HEALTH. PRESENTED BY PHILIP HILDER PSYCHOLOGIST PHILIPHILDER@IPRIMUS.COM.AU Substance Abuse DEFINING SUBSTANCE ABUSE AND PROBLEM GAMBLING Repeated use of a psychoactive substance or substances, to the extent that the user is periodically or chronically intoxicated, shows a compulsion to take the preferred substance (or substances), has great difficulty in voluntarily ceasing or modifying substance use, and exhibits determination to obtain psychoactive substances by almost any means. Typically, tolerance is prominent and a withdrawal syndrome frequently occurs when substance use is interrupted. The life of the addict may be dominated by substance use to the virtual exclusion of all other activities and responsibilities. Problem Gambling World Health Organisation (WHO) Gambling involves the staking of money or items of value on the outcome of an uncertain event that is determined by chance Participation is voluntary. There are motivational drives to risk items of value and to obtain subjective gain: money, status/identity, or mood alteration Prof Alex Blaszczynski, 1999 1
SYMPTOMS & OUTCOMES OF SUBSTANCE ABUSE/MISUSE Substance misuse is the harmful use of substances (like drugs and alcohol) for non-medical purposes. The term substance misuse often refers to illegal drugs. However, legal substances can also be misused, such as alcohol, prescription medications, caffeine, nicotine and volatile substances (e.g. petrol, glue, paint). Typical signs of substance misuse or addiction include: Neglecting responsibilities and activities you used to enjoy (e.g. work, family, hobbies, sports, socialising) Participating in dangerous or risky behaviours (e.g. drink driving, unprotected sex, using dirty needles) Criminal problems (e.g. disorderly behaviour, drink driving, stealing) Relationship problems (e.g. arguments with partner/family/ friends, losing friends) Physical tolerance (e.g. needing more substance to experience the same effects, symptoms of withdrawal when not using) Losing control of your substance use (e.g. unable to stop using, even if you want to) Substance use takes over your life (e.g. spending a lot of time using, finding/getting drugs and recovering from the effects). DSM5 PATHOLOGICAL GAMBLING A. Persistent and recurrent maladaptive gambling behaviour as indicated by four five (or more) of the following: 1. Preoccupation 2. Tolerance 3. Loss of control - difficulty in controlling, cutting back or stopping 4. Withdrawal symptoms 5. Escape and mood alteration 6. Chasing losses 7. Deception and lies Illegal acts 8. Loss of relationships and opportunities 9. Bail out B. The gambling is not better accounted for by mania 2
DURAND JACOBS - PREDISPOSITION Chronic states of negative self-belief combined with hyper and/or hypo (dysregulated) ANS arousal are believed to predispose a person to a rather narrow window of stress reducing but potentially addictive substances or experiences DURAN JACOBS: GENERAL THEORY OF ADDICTIONS Psychological and Physiological escape from pain Psychological factors: Negative self-beliefs that stem from childhood developmental experience Physiological factors: Dysregulation of the ANS - Heightened or Depressed ANS resting states A chance stress reduction event begins and maintains an addictive pattern E.g. Gambling, drinking, drugs 3
3 STAGES IN THE COURSE OF ADDICTION Stage 1DiscoveryStage 2Resistance tochangestage 3Exha JACOBS: 3 FACTORS IN ADDICTIVE AND DISSOCIATIVE BEHAVIOUR 1. It blurs reality 2. It lowers self-critique and self-consciousness 3. It permits complimentary day dreams about oneself (altered identity) 4
DSM III (1980) - PATHOLOGICAL GAMBLING PREAMBLE The essential features of this disorder are a chronic and progressive failure to resist impulses to gamble and gambling behaviour that compromises, disrupts or damages personal, family and vocational pursuits The gambling preoccupation, urge and activity increases during periods of stress. Problems that arise as a result of gambling lead to an intensification of the gambling behaviour Characteristic problems include extensive debt and consequent default on debts and other financial responsibilities, disrupted family relationships, inattention to work and financially motivated illegal activities to pay for gambling WINNING!!! Players can only get ahead of a machine on a short term basis at best. In the long term this outcome is virtually impossible Australasian Gaming Machine Manufacturers Association, 2000 5
THE CYCLE OF PROBLEM GAMBLING BY MITCHELL BROWN Desire to Escape Desire to Win Feeling bad No money More Loss Chasing Gamble Lose Win Blame Denial Dishonesty Secrecy THREE BASIC FEATURES Gambling to excess Failure to control Negative consequences (relationships, financial, legal, health, mental health, self-harm, suicide) 6
LEFT & RIGHT HEMISPHERES HIERARCHY OF BRAIN, MIND, FUNCTION 7
THERE ARE STRONG CHEMICAL HOOKS IN CERTAIN DRUGS? Q. Are there strong chemical hooks in certain drugs? Experiment: Put a rat in a cage, alone, with two water bottles. One is just water. The other is water laced with heroin or cocaine. Almost every time you run this experiment, the rat will become obsessed with the drugged water, and keep coming back for more and more, until it kills itself. THERE ARE STRONG CHEMICAL HOOKS IN CERTAIN DRUGS? But in the 1970s, a professor of Psychology in Vancouver called Bruce Alexander noticed something odd about this experiment. The rat is put in the cage all alone. It has nothing to do but take the drugs. What would happen, he wondered, if we tried this differently? So Professor Alexander built Rat Park. It is a lush cage where the rats would have coloured balls and the best rat-food and tunnels to scamper down and plenty of friends: everything a rat about town could want. What, Alexander wanted to know, will happen then? In Rat Park, all the rats obviously tried both water bottles, because they didn't know what was in them. But what happened next was startling 8
THERE ARE STRONG CHEMICAL HOOKS IN CERTAIN DRUGS? The rats with good lives didn't like the drugged water. They mostly shunned it, consuming less than a quarter of the drugs the isolated rats used. None of them died. While all the rats who were alone and unhappy became heavy users, none of the rats who had a happy environment did. THERE ARE STRONG CHEMICAL HOOKS IN CERTAIN DRUGS? After the first phase of Rat Park, Professor Alexander then took this test further. He reran the early experiments, where the rats were left alone, and became compulsive users of the drug. He let them use for fifty-seven days -- if anything can hook you, it's that. Then he took them out of isolation, and placed them in Rat Park. He wanted to know, if you fall into that state of addiction, is your brain hijacked, so you can't recover? Do the drugs take you over? What happened is -- again -- striking. The rats seemed to have a few twitches of withdrawal, but they soon stopped their heavy use, and went back to having a normal life. The good cage (rich social environment) saved them 9
RICH SOCIAL ENVIRONMENTS Here's one example of an experiment that is happening all around you, and may well happen to you one day. If you get run over today and you break your hip, you will probably be given diamorphine, the medical name for heroin. In the hospital around you, there will be plenty of people also given heroin for long periods, for pain relief. The heroin you will get from the doctor will have a much higher purity and potency than the heroin being used by street-addicts, who have to buy from criminals who adulterate it. So if the old theory of addiction is right -- it's the drugs that cause it; they make your body need them -- then it's obvious what should happen. Loads of people should leave the hospital and try to score morphine on the streets to meet their habit. RICH SOCIAL ENVIRONMENTS But here's the strange thing: It virtually never happens. Medical users just stop, despite months of use. The same drug, used for the same length of time, turns street-users into desperate addicts and leaves medical patients unaffected. If you still believe that addiction is caused by chemical hooks, this makes no sense. But if you believe Bruce Alexander's theory, the picture falls into place. The street-addict is like the rats in the first cage, isolated, alone, with only one source of solace to turn to. The medical patient is like the rats in the second cage. She is going home to a life where she is surrounded by the people she loves. The drug is the same, but the environment is different. 10
RICH SOCIAL ENVIRONMENTS This gives us an insight that goes much deeper than the need to understand addicts. Professor Peter Cohen argues that human beings have a deep need to bond and form connections. It's how we get our satisfaction. If we can't connect with each other, we will connect with anything we can find -- the whirr of a roulette wheel or the prick of a syringe. He says we should stop talking about 'addiction' altogether, and instead call it 'bonding.' A heroin addict has bonded with heroin because she couldn't bond as fully with anything else. So the opposite of addiction is not sobriety. It is human connection. TREATMENTS Substances Harm Minimisation Detox/Hospital Rehab 12-step (A.A., N.A., etc) Therapeutic counselling Welfare support Legal support Health funding (Fed & State) Problem Gambling Responsible gambling Self-exclusion 12-step (G.A.) Therapeutic counselling Financial counselling Legal support Industry funding (State) 11
BOUNDARIES & LIMITS Recovery from both substance misuse/abuse and problem gambling requires treatment boundaries and limits Enabling emerges when a client is rescued, bailed out or distracted from the negative consequence of their actions BOUNDARIES AND CHANGE Change Therapeutic change is achieved in the following ways: Clear education and contract re: service, service rules, guidelines, expectations boundaries and limits including clear behavioural consequences Giving people a chance to address and repair their mistakes Empathy, Validation, Acceptance, Support Invitation or suggestion to address and change Direct encouragement to change You must do You must not do... You will be discharged for.. attitude & behaviour 12