Frequently Asked Questions
What are the requirements for license renewal Licenses Expire CE Hours Required 36 hours. LMFT, LPCC, LEP and LCSW - Biennial renewals are due on the 18 hours for initial license renewal. last day of your birth month. (All hours are allowed through Cat. I, electronic courses) Mandatory Courses License Expiration PRIOR to July 1, 2015 License Expiration AFTER to July 1, 2015 ALL LICENSEES - 6 hours of Ethics every renewal cycle. ALL LICENSEES - 6 hours of Law & Ethics every renewal cycle. LMFT, LCSW & LPCC - 7 hours of HIV/AIDS - (one-time only) LMFT, LCSW & LPCC - 7 hours of HIV/AIDS - (one-time only*) LMFT & LCSW - 7 hours of Spousal/Partner Abuse - (one-time only) LMFT & LCSW - 7 hours of Alcohol and Other Chemical Substance and 3 hours of Aging and Long Term Care - (one-time only) Dependency (one-time only*) LEP - 7 hours of Child Abuse Assessment (one-time only) and 15 hours of LEP - 7 hours of Child Abuse Assessment (one-time only) and 15 hours of Alcoholism and Other Chemical Substance Dependency (one-time only) Alcoholism and Other Chemical Substance Dependency (one-time only) * Courses taken prior to 7/1/15 will satisfy the one-time requirement but cannot be counted towards the 36-hours of CE.
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How much will it cost? Cost of Courses Course Title CE Hours Price Couples Counseling 4 $16.00 Elderly Abuse in America: Prevalence, Etiology and Prevention 5 $20.00 Ethics in Social Work and Counseling and HIPAA Privacy Rules 6 $24.00 Internet Addiction to Cybersex and Gambling: Etiology, Prevention and Treatment 8 $32.00 Prescription Drug Abuse: Etiology, Prevention and Treatment 8 $32.00 Understanding Adolescent Suicide for Mental Health Practitioners 5 $20.00 BEST VALUE SAVE $65 - Entire 36-hour Course 36 $79.00
Are you a California board approved provider? Yes, Elite is approved by the California Board of Behavioral Sciences. Our provider number is PCE 5254. Courses meet the qualifi cations for 36 hours of continuing education credit for MFTs, LPCCs, LEPs and/or LCSWs as required by the California Board of Behavioral Sciences.
Are you a nationally approved provider? Yes, Elite is an NBCC-Approved Continuing Education Provider (ACEPTM) and may offer NBCC-approved clock hours for events that meet NBCC requirements. The ACEP solely is responsible for all aspects of the program. Provider number 6341. Elite is approved by the National Association of Social Workers (NASW); provider number 886463821.
Are my credit hours reported to the California board? No, the California Board of Behavioral Sciences performs audits at which time proof of continuing education must be provided.
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Important information for licensees: Always check your states’ board website to determine the number of hours required for renewal, and the amount that may be completed through home-study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on fi le. See page 141 for Board contact information.
SocialWork.EliteCME.com Page i Table of Contents
CE for California Mental Health All 36 Hrs ONLY Professionals $79 CHAPTER 1: COUPLES COUNSELING Page 1
In this course, we will explore the history of couples counseling, the theoretical basis for family therapy and couples therapy, and the different models of intervention for couples in therapy. In addition, we will look at some subtypes of couples therapy, including work with stepfamilies, families with domestic violence and families with substance abuse, as well as the assessment of marital issues with measurement tools. Furthermore, the Want more courses to ethical issues that face clinicians performing couples therapy also will be explored. choose from? Finally, we will examine research related to the effi cacy of couples counseling.
Couples Counseling Final Exam Page 17 No problem!
CHAPTER 2: ELDERLY ABUSE IN AMERICA: PREVALENCE, Here are just a few of our most popular courses: ETIOLOGY AND PREVENTION Page 18 • Autism Spectrum Disorder in Elderly mistreatment and care are critical and troubling areas in America, with state and Children federal governments spending far less on research and prevention compared with peer • Bullying in Children and Youth nations. On October 21, 2011, the media reported plans to cut Medicaid benefi ts further, affecting millions of aging Americans. As baby boomers continue to age, this becomes • Elderly Mental Health: an even more pressing problem. Though the rate of disability among the elderly has Depression and Dementia declined, life expectancy continues to rise. The number of cases of elderly mistreatment • HIV and Mental Health will undoubtedly rise over the next several decades as the population ages. • Refl ective Supervision in Infant Mental Health Practice Elderly Abuse in America: Prevalence, Etiology and Prevention Final Exam Page 38 • Sensory Processing Disorders in Infants and Children CHAPTER 3: ETHICS IN SOCIAL WORK AND COUNSELING AND HIPAA PRIVACY RULES Page 39 Visit SocialWork.EliteCME.com to view our entire course library Ethics violations occur in all professions, making the study of ethics a critical issue for and get your CE today! all professionals. Professionals in the fi eld of mental health face many complex ethical considerations. Managed care requires practitioners to consider issues of confi dentiality, informed consent and multiple relationships with clients in a constantly changing culture with many diverse populations. In an increasingly litigious society, strict adherence to a PLUS... code of ethics by all mental health professionals and their staffs is essential. Lowest Price Guaranteed A+ Rating from BBB Ethics in Social Work and Counseling and Serving Professionals Since 1999 HIPAA Privacy Rules Final Exam Page 63
All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional advice. Elite Professional Education, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials.
Page ii SocialWork.EliteCME.com Table of Contents
CE for California Mental Health All 36 Hrs ONLY Professionals $79 CHAPTER 4: INTERNET ADDICTION TO CYBERSEX AND GAMBLING: ETIOLOGY, PREVENTION AND TREATMENT Page 64
Many individuals today are drawn by the power of the Internet to expand their world. The Internet can be a positive tool in business, education, research and communication, and has revolutionized opportunities to establish social networks worldwide. However, We do more than just this unlimited access can also lead to self-destructive behaviors and addictions in many areas. Some individuals like to escape into novel experiences, and they develop Mental Health CE! alternative personalities that are more aggressive, less inhibited, more sensual, and more likely to take risks. Additional professions include: • Addiction Studies Internet Addiction to Cybersex and Gambling: Etiology, Prevention and Treatment Final Exam Page 92 • Barber • Community Association Manager CHAPTER 5: PRESCRIPTION DRUG ABUSE: ETIOLOGY, PREVENTION AND TREATMENT Page 93 • Cosmetology • Esthetician Prescription drug abuse is the nation’s fastest growing drug problem. While there has • Manicurist been a decrease in the use of some illegal drugs like cocaine, data from the National Survey on Drug Use and Health (NSDUH) showed that nearly one-third of people age • Dentist 12 and over who used drugs for the fi rst time in 2009 begin by using a prescription • Dental Hygienist drug nonmedically (NSDUH, 2009). The same survey found that more than 70 percent • Funeral who abused prescription drug pain relievers got them from friends or relatives, while approximately 5 percent got them from a drug dealer or the Internet. • Massage Therapist • Nurse Prescription Drug Abuse: Etiology, Prevention • Electrician and Treatment Final Exam Page 123 • Pharmacist CHAPTER 6: UNDERSTANDING ADOLESCENT SUICIDE • Pharmacy Technician FOR MENTAL HEALTH PRACTITIONERS Page 124 • Veterinarian
Suicide remains the third-leading cause of death for adolescents, following motor vehicle accidents and homicide. Despite a decline reported in the 1990s, The Science Daily Visit www.EliteCME.com to view reported in September 2007 that the adolescent suicide rate for 10- to 14-year-olds our entire course library and get increased by 8 percent from 2003-2004, the largest increase in 15 years. The Science your CE today! Daily report also cited a Centers for Disease Control survey of youth in grades 9-12 in both public and private schools in the United States that found that 17 percent surveyed reported seriously considering suicide, 13 percent had created a plan for committing suicide and 8 percent had attempted a suicide in the 12 months prior to taking the survey. In addition, the CDC also notes that each year, approximately 125,000 young people ages 10-24 within the United States are taken to emergency rooms because of self- infl icted injuries from suicide attempts.
Understanding Adolescent Suicide for Mental Health Practitioners Final Exam Page 140
SocialWork.EliteCME.com Page iii CHAPTER 1: Couples Counseling
4 CE hours
By: Leah Kulakowski, LMFT with: Kathryn Brohl, LMFT and René Ledford MSW, LCSW, BCBA
Learning objectives
Review theoretical perspectives of couples therapy. Learn an overview of approaches to sex therapy with couples. Distinguish between marital education and marital therapy. Identify issues in working with couples in stepfamilies. List the stages of marital confl ict and how they are treated in therapy. Describe approaches to working with couples experiencing Describe the different measurement tools used in couples therapy. domestic violence. Identify several therapeutic models used with couples, including Identify and review ethical issues in couples counseling. cognitive behavioral therapy, emotionally focused therapy and List some research related to couples counseling. Gottman’s approach to work with couples. INTRODUCTION – CASE EXAMPLES
Margaret and James
Margaret and James are both 45 and have been married for 23 years. father’s alcoholism. His parents divorced when James was 15. James They have three daughters, ages 19, 15 and 11. They grew up in the seldom speaks to his father, who has been sober and active in AA for same small town, dated from their junior year of high school and the last 20 years. attended college together at a state university. They married at the Margaret always thought she had a happy marriage but recently age of 22, just after graduating from college. Margaret and James discovered James was having an affair with a divorced woman he both hold very traditional views of marriage, with James being the met at their church. James wants a divorce and says Margaret is dull, primary breadwinner. Although Margaret was the superior student, boring and is constantly nagging him. He is resentful about having graduating magna cum laude with a degree in accounting, she works married young and missing out on dating more women. He feels his only to supplement their income and has always placed James’ career life is passing him by. He wants a divorce but he is afraid it will ruin fi rst. James has a successful career as the high school principal in their his career, and divorce will force Margaret to work full-time, just like hometown, a position he has held for the past fi ve years. Margaret works his mother, which fi lls him with guilt and shame. He always wanted a part time as a bookkeeper in her father’s building supply business. happy family for his children, with both parents present and a full-time Margaret is very close to her traditional parents, who have been mother, but cannot stand the thought of being married any longer. married for more than 50 years and are well respected in their Margaret desperately wants to save her marriage and is willing to community. James acknowledges that his father, who was from a forgive him at any cost, which her mother supports, but her sister is prominent family, was the “town drunk,” and his mother was forced telling her to dump him, telling her “once a cheater, always a cheater.” to work to take care of James and his three brothers because of his Margaret is desperate, hurt and confused.
Ron and Michelle
Ron and Michelle have been married for two years. Ron is 49, and has Michelle disagrees with Ron’s punishments, he accuses her of taking a successful construction business. He was married for 20 years and her children’s side. Ron also resents the fact that Michelle’s ex cannot divorced for two years before marrying Michelle, who owns a hair take the boys for any length of time to “give us a break,“ and says that salon. He has two daughters, ages 20 and 22, who see him about once between work and her children, they never have any “couple time.” a week. This is the third marriage for Michelle, who is 39. She was Ron feels he has no authority in his own home; Michelle thinks that married for a few years at the age of 20, a marriage that ended when Ron is a tyrant. Ron feels he has to share Michelle with others too her husband died. Shortly after his death, she married again at the age often, but Michelle argues Ron knew that the children were a full of 24 to the father of her two sons, who are now ages 10 and 12. She time commitment when they married, so he should “grow up” and get stated that she and the boys’ father argued constantly. The marriage over how much time they take away from her and Ron as a couple. lasted 12 years and ended two months before she met Ron. Michelle wants a divorce, and Ron thinks everything would be great if Her former husband is working overseas and hasn’t been able to see the kids weren’t around. He frequently thinks of just giving it up and the boys very much in the last two years. Right now, she feels Ron is fi ling for a divorce. too strict with her sons, and they are becoming very rebellious towards These two scenarios describe two very different families, one a him and say he is “mean.” Ron complains that Michelle is too easy on traditional, long-term marriage and the other a blended stepfamily. the boys and he has to exert control because she won’t do it. Michelle They both illustrate marriages that are clearly in crisis. The issues that feels she is a good parent and prefers to talk things over with her sons face both of these marriages appear to be quite different. But both of and negotiate and compromise. Ron believes that his rules should these cases, while appearing different on the surface, can be assessed be obeyed without question, just as they were in his family. When and treated by a therapist using the same theoretical orientation. A
Page 1 SocialWork.EliteCME.com couples therapist using either emotionally focused therapy (EFT) different models of intervention for couples in therapy. In addition, or cognitive behavioral therapy could be effective in both of these we will look at some subtypes of couples therapy, including work situations, even though they are very different approaches. However, with stepfamilies, families with domestic violence and families with treating couples in these types of situations is never easy, and to substance abuse, as well as the assessment of marital issues with be successful in helping them, therapists need specifi c training and measurement tools. Furthermore, the ethical issues that face clinicians supervision in whichever modality they choose. performing couples therapy also will be explored. Finally, we will In this course, we will explore the history of couples counseling, examine research related to the effi cacy of couples counseling. the theoretical basis for family therapy and couples therapy, and the
What is a couple?
Marriage is often described as the one familial relationship that we not necessarily present in an unmarried coupling, regardless of the can choose. As noted by the eminent scholar and practitioner, William duration of the unmarried relationship,” (p. 12). As the acceptance of Nichols, “Marriage is the lone voluntary relationship in the family,” same-sex marriages increases and more couples choose not to marry, it (1988, p.6). We cannot choose siblings, children or parents, but we is diffi cult to know whether Nichols’ words will continue to be as true certainly can choose our spouses, and in some cases, “un-choose” them. 10 years from now as they were in 1988. Certainly, parents can cut off children; children can cut off their parents; However, in this course, the terms marital intervention, marital and siblings can go for years without speaking. But unlike ex-spouses, therapy, marriage therapy, couples counseling and couples therapy we never hear someone refer to my “ex-father” or my “ex-child.” will be used interchangeably and unless otherwise noted, are generally applicable to all types of couples. It is critical to realize that some of the theorists and practitioners noted in this module may have only conducted research or performed these interventions with married couples and may not have intended for their work to be generalized to unmarried or same sex couples. When the writer has direct knowledge of this information, it will be noted. The oft-quoted statistic is that 50 percent of the approximately 2 million marriages that occur each year in the United States will Marriage is also a rapidly changing relationship in our culture. Same- fail (http://www.cdc.gov/nchs/fastats/divorce.htm). But that also sex marriage as well as multiple marriages and divorces throughout means that 50 percent of marriages will not end in divorce. A recent a lifetime were unknown a century ago. Marriage is in most states a study analyzing 20 previous studies of marriage and family therapy legal union of a man and a woman. However, some states do allow concluded that therapy is effective (Shadish and Baldwin, 2003). same-sex marriages and some allow civil unions, which give couples Despite these fi ndings, only about one-third of divorcing couples have certain rights but are not recognized as marriage. ever even attempted marriage counseling (Johnson, et al., 2002). The most commonly noted reasons for seeking counseling are problems In addition, many couples, regardless of gender or sexual orientation, with affection, problems with communication, a general desire to choose cohabitation over marriage or civil unions, short-term and increase marital satisfaction and worries about the potential for divorce permanently. Although this point could be debated at length, it is (Doss, Simpson and Christensen, 2004). important to note that marriage is a socially recognized institution and does have a social meaning that differs from a long-term It is also important to note that in this course, couples counseling is cohabitating relationship. Nichols (1988) observed several decades largely explored from the perspective of European or North American, ago that relationships do change when couples enter the social realm middle- and upper middle-class persons from Caucasian backgrounds. of marriage and take on new roles of husband and wife. Marriage, he There is a dearth of research in family therapy about people from notes, “holds expectations and meanings for many persons that are lower socioeconomic backgrounds, African Americans, Asians and Hispanics or research in non-Western countries. A BRIEF HISTORY OF MARRIAGE THERAPY
Marriage therapy or couples therapy is a relatively new form of A course on marital therapy requires a general look at theoretical counseling. In the traditional focus of family therapy, work with approaches to family systems and family therapy; in general, the families instead of the marital dyad received more attention overall. In therapy models can be divided into fi ve groups: fact, in major family therapy textbooks, only about one-quarter of the ● Communication. material emphasizes couples therapy (Nichols and Schwartz (1998) ● Psychodynamic. and Gurman and Kniskern (1981, 1991). ● Intergenerational. ● Experiential. ● Postmodern.
Communications model
The communication models are further subdivided into the approaches in the here and now, with little involvement with a person’s past of the Mental Research Institute (MRI), Milton Erikson, the Milan experiences or internal, psychodynamic processes. team, structural therapy, strategic therapy and solution-focused In addition, these approaches place a good deal of emphasis on the therapy. The communication models involved such infl uential family power of the therapist to bring about change within the family (Piercy, therapists as Don Jackson, Lyman Wynne, Milton Erickson, Jay Sprenkle and Wetchler, 1996). Don Jackson contributed insight into the Haley, Sal Minuchin, Steve de Shazer and Insoo Kim Berg. While martial relationship within the family system. His major contribution these approaches may differ in technique and emphasis, the overriding to couples therapy was the concept of marital quid pro quo, which is common factor in these approaches is the emphasis on communication
SocialWork.EliteCME.com Page 2 an unconscious set of rules that guide the relationship into essentially Jay Haley was also highly infl uential in marital therapy. He believed an exchange wherein one person in a couple gives something, then that all marital problems stemmed from power and control issues. Haley the other receives something in return. Jackson asserted that there are (1963) noted that, “the major confl icts of marriage center on the problem rules, though not always explicitly stated, that govern these exchanges. of who is to tell whom what to do and under what circumstances,” (p. Jackson felt that establishing a clear quid pro quo was important to 227). Haley did not care about the history or experiences of the couple, achieving harmony in a marriage (Lederer and Jackson, 1968). or about insight or feelings. He felt that the major job of the therapist is to create interventions that bring about change.
Psychodynamic model
In contrast, the psychodynamic models of family therapy emphasized the mother fails to meet these needs and the child is angered by not the internal process as related to a person’s present issues and having his needs met, he splits the mother into good and bad objects. problems, and are strongly rooted in the psychodynamic theories of The good mother allows the child to feel secure and loved. The bad Freud. The best known of these theories is object relations family mother is an internal object that causes the child to feel unloved. The therapy. Ronald Fairbairn (1952) popularized this theory, which is “introjects” of the good and bad mother are integrated into an adult’s highly complex and is rather diffi cult to summarize. An infant learns personality and continue to be projected onto others. The negativity to see his mother as “good” through her meeting his needs. But when and severity of these projections varies from person to person.
Intergenerational model
One of the more infl uential models of family therapy is of children was an attempt to draw attention to the parent’s marital intergenerational, which was developed by Murray Bowen and later, problems and help the parents’ marriage by bringing them into therapy. Ivan Boszormenyi-Nagy. In general, the infl uences of our family of It is important to note that Bowen’s theories were from the mid-20th origin are carried with us into our adult relationships, and we are century and were developed before the model of the nuclear family able, through processes such as differentiation and individuation, changed to what it is today. It does not always adequately explain how to work through these infl uences and become healthy adults with these processes work for persons who are not married, who do not well-functioning marriages. Bowen described differentiation as the have children or are single parents. process of developing individual thought that is rational and not driven Nevertheless, in work with couples, the key was to remain present but by emotions. Persons who are well differentiated are able to think not triangulated into the marital confl ict. Bowenian therapy has often logically, not be unduly infl uenced by emotion and separate their been viewed as the bridge between individual psychoanalytic theory emotions from their actions. and systems-oriented family therapy. While the approach disavowed In other words, a person who married within days of meeting a spouse such concepts as the id and ego, it still paid attention to the inner is likely to be poorly differentiated. A person who met someone and workings of a person, but from the larger perspective of the impact of then dated the person for two years while determining whether he/she one’s family of origin and its related infl uences on a person’s thoughts was a good potential marital partner is likely to show signs of higher and behaviors (Lebow and Gurman, 1998). Gurman and Fraenkel levels of differentiation. Likewise, a person who is independent of the describe Bowen’s approach as acknowledging “the past as well as the undue infl uences of a family of origin and can think independently is present, to the intrapersonal as well as the interpersonal, and to the demonstrating characteristics of being well individuated. affective as well as the cognitive. It was the only couple therapy theory For example, someone who is individuated might choose, after much of its day emerging from family therapy that simultaneously addressed careful thought and exploration, to follow a different religion than his the individual, the dyad, and the family of origin,” (p. 218). or her family of origin. This person is aware that this change will upset As they built on the work of Bowen, Boszormenyi-Nagy and Ulrich parents and siblings, but is willing to displease others in order to be (1981) explored the concepts of fi lial loyalty as a motivating factor happy with his/her chosen religious faith. These choices, though, are in people’s behavior as marital partners and as parents. They theorize not reactionary and rebellious. Rebellion is not a sign of being well that people have a certain loyalty to the parental relationship and in a differentiated or individuated, but rather just the opposite. A person strange way of showing loyalty, have a diffi cult time becoming a better who chooses to become Jewish to shock or provoke Catholic parents parent than their parents were. They believe that if a person acts very is not behaving in a well-differentiated or individuated way. According differently than his or her own parents did, it is a way of condemning to Bowen, a person who acts rebellious to upset his/her family is every the parents by implying that they were bad parents. Likewise, if a bit as poorly individuated as someone who will not date a person of person has a better marriage than his or her parents, it is a way of another religious faith solely because of fear of upsetting parents. admitting that the parents’ marriage was not ideal and was unhappy, Bowen further explores how persons of similar levels of differentiation and that triggers feelings of disloyalty in some people and blocks tend to be attracted to one another and marry. Therefore, when two their ability to grow and change. The goal of therapy is to help people persons who are poorly differentiated marry, their relationship is understand that changing behavior is not disloyal. likely to be characterized by heated emotional exchanges, impulsive Bowen also made several distinct contributions to marriage therapy. behaviors and poor acceptance of responsibility. Bowen’s theory was that relationships caused all psychological Another major concept of Bowen’s theory that is fundamental to problems, and that marital problems really stemmed from relationship marital therapy is the concept of triangulation. Triangles are formed problems in one’s family of origin. Bowen emphasized the calm and when two persons incorporate a third person into the relationship rational response to distressing situations and in marital therapy. A to release tension. For example, parents who focus on a child’s therapist who had a great deal of training on self-differentiation that behavioral issues can avoid focusing on their own marital issues. enabled him to remain calm in highly emotional situations, Bowen Triangles become unhealthy when they become static and unchanging. would have the couple speak to him, rather than to each other. In this Bowen had stated that all family therapy eventually becomes marital process, Bowen would refl ect upon the situation and objectively coach therapy, indicating his belief that most of the acting-out behavior each partner.
Page 3 SocialWork.EliteCME.com The experiential model
The experiential theories are based in both communication and emotions, and the emotions experienced are thought to mirror those of psychodynamic theories. However, unlike psychodynamic approaches, the family. If a therapist is feeling little emotion in the session, then it these theories emphasize thoughts and feelings in the here-and- is likely that the family is not feeling much either. Experiential therapy now instead of the past. The inner working of one’s thoughts are is often spontaneous and even can appear irrational in its approach to acknowledged as very real, but are seen as a result of the processing of a problem. The goals in experiential therapy are often more general life experiences and not stemming from concepts such as Freud’s ego than specifi c, emphasizing goals to increase self-esteem and overall and id. This approach has been largely “personality driven” by Virginia functioning of a relationship instead of quantifi able, measured Satir and Carl Whitaker; experiential therapy owed much of its success outcomes (Whitaker and Keith, 1981). Satir took these general goals to the personal qualities of these practitioners. There is a good deal further, involving an emphasis on world peace (Satir, 1988). Satir of emphasis on the therapist being open and vulnerable with a family contributed to couples therapy through her strong emphasis on self- and avoiding expert approaches. The therapist is expected to feel worth and communication as the cornerstones of successful marriage.
Post-modern models
The post-modern models of family therapy include constructivist, about what they observe and think about the session. (Anderson, postmodern, solution-focused and narrative, and in the most 1987). Another major approach of post-modern therapy is that of basic terms support the “concept that reality is an intersubjective solution-focused therapy. This therapy, popularized by Steve de Shazer phenomenon constructed in conversation among people,” (Wetchler, and Insoo Kim Berg (1992), is similar to narrative therapy in that the pg. 129). Steven Friedman (1993) noted “We no longer live in a client is encouraged to move from being problem-saturated in his/ coherent social world with a consistent set of truths, and meaning her life story towards retelling the story with an emphasis on success. is co-constructed in conversation” (p. xiii). There is a great deal of They also made use of the well-known “miracle question” in which emphasis on the therapist taking a collaborative approach instead the client is asked what life might be like if a miracle occurred and of an expert stance with a family. There is much emphasis on not the problem no longer existed. This is used to help clients discover simply diagnosing families as pathological, particularly when dealing the goals they have for treatment. The cause of the problems is not with persons of another culture, and instead accepting a family’s the point of this therapy; the emphasis is on change, regardless of the own culture rather than expecting it to conform to the standards of cause of the issues. the dominant culture (White, 1995). The narrative therapy of White In addition to the therapy models that are derived from these family encourages families to tell their life stories, and through this process, systems theories, there are also three very important frameworks move the family from emphasizing problems in those stories to talking essential to the understanding of a clinician doing couples therapy. The about their successes when dealing with those problems. fi rst of these is the family life cycle, the second is ecosystemic and the Other therapists of the post-modern stance have used refl ecting teams, third is family-stress theory. who observe a client and therapist and comment directly to the clients
The family life cycle
The family life cycle approach theorizes that all families pass through 5. Launching children and moving on. Negotiate adult-to-adult predictable life stages, much in the same way that an individual passes relationships with children, incorporate new roles as grandparents through the stages of life. However, each family is infl uenced by the into the family system. Adjust to living in home without children times in which they live. A classifi cation table lists six stages of the and refocus on couple issues again. family life cycle and the basic tasks of each cycle: 6. Families in later life. Dealing with loss of spouse and peers and 1. Leaving home: single young adults. Tasks are to form romantic adjusting to physical limitations that come with aging. Accept relationships and establish one’s self in the world of work. caregiving roles of adult children. Prepare for death. 2. The joining of families through marriage: The new couple. Each stage consists of developmental tasks that must be completed Adjusting family of origin relationships to incorporate the partner in order for the family to pass to the next phase successfully. When and develop ways to live together. a family cannot complete the tasks, its members often become stuck 3. Families with young children. Tasks are to adjust the marital and cannot move on to the next phase. It is helpful for therapists to relationship to incorporate children. Develop parenting roles and understand these typical stages so that they can better understand the incorporate the role of grandparents into the system. couple’s stage in the family life cycle and use this framework to help 4. Families with adolescents. Taking care of members of the family guide their interventions. The therapist’s job is to help families work of origin and develop patterns of parenting that incorporate through these tasks and move forward (Carter and McGoldrick, 1988). autonomy of the adolescents.
Ecosystemic theory
Ecosystemic theory is formed from the work of Urie Brofenbrenner is slightly different in general, ecosystemic theory emphasizes how (1979) and Richard Lerner (1991), who were developmental the individual and the environment interact in a reciprocal fashion psychologists, as well as Margaret Bubolz and M. Suzanne Sontag to infl uence human development (Bronfenbrenner, 1979, Lerner, (1993), who came from the fi eld of family ecology. Brofenbrenner 1991). It explores causality, not as a linear cause-and-effect outcome, focused on the interaction of the environment and a person’s but rather examines outcomes from a multidimensional perspective development, Lerner’s perspective was developmental change and is especially helpful in the examination of dyadic and triadic throughout the lifespan; Bubolz and Sontag’s perspective was the relationships (Braverman, 1993; Buobolz and Sontag, 1993). interaction of the family and the social and physical environment, Brofenbrenner (1979) notes that there are four contexts for any with an emphasis on decision-making as it relates to the allocation individual and they are “nested,” meaning that each context is placed of resources available to a family. While each of these perspectives within the other, larger context. For example, the family context is
SocialWork.EliteCME.com Page 4 embedded, or nested, within the larger context of the community. Macrosystems are those systems over which a family has little control The contexts that Brofenbrenner describe include microsystems, or infl uence, but which incorporate all of the above relationships mesosystems, exosystems and macrosystems. The relationship of and infl uence all the subsystems, such as society, culture and public parent to child is a microsystem, as is the relationship of spouses. A policy, all of which can greatly affect relationships within the family. mesosystem is the linkage of two microsystems, which, for example, For example, a macrosystemic issue is gay marriage. The refusal of could be the interaction of a child’s family and school. Couples some states to recognize civil unions or marriages between same- and their children are embedded within the various mesosystems sex persons affects these couples and their children tremendously at of schools, neighborhoods and church. An exosystem consists of the microsystemic level. The macrosystem also includes elements areas beyond the control of the family, but is a system that affects a regarding cultural patterns related to race, gender, socioeconomic family, such as the ongoing relationship with social services agencies. status and history.
Family stress theory
Reuben Hill (1949, 1958) was the originator of family stress theory, As an example, one family may see the event (A), the burning down in which he developed a model that attempted to incorporate a of their home, as a crisis due to a lack of resources (B), if the family developmental and systemic perspective in the study of families (Klein has no insurance or money to fi x the home. This event is perceived and White, 1996). He was curious as to why some families did well as overwhelming, (C), because the family cannot see a solution to the under circumstances that destroyed other families, and began his problem of now being homeless, which results in a crisis (X) for this search for what made families different from one another by studying family. Another family sees the same event as very upsetting, but their families in the Great Depression and soldiers reunifying with their resources (B) are quite good. They have the money and homeowners families after World War II. insurance to take care of the problem and to fi nd temporary shelter. Their The basic component of his model was the “ABCX” model of family perception of the event, while certainly not positive and very distressing, stress. The A is any stressor that taxes a family’s resources, whether is not the overwhelming calamity that it was for the fi rst family. The it is an internal issue, such as a marital problem, or an external issue, perception is quite different, and the outcome is that the crisis for the such as loss of a job. The B represents any resources that a family second family will not be as devastating as it is for the fi rst family. may possess to cope with the stress induced by the A event. Resources With married couples, it is assumed that based upon Hill’s model, the can be money, social support or a strong marriage. The C refers to increase of protective factors (B), such as strengthening the marital a family’s perception of the event, and involves how stressful they relationship, will enable the family to handle the inevitable stressors perceive it to be. The interaction of these ABC factors thus results in (A) that arise from daily life, or serious life events, and hopefully the crisis, or the X. lessen the impact of a stressor that arises.
The developmental phases of couples therapy
Despite the legacy of numerous theoretical orientations in the fi eld of psychotherapy of a couple by the same psychoanalyst, who would treat family therapy, couples therapy often seemed to develop without a real one martial partner and then start seeing the other partner once the fi rst theoretical basis and did not necessarily link to any of the established partner had completed psychoanalysis. Gurman and Fraenkel then note family theories. Gurman and Fraenkel (2002) note that there were four that Bela Mittelman (1948) began performing concurrent treatment, phases that led to the development of couples therapy: in which both parties were treated simultaneously in separate sessions I. Atheoretical marriage counseling formation (1930-1963). by the same practitioner. Eventually, the psychoanalyst would then II. Psychoanalytic experimentation (1931-1966). hold joint sessions with the couple. Mittelman undertook this process III. Family therapy (1963-1985). because he would get different stories from each spouse about the IV. Refi nement, extension, diversifi cation and integration (1986-present). same events and felt joint sessions would help him discern the truth of The fi rst phase involved the practice of counseling by persons who what was taking place. were in related professions, such as pastors, obstetricians and social Gurman and Fraenkel note on page 208 of their journal article that workers, who were viewed as assisting with marital adjustment and not although these methods were used on occasion, individual therapy dealing with major mental health issues. Marriage counselors focused was still the predominant modality of couples therapy, and thus, the on the here and now, the presenting issues and provided guidance to practitioner was still seen as the “central agent through which change resolve problems. The help focused extensively on giving advice and must perforce occur.” This refl ects the expert-oriented approach that was oriented toward education. Interestingly, the vast majority of these predominated much of family therapy until the postmodern schools counseling sessions during the 1930s, ’40s and ’50s were not done with of thought began to emerge. Gurman and Fraenkel acknowledged that couples at all, but with individuals. By the mid-1960s, couples were although therapists in the 1960s began to use conjoint therapy more and usually seen together. During this time, the practitioners in the fi eld also more, there was still a heavy emphasis on psychoanalytic theory, with established the American Association of Marriage Counselors. its use of defenses, free association, dream analysis and the examination A large portion of Phase II actually ran parallel to Phase I. Many of the underlying internal processes of individual pathology, which were psychoanalytic practitioners, who were all psychiatrists at that time, then manifested in the marriage. They quote Ralph Gundlach (1971): were performing individual psychotherapy. Over time, many of the “I am not primarily involved in treating marital disharmony, which is a analysts became frustrated with the lack of progress in individual symptom, but rather in treating the two individuals in the marriage.” therapy when marital issues were a major problem for their patients. This model of couples therapy eventually would fall out of favor, Psychoanalysis placed a great emphasis on the relationship of the primarily because it was not particularly effective because it still therapist and client, with its emphasis on transference from patient to emphasized individual treatment and did not address the issues analyst as an agent of change. Psychoanalysts also held very strong between partners. But Phase III, family therapy incorporation, brought views against confusing this relationship by bringing in others. a systemic perspective to the fi eld, which focused on interactional Despite this traditional resistance to anything other than individual patterns but also pushed couples therapy, with its individually oriented therapy, Gurman and Fraenkel (2002) cite Clarence Oberndorf, approaches, out of the limelight for about 20 years. From 1963-1985, who wrote in a paper in 1934 about the emergence of consecutive family therapy emphasized the systemic process of the whole family,
Page 5 SocialWork.EliteCME.com but did not really focus much on the dyadic interaction of the couple. There are numerous forms of couples counseling, and the major Nonetheless, Gurman and Fraenkel (2002) noted that several of the interventions will be discussed in greater detail. It is important to note prominent family therapists, including Murray Bowen, Don Jackson, that not all interventions for couples are the same. Some are better Virginia Satir and Jay Haley, made major contributions to couples classifi ed as marital education, while others are marital interventions. therapy during this time. The major differences are highlighted in the next section.
Marital education
Marital education differs from marital therapy or couples counseling in support, encourage honesty and the open exchange of feelings and that marital education is designed to enrich or enhance a relationship, emotions, and encourage couples to spend time together. It is also not to solve major problems or save a rapidly failing marriage. Marriage important for couples to learn to express fewer negative emotions, education is designed to build skills, such as communication, and is such as contempt and criticisms. And it is helpful with marriage more general in nature instead of focusing on specifi c problems. Marital education to incorporate education about the process of marriage in education harkens back to the early marriage counseling movements general, such as life stages and typical adjustments that are common with the emphasis on giving advice, but has been refi ned over decades to marriages. Interactive participation was also very helpful as it to place greater emphasis on problem-solving and communication allowed couples to practice communication skills (Adler-Baeder, skills. Moreover, the participation in such educational programs today Higginbotham and Lamke, 2004). is usually conjoint. There is a good deal of evidence that marriage Some of the most popular forms of marriage enrichment or education is effective for couples who are not in crisis (Adler-Baeder, education are the Association of Couples in Marriage Enrichment Higginbotham and Lamke, 2004; Halford, Markham, Kline, and Stanley, (ACME), Marriage Encounter, and Prevention and Relationship 2003; Hawkins, Blanchard, Baldwin and Fawcett, 2008). Enhancement Program (PREP). ACME is led by other couples who The intended outcome of marriage education is to improve marital have been trained in the process. ACME does not have a religious satisfaction, which can be affected by three general components: focus. Worldwide Marriage Encounter is supported by the Catholic interactions, contextual factors and personal characteristics (Bradbury, Church but is used by those of many different faiths and presents an Fincham and Beach, 2000; Halford, et al., 2003; Larson and Holman, emphasis on God and spirituality. PREP has several components, 1994). Marriage education tends to focus mostly on interactions between including modules specifi cally designed for presentation to low- the couple, as these are the issues most likely to change with a short- income couples and couples making the transition to parenting. term intervention. More in-depth issues, such as ongoing stressors like PREP is also recognized by the Substance Abuse and Mental Health money or substance abuse as well as individual personality disorders, are Administration (SAMHSA) as an evidenced-based practice that has very hard to change, and are best addressed in the setting of long-term demonstrated effi cacy in several research studies. PREP was found to intensive marital therapy (Halford, et al., Karney and Bradbury, 1995). increase relationship satisfaction, improve confl ict management and Overall, it was determined that successful marriage education communication and decrease levels of problem intensity. programs should emphasize positive exchanges of love and emotional
Cognitive behavioral therapy
Marriage education may be helpful for some types of couples’ with these issues expect to be criticized for a particular behavior, confl icts, but more serious cases of confl ict needs treatment through so even the slightest mention of something related to that behavior couples therapy. A popular approach to couples therapy is cognitive may set off a reaction, even if the topic is mentioned using non- behavioral therapy. According to Schmaling, Fuzzetti and Jacobson critical language. Consequently, reactivity makes it harder to listen (1989), behavioral therapy has its roots in the work of B.F. Skinner. to each other because each is so wrapped up in preparing his/her own Negative material interactions were controlled by the threat of responses to this perceived attack that he/she cannot stop and hear the punishment. The purpose of early behavioral therapy for marital other person. Over time, a buildup of unresolved arguments leads to problems focused on the replacement of negative interactions with increasing bitterness and anger, as well as a loss of hope that future positive interactions that would have spouses act in ways that elicit confl ict can ever be resolved successfully. positive reactions from one another. As the sophistication of this Cognitive behavioral therapy approaches involve several sessions of approach evolved, the impact of cognitive processes became more assessment. This includes identifying problems areas with couples as evident. As they note, “the clinician must assess the attributions that well as gathering relationship histories, which are designed to identify spouses make for their own and their partner’s behavior. Attributions positive areas of relationships that used to be prevalent and could are the beliefs spouses have about the causes of and reasons for each possibly be again. The authors also recommend an individual session other’s behaviors. In addition to assessing the perceived causes of for each partner to assess past relationships, trauma history, family of behaviors, a marital therapist must assess the way in which each origin, sexual history and the partner’s commitment to therapy. spouse interprets the impact of his/her own and the partner’s behavior (cognitive style),” (p. 349-340). Couples therapy is contraindicated when either partner is having a continued affair, has severe mental illness or wants a divorce. Couples The authors note that couples may come to therapy for marital with issues of physical violence and substance abuse will need problems, but an individual often will present with anxiety or additional interventions to be able to work in couples therapy. After depression, and issues about marital problems will arise during the these assessments are completed, then the couple will meet with the course of therapy. This means that a thorough assessment of any therapist who will outline expectations for the therapy. In addition, the client for relationship issues is important. They go on to describe the therapist will emphasize to the couple that the situation is mutual and behavioral patterns of distressed couples. Couples with relationship that one partner alone is not to blame. issues will engage in reciprocated negative behavior in which each partner behaves negatively in response to negative behavior from the Each subsequent session is 90 minutes long, and is quite structured. other, thus setting up a vicious cycle. These couples are also highly The therapist sets an agenda at the beginning of each session, evaluates reactive, and their perceptions about the relationship can change progress, debriefs homework assignments, opens discussion of new rapidly in response to seemingly minor events. In addition, couples skills and assigns tasks. The therapist is also required to provide:
SocialWork.EliteCME.com Page 6 ● Structure: The therapist is very much in control of these sessions Communication skill building is a very important component of the and must be able to keep the couple on task and not allow one or cognitive behavioral approach. The therapist begins by modeling these both to derail the session to lodge complaints against the other. skills and then gradually becomes a coach as the couple uses these ● Instigate: The therapist is trying to enable the couple to eventually skills. Communication skills training steps are broken down into the be able to solve their own problems. The therapist encourages following steps: compliance with homework, encourages collaboration and 1. The therapist models “negative non-listening” by looking away gradually gives the couple more and more responsibility to and doodling while a client speaks and elicits information from practice skills without the therapist present. the client about their feelings about this lack of attention when he/ ● Teach: The therapist has to teach and model various skills and she was speaking. The therapist then models “positive non-verbal provide direct feedback to each partner in skill demonstrations. listening behaviors,” such as making eye contact and then asks ● Create positive expectancies: The therapist needs to convey both participants how this felt to them. both optimism and realistic expectations to a couple. It is also 2. The therapist models “negative verbal receptive skills” such as important to predict some setbacks after the couple’s relationship interrupting, and then asks the couple to provide examples of times becomes more positive. Otherwise, as the couple begins to have a they have demonstrated these behaviors. recurrence of the issues that brought them into therapy, they may 3. Another learned communication skill is to paraphrase, by having discredit the therapist as not really having helped them after all. the therapist speak and have each partner practice by asking the But the therapist should also remind the couple that after some therapist whether the client’s perceptions about what is being said initial setbacks, progress will be regained to a large degree. are correct. The authors cite such examples as asking, “Is that ● Provide emotional nurturance: The therapist needs to provide right,” or “Is that what you meant?” The couple then practices an atmosphere of support to enable the couple to continue with the paraphrasing each other using a positive topic. diffi cult process of therapy. 4. The last step is to have the couple identify emotions in paraphrasing. ● Alliance building: A therapist must be able to fi nd empathy for both This helps the couple realize the effect of an action on the partner. clients, even if one of them is unpleasant or hostile. The therapist An example of this would be to have the couple practice saying should also be careful to not blame one partner for the whole problem things like, “I feel happy when you bring me fl owers.” and focus too much on this partner. Nonetheless, the therapist must be Problem-solving is also integral to this approach and can be divided able to recognize that some issues do require one partner to be more into phases of identifying the problem and coming up with solutions. In challenged to change behavior than the other partner. problem defi nition, the spouses identify a particular issue, acknowledge Typical techniques used by cognitive-behavioral therapists use they each contribute to it and then brainstorm possible solutions. behavioral exchanges to increase positive feelings. Couples are Troubleshooting can also be used when couples report unresolved assigned tasks to do positive things for one another, drawing from arguments between sessions. The therapist guides the couple through a positive courtship experiences and asking what actions that they reconstruction of the arguments and discusses such topics as the intent believe would please their spouses. Partners are asked to develop lists of behaviors and actions, how each partner felt about those behaviors and share them with one another, although the spouse who performs and exploring with the couple what behaviors might have stopped the the tasks will choose which tasks to engage in. This allows the other argument or solved the problem. partner to feel that the spouse’s positive actions towards them are not forced and thus allows the receiving spouse to assign a positive Another intervention is to identify and alter negative patterns of attribution to the spouse’s giving actions. interaction. This intervention will help clients recognize what general pattern their confl ict follows. Typical patterns are: Therapists also use cognitive interventions. The meaning given to a ● Demand/withdraw in which one partner tries to demand emotionally spouse’s behavior is derived from beliefs about the intent of a spouse’s from the partner who keeps withdrawing. The harder the demander actions. This meaning will then contribute to a person’s emotional pushes, the more the other withdraws. The demander feels ignored response, whether it is anger or pleasure. Partners are encouraged through and discounted, and the one who withdraws feels overwhelmed. this intervention to fi nd positive attributions for their partner’s behaviors. ● Relationship vs. work. This pattern has one partner who is more The therapist works through examples of these types of situations with the invested in a career and one who is more invested in the relationship. couple and helps them determine whether the behaviors are misinterpreted ● Emotional/rational. In this situation, one partner becomes highly or whether it is an action or behavior that it coming from a negative intent, erratic and the other remains calm. in which case the behavior is targeted for change.
Assessing marital confl ict
Some forms of couples counseling places a good deal of emphasis developed with married couples, it can be utilized for all couples. on assessing couple’s confl ict stage or type, in order to determine Their guidelines for assessing marital confl ict are listed below. more specifi c couple interventions that are designed for the specifi c Most Stage I couples have little confl ict and are unlikely to enter therapy. stages of confl ict that a couple is experiencing. As any clinician who Occasionally, a Stage I couple will enter therapy, but this is relatively rare. has ever worked with couples knows, assessing relationship confl ict Guerin, et al., (1987) notes that Stage I occurs mostly in the fi rst few years can sometimes be diffi cult when couples enter the therapist’s offi ce, of marriage when couples both come from families of origin with fairly bickering, angry or refusing to speak at all. At fi rst glance, all confl ict low levels of stress and that have been relatively functional. can appear to look very much alike. In Stage II, there is increased criticism and there is less intensity of However, to the trained clinician, subtleties in various dimensions passion. Power struggles are minimal. Often, there is a tendency for of confl ict do emerge with further assessment. Marriage therapists one partner to be a pursuer who pushes the other partner to engage in Guerin, Fay, Burden and Kautto (1987) describe four stages of marital interactions and be closer, while the other partner feels overwhelmed confl ict as it is manifested in interpersonal relationship, and they by this pursuit and retreats. This sets up a pattern in which the pursuer emphasize that it is important for a therapist to understand and assess keeps pursuing, the “distancer” keeps retreating when feeling pressured, what stage of confl ict a couple is in to determine which interventions which in turn just encourages the pursuer to keep chasing even harder. need to occur. The Stages of confl ict are like a map that guides the therapist to utilize certain interventions. Thought their work was Stage III, in addition, is marked by sudden changes in the emotional climate. There is a good deal of emotional reactivity, criticism is high
Page 7 SocialWork.EliteCME.com and couples spend little time together. Couples become locked into Stage IV is extreme and is often characterized by one or both spouses power struggles and want to win at all costs. Self-disclosure takes the hiring an attorney to proceed with a divorce. Guerin et al., notes form of suppressed anger that is unleashed without restraint. There is that couples in this stage are past treatment, and treatment typically a great deal of blaming the other and avoiding responsibility for one’s becomes divorce therapy, with the therapists assisting the couple in part in the confl ict. getting through the dissolution of the marriage with the least emotional damage to the couple and any children.
Marital confl ict Stage I II III IV Communication Open, some confl ict Open, with confl ict Closed, with confl ict Closed Information exchange Excellent Good Compromised Poor Self-disclosure Good Adequate Reactive Absent Criticism Low Moderate High Very high Credibility Very high High Moderate Low Relationship time and activity Excellent Good Compromised, minimal Minimal
Treating Stage I
Interventions do vary greatly by stage. In Stage I, couples are treated that often arise in marriage: sex, money, alcohol and death. There is through psycho-educational interventions, which are primarily also an emphasis on the transition to parenthood for young couples presented in a group format. Couples are educated on such issues and parenting adolescents for older couples. The emphasis is on as normative family life cycle changes, the impact of the couple’s encouraging couples to confront and discuss issues in a healthy way. family of origin on current relationships, and the toxic situations
Treating Stage II
In Stage II, the therapist works with the couple around issues of pursuit Typically, the emotional distancer needs to begin extended family work and distance. Guerin and his colleagues see the pursuer and distancer sooner than the pursuer. As the distancer would rather defocus on the patterns as a key issue in this stage. Pursuers are encouraged to back relationship with his or her spouse, the beginning of therapy is an ideal off from chasing the emotional distancer, who will often begin to move time for the distancer to work on extended family issues. Typically, when closer to the pursuer with the intense pressure to connect being lifted. the pursuer initially enters therapy, the pursuer is usually too focused Extended family work with each person is also important. Guerin et al. on the primary relationship and solving the problems with the spouse describe the reasons for this work as threefold: to be able to step back and look at the various issues within the extended 1. To establish a linkage between what is happening in the extended family that also need to be explored. The pursuer usually needs time to family and the interaction within the marriage. be ready to be redirected into other issues rather than their relationship 2. To increase each spouse’s sense of belonging and support in his or with the partner. However, once the pursuer can begin working on other her family. issues, the extended family work offers an alternative place for the pursuer 3. To bring out the connections between the key triangles of the extended to expend emotional energy. Usually, if these efforts are successful, the family that later drive the marital confl ict to Stage III (p. 193). pursuer retreats and works on his/her extended family, which then gives the distancer the responsibility to work on his or her own family issues.
Treating Stage III
Stage III confl ict is overt, but couples may also come into therapy to In order to process bitterness, the couple has to acknowledge fantasy deal with a symptom, such as depression, or problems with a child. solutions to the problem (such as death of spouse or divorce). The Therapists must be careful in these situations to not force the couple therapist encourages the person to stop daydreaming about ending the early on to deal with the underlying problem of the marriage and relationship as a way to escape reality and instead focus on real change instead work on the presenting symptom fi rst. Going straight towards with the spouse. If the partners agree to work on the relationship, the marital confl ict will usually cause these couples to quit therapy bitterness is then explored. Guerin and his colleagues call this the “bitter because they often carry a high level of denial about their marital bank,” in which a person stores up hostility towards the partner over issues, instead focusing on the other symptoms as the real problem. wrongdoing and allows it to control him/her emotionally. Tracking When couples enter treatment in Stage III, one of the fi rst interventions bitterness is the next step, and it involves focusing on each partner’s is for the therapist to reduce emotional reactivity. This often requires emotional journey through the marriage, which actually creates more the therapist to get an agreement from the couple to refrain from self-focus. But when couples cannot make these changes, and either one hostility in session and to direct their comments to the therapist instead makes a move towards divorce, they have entered Stage IV. of each other. Couples in this stage have a large amount of bitterness that has built up over time.
Treating Stage IV
For couples in Stage IV, there is such confl ict and bitterness that some couples enter treatment with both wanting therapy to help divorce is on the horizon. Very often, in Stage IV, one spouse will minimize the emotional impact of divorce on their children. This type want a divorce but the other does not. It must be noted, though, that of intervention is unusual, as confl ict usually prohibits this kind of
SocialWork.EliteCME.com Page 8 cooperation. Sometimes couples who were thought to enter therapy divorce. The basic functions of Stage IV are to help the couple in Stage III may well have been what Guerin et al. call “pseudo transition their relationship in such a way that children and extended Stage III” clients. These couples go through the motions of Stage family are damaged as little as possible. Parenting plans are often part III therapy knowing full well they want out of the marriage but also of this therapy. In addition, helping a couple to realize that each played want to say they have done all they could to save it. Therapy is a way a role in the marriage’s demise is critical to help them move past the of minimizing guilt in these cases. In other cases, a person entering rigid perceptions of “villain and victim.” This enables them to move therapy as a pseudo Stage III client wants to hand over the care of the on with their lives without lingering bitterness. spouse to a therapist who can help the spouse through the upcoming
Divorce therapy
In a similar fashion to Guerin and his colleagues, researchers Douglas and threats to separate, which it is important for the therapist to Sprenkle and Pilar Gonzalez-Doupe (1996), note that divorce therapy manage effectively. In this phase, separation may occur, but can be is a very important component of couples therapy that has been paid time-limited and used as a tool to examine the ability of the couple relatively little attention in the fi eld of marital therapy. They presume to reunify. During separation, couples attend therapy weekly. this lack of attention to divorce therapy is related to the perception 2. Therapy for divorce restructuring. This phase is a lot like mediation by therapists that divorce is a failed outcome of therapy. Conversely, in that the therapist helps the couple negotiate issues about parenting, the authors argue that this is not the case. The reality is that many fi nances and various legal and emotional issues they face when couples get divorced in this country each year, and some of these divorcing. The spouse who did not really want the divorce often will divorces certainly could have been preventable if treatment was more seek counseling, but the spouse who chose to leave will be diffi cult to successful. In some cases, divorce may be the best option for many engage in therapy, if the person participates at all. The therapist will couples for many different reasons. Therapists who feel their work typically dedicate a good deal of time to helping the couple’s children is over once the couple goes ahead with divorce and who continue deal with the emotional issues related to divorce. to perceive divorce as a failed therapeutic outcome are missing out 3. Therapy for post-divorce recovery and remarriage. This phase on a vitally important opportunity to assist one or both partners in typically takes place after the issues of life that occur immediately emotional healing and transition beyond divorce into another phase after a divorce are somewhat resolved. The focus of this stage of of life. There has been quite a large amount of research on the effects therapy is on rebuilding of social relationships and moving on of divorce on children, and typically, when a couple continues to seek towards a new life stage. Very often, clients will participate in therapy during or after a divorce, it is to get counseling for the children group therapy as part of this process. There is also an emphasis to deal with the divorce. Traditionally, researchers have paid very little on continuing support for those who are single parents, with attention to the effects of divorce on the couple themselves. Sprenkle therapeutic interventions that focus on parenting. The other facet and Gonzalez-Doupe outline the three stages of divorce therapy: of treatment in this stage includes the development of rituals to 1. Therapy for pre-divorce decision-making. This stage of mark the change in life stage, such as having a party to mark the therapy has not quite reached the level of the decision to divorce. anniversary of the divorce. In addition, the fi nal phase of this stage The therapist spends a good deal of time assessing the couple’s of treatment would be the transition to remarriage. willingness to commit to treatment as well as the likelihood that The typology varies to a certain degree from Guerin, et al., but Sprenkle their differences can be worked through. However, the couples and Gonzalez-Doupe’s Stage 3 is similar to Guerin and his colleagues’ have erratic behavior patterns and switch between commitment Stage 1. Stage 2 in this model is similar to Guerin’s Stage 4.
Assessing marital quality
At this point, we have examined several types of therapy, and noted measures the degree of the demonstration of affection and sexual that the assessment of marital confl ict and satisfaction can be an intimacy; dyadic satisfaction, which measures the degree to which important component of the therapeutic process. It is important to couples are satisfi ed with their relationship; and dyadic cohesion, note there are several instruments therapists can use to determine the which measures the degree of closeness and shared activities severity of dissatisfaction in a relationship. All of them can help a experienced by couples. The overall scores range from 0-69, counselor evaluate a relationship, and most can be used pre- and post- with higher scores indicating great relationship satisfaction. The intervention for measuring change. The most popular tools are: instrument has high internal consistency and constructs validity. ● Marital Satisfaction Inventory, Revised, which is the most ● Kansas Marital Satisfaction Scale. Developed by Schumm, et commonly used by therapists in working with couples. This is a al. (1986), it is a general measure of relationship satisfaction that multi-dimensional evaluation of the couples’ assessment of many includes three Likert items that assess a spouse’s character. It is a areas of their relationship, including subscales measuring problem- widely used instrument for measuring marital satisfaction. Higher solving, affective communication, sexual dissatisfaction, time scores indicate greater marital satisfaction. spent together and disagreements about money. Recognizing levels of confl ict and areas of distress in the couple’s ● Revised Dyadic Adjustment Scale. It is a general measure of relationship can give a therapist several areas on which to focus relationship satisfaction and consists of 14 items that provides treatment. But in addition to this assessment, several recent approaches a total score and four sub-scores of dyadic consensus. These have provided more focused forms of treatment with greater emphasis measure the degree to which couples agree on matters of on theoretical orientations and evidenced-based practices. importance to their relationship; affective expression, which
John Gottman and the sound marital house model
John Gottman’s 1999 book, “The Marriage Clinic,” introduced the to create lasting change … interventions needed to enhance the overall model of the sound marital house. He notes that the two “necessary level of positive affect in both no-confl ict and confl ict by accepting staples of marriages that work are 1) an overall level of positive affect, one another’s infl uence,” (p. 105). and 2) an ability to reduce negative affect during confl ict resolution …
Page 9 SocialWork.EliteCME.com The goals of receiving the intervention is to have the couple and feels no other option except to escape and cut off the discussion. create a strong foundation of friendship, which is a longer-lasting Gottman recommends 12 sessions of therapy, which include: relationship than just having feelings of attraction; increase positive ● Stage 1: Forming a therapeutic alliance and assessment. exchanges, which enable a couple to increase their affection and love ○ Sessions 1-4: Establishing rapport, assessment through oral for one another; manage confl ict; and develop shared meaning in a history interview, battery of assessment instruments, review relationship, such as having shared dreams and values. of assessment, outline of treatment goals (building friendship, reducing destructive confl ict) and an overview of the sound It is important to note that the absence of confl ict is not a goal. In martial house theory. reality, the expectation is that the couple will be able to create enough ● Stage 2: Implementation of the relationship education program. positive exchanges to buffer their relationship from harm when ○ 5th session: Creating love maps, nurturing fondness, diffi cult subjects are discussed. The confl ict can remain, but is handled admiration and turning “toward” instead of turning “away.” in such a way that it does not do damage. Gottman also explored the ○ 6th session: Positive and negative sentiment override, types of communication that should not occur in relationship in order fl ooding, exercises for developing a break ritual, four to increase positive exchanges and manage confl ict appropriately. destructive behaviors. He notes that a “harsh start-up” is a discussion that is likely to not ○ 7th session: Acceptable emotions, lectures on differentiating end very well, as it starts with negativism and sets the stage for between anger and abuse, regulation of confl ict and effective defensiveness on the part of the person being verbally attacked. problem solving. The person who engages in a harsh start-up is engaging in one or more ○ 8th session: Repair attempts, exercises on softened start-up. of the “four horsemen of the apocalypse” in relationships: criticism, ○ 9th session: Accepting infl uence and the art of compromise contempt, defensiveness and stonewalling. Criticism is an attack on and practicing skills. someone’s personality. Contempt is more than just criticism; it is ○ 10th session: Dreams within confl ict, shared meanings and actual disdain for one’s partner. Defensiveness is a refusal to accept rituals of connection. responsibility for one’s actions and to try to place the blame for the ● Stage 3: Fading/assisting in transition. behavior on someone else. Stonewalling is literally just that: a person ○ 11th session: Relapse prevention, promotion of treatment gains. symbolically puts up a stone wall and refuses to engage in further ○ 12th session: Post assessment data gathering and referrals for discussion and may walk out of the room. The person who shuts further services if needed. Termination of therapeutic relationship. down is feeling overwhelmed by negative emotions from the partner
Emotionally focused therapy (EFT)
Emotionally focused therapy EFT is a popular therapeutic approach you what health is. It gives you a sense of key moments and key to working with couples that was developed by Sue Johnson and Les processes that lead to health, and the key moments and processes Greenberg (1988). The major goal of EFT is to change emotional that lead to dysfunction. I think in a very concrete way, it focuses the interactions through a combination of systemic therapy and couple’s therapist on what matters. It gives you a compass. It tells experiential/humanistic therapy. There is a major emphasis in this you what matters; what to focus on in the session. It tells you where therapy on affective emotion. In general, EFT works with troubled the couple needs to go next. As it seeps down through various levels, couples. It is generally a short-term therapy lasting from eight to it translates into knowing what interventions to use.” (p. 265). 20 sessions. Johnson and Greenberg based the EFT approach in The goals of EFT are “to expand and re-organize key emotional attachment theory, noting that many previous approaches to couples responses – the music of the attachment dance; to create a shift in partners’ therapy lacked a theory and were only a group of techniques without a interactional positions and initiate new cycles of interaction; and to foster focus about why couples really behaved the way they did. the creation of a secure bond between partners,” (www.iceeft.com). They believed that most behavior that appears dysfunctional is really The nine stages of EFT are: an expression of an emotional need that is not being met. Johnson 1. Delineation of confl ict issues. and Greenberg had felt that other therapeutic approaches to couples 2. Identifi cation of the interactive cycle. therapy lacked this focus on the emotional aspects of a relationship, 3. Accessing unacknowledged feelings underlying partners’ and they attempted to create this focus on emotion through the EFT interactional positions. approach. Greenberg noted, the fundamental premise behind EFT is 4. Reframing the problem in terms of partners’ underlying feelings that all human beings have a wired-in need for consistent, safe contact and attachment needs. with responsive and caring others, i.e., an innate need for relational 5. Identifi cation of disowned needs and aspects of the self, and security. EFT, then, sees marital confl ict and disharmony as dependent integrating these into the relationship. upon the degree to which marital partners’ basic needs for bonding and 6. Promoting acceptance of the partner’s experience and being attachment are satisfi ed, (p. 20). In one interview, Johnson noted: responsive to partner’s new behavior in the interaction. “I think applying John Bowlby’s attachment theory to adults and 7. Facilitating the expression of needs and wants, and creating using it as a map for couples therapy is what I mean by ‘map.’ It emotional engagement. gives you a direction for therapy. It helps you understand what is 8. Facilitating the emergence of new solutions to old issues and wrong. It helps you understand what doesn’t fi t in this landscape, problems. what is wrong in the landscape. It gives you a direction. It tells 9. Consolidating the new positions the partners take with each other.
Other treatment for couples
Issues related to intimacy are really the underlying elements of most 2. Expressiveness – the degree to which thoughts, beliefs, attitudes issues that couples face. Edward M. Waring (1988), a researcher who and feelings are communicated within the marriage. studied intimacy extensively throughout his career, states that intimacy 3. Compatibility – the degree to which the couple is able to work is made up of eight elements: and play together comfortably. 1. Affection – the degree to which feelings of emotional closeness 4. Cohesion – a commitment to the marriage. are expressed by the couple.
SocialWork.EliteCME.com Page 10 5. Sexuality – the degree to which sexual needs are communicated underlying anger towards a partner, variances in sexual desire and fulfi lled. levels, refusal to participate in certain sexual behaviors or a history 6. Confl ict resolution – the ease with which differences of opinion of abuse. Other problems can include fears of losing oneself or a are resolved. loss of power. 7. Autonomy – the couple’s degree of positive connectedness to 10. Common blocks to intimacy. Fears of being dependent, projections family and friends. on partners, the extreme need to always be right, being negative 8. Identity – the couple’s level of self-confi dence and self-esteem, and critical – are all common behavior patterns that block intimacy. (p. 23). The approaches described by Sherman, Oresky and Roundtree are Waring also notes that intimacy is the cornerstone of relationships, used by many couples therapists in treating relationship issues and stating, “The behavioral aspect of intimacy is predictability; the contain a good deal of interventions that are drawn from the cognitive emotional aspect is a feeling of closeness; the cognitive aspect is behavioral model. The authors recommend dealing with intimacy understanding through self-disclosure; and the attitudinal aspect is issues through the following steps: commitment,” (p. 38-39). 1. Assign good intentions. This phase has client engage in reframing Sherman, Oresky and Rountree (1991) note the differences in attitudes intentions and learn to ask for clarifi cation of meanings of actions towards intimacy that are often a source of differences. Ten different and words. types of differences are described here. 2. Teach and practice psychoactive listening. Couples are taught 1. Symbiotic attunement. In this instance, a person who has to fully pay attention to each other when their partner speaks to emotional needs expects the partner to know what he or she needs. them. It is also important that both of them note that they heard the The person does not like having to tell the other person what those other. The therapist should remind the couple that in psychoactive needs are and feels that the partner should understand these needs listening, the point of listening is to hear, and agreement is not without them having to be explained. necessary. 2. Intensity. Issues around intensity can often involve a situation 3. Enjoin the partners to take an “I” position to bring about in which the listener does not pay attention because the sharer is change. This technique involves having both persons take either not expressive enough and the listener does not realize that responsibility for themselves, their behavior and their change. An the emotions expressed are signifi cant. In other situations, the example cited by the authors is when a spouse says: “I feel upset sharer is so overwhelming in the expression of feelings that the when you come home late and don’t call,” rather than “You are listener refuses to listen. mean and inconsiderate or you would be home on time.” 3. Being vs. doing. In general, women prefer to share, or what the 4. Reframe differences among the partners as positives. This authors term as “being,” in that they like to interact verbally, share technique involves reframing behaviors as the result of being feelings and express issues as a way or creating intimacy with their different people with different personalities, rather than attributing partners. Usually, men tend to prefer shared activities, including behaviors to being mean or intending to do harm. sex, as expressions of intimacy. Men tend to share less openly, and 5. Label each person a “good-hearted teacher.” This approach has nds offensive this often leads women to get upset and feel that men do not share. the therapist attribute behaviors that each partner fi as stemming from a partner’s attempt to “teach” something to the 4. Control. This can take many forms. At times, people may demand partner. In other words, a man who is not sharing with his wife can a great deal but give very little in return. A person may withhold be asked whether he is, by withholding sharing, trying to teach his sex, money, affection or information as ways of maintaining wife to be more independent. control over others. 6. Explore gender expectations and resentments. The therapist 5. Territoriality. This involves the issues of possessiveness over both explores with both partners their perceptions about gender roles. the physical and emotional. It can include jealousy over emotional The therapist might ask the couple to complete sentences like, “As alignments. Furthermore, there are often issues with how tolerant a man, I must ...” or “As a woman I must. ...” each person can be of emotional closeness, and one partner can 7. Help them identify and spell out their feelings and beliefs often feel intruded upon by the other. about territoriality. The therapist discusses with the couple 6. Private language of intimacy. Everyone has his or her own the issues about jealousy, about physical boundaries and taboo pattern of preferred intimacy, which is typically learned in subjects. The increased awareness of these differences can help the the family of origin. There are marked differences in these couple reach compromises about these issues of territoriality. preferences. For some people, being together without sharing 8. Construct an intimacy genogram. The issues in each partner’s information is seen as closeness. For others, sitting near family of origin can be explored using a genogram, which charts someone and not sharing is perceived as a non-intimate activity. each family member and their relationships to one another. Through Misunderstandings about these interpretations lead to confl icts. the genogram, couples can explore the impact of their families of 7. Wanting to change the other. Relationships in which one or both origin on their current relationships in relation to intimacy. parties are very dissatisfi ed with the other and then try to force the 9. Construct a family fl oor plan. In this intervention, each partner other person to change will lead to problems with intimacy. The draws out a map of how each of them uses physical space in the authors posit that this push for change stems from a lack of respect home and the rules that exist for the physical space. In addition, for each other’s differences. couples can do the same for the homes in which they grew up. There 8. Being of several minds. The authors describe this intimacy issue is also further questioning about closeness, distance and privacy. as a situation in which a person may want intimacy and then rejects 10. Examine language and style in expression of emotions. This it when it occurs. The withdrawal is confusing to the person who approach involves the examination of how each partner knows offers the intimacy. Typically, the person who wants and yet fears when the other is expressing something important; how they show intimacy is someone with a fear of abandonment or abuse in life. important emotions to others; what did they like about emotional 9. Sexual intimacy. At times, there is sexual performance without an expression growing up; and what did they dislike about emotional emotional connection, which does not build intimacy and leaves expression in their families of origin. This helps the partners to a partner feeling lonely and used. There are a great number of increase their mutual understanding of differences as differences in issues that can block sexual intimacy: guilt and shame about sex, behavior and not as a lack of caring.
Page 11 SocialWork.EliteCME.com Ethical issues in couples counseling
There are several issues related to professional ethics that arise in it better, as a whole, for society to have intact families, or should an couples therapy that do not occur in individual therapy. According to individual’s personal happiness dictate whether a couple ends their Gottlieb, Lasser and Simpson (2008), these ethical issues can be diffi cult relationship? This situation is addressed in the AAMFT Code of Ethics to handle correctly. One important issue is that of confi dentiality. Many (2001) that clearly states in section 1.8: therapists have found themselves caught in the situation of being asked “Marriage and family therapists respect the rights of clients to to keep secrets for one or both persons in a couple. For example, a make decisions and help them to understand the consequences woman may reveal to the therapist that she is having an affair. Naturally, of these decisions. Therapists clearly advise the clients that they the woman wants to keep this hidden, but hiding such information from have the responsibility to make decisions regarding relationships the woman’s partner is uncomfortable as well as potentially damaging such as cohabitation, marriage, divorce, separation, reconciliation, to the therapeutic relationship of the therapist and the woman’s partner. custody and visitation.” One suggestion is for therapists to have couples sign clearly worded It must be noted that the therapist’s own beliefs about personal consents that indicate that all information brought to a therapist is to be happiness at any cost, or the belief that marriage is sacred and divorce shared with all parties, and no secrets can be kept. Unfortunately, this is always bad, could color their work with clients. This was highlighted approach has the potential to stifl e the sharing of information critical to by the views of scholar and therapist Dr. William J. Doherty, who in working on problems in a relationship. addressing the 1999 Smart Marriages conference stated that he while Another issue that arises in conjoint therapy is record keeping. When a did not want clients to stay in abusive or truly terrible marriages, he couple attends therapy together, therapists often keep one record. But felt that martial counselors were too likely to encourage divorce when when records are released, is it acceptable to release the joint record the persons involved were unfulfi lled or just tired of a marriage. He with only one person’s consent? This often becomes an issue when blamed much of this on a push toward “individual fulfi llment at any couples later divorce, and especially in child custody cases. How does cost” movements in the 1970s and the changing attitude in society a therapist decide to release information that could harm one client toward marriage as a temporary, rather than lifelong relationship. He and help the other? Nonetheless, the ability to keep a coherent record referred to this as “hyper-individualist” attitudes towards marriage. for couples really does require keeping a joint record. The authors Doherty goes on to note that many therapists hear only one aspect of suggest that keeping joint records is best for clinical practice, but that the above-mentioned code of ethics provision that states that decisions a therapist should refuse to release information without the consent of are up to the client. He noted that many therapists would never both parties, and only do this under court order. dream of telling a client they should stay married, as that is correctly Gottlieb, Lasser and Simpson (2003) also noted that couples therapists perceived as being unethical because the therapist should not tell a also have to identify who the client is in couples therapy. Is it each client what to do. Yet many are guilty of telling clients that they should individual, one individual or the dyad? This is very important to leave relationships in order to be happy and encourage this behavior. discern, because any intervention with a person will have an effect on Both attitudes violate the stance of neutrality. Doherty’s main point the other person in the relationship. The competing needs of a couple is that therapists who do couples therapy should be careful not to can also present diffi cult ethical dilemmas for therapists. For example, undermine marriages that stand a chance of survival by jumping too a woman may be happier if she were no longer married to a depressed quickly onto the bandwagon of individual fulfi llment and personal husband. It is possible, though, that the husband might develop worse happiness. He made many valid points in his address, but the movement depression if she were to leave the marriage. In whose interest should towards the preservation of marriage continues to be highly debatable. the therapist act? A couple may be better off divorced from their own Regardless of the feelings that a therapist may have towards his issue, perspectives, but what about the impact of divorce on their children? it is helpful to examine the points that Doherty makes in his argument. The authors note that legally, a therapist is not responsible for the other His essay illuminates how challenging the job is for a therapist to try people in their client’s family system, but how ethically responsible a to advocate for both persons in a couple and still maintain neutrality, therapist is to these other parties is not really always clear. especially if one partner really wants a divorce and the other does not. Values are another ethical issue that surfaces in couples therapy. A common question that arises is: should a couple divorce or not? Is
Same sex couples
Most of the literature on couple’s issues and therapy deals with Another scholarly examination of gay and lesbian couples in therapy heterosexual couples. There has been rather limited literature on notes that these couples’ relationships are affected by homophobia therapy with same sex couples. Interestingly, a recent comprehensive in overall culture, the coming-out process and different expectations study indicated that the emotional processes in marriage are similar to of social and family support than exist in heterosexual culture. The heterosexual couples. While this study did not examine interventions authors note that homophobia can lead many couples to act artifi cially with same sex couples, the authors did note some interesting distant in public for fear of violence and job discrimination. The act of differences between them and heterosexual couples. In general, gay coming out also needs to be understood as a critical process in the life and lesbian couples tend to handle disagreements in a more positive of the gay or lesbian person, but that each person may choose to come fashion, tend to be less controlling and are less likely to have their out in different ways and at different times, and the differences in the feelings hurt by a negative comment from their partner. However, when coming out process can lead to confl ict. it comes to confl ict repair, male gay couples differ from straight and Furthermore, a phenomenon often exists in the gay culture that gives lesbian couples. If the initiator of confl ict in a gay relationship becomes a high level of acceptance to former lovers remaining friends after too negative, his partner is not able to repair as effectively as lesbian the romantic relationship has ended. This occasionally happens in or straight partners. “It is therefore possible that gay men could render heterosexual culture, but it occurs much more frequently in gay and more damage through negativity directed at a partner than lesbian lesbian culture. The authors believe that this common acceptance of women or heterosexual men or women. One inference from this data former lovers in the social network of a gay or lesbian couple is due is that gay men need to be coached to be extra careful in expressing to a traditional isolation of homosexual persons from their families negative emotions in a relationship,” (Gottman, et al., 2003). of origin over their sexual orientation. Consequently, gay and lesbian
SocialWork.EliteCME.com Page 12 persons have had to rely on friends to be a “family of choice” and are Counselors also need to be aware that lesbian couples also have confl icts loathe to cut off someone as a friend even after they are no longer a surrounding female friendship. Where a woman in a heterosexual couple couple due to the loss of social support. It is important for a couple’s can confi de in other women regularly, in lesbian couples, there can be therapist to understand this behavior as normal in gay and lesbian couples. high degrees of jealousy about a partner’s female friendship becoming Furthermore, many gay and lesbian couples have a great deal of sexual, particularly if the friend is also lesbian. This is similar to the confl ict over how “out” to be with their families of origin. One partner tension that heterosexual couples would have if a woman became friends wants both families to accept the relationship totally and for the pair to with a man. It is also important to note that in general, gay and lesbian hold nothing back as far as displaying affection around their families; couples often assign different meanings to monogamy and sex than do the other prefers to downplay relationships out of respect for family heterosexual couples. It is critical for the therapist to be non-judgmental members or fear of confl ict with relatives who tolerate, but do not and explore these meanings to see whether they are shared by each embrace them. This is not an issue with most heterosexual couples, partner. The attitudes are only problematic if the couple does not share and is a unique tension for gay and lesbian couples that counselors the same attitude (Bepko and Johnson, 2000). need to understand is a common issue of confl ict.
Sex therapy
Early sex therapy was developed by Masters and Johnson, (1966, 1970), the need for individuality and togetherness (Schnarch, 1991). The as well as Helen Singer Kaplan (1974). These researchers helped to lack of differentiation in a person is what leads to relationship issues identify different types of sexual dysfunctions as well as appropriate and sexual dysfunction. His approach is best summarized as “poorly clinical treatment of these dysfunctions. These scientist-practitioners differentiated persons experience an anxiety-driven pressure for emphasized various techniques to overcome such issues as premature togetherness, thus losing autonomy, and in turn placing responsibility for ejaculation, erectile dysfunction and low sexual desire. However, these adequate functioning in the hands of the other person in a relationship,” early approaches apparently did not treat psychological issues that could (Goldenberg and Goldenberg, p. 338). be sustaining or creating these problems within the couple’s relationship. Another recent approach to sex therapy, the intersystems approach, There has been a curious disconnect between the fi elds of sex therapy and attempts to maintain the focus on not only the systemic factors couples therapy, which would seem to be two areas that would carry over surrounding a couple, but also to provide more direct treatment of sexual to each other. Yet this has not traditionally been the case. Fragmentation dysfunction than Schnarch’s approach. The approach assesses the couple is noted in both professional identity and theory. At the professional level, at the individual and dyadic levels. The levels of assessment are: such national organizations as the American Association for Marriage and ● Individual – The individual is assessed for cognitive distortions Family Therapy (AAMFT) and the American Counseling Association about sex, through assessing the person’s beliefs and attitudes (ACA) have required little in the way of education or professional towards sex. development in the fi eld of sex therapy or human sexuality, which ignores ● Intergenerational – Both people are questioned about sexual a large area of problems for many couples. Likewise, the American history, such as what they learned about sex in their family of Association of Sex Educators, Counselors and Therapists (AASECT) does origin, messages they received about sex from families and as not emphasize developing skills in couples therapy as part of the training episodes of trauma. to be a sex therapist, which ignores much of the relationship component ● Interactional – This portion assesses how couples behave sexually of sexual problems. This disconnect in professional organizations should with one another, including typical patterns and communication not be too surprising given that the development of theory in the fi eld of surrounding sex. sex therapy tended to emphasize focusing on sexual problems without This multidimensional approach provides a broader perspective of attention being paid to couple’s other problems. how sexual dysfunction may develop, and helps the therapist focus However, some recent developments have led towards a more cohesive on the underlying relational aspects of sexual dysfunction, as well as approach to combining family systems theory with sexual interventions. how sexual dysfunction can lead to relationship diffi culties through David Schnarch, a prominent therapist and scholar, noted in his feelings of blame and anger (Hertlein and Weeks, 2009). It is similar to well-known 1991 book, “Constructing the Sexual Crucible,” that Schnarch’s approach in that it emphasizes relationship issues as key to the emphasis of sex therapy needs to be more on the intimacy issues achieving sexual harmony, but it does focus more on actual techniques between couples than on actual physiological techniques of treating to overcome sexual dysfunction. In addition, intersystems theory does sexual dysfunction. Schnarch noted, “If you have a sex problem, not place quite as much an emphasis on differentiation and autonomy you have to get your relationship to a state that supports good sexual as Schnarch’s. functioning,” (2002). Schnarch’s work is based in Bowenian therapy, In summary, recent advances in sex therapy are showing a greater and encourages the development of differentiation and autonomy as integration of couples therapy and sex therapy than was present in past the key to interpersonal happiness. Differentiation is the balance of decades.
Stepfamilies
Stepfamilies present a unique challenge in couples therapy. According Mark Fine and Lawrence Kurdek (1995), two researchers who have to White and Booth, (1996), stepfamilies with children are twice as extensively examined divorce issues and stepfamilies, did fi nd a likely to be divorced as families without children. Stepfamily couples strong correlation between the quality of the stepparent and child were also much more likely to report unhappiness in their marriages relationships and the quality of the marital relationship. This relates to and to say that they would not marry again, compared with couples one of the key elements of successful stepfamily marriages: Agreement without children. The stepfamily will have marital issues that are on the expectations of the stepparent roles between the couple has the related to the children in a stepfamily, usually not the same types of greatest impact on preventing divorce. Overall, it is not the intensity issues that couples with only their own children have in a relationship. of a child’s behavior that has the greatest impact on marital happiness, Stepfamilies have confl icts that non-stepfamilies will not face, such as but rather an agreement over parenting that predicts confl ict and visitation schedules, tension between the children’s two households, divorce (Pasley, Koch and Ihinger-Tallman, 1993). and arguments about rules at one house versus another.
Page 13 SocialWork.EliteCME.com Papernow is one of the few researchers who have focused on ● The adjustment of a couple to each other may be quick; however, stepfamilies. Papernow (1993) noted that stepfamilies go through children do not always have the ability to accept shifts in parental seven stages of development: and stepparent roles, which leads to confl ict. A couple may feel 1. Fantasy: All members are naïve and believe that everything will happy with one another but be distressed and have confl ict over work out without confl ict. their children’s failure to adjust. 2. Immersion: Members struggle with the unreality of the fantasy ● The family lifecycle stages can be out of sync and at odds. For and developing the ability to state needs and wants. example, just as a couple is forming a new family and desiring 3. Awareness: Each member becomes aware of others’ needs and time to build a family unit, there might also be children in feelings. adolescence who want to be independent, which makes the normal 4. Mobilization: Confronting differences about each person’s belief stages of developmental progress diffi cult to achieve. about the family. ● The pre-existing parent-child bond predates the marital bond and 5. Action: Reorganizing the family. Developing new rules and rituals. may be stronger than the marital bond. Single parents and their 6. Contact: Boundaries and roles are more clearly defi ned by the family. children often become very close, and this can make accepting a 7. Resolution: Family is secure in its identity. stepparent very diffi cult. ● Stepchildren can sometimes attempt to undermine the marriage. Only a few studies have examined marital relationships and stepfamily issues. It was found that couples in blended families have several There is no integrative model of therapy yet for stepfamily marital different unique stressors that are not present in couples who do not therapy. Nor are there any empirical evaluations of marital therapy have stepchildren. These issues include: with stepfamilies that could be located. Nevertheless, it is important ● Lack of alone time to develop as a couple before parenting. for couples therapists using any form of marital therapy to be aware of ● Arguments over the role of stepparents. In contrast, non-blended the unique issues inherent to stepfamilies. families have fairly well prescribed social roles and expectations, like father and mother.
Domestic violence
Therapy with violent couples is a very controversial topic. As noted by It is also critically important to distinguish between the violence as family researchers Eric McCollum and Sandra Stith, (2008), “Women one issue and relationship problems as another issue. Otherwise, the are asked to be open and honest about their complaints and grievances batterer can start using relationship problems as an excuse to resort to in a conjoint session, sometimes with a false sense of security arising violence out of frustration. from the fact that the man has agreed to treatment – only to face Goldner outlines a model that begins with a therapeutic paradox. retaliatory violence after the session for embarrassing or challenging Traditionally, before couples therapy could take place with these people, him.” They argue that conjoint treatment is better because most violent the therapy community asked “couples to resolve the presenting problem couples stay together ultimately, and traditional batterer’s intervention of the man’s violence and the woman’s lack of safety before getting the programs focus only on the man’s anger and violence but offer no therapy they need to accomplish this goal,“ (Goldner, 1998, p. 7). Thus, venue for the couple to deal with their marriage. However, in cases of the fi rst few sessions of therapy are described as a consultation and not very severe abuse resulting in severe physical harm, couples therapy as therapy, to convey to the couple how they must accomplish the goals may not be appropriate. of abstaining from violence and creating safety. Consequently, “we take Family therapist Dr. Virginia Goldner has worked extensively with the position of offi cially withholding therapy unless the violence stops, couples with domestic violence issues. In her 1998 article on couples while de facto providing therapeutic input to make sure that the violence therapy and domestic violence, she outlines an approach to conjoint stops,” (p. 7). During this time, assessment occurs and suitability for therapy with couples with whom violence is the presenting issue. She treatment is determined. says that the traditional stance against conjoint therapy that “placing a The two major goals of therapy are to have men take responsibility for violent man and his victim in close quarters and inviting them to address their actions and for women to commit to putting their safety fi rst ahead contentious issues in their relationship has the potential to re-victimize of anything else. For the men, the therapist is careful to acknowledge the woman physically and psychologically and to provide the offender the man’s experiences, but must emphasize it is his choice to act out. with a platform for self-justifi cation,” is somewhat correct ( Goldner, Goldner notes that the therapist can respond to a man saying he “lost it” 1998, p. 1). But she also notes that there is no evidence that men-only by asking, “what made you chose to lose it?” For women, it is reminding batterer’s treatment has been shown to be more effective than couples them that regardless of whatever else exists in the relationship, “personal therapy for domestic violence, and many couples do want couples therapy. safety must be their primary concern,” (Goldner, 1998, p.12). Furthermore, as many of these couples do not separate during the course of treatment, how is it that separate treatment can promote safety? She To date, there have been no empirical studies conducted on Goldner’s also notes that she is emphatic that the violence is in no way caused by the approach, but her approach and others similar to it have become relationship and is a real part of the relationship dynamic. She emphasizes more acceptable and are used with some frequency. Nevertheless, that treatment must be initialized based on a combination of different critics such as Rivett (2001) are concerned with the treatment of types of abusers and victims, and for many couples, conjoint therapy is domestic violence by solo-practitioner therapists who do not have the appropriate for dealing with domestic violence. community resources to ensure women’s safety in these scenarios. He emphasizes that there must be a systemic effort between law She notes that this type of work is diffi cult, and the therapist must be enforcement and protective services agencies to ensure the safety of careful not to allow “the perpetrator to misuse psychological insight women and children if they are in the home. to avoid taking responsibility for his actions,” (Goldner, 1998, p. 4).
Substance abuse
Researchers and practitioners Steinglass, Bennett, Walin and Reese indicates that alcohol usage is linked to spousal abuse and higher (1991) noted that there is a good deal of debate as to how frequently divorce rates. However, Steinglass and his colleagues argue that it is the use of alcohol contributes to severe marital discord. Some research
SocialWork.EliteCME.com Page 14 impossible to prove that alcohol causes these issues, and that many Stage III: The emotional desert. As the typical alcoholic family has more families manage to cope with alcoholism: been organized around the alcoholic’s drinking, the family “By making do, we mean that a substantial group of families with may have a diffi cult time changing behaviors that involved alcoholic members seem to remain intact over their life span (no alcohol. Most aspects of interaction have modifi ed in divorce, continue to live with the alcoholic member), are economically response to the alcoholic’s drinking. As a result, many viable, avoid the more dramatic and devastating types of family times a family does not rejoice over the cessation of violence, and suffer no higher levels of anxiety and depression than drinking, but instead fi nds themselves at loose ends, the general population. … They seem to know that they are hurting, unsure of where to go next. but it feels more like a dull ache than a sharp, localized pain,” (p. 23). Stage IV: Family restabilization versus family reorganization. They go on to note that these conclusions are based on several surveys After a period in the emotional desert, families move in which many respondents say that alcoholism has a negative impact into the next phase in which resolution is reached. Very on their families, but then are not able to say in which specifi c ways often, couples and families fall into a pattern in which the that the alcohol usage actually affects them. As Steinglass et al., note, alcoholic may not drink, but the patterns remain the same. “over time, alcoholism may sap the family’s energy and resources, but Sometimes in this phase, couples reach a crisis point, after in the short run, it may not be perceived by the family as a signifi cant which there is a major change in family patterns. threat to its survival,” (p. 24). Another approach that draws from the behavioral treatment approach Substance abuse does present often as an issue in couples counseling. is behavioral couples therapy (BCT). This frequently used approach There are several key theoretical approaches to working with couples has three major components: Stop the drug or alcohol user from using counseling in which substance abuse is involved, as noted by Fals- substances; enlist the family to provide support to the addict/alcoholic; Stewart, O’Farrell, Birchler, (2004): and stop the patterns of behavior that have enabled this to occur “The family disease approach, the best known model, views over time. This approach requires the processing of a good deal of alcoholism and other drug abuse as illnesses of the family, suffered information and is therefore not an ideal approach for those who have not only by the substance abuser, but also by family members, who moderate to severe cognitive defi cits. In addition, it is most effective are seen as codependent. Treatment consists of encouraging the when only one person has alcohol or drug problems. Couples are seen substance-abusing patient and family members to address their 15-20 times over six months of treatment. respective disease processes individually; formal family treatment In this approach, the typical behavioral techniques are utilized. Couples is not the emphasis. make abstinence contracts in which one or both agree to abstain from “The family systems approach, the second widely used model, using alcohol and/or drugs. Partners agree to have daily check-ins applies the principles of general systems theory to families, paying regarding the use of substances. The other partner will in turn thank particular attention to the ways in which family interactions become them for not using. The non-using partner records these activities organized around alcohol or drug use and maintain a dynamic daily as a way of being accountable to the therapist for following balance between substance use and family functioning. Family the treatment plan. Other activities include a “caring day” in which therapy based on this model seeks to understand the role of substance each partner plans pleasant surprises for the other, planned family use in the functioning of the family system, with the goal of modifying activities and practicing communication skills taught by the therapist family dynamics and interactions to eliminate the family’s need for to the couple. Couples are asked not to discuss past substance abuse the substance-abusing patient to drink or use drugs. or concerns about sobriety in the future when they are not in sessions “A third set of models, a cluster of behavioral approaches, assumes with the therapists. The authors have found that such talk often ends in that family interactions reinforce alcohol- and drug-using behavior. confl ict and often ends in relapse. There is also a good deal of work that Therapy attempts to break this deleterious reinforcement and instead is done with the non-abusing spouse to address the relapse/recovery foster behaviors conducive to abstinence,” (p. 31). cycle and for them to not view a relapse as a total betrayal of trust, but to normalize it as part of this process. There is a strong emphasis Steinglass and his colleagues utilize a family systems approach. The on couples committing to completing their homework assignments in typical course of therapy involves: between sessions and addressing noncompliance as it occurs. Stage I: Diagnosing alcoholism and labeling it a family problem. This phase involves assessment of the level of substance Couples therapy combined with alcohol treatment may be particularly abuse, the family interactional patterns and whether or not benefi cial for the female alcoholic. A recent study (Fals-Stewart, a family is committed to treatment. Birchler and Kelley, 2006) compared females in treatment using Stage II: Removing alcohol from the family system. Abstinence is this approach to women who received only individual counseling emphasized as a key factor in the progression of treatment. and found that women who received couples therapy demonstrated The therapist acknowledges that the path to recovery may signifi cant increases in relationship satisfaction and signifi cant involve some lapses in sobriety, but the alcoholic cannot reductions in drinking. be allowed to drink without the issue being confronted.
Research
A recent meta-analytic study indicated that a couple receiving therapy ● The therapist having a theoretical framework to guide treatment was 84 percent better off than couples who had none. Overall, couples towards goals. therapy is effective, regardless of the specifi c model used and what the ● The therapist’s success in conveying to the couple what he/she presenting issue might be (Shadish and Baldwin, 2002). believed the problem to be, based upon a specifi c model being used. ● The therapist’s ability to raise awareness of the cycle. This last Davis and Piercy (2007) examined three models of couples therapy concept involves three phases as well: in search of common factors, which are described as those factors ○ Slowing down the process by giving each person time to talk in that were helpful to couples being treated with three different therapy a structured way so that each can express him/herself openly. models: EFT, cognitive behavioral therapy and internal family systems ○ Helping both people to be aware of their actions and to be theory. Common factors found across models of marital therapy that more objective about their partner’s intentions and motives. seemed to be linked to change were: ○ Getting both partners to take responsibility for their actions.
Page 15 SocialWork.EliteCME.com ● Other common factors included the use of metaphors, explaining of these studies, EFT is found to be the most effective, and in the Wesley the infl uence of the family of origin on current-day problems and Waring study, at least as effective as other modalities. and issues, reframing of partner intentions; educating clients to In summary, the growth of couples therapy has come a long way regulate their affective emotions; and encouragement of changing in less than 100 years. From its roots in advice by clergy and lay behaviors. persons, to individual psychoanalytic sessions that eventually became While there are common factors to many approaches to couples therapy, conjoint sessions, and then on to an explosion of theory-based efforts there is some debate over which models are the most effective. In one in the 1960s and 1970s, couples therapy today is now growing into a study, EFT and behavioral therapy appear to be the most effective, an evidence-based practice with a strong theoretical underpinnings. (Johnson and Lebow, 2000). Gurman and Fraenkel (2002) reported that Future challenges for couples therapy will include keeping up with overall support was strongest for EFT and for insight-oriented therapy. the changing defi nition of what a “couple” really is, and to work Wesley and Waring (1996) found that overall, EFT, insight-oriented, with diverse partners beyond middle- and upper-class Caucasian, cognitive therapy and behavioral therapy all appeared to be effective, heterosexual married couples. and no one model was superior to the other. It does appear that in three
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COUPLES COUNSELING Final Examination Questions Select the best answer for each question and then proceed to SocialWork.EliteCME.com to complete your fi nal examination.
1. EFT stands for: 4. Reuben Hill was the originator of “family stress theory, ” the basic a. Emotionally focused therapy. component of his model was the: b. Effi cient family therapy. a. “ABCD model.” c. Essential focused therapy. b. “ABCX model.” d. Effective functional therapy. c. “ABCY model.” d. “ABCZ model.” 2. Which model of therapy is often spontaneous and even can appear irrational in its approach to a problem? 5. Steinglass uses a family system approach to substance abuse. The a. Communications model. typical course of therapy involves how many stages? b. Psychodynamic model. a. 6. c. Intergenerational therapy. b. 4. d. Experiential therapy. c. 3. d. 7. 3. The family life cycle approach theorizes that all families pass through predictable life stages, a classifi cation table lists: a. Four stages of the family life cycle. b. Five stages of the family life cycle. c. Six stages of the family life cycle. d. Seven stages of the family life cycle.
SWCA04CN14
Page 17 SocialWork.EliteCME.com CHAPTER 2: Elderly Abuse in America: Prevalence, Etiology and Prevention
5 CE Hours
By: Deborah Converse, MA, NBCT with Kathryn Brohl, MA, LMFT
Learning objectives
Identify fi ve warning signs that may indicate elderly abuse. Defi ne fi ve resident rights included in the Nursing Home Reform Act. List and describe fi ve forms of elder abuse. Explain the scope and severity categories of defi ciency citations. Describe the prevalence of elder abuse, including gender and age. Describe fi ve strategies that can be used to prevent elder abuse. Discuss fi ve facility regulations included in the Nursing Home Discuss three current trends in nursing home reform. Reform Act.
Introduction
Elderly mistreatment and care are critical and troubling areas in Researchers note there are different defi nitions for elder abuse, America, with state and federal governments spending far less on and there is no “gold standard” test for abuse and neglect (Dyer et research and prevention compared with peer nations. On October al., 2003). Those working with elders who have been abused and 21, 2011, the media reported plans to cut Medicaid benefi ts further, neglected must rely on forensic markers. This presents a problem affecting millions of aging Americans. As baby boomers continue because adult protective services agencies and physicians are not to age, this becomes an even more pressing problem. The over-65 trained to distinguish between injuries caused by mistreatment and population of 39.6 million in 2009 will grow to 78 million in 2040, those that are the result of accident, illness or aging. according to the U.S. Census Bureau (Daschle, 2008). Though the rate Adding to the diffi culty in diagnosis is that many elderly individuals of disability among the elderly has declined, life expectancy continues suffer from diseases and conditions that produce symptoms that mirror to rise. The number of cases of elderly mistreatment will undoubtedly those resulting from abuse. Because these symptoms may mask or rise over the next several decades as the population ages. mimic indicators of mistreatment, their presence does not send up a The National Academy of Sciences published an extensive panel red fl ag for physicians or medical examiners determining cause of review of mistreatment of the elderly in 2002. The panel investigated death. Doctors may fail to recognize psychological conditions, such the increasing prevalence, risk factors, social issues, legislation and as depression and dementia, which may put an elder at greater risk for research on prevention and intervention to address elder mistreatment falling victim to abuse. Psychological conditions may indicate that (Bonnie and Wallace, 2002). neglect or abuse has taken place (Jones et al., 1998). Since 2002, the National Institute of Justice (NIJ) has conducted Even if a physician suspects abuse, police offi cers are rarely trained to additional research. Its goal was to build a body of knowledge to assist investigate elder abuse and may not know how to interview an older caretakers, medical personnel and law enforcement offi cers to recognize adult, especially a person with dementia; may not collect forensic abuse indicators, known as forensic markers, and isolate factors that put evidence; or may not recommend charges be brought when responding elderly individuals at risk (Dyer, Connolly and McFeeley, 2003). to injuries at care facilities or in homes. Catherine C. McNamee and Mary B. Murphy (2006) cite the following At the next step, the National Institute of Justice (NIJ) researchers noted example of the scope of elderly abuse and lack of prevention: prosecutions might be impeded by the absence of qualifi ed experts to To most people, Charles Cullen was an experienced nurse attending testify to a reasonable medical certainty that the injuries were a result to the elderly in hospitals and nursing homes. The perception of abuse and neglect. Medical testimony is critical because victims are of Cullen as a devoted caretaker came to an abrupt end in 2004 often too ill or incapacitated to provide a coherent explanation of how when he admitted that he intentionally administered fatal doses of the injury occurred. Again, the absence of a standardized law defi ning medication to almost 40 patients in various institutions over a 16- elder abuse further complicates and constrains the ability to prosecute year period. Because most of Cullen’s early victims were elderly and offenders (McNamee and Murphy, 2006). seriously ill, and because toxicology and other tests were not done The Government Accountability Offi ce completed a comprehensive to detect whether there had been wrongdoing, medical examiners study on the effectiveness of sanctions to improve the quality of did not classify the deaths as homicides. As a result, no criminal care (2005). The study concluded that even when nursing homes investigations were initiated for several years, which resulted in the are inspected, issued citations, sanctioned and corrective action was loss of valuable forensic evidence. (Quigley 2004) enforced by state and federal agencies, some nursing homes were not Cullen’s case is an extreme example of what happens when care staff deterred from repeatedly harming residents. Many facilities continued and professionals fail to recognize, prevent or prosecute incidences of to cycle in and out of compliance, so abuse and neglect continued. elder abuse.
Defi nitions of elderly abuse
The National Academy of Science research panel has noted there is no widely accepted operational defi nition and validated and standardized universal defi nition of elderly mistreatment, and “the development of a measurement methods for the elements of elder mistreatment is
SocialWork.EliteCME.com Page 18 urgently needed to move the fi eld forward.” (Bonnie and Wallace, The NCEA study notes that mental health issues and substance abuse 2003). The panel traced the terminology that has been used to defi ne affecting the elderly victim or the abuser are common factors in elderly individuals who need care in order to receive protective services. The mistreatment cases. Here are specifi c defi nitions and descriptions of U.S. Department of Health Education and Welfare in 1966 defi ned the forms of abuse outlined by the NCEA: these individuals as “people with physical and /or mental limitations, ● Physical use of force – To threaten or physically injure a who were unable to manage their own affairs, or who were neglected vulnerable elder. or exploited” (2011). ● Emotional, psychological, verbal abuse – Attacks, threats, rejection, isolation or belittling acts that cause or could cause In 1974, the Congress amended the Social Security Act to require mental anguish, pain or distress to vulnerable elders. states to establish protective service units for adults. The funding for ○ Even though this form or abuse leaves no physical injury, these services came from the federal government and gave the states it is no less serious than physical abuse. It can range from social services block grants (SSBG) and directed the states to provide threatening to abandon an elderly person or to put them in a protective services to “adults who as a result of physical or mental nursing home to threatening the elder if he or she does not limitations, are unable to act on their own behalf, are seriously limited cooperate in daily tasks or taking medication. Repeated insults in the management of their own affairs, are neglected or exploited, or and shouting are forms of psychological abuse because they are living in unsafe or hazardous conditions” (2011). undermine the victim’s sense of self-worth and security. There are defi nitions that outline the type of assistance required by ● Sexual abuse – Contact, force, or threatened or coerced sexual elderly individuals. The Administration on Aging (1997) identifi ed contact upon a vulnerable elder who cannot grant consent. individuals with age-related diseases and disabilities requiring ● Neglect – Failure or refusal to provide for the vulnerable elder’s assistance in one of the following types of activities: safety and physical or emotional needs that put the elder at risk. ● Assistance with activities of daily living (ADL). ● Exploitation – Theft, fraud, misuse or neglect or the use of undue ○ Eating. infl uence as a lever to gain control over an elder’s money or property. ○ Dressing. ● Financial abuse – May include using the victim’s ATM card, ○ Bathing. checks, investments or online accounts without permission, or using ○ Transferring from bed to chair. the victim’s power of attorney to take property or money from bank ○ Toileting. accounts. More covert forms of fi nancial exploitation may occur ○ Controlling bladder and bowel. when the abuser has close and frequent contact, such as a relative ● Instrumental activities of daily living (IADL). who lives with the victim. The caregiver with access to the elder’s ○ Preparing meals. accounts can secretly spend monthly retirement or Social Security ○ Performing housework. benefi ts for their own use or for other family members or friends. ○ Taking medications. ● Abandonment – Desertion of a frail, vulnerable elder. ○ Managing fi nances. ● Self-neglect – Inability to understand the consequences of one’s ○ Making phone calls. own actions, taking actions that lead to harm or endangerment, or ○ Running errands. inaction that leads to harm. The nursing home population tends to be older and more severely ○ Self-neglect refers to an elder person’s inability to care for disabled than elders residing elsewhere, with about half of the him- or herself or make appropriate arrangements for care. residents 85 or older and about half having fi ve ADL limitations. Four This form of mistreatment is included in most state statutes out of fi ve elderly persons with ADL or IADL impairments live in the as a basis for instituting protective action to ensure the elder’s community setting (Alecxih et al., 1997). safety. When intervention is warranted, it may make take the form of voluntary protective services, such as home-delivered Regardless of where they reside, the elderly population is vulnerable to meals or housekeeping assistance, or involuntary measures age-related infi rmities and suffering from disease and disability as well such as guardianship. The type of protective intervention as neglect, abuse and exploitation from others, including caregivers. service depends on the degree of self-neglect and the ability The National Institute on Aging (NIA) found elderly mistreatment of the vulnerable elder to make rational decisions for daily research had been confi ned to a small community of investigators who independent functioning, self-care and safety. produced a limited body of knowledge. Efforts to prevent and improve Abusive acts often contain elements that are physical, psychological the quality of care have been sporadic, inconsistent and underfunded and fi nancial. A family member may take an elderly relative home across the United States. Because of the lack of research, the NIA asked for a visit and then seek permanent guardianship over the elderly the National Research Council to commission a study in an effort to relative, arguing that he or she is no longer capable of managing home broaden and deepen the knowledge about the mistreatment of elders. A maintenance, housekeeping, personal care and fi nancial decisions. panel was convened, and the study was completed in conjunction with Using guardianship as a means of control over the elder person and his the National Institute of Health, the Agency for Health Care Research and or her assets can be a form of legal kidnapping when the individual is Quality and the National Institute on Aging (Bonnie and Wallace, 2003). not in the position to object to the arrangement (Whitton, 2007). Results from the panel study will be referenced throughout this course. Threats of abandonment or nursing home placement may pressure the The National Center on Elderly Abuse (NCEA) defi nes elderly abuse elder to agree to this arrangement. Controlling family members have as “intentional or neglectful acts by a caregiver or trusted individual been known to cut off communication between elder family members that leads to harm of a vulnerable, elderly individual” (2002). It may and friends, isolating them from the outside world. There is an increase take the form of: in the frequency of adult children fi ghting over their parent and their ● Physical abuse and neglect. parent’s assets, which have prompted some elder advocates to call these ● Emotional and psychological abuse. “will contests while the person is still alive” (Frolik and Whitton, 2010). ● Verbal abuse and threats. ● Financial abuse and exploitation. ● Sexual abuse and abandonment. ● Self-neglect.
Page 19 SocialWork.EliteCME.com Indicators of mistreatment
As mentioned above, the NIJ research projects identifi ed 14 potential ○ Statements from family concerning adequacy of care. abuse and neglect indicators known as forensic markers (McNamee ○ Observations about the level of care for residents with non- and Murphy, 2006). They include: attentive family. ● Abrasions. 2. Facility characteristics. Specifi c markers include: ● Lacerations. ○ Unchanged linens with strong odors of urine and feces. ● Bruising. ○ Trash cans not emptied. ● Fractures. ○ Unclean food prep areas or previous food sanitation issues ● Restraints. violations. ● Decubiti (bedsores). 3. Inconsistencies. Specifi c markers include: ● Weight loss. ○ Inconsistencies between medical records, statements from staff ● Dehydration. or observations of investigators. ● Medication issues. ○ Inconsistencies between the reported time of death and the ● Burns. condition of the body. ● Cognitive and mental health problems. 4. Staff behavior. Specifi c markers include: ● Hygiene. ○ Staff members who follow an investigation too closely. ● Sexual abuse. ○ Lack of knowledge or concern about a resident. ● Financial fraud and exploitation. ○ Unintended or purposeful verbal or nonverbal evasiveness. ○ The facility’s unwillingness to release medical records. In one NIJ study, researchers examined bruising, one of the most common indicators of abuse and neglect. There is a body of research Lindbloom’s research team also conducted focus group interviews on the site, pattern, and dating of bruising in children, but research with medical examiners, coroners and geriatricians across the United on the differentiation between accidental and intentionally infl icted States to assess the state of forensic investigation of nursing home bruising in the elderly population does not exist. deaths. They hoped to determine ways to identify how abuse and neglect leading to mistreatment deaths might be identifi ed. Results Researcher Laura Mosqueda, M.D., of the University of California, from the focus groups revealed that many professionals believe that Irvine, documented the occurrence, progression and resolution of deaths due to mistreatment are rare, so forensic investigations would accidentally infl icted bruising on elderly individuals (Mosqueda et be of little value in improving the quality of care. al., 2006). The research indicated that accidental bruising occurred in predictable locations on older adults as follows: Researchers also identifi ed a number of medical examiners and ● 90 percent of all bruises were found on the extremities. coroners who exhibited ageism, a belief that focusing on nursing ● No accidental bruises were observed on the ears, neck, genitals, home deaths was “a waste of their time and resources because of the buttocks or soles of the feet. poor health status of most nursing residents who would die anyway” ● The color of the bruise at the initial appearance is unpredictable. (Lindbloom et al., 2005). ● More bruising was observed on individuals taking medications These beliefs are major impediments to improvements in the forensic known to impact the blood clotting system. identifi cation of elder deaths. Improvements in identifi cation could ● More bruising was noted on individuals with compromised help investigators and prosecutors take action against nursing homes functional ability. where mistreatment occurred and take steps to improve the quality of The NIJ researchers also examined data on the deaths of elderly care in the future. residents in long-term care facilities to identify potential markers of Researchers in the NIJ study also examined how psychological abuse. Led by Erik Lindbloom, M.D., of the University of Missouri- conditions place elders at risk for abuse, in particular, sexual abuse. Ann Columbia, the study examined coroner’s reports of elderly nursing home Burgess, Boston College, examined 20 nursing home residents who had residents in Arkansas over a one-year period (Lindbloom et al., 2005). been sexually assaulted and found that the presence of a preexisting This ongoing research is contributing to a body of data that offi cials cognitive defi cit such as dementia not only impairs the ability to can use when they suspect that an elderly person with bruising has communicate but also compounds the trauma of the assault (Burgess been abused. and Hanrahan, 2006). The vulnerability of this population places them at The study found that a majority of coroner investigations did not unusually high risk to severe traumatic reactions to assault. raise suspicions of mistreatment, but the researchers in Lindbloom’s Many victims had remain silent, and the incidents were discovered study identifi ed four categories of markers that often led to further after suspicious signs were noted by staff or family members (Jones, et investigation: al., 1998). 1. Physical condition/quality of care. Specifi c markers include: The study highlighted the importance of training caregivers to identify ○ Documented but untreated injuries, undocumented injuries and signs of assault-related trauma, particularly in victims who are not fractures, multiple untreated or undocumented pressure sores. likely to report the assault. Researchers noted disturbing evidence that ○ Medical orders not followed. nursing staff diminished the seriousness of assaults on residents, with ○ Poor oral care, poor hygiene and lack of cleanliness of residents. responses ranging from cynical disbelief to amusement. ○ Malnourished residents who have no documentation for low weight. NIJ’s portfolio of research will help in identifying forensic markers ○ Bruising on non-ambulatory residents; bruising in unusual that can be used to help defi ne abuse, identify cases of abuse and locations. prosecute offenders.
Historical perspectives
The National Research Council, as part of the panel study, reexamined over the past 50 years, the social response toward the mistreatment the issue of elderly mistreatment and the recent recognition that it of the elderly has evolved in part due to the response to child is a distinct and important social problem. The study reveals that protective services and family violence. The increasing concern,
SocialWork.EliteCME.com Page 20 acknowledgement and protection for victims of child and spouse abuse ● The questions raised by that important study prompted Congress developed awareness and concern for elderly neglect and victimization to amend the Social Security Act to require states to establish (Bonnie and Wallace, 2003). protective service units for the elderly and fund them with social Until the late 19th century, there was no legal basis for intervention service block grants (SSBG), which had been used exclusively for in family issues of abuse or neglect. “The juvenile court system in child protective services. ● This new federal program directed states to provide protective the early 20th century represented the fi rst example of a collective responsibility for protecting children who were ungovernable, and over services to adults who “as a result of physical or mental limitations, the following decades, this was extended to protect children who were are unable to act in their own behalf; are seriously limited in the neglected or abused by their parents” (Platt, 1969). management of their affairs; are neglected or exploited; or are living in unsafe or hazardous conditions” (Bonnie and Wallace, 2003). The legal foundation for modern policies and programs for elderly ● Congressman Claude Pepper held widely publicized hearings, protection were put in place after World War II. Panel researchers calling attention to the “hidden problem” of elder abuse in the noted an emphasis on remediating social problems that can be traced nation’s families, including what one witness characterized as to the 1970s, with signifi cant changes in programs to address child “granny battering” (Wolf, 1986). protection and family violence. The study by the National Research ● Pepper’s hearings led to state action in the early 1980s with Council (2003), part of the panel research, presented a summary of the many states requiring mandatory reporting of abuse, bringing the origins of adult protection programs beginning in the 1960s and traced problem within the scope of adult protective services. the development of protective services. Here are the results of the ● By 1984, 46 states had designated a responsible agency for elderly National Research Council study as reported to the panel: protective services. ● New adult protective service units were established to provide ● Pepper continued to press for a federal response to elder mistreatment, social services and legal guardianship as well. and a 1981 report (Pepper and Okar, 1981), provided evidence that ● Federal interest increased in 1962, and Congress passed the Public elder abuse was increasing and recommended that Congress act Welfare Amendments to the Social Security Act, authorizing immediately to help the states identify and assist elderly abuse victims. payments to states for protective services for “persons with ● Spouse abuse and other varieties of intimate partner violence physical or mental limitations, who were unable to manage have received increasing professional and political attention since their own affairs … or who were neglected or exploited” (U.S. the 1980s, leading to a variety of interventions and a substantial Department of Health, Education and Welfare, 1966). investment in research (National Research Council, 1996; National ● A demonstration project by a team at Benjamin Rose Institute Research Council and Institute of Medicine, 1998). (1974) in Cleveland compared elders in the community receiving ● As the consciousness of health professionals was raised, family traditional services to those receiving protective services. The violence was viewed as a public health problem, recruiting study found those receiving protective services had a higher researchers and advocates for injury prevention and public health mortality and higher nursing home placement rate than those to the fi eld (Institute of Medicine, 1999). receiving traditional services. DETERMINING PREVALENCE AND INCIDENCE OF ELDERLY MISTREATMENT
The NCEA in a 2005 study and the Government Accountability Offi ce ● The studies are primarily based on cases uncovered through (GAO) study from 2000-2005 reported that no one knows precisely surveys of community professionals, nurses, social workers, legal how many older Americans are abused, neglected or exploited. These aid lawyers and law enforcement agencies. They are cases that studies indicate there are no offi cial statistics for a number of reasons: have come to the attention of the public. However, other studies ● Defi nitions of elder abuse vary, and the problem often remains of family violence using non-clinical populations show that only hidden. a fraction of cases gain public attention, and those cases are not ● State statistics vary widely, and there is no uniform reporting system. representative of the problem at large (Gallup Poll, 1995). ● Comprehensive national data is not collected. ● Because the information and research data did not come directly The studies did highlight the most widely used estimates of elder abuse from the victim but instead from professionals and outsiders, it prevalence and incidence in the United States today. Prevalence refers is secondhand knowledge. This may distort the evidence and the to the total number of people who have experienced abuse, neglect or actual events by failing to present the problems and their effects as exploitation in a specifi ed time period. Incidence is the number of new the actual participants perceive them. ● Case reports have little value in studying forms of mistreatment that cases identifi ed or reported at a given point in time, usually one year are rarely reported to adult protective services agencies. Unreported (NCEA, 2005). cases may occur in institutional and community settings. Many factors affect actual prevalence and incidences. National In an effort to generate a national estimate of the incidence of elder estimates vary due to differences in research, inspections, reporting abuse and neglect based on case identifi cation by professional methods, sample sizes and defi nitions across studies conducted by “sentinels,” the NCEA in conjunction with Westat Inc. conducted the different states. It is widely recognized that reported cases are highly National Elder Abuse Incidence Study (NCEA, 1998). In this study it selected samples, and there are large numbers of unreported and was acknowledged that the fi ndings detected only the most overt cases undetected cases of elder mistreatment, particularly in community and thus underestimated the incidence of elder mistreatment. Research and home settings. Samples of reported cases may suggest common concerning elder mistreatment is underdeveloped, and the National patterns and correlates of mistreatment when paired with a control Academy of Sciences panel identifi ed the following factors to explain group, but the data must be interpreted with great care (Wolf, 1986). this issue: The question of the extent of elder mistreatment cannot be answered ● Many investigators believe the victims and family members are by studies of reported cases, according to the National Academy of not suitable respondents for interview studies because they are not Science study panel (Bonnie and Wallace, 2003). There are major reliable, not willing to be interviewed or incapable of giving the problems with focusing on reported cases of mistreatment to determine necessary consent. prevalence: ○ In fact, many victims are more willing to be interviewed and are reliable respondents able to give the necessary consent.
Page 21 SocialWork.EliteCME.com Surveys including these respondents have uncovered serious available for research on elder mistreatment. Annual expenditures by cases of mistreatment, and a variety of studies have been NIA, the leading agency for aging research, have increased less than conducted in which victims were interviewed. $300,000 per year in 1990 to $1.3 million in 2001. Funding to study ● In general, methods used successfully to investigate forms of family elderly mistreatment is modest even when compared to the violence have not been applied to research on elderly mistreatment. underfunded area of child abuse research, where federal agencies Gerontologists who study elder mistreatment tend to follow their spend $3.8 million a year (Bonnie and Wallace, 2003). interests in family care giving and view the problem in this context. ● The existing body of research is largely descriptive rather than ○ Because elder mistreatment does not often occur in family care empirically based on concepts measured using sound research giving situations where a gerontologist is involved, this has methods. This type of research results in the practice of combining been a serious limitation to research. all forms of mistreatment within a single category. ○ Furthermore, the technology for studying elder violence has ● Individuals who conducted research on elder abuse report not been developed and refi ned by gerontologists, and many they have been hindered by limited cooperation from agencies have not been trained in sampling methods and measurement responsible for identifying and treating elder abuse victims. Adult techniques. protective agencies have been reluctant to assist researchers, ● It is very diffi cult to obtain access to perpetrators of mistreatment. particularly when it involves interviewing victims and their In studies of intimate partner violence, researchers have used families. Reasons for lack of agency cooperation include patient treatment programs for abusers as a source for research subjects. privacy issues, disruption to victim’s lives, additional trauma to the These treatment programs do not exist for elder abusers. victim, concern over the results of evaluation research, a shortage ● The exclusion of some abuse victims can seriously bias of staff and time to devote to research. research fi ndings. The problem is most evident when residents ● Although every state has statutes requiring and regulating of institutions with cognitive challenges are excluded from intervention, they vary widely in methods of implementation population samples. When studying targeted populations, whether and level of compliance. States use different ages for eligibility, community-dwelling or residing in an institution, excluding elders approach home and institutional abuse differently, employ based on cognitive defi cits can seriously limit or alter results. different defi nitions of abuse, and have varying classifi cations of ○ There is anecdotal evidence that institutional review boards abuse as civil or criminal (Bonnie and Wallace, 2003). have restricted categories of respondents, severely limiting and ○ These state statute variations lead to confusion and lack of excluding valuable data. comparability when studying reported cases. When data is ● Few investigators have been drawn to this fi eld of research. Reviews reported, the same statute may trigger reports in different of the literature reveal a small set of researchers entering and categories in different states (GAO, 2005). continuing in the fi eld. This can be explained by the lack of funding
Prevalence
According to NCEA, the best available estimates for elder ● Data on elder abuse in domestic settings suggest that 1 in 14 mistreatment are: incidents, excluding incidents of neglect, come to the attention of ● Between 1 million and 2 million Americans age 65 and older have authorities (Pillemer and Finkelhor, 1988). been injured, exploited or mistreated by someone they depended ● Current estimates put the overall reporting of fi nancial exploitation on for care or protection (National Research Council Panel, 2003). at only 1 in 25 cases, suggesting there are 5 million fi nancial abuse ● Estimates on frequency of elder abuse range from 2 percent to victims each year (Wasik, 2000). 10 percent based on various sampling, survey methods and case ● It is estimated that for every one case of elder abuse, neglect, defi nitions (Lachs and Pillemer, 2004). exploitation or self-neglect reported to authorities, there are fi ve more that go unreported (NCEA, 2003).
Incidence
● In 1996, 450,000 adults aged 60 and over were abused or the life expectancy of people born in the United States has been neglected in domestic settings. Factoring in self-neglect, the total rising throughout the past century. Between 1950 and 2000, the total number of incidents was 551,000. population of the country increased by 87 percent. The study included ● A University of Iowa study based on 1999 data found 190,005 the following information relating to prevalence and incidence: domestic elder abuse reports from 17 states; 242,430 elderly abuse ● The population age 65 and older increased by 188 percent, and the investigations from 47 states; and 102,879 substantiations from 35 population 85 and older increased by 635 percent (Eberhardt et al., states. Signifi cantly higher investigation rates were found for states Hetzel and Smith, 2001). that require mandatory reporting and tracking of reports (Jogerst, ● From 1950 to 2000, the life expectancy of people age 65 increased et al., 2003). from 13.9 years to 17.9 years (National Center for Health ● In 2000, states were asked to indicate the number of elderly abuse Statistics, 2001). reports received in the most recent year for which data were ● The U.S. Bureau of the Census predicts that by 2030, the available. Based on fi gures from all states, the total number of population over age 65 will likely triple to more than 70 million reports was 472,813 (NCEA, 2003). people, and older people will make up more than 20 percent of the ● In 2003, state long-term care ombudsman programs nationally population (Populations Projection Program, 2000). investigated 20,673 complaints of abuse, gross neglect and ● Among people age 75 and older in 1999, 70 percent described exploitation on behalf of nursing home and board-and-care their health as good or excellent (Eberhardt et al.). However, aging residents. Among seven types of abuse categories, physical abuse populations are associated with age-related diseases and disabilities. was the most common type reported (2003). ● Of the estimated 12.8 million Americans reporting need for assistance with activities of daily living (ADLs) or instrumental The National Academy of Sciences (NAC) study panel agrees that elder activities of daily living (IADLs), 57 percent were over the age of mistreatment is a recognized social problem of increasing magnitude. 65 (Administration on Aging, 1997). The aging population is a well-recognized demographic fact, and
SocialWork.EliteCME.com Page 22 ● Dementia is present in approximately 5 to 10 percent of persons ● In 2003, the average cost for a room in a private nursing home over age 65 and older and 30 to 39 percent of people age 85 and was $66,000 a year. By 2021, the average annual rate may rise to older (Rice et al., 2001). $175,000 (2010). ● Among people 85 and older in 1999, 16 percent had Alzheimer’s ● Among people age 85 and over, 21 percent were in nursing homes disease (Brookmeyer et al., 1998). in 1995 and 49 percent were community residents with long-term Given the projected growth in the elderly population, long-term care care needs (Alecxih, et al., 1997). ● The nursing home population tends to be older and more severely for the elderly has become an increasingly urgent policy concern disabled than elders residing elsewhere, with about half of the (Institute of Medicine, 2001). The settings in which long-term care residents being 85 or older and about half having fi ve ADL is provided depend upon a number of factors, including the person’s limitations, in1996 (Stone, 2000). needs and preferences, availability of informal support, and the source ● More than 7 million Americans, mainly family members, provided of funding or reimbursement for care. Statistics on care facilities from 120 million hours of care to elders with functional disabilities the panel show: ● Among the 34 million persons over age 65 in 1995, 5 percent were living in the community, according to the National Long Term in nursing homes and 12 percent lived in the community setting with Care Survey (1994). ADL and IADL limitations. The estimate is 1.8 million of the 39.6 Most long-term care for elders in the community is provided in a million over age 65 reside in nursing homes in the United States. traditional home setting, in an the elder person’s home with or without a ● Roughly 75 percent of the residents in nursing homes were spouse, or in the home of a relative. However, the nature and character women, and 50 percent of them were age 85 or older. of long-term care services in the home may change (Stone, 2000). The ● In 1999, another 500,000 elderly people were living in assisted potential pool of adult children who can serve as caregivers is already living facilities (Hawes et al., 1999). decreasing as a result of demographic trends, including divorce, smaller ● Nursing home residents are younger today than 10 years ago, and families and increasing workforce participation (Himes, et al., 1996). the percentage of nursing home residents under the age of 65 has These factors increase the pressures on families caring for their elderly doubled from 7 percent to 14 percent, with the average age of 79, relatives and may increase the demand for institutional care. down from 83. ETIOLOGY OF ELDER ABUSE
Most elders who need assistance get the care they need from family paid employees connected to social services or health care systems. The members or friends. Some receive help from caregivers who work term informal caregiver refers to family members and friends who are for agencies or independently. Despite the signifi cant physical and the primary source, providing care for three-quarters of impaired older emotional demands of providing care, the majority of caregivers adults who live in the community. Beyond the ADL and IADL activities, are meeting the challenge (NCEA, 2002). But reports of abuse by some caregivers have added responsibilities, including administering caregivers are not uncommon and are on the rise. medication, turning patients who are immobile to avoid pressure sores, Elder abuse occurs in institutional settings, which include nursing and other tasks related to the elder person’s illness or disability. homes, assisted living facilities and board-and-care homes. It also Published in 2009, Donna Reed’s book, “An Insider’s Guide to happens in non-institutional settings, such as the victim’s home or the Better Nursing Home Care: 75 Tips You Should Know,” cites home of a caregiver, who is often a family member. The impact of the specifi c newspaper articles that outline the horrifi c forms that elderly abuse on victims is essentially the same no matter where it occurs, and mistreatment may take and situations and circumstances that lead to it happens more frequently to elders who are dependent and isolated. abuse. Her research covered long-term care nursing homes through out The term caregiver refers to anyone who routinely helps others who the United States, but these cases are found in private homes and other are limited by chronic conditions. Formal caregivers are volunteers or types of care facilities as well.
Medication control
Overmedication is a serious problem for elderly individuals. Some Reed stresses the importance of monitoring all medications taken by elders have diffi culty keeping track of when and how often they residents using the following procedures: take various medications or the correct dosage to take. Sometimes ● Keep a written record that can be reviewed by physicians and family. one or more physicians may prescribe medications that may interact ● Have a policy for periodic review of all medications the resident is adversely with other drugs the person is taking. Long-term care taking. facilities can add to this problem by encouraging residents to take ● Have a policy that the physicians clear all new medications or “as-needed” medications, such as sedatives, relaxants and sleeping supplements and inform the family. medications, on their own. ● Have a clearly stated policy about a resident’s right to refuse unwanted medication and a system to inform the physician and family.
Mistreatment in care facilities
Abuse and neglect are more common in institutions that serve Even institutions that serve the middle class frequently have too few impoverished residents. These institutions are operating on limited funds staff, low wages and provide inadequate training. One of the primary and may not be able to provide the same level of quality in terms of reasons for these problems is inadequate public funding for residents employees and care. Undertrained, overworked and poorly supervised who have run out of funds to pay for their own care. Medicaid, employees are the ones who may lash out at the residents in frustration. fi nanced by both federal and state governments, is the sole source of Financially stressed institutions may cut corners on the amount of staff payment for a majority of nursing home residents. Unfortunately, the and other services in order to meet their budgets. The isolation and Medicaid reimbursement rates pay only about 70 percent of the actual dependency of residents and their lack of housing alternatives leaves cost of resident care, leaving nursing homes to fi nd creative ways to them no choice but to endure unsatisfactory living conditions. balance their budgets.
Page 23 SocialWork.EliteCME.com Reed’s review of abuse that occurred throughout the country ● Issues related to special needs – Some facilities are not equipped uncovered the following incidences: to handle Alzheimer’s or dementia patients and may not have ● Neglect – This form of abuse often includes inadequate attention a facility that provides separate living arrangements. This may to resident needs, such as not responding to call buttons, providing cause diffi culties for both types of residents. In the mixed setting, substandard care or failing to provide a decent emotional the long-term care residents may be subjected to the behavioral atmosphere of safety and concern for the elder’s well-being. incidents common in Alzheimer’s or dementia residents. These Individuals left unattended have suffocated when wedged between a residents may wander and take things that belong to other mattress and wall; suffered from malnutrition, dehydration, infected residents. They need constant supervision, which means additional sores and heatstroke from lack of air conditioning; frozen from the staff members trained to meet their unique needs. cold; choked while eating and drinking unattended and choked or ● Unsafe facility – These include fi re safety violations and lack of suffocated from restraints; been bitten by ants and had maggots in accessible escape routes; unguarded stairs or low or unguarded wounds, feeding tubes and body cavities; and died from failure to windows; lack of railings in bathrooms, hallways and stairs; monitor breathing and heart rate to know when to resuscitate. unlocked storage of medications and supplies; unprotected heating ● Physical abuse – This includes striking, slapping, pulling hair, sources, such as radiators or space heaters, or a lack of proper tripping, kicking, pushing, choking, withholding food or water, heating, cooling and ventilation systems; improperly maintained dropping patients and restraining improperly. devices for lifting and moving patients; unsanitary conditions and ● Sexual assault. poor hygiene techniques and poor sanitation in food preparation ● Medical malpractice – This can include over- or under- and storage; fl ooring that is unsafe; lack of safety procedures for medicating and mixing or switching medications resulting in injury evacuation or lockdown during natural disasters or emergencies or death; improper use of catheters, feeding tubes and oxygen and a lack of communication or alarm notifi cation systems, supplies; failing to monitor vital signs or misuse of monitoring including procedures to contact emergency personnel inside and equipment; improper emergency procedures and techniques, outside the facility; and a lack of controls, alarms and procedures including fi re safety, failure to apply CPR or attend to seizure to prevent wandering incidents and the lack of safe grounds to disorders; and the lack of trained medical personnel and staff. allow clients to exercise and socialize safely. ● Staffi ng-related issues – This might include no trained medical staff ● Financial exploitation – Although residents are discouraged from in charge at the facility or consulting in the home, improper medical keeping cash and valuables in their rooms, theft still occurs in the charting or falsifi ed charts and documents, errors in following institutional setting. Financial abuse not only includes theft of doctors’ orders or in reports on medical issues to the physician petty cash but also jewelry, radios, computer, televisions and other or nursing supervisors, inadequate staff numbers, an untrained or items of value. This can easily occur when residents are sleeping inattentive staff, lack of background checks and drug testing for or out of their room for meals and activities. staff, theft by staff, overscheduling staff or extended shifts, and a lack of certifi cation and continuing education availability.
Mistreatment in the traditional home setting
According to NCEA data, in 90 percent of all reported elder abuse attention by a caregiver or a “new best friend” is genuine. The victim cases, the abuser is a family member. It is not known how many of the can be manipulated into making gifts or giving the abuser access to the abusive family, the victim’s friends or other family members may be victim’s bank accounts or other property (NCEA, 2003). unaware it is happening. Some victims endure the abuse because they Some abusers have the specifi c intent to exploit or injure their victims. fear they will lose the caregiver or that the caregiver, usually an adult They select the victims because they are available, vulnerable and child, will get into trouble with the law. Other victims are too isolated less likely to report the abuse. The Internet has increased access by or too physically or mentally incapacitated to seek help. those seeking to exploit vulnerable elder citizens. Others, often family Some abuse occurs when caregivers fail to understand the elder person’s members, believe they are entitled to use the victim’s property and medical or dietary needs and do not provide the proper diet, which money as payment for care giving or as part of an inheritance that may affect the medical condition and effectiveness of the medication. will eventually be theirs. In other cases, caregivers simply become so Other abuse is negligent care giving and may range from failing to frustrated with their duties and so angry with the older person that they seek medical attention soon enough to more intentional abuse, such as lash out from the fatigue of caring for someone who may be physically leaving bedridden elders to lie in their own waste or refusing to feed or verbally abusive to the caregiver. them by hand because it is too much work or too time consuming. To be sure, the stress of care giving can lead to despair, anger and Financial exploitation by caregivers is fairly common and diffi cult resentment, but abuse is never an acceptable response. Researchers to uncover. When the caregiver lives with the victim, it is easy to have estimated that 23 percent of all caregivers are physically abusive, commingle funds and use the elder’s money for the caregiver’s support. and most agree this is often due to stress associated with providing The elderly victim may be lonely or depressed and believe that fl attering care (NCEA, 2003).
Caregiver stress
Stress is often described as the body’s “fi ght or fl ight” response to Some stress is normal, and researchers for NCEA have found stress danger when the body goes on high alert to protect itself. Essential affects caregivers very differently. Some who provide high levels of functions like respiration and heart rate speed up while the less essential care experience no stress, while others who provide relatively little functions, such as the immune system, shut down. Although the stress care experience high levels of stress. Experts feel that these differences response is a healthy reaction, the body needs to repair itself once the can be explained by subjective factors, such as how caregivers feel danger is removed. Because caregivers’ stress often results from fatigue about providing care, their current and past relationship with the elder, and confl icts that never go away, their bodies never get a chance to heal. and their coping abilities. Some caregivers fi nd certain behaviors by If the immune system is not functioning fully, the caregiver is at greater elder to be particularly stressful, including aggression, combativeness, risk for infections and disease. Some experts believe that stress causes wandering and incontinence. Others report that they experience stress hypertension, coronary disease or even premature death.
SocialWork.EliteCME.com Page 24 because they do not get enough rest, privacy, support or time for ○ Exhibits disturbing behaviors, such as inappropriate behavior themselves (NCEA, 2003). or embarrassing public displays. ● The caregiver and the elder: It was found in the NCEA report that some of the same factors that ○ Live together. are believed to cause caregiver stress also raise the risk of abuse. For ○ Had a poor relationship before the onset of the illness or example, when the relationship between a caregiver and elder was disabling condition. poor to begin with, the caregiver is more likely to become stressed ○ Are married and have a marital relationship characterized by and become abusive. The link between caregiver stress and abuse is confl ict. not fully understood, and more research is needed to understand what factors predict and contribute to caregiver abuse. Specifi c areas that Family discord and mistreatment was seldom a public issue for much need to be explored include how aggression by caregivers raises the of this country’s history. Responsibility for assisting families in need risk of abuse, why some caregivers fear they will become aggressive was assumed mainly by religious organizations and private charitable or abusive, whether those who fear they will become abusive are more organizations. There was no legal basis for intervention into families until likely to actually abuse, and how coping patterns play a role. the late 19th century, when industrialization, immigration and urbanization increased family problems, including poverty and internal confl ict, and Drawing on the NCEA study on caregiver abuse, there are some also exposed them to public view (Bonnie and Wallace, 2003). factors that may lead to abuse: ● The caregiver: Many of the preventative and protective tools developed in the context ○ Expresses fear that he or she will become violent. of intimate partner violence have now been directed to violence ○ Suffers from low self-esteem. against elders. Bringing elderly mistreatment into the domain of family ○ Says he or she is not getting adequate support and help from violence brings new ideas about etiology. Researchers note that it also others. exposes tensions between social service agencies, with their traditional ○ Expresses that care giving is a burden. helping approach, and many family violence specialists, with their ○ Experiences emotional or mental “burnout,” anxiety or greater emphasis on criminalization and punishment of abusers. depression. Studies have found that some abuse is revenge motivated, adult ○ Feels caught in the middle of providing care to children and children retaliating against their older parents for abuse committed elderly family members at the same time. against them as children. Other abusers consider violence a normal ○ Feels anger toward the care of the elder that can be traced to and acceptable way of handling someone who is uncooperative their relationship in the past. or burdensome. Many abusers are suffering from drug or alcohol ● The elder: dependency and fi nancially exploit the victim to support their ○ Is aggressive or combative. addiction. For others, abuse is a way of gaining control and satisfying ○ Is verbally abusive. an emotional need to dominate the victim.
Agency factors
The current system for protection for the elderly has its roots in the recently, partner violence. Prevailing policies and practices in these child protection system legislation, The Child Abuse Prevention and related domains are not fully applicable to elder mistreatment and Treatment Act of 1974, that mandated reporting and investigation for are often controversial (Bonnie and Wallace, 2003). The National the protection of children (Nelson, 1984). Research Council and Institute of Medicine panels have repeatedly Relying on the parens patriae authority to protect helpless citizens, called for sustained and aggressive research on the magnitude, a few states started public welfare systems in the 1940s and 1950s etiology, consequences and interventions for elder mistreatment to protect adults who could not independently care for and protect (National research Council, 1993, 1996; National Research Council themselves. Adult protective services were developed to provide and Institute of Medicine, 1998). social, legal and guardianship services. Overall, the panels found the national response to elder mistreatment The context of elder mistreatment varies, from the forgotten and to be weak and incomplete. Adult protection is poorly funded, and helpless nursing home resident, the battered or exploited elder, the Rep. Pepper’s emphasis on the issue has not been sustained by his stressed caregiver, and the abusing spouse or relative. The system successors in Congress. In addition, the panel noted that this problem of adult protective services has emerged to respond to these varied is compounded by the public’s preoccupation with youthfulness, and problems as well as other issues related to adults with disabilities. that the nation seems to be uncomfortable with the process of aging and the issue of elder care. As a result, elder mistreatment remains The system for adult services is based on ideas and structures hidden, poorly defi ned and largely unaddressed more than two decades borrowed from policy and practice in child mistreatment, and more after Claude Pepper’s hearings fi rst exposed it to the public. PREVENTION AND INTERVENTION
Reducing the risk of elder abuse by caregivers will require the effort ○ Develop relationships with other caregivers. Caregivers with of caregivers, agencies and the community. The NCEA offers the strong emotional support from other caregivers are less likely following suggestions: to report they experience stress or to fear they will become ● Family caregivers should: abusive. ○ Get help. Make use of social and support agencies, including ○ Get healthy. Exercise, relaxation, good nutrition and adequate support groups, respite care, home delivered meals, adult rest have been shown to reduce stress and help caregivers cope. day care and assessment services, which can reduce stress ○ Hire help. Attendants, homemakers or personal care attendants associated with abuse. can provide assistance for most daily activities. Caregivers ○ Recognize the triggers that cause the stress and anxiety. who cannot afford to hire help may qualify for assistance. ○ Learn to recognize and understand the causes of diffi cult ○ Plan for the future. Careful planning can relieve stress by behaviors in elders and techniques for handling them more reducing uncertainty, preserving resources and preventing effectively. crises. A variety of instruments exist to help plan for the future,
Page 25 SocialWork.EliteCME.com including powers of attorney, advanced directives for health ● Transparency in ownership and enforcement – To urge the care, trusts and wills (NCEA, 2005). state of Kentucky to maintain and display on its website an up-to- ● Agencies providing assistance for in-home caregivers should: date and complete fi le of information on the ownership of every ○ Carefully screen caregivers and patients for the risk factors nursing home; notify the public about serious defi ciencies in associated with caregiver abuse. nursing homes; and to release a quarterly report of nursing home ○ Provide information and support to caregivers to lower their defi ciency citations and those with no defi ciencies. risk. ● Oral health – To urge state enforcement of oral health ○ Provide instruction to caregivers though materials, classes, requirements in the care of nursing home residents. websites or support groups. They could address confl ict ● Criminal background checks – To amend current state law to resolution and how to deal with diffi cult behaviors such as require that all employees of nursing homes receive a criminal violence, combativeness and verbal abuse. background check before they are hired. ○ Promote better coordination between agencies that offer ● Random drug testing – To address the evidence that drug abuse protection to victims and those that offer services to caregivers. problem exists among nursing home staff and urge that a law be This can be achieved through cross-discipline training, enacted to require random drug testing of all nursing home employees. interagency protocols and multidisciplinary teams (NCEA, 2005). ● Train Alzheimer’s caregivers – To address the more than half ● Concerned citizens can: of the states’ nursing home residents who suffer from some ○ Lend a hand to a caregiver who needs help. form of dementia, including Alzheimer’s disease. To urge the ○ Report abuse. In most communities, an adult protective establishment of a program to train all caregivers in best practices services (APS) agency can accept and investigate reports. to care for these residents. ○ Advocate for public policy to increase the scope and access to ● Standardized end-of-life regulations – To address the lack of a services available for caregivers. standardized system to address residents’ end-of-life decisions, ○ Volunteer. Volunteers can make friendly visits, serve as including DNR, by incorporating a combination of wristband I.D. guardians, run errands and provide respite care. and DNR documentation in residents’ charts. ○ Arrange for educators and speakers to make presentations at ● “Dumping” of nursing home residents – To form a committee churches, clubs or civic organizations (NCEA, 2005). to study the serious situation that occurs when nursing home Kentucky residents led by Bernie Volderheide recently formed a grass residents are forced from nursing homes because of alleged “bad roots organization called Kentuckians for Nursing Home Reform behavior” and moved to an out-of-state nursing home. ● Use of anti-psychotic drugs – To address the overuse of drugs (2008). They developed an action agenda for nursing home reform to to quiet over-active residents that has become prevalent in many address the needs of the 23,000 people in the state’s nursing homes. nursing homes. They describe Kentucky’s nursing home residents as the “forgotten ● Form a committee to oversee the Civil Monetary Penalties people,” and their statewide initiative addresses areas in need of Fund – To form an advisory committee to created by the governor reform to bring the state into compliance with all federal regulations. to oversee the use of these funds to benefi t nursing home residents. They targeted the following areas: ● Quality staffi ng – To continue to press lawmakers and state ● University research on long-term care – To urge the University government offi cials to create minimum staffi ng standards for of Kentucky to expand its ongoing research on aging to establish caregivers in all nursing homes. an institute on long-term care, and to use the Cooperative Extension Service to deliver the results of research on long term- care through its county offi ces across the state.
Culture change
“Culture change” is a grassroots movement to transform the culture of different approaches to culture change, each focused on the individual aging as a way to address elder mistreatment and nursing home reform. resident and reinstating choice in daily life. Through culture change, nursing homes and other senior living facilities The following changes would be implemented in the new model for change from hospital-like institutions to communities that more closely culture change to reform nursing homes: resemble home. In “Almost Home,” fi lmmakers Brad Lichtenstein and 1. No agenda would be kept, so residents could enjoy choice and Lisa Gildehaus (2006) chronicled the daily lives of staff and residents at control over daily activities that bring them pleasure. Saint John’s on the Lake, a retirement community in Milwaukee whose 2. Staff is trained to handle stress and attend to their own needs to leaders are striving to improve quality of life for residents and staff. become better caregivers. Part of the Nursing Home Reform Act of 1987 declared, ”Residents in 3. All staff is evaluated on the joy they bring to elders’ lives. nursing homes need a home where they can live for the rest of their lives 4. The focus is promoting feelings of home and community among as individuals.” Social, spiritual, emotional, occupational, recreational residents and staff. and cultural needs are deemed as important as physical ones. 5. Dining is a social experience with made-to-order meals. Culture change in long-term care is described as an ongoing 6. Décor is warm, home-like and pleasing. transformation based on person-directed values that restore control to 7. Doing nothing is an activity choice as well. elders and those who work closest to them. “Almost Home” explores the New York-based Pioneer Network, which In March 1997, progressive thinkers in the long-term care fi eld, includes seniors, family members, physicians, caregivers, educators, those who believed that aging could be a gratifying and dignifi ed researchers and friends all working to educate seniors, their families, experience, convened in Rochester, N.Y., to exchange ideas for culture legislators and nursing home administrators. Their goal is to create deep change. This change would involve the transformation of the nursing and lasting change in the way society ages and the way our culture cares home atmosphere and structure as a whole, including the physical for the elderly. The tenants of the Pioneer Network include: environment, staff routines, authority structure and daily care. In ● Know each person, identify unique talents. Rochester, four models of culture change were introduced. Each ● Promote choice and creativity. demonstrated that changing the way the nursing facilities operated ● Respect individuality and risk-taking. had a major impact on residents as well as staff. Although there were ● Trust staff. ● Keep decision-making close to the resident.
SocialWork.EliteCME.com Page 26 ● Shape environments, social, physical and organizational policies ● Support function and mobility. and activities to refl ect values. ● Build on strength and potential for healing growth. ● Ensure representation of all community members in policy decisions. ● Devote time and space to building community. ● Expect leaders to model values. ● Look for meaning in all behaviors. ● Respect the need of all to give as well as receive. ● Work with residents, do not argue with them. ● Support relationships with people of all ages, animals and nature. ● Respect ethnic and cultural identities and religious beliefs.
Efforts to improve long-term care facilities
Donna Reed, nurse and attorney, in her book, “Better Nursing Home and nursing assistants they must have on duty for a certain number Care: 75 Tips You Should Know,” provides insight into improvements of residents, although a few states have mandated their own staffi ng that could prevent abuse in care facilities. She addresses the forms of standards. Because most facilities employ a small number of nursing abuse she noted throughout the country as listed above in the etiology personnel to care for a large number of residents, many shortcuts must section (Reed, 2009). be taken during the delivery of nursing care. Reed points out that most nursing homes are understaffed, and that is The second point Reed makes is that nursing home nurses may be one of the main reasons for poor care. They are understaffed because trained and encouraged to conduct nursing business in a manner that the nursing home industry in almost every state is not bound by any protects the facility. The staff must move quickly and deliver care in legal standard that would mandate a specifi c staffi ng requirement. a systematic manner, which she describes as sometimes “robotic” and Facilities are therefore free to value profi t over adequate nursing done at the convenience of the staff in some situations. staff. There is no federal law to tell nursing homes how many nurses
Staffi ng issues
I’ve had my call bell on for twenty minutes. It’s too late. I’ve of the day and night. These issues take time and energy away from already wet the sheets. I’m sorry. patient routine and emergency care. – Nursing home resident (Reed, 2009) There should always be a nursing supervisor on staff, preferably in the The Nursing Home Reform Act of 1987 addresses the issue of nursing building. Minor emergencies occur on a constant basis, and it takes staff in the following regulations: time to handle and document them effectively. ● 483.30 Not all emergencies are of a magnitude to require much of a nurse’s ○ The facility must post the following information on a daily time, but if the duty nurse is expected to handle both a nursing basis: the total number of the actual hours worked by the assignment of 30 residents and supervisory responsibilities, then the following categories of licensed and unlicensed nursing staff nurse-resident ratio would actually be higher. directly responsible for resident care per shift: registered nurses, licensed practical nurses, licensed vocational nurses Reed states from experience that if nurses do their own documentation, and certifi ed nurses aides per shift. treatments and medication passes for their residents, 15 to 25 non- ○ The facility must post the nursing staff data (A) in a clear skilled-care residents for a day and evening shift is realistic and safe if and readable format and (B) in a prominent place readily the unit has the appropriate number of nursing assistants. In addition, accessible to residents and visitors. Reed notes the only true test to determine the appropriate nurse-to- ○ The facility must, upon oral or written request, make staffi ng resident ratio is to know whether nurses are able to get their work done data available to the public for review at a cost not to exceed within the allotted time frame. If a nurse is getting all work done, she the community standard. has a reasonable workload with room for additional assignments. If ○ The facility must maintain the posted daily nurse staffi ng the nurse is taking shortcuts to get it done, the workload is too heavy. data for a minimum of 18 months, or as required by state law, Unfortunately, most facility managers do not consider a workload test whichever is greater. but may overload nurses to get the most nursing care for their dollar. ○ The facility must have suffi cient nursing staff to provide Likewise, if there is no overtime policy, rather than risk being nursing and related services to attain or maintain the highest reprimanded by management for a late punch-out, the staff may practicable physical, mental and psychosocial well-being neglect tasks or leave tasks to be done for the next shift in order to of each resident as determined by resident assessments and leave on time. The oncoming shift cannot be responsible for any individual plans of care. unfi nished documentation, so the departing staff often neglects it or Determining the appropriate ratio of nurses to residents depends on a completes it hurriedly to leave on time. number of factors. These include availability of support staff, the level Other staffi ng issues involve the number of hours nurses may be of care required by the residents, the time of day or night, the nursing required to work. Nurses often have to work a 16-hour shift because of assistant-to-resident ratio, and the capability of the nursing staff. the illness of a coworker, weather conditions that prevent a relief nurse Without suffi cient support staff, the nursing staff will be answering from traveling or other emergencies. Reed explains that there are many phones, doing paperwork and handling facility issues such as jobs that can be performed safely for 16 consecutive hours, but nursing plumbing, heating and electrical emergencies that occur at all hours is not one of them. The continuous physical and mental demands dull the abilities of even the sharpest nurse when working those hours.
Registered and licensed nurses
Two types of nurses usually occupy the position of staff or fl oor nurse. Ideally, when the same nurse works with the same residents everyday, The signifi cant difference between the registered nurse (RN) and the better care is delivered because the nurse will be familiar with licensed practical nurse (LPN) or licensed vocational nurse (LVN) is that residents, their routines, desires and special needs. Many facilities the RN has completed at least one more year of education. Both can fi ll have full-time, part-time, and per diem nurses who work on an as- the position of staff nurse, sometimes known as the medication nurse. needed basis (Reed, 2009).
Page 27 SocialWork.EliteCME.com Medication control
“I don’t have enough staff to babysit her. She needs to be medicated.” The following guidelines and regulations from the Nursing Reform - A statement made by nursing home nurse who medicates Act focus on overmedication issues: overactive residents because there is not enough staff to closely ● 483.25 monitor everyone (Reed, 2009). ○ The facility must ensure that each resident’s drug regimen is free from unnecessary drugs. Overmedication is a serious problem for elderly individuals. Some ○ The facility must ensure that residents who have not used elders have diffi culty keeping track of when and how often they take antipsychotic drugs are not given these drugs unless anti- various medications or the correct dosage to take. Sometimes one or psychotic drug therapy in necessary to treat a specifi c more physicians may prescribe medications that interact adversely condition as diagnosed and documented in the clinical record. with other drugs the person is taking. Long-term care facilities can ○ The facility must ensure that residents who use anti-psychotic add to this problem by encouraging residents to take “as-needed” drugs receive gradual dose reductions and behavioral medications such as sedatives, relaxants and sleeping medications. interventions, unless clinically contraindicated, in an effort to For these reasons, it is important to have the facility monitor all discontinue these drugs. medications using the following procedures: ● 483.60 ● Keep a written record that can be reviewed by physicians and family. ○ A licensed pharmacist must review the drug regimen of each ● Have a policy for periodic review of all medications the resident is resident at least once a month. taking. ○ The facility must ensure that residents are free of any ● Have a policy that the physician clear all new medications or signifi cant medical errors. supplements and inform the family. ● Have a clearly stated policy about a resident’s right to refuse unwanted medication and a system to inform the physician and family.
Infection control nurse
A registered nurse is usually on staff to monitor residents with ● 483.65 infections and those at risk for developing infections. Often they ○ The facility must establish and maintain an infection control assumed the title of infection control nurse, which can be a full-time program designed to provide a safe, sanitary and comfortable position depending on the type of facility and the number of non- environment and to help prevent the development and ambulatory or diabetic residents. transmission of disease and infection. ○ When the infection control program determines that a resident The nurse reviews resident/patient charts and conducts educational needs isolation to prevent the spread of infection, the facility training for employees to ensure that the facility remains in must isolate the resident. compliance with infection control policies. The nurse would watch for ○ The facility must prohibit employees with a communicable communicable disease that could spread between roommates and work disease or infected skin lesions from direct contract with to ensure the safety of patients with compromised immune systems. residents or their food if direct contact will transmit the disease. Regulations require that a sign be placed on the door telling potential visitors to report to the nurse’s station before entering the rooms.
Wound care nurse
Residents can get wounds quite easily because their skin is thin and wound. The nurse would consult a wound specialist if the wound does fragile and can be broken from simply rubbing against an object, such not improve or worsens. as a door or wheelchair. Facilities may designate a nurse to focus on The following regulations of the Nursing Home Reform Act focus on wound care. A common type of wound treated by a nurse is a pressure pressure sores: sore or bedsore. These sores are usually found over bony areas such as ● 483.25 the heel, hip, coccyx or any area of the back. ○ The facility must ensure that a resident who enters the facility The treatment nurse inspects and treats all wounds and implements without pressure sores does not develop pressure sores unless skin-care regimens for all residents in the facility. This nurse would the individual’s clinical condition demonstrates that they are have advanced training in the newest and best-practice methods for unavoidable. wound care and skin treatment. A wound is usually measured, and a ○ The facility must ensure that a resident having pressure sores record is kept in the patient’s chart. The same nurse regularly treating receives necessary treatment and services to promote healing, the wound can notice changes in the size, color or drainage of the prevent infection and prevent new sores from developing.
Nurse’s aides and licensed nursing assistant
Nurse’s aides or licensed nursing assistants are the backbone of the Reed says the optimal ratio of a nurse’s aides to residents should be no nursing home, often the hardest working and lowest paid. They are more than six residents requiring moderate to maximum care to one closest to the resident and often have the most diffi cult and unpleasant nurse’s assistant. Her studies show this is not the ratio found in most jobs. Many times they are the primary caregivers and have the most to facilities, which may explain the high rate of job-related injuries and do in the least amount of time. turnover among nurse’s aides.
SocialWork.EliteCME.com Page 28 Comprehensive care plan
The Nursing Home Reform Act outlines the following regulations Nursing homes that accept Medicare or Medicaid are bound by this addressing the comprehensive care plan: requirement by law. ● 483.20 The meetings should be held every month or quarter and are normally ○ The facility must develop a comprehensive care plan for each attended by the nursing home resident and one nursing home employee resident that includes measurable objectives and timetables to from each discipline involved in the resident’s care. For example, meet a resident’s medical, nursing, mental and psychological representatives from dining services, rehabilitation therapies, nursing needs that are identifi ed in the comprehensive assessment. and social services gather together to discuss the current plan of care ○ The care plan must describe the services that are to be for the resident. The resident’s family is encouraged to attend in furnished to attain or maintain the resident’s highest person or a conference call can be arranged. This is the best forum practicable physical, mental and psychosocial well-being. for all parties to ask questions and offer suggestions about the elderly ● 483.25 resident’s care. It is important for a family member or representative ○ Each resident must receive and the facility must provide the to be there in case the resident cannot be present or is not alert or necessary care and services to attain or maintain the highest competent to make comments about the way care is delivered. practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Researchers note that when a staff is accountable to a family member for fi nding a solution to a complaint, greater results are achieved than Care plan meetings are federally mandated and designed to improve when the staff is accountable only to the resident. The resident and the quality of care for nursing home residents by identifying care family member should always be present, and all documents that were issues and implementing a preventive or corrective plan for treatment. generated during the care plan meeting should be reviewed.
Nutrition documentation
The nurse’s notes should include a description of everything that was ○ If a qualifi ed dietician is not employed full time, the facility done for the patient that day, including documentation of complaints, must designate a person to serve as the director of food behavioral changes, medication changes, new symptoms, bruises, services who receives frequently scheduled consultations from status of medical equipment, vital signs, feeding, toileting, weight, a qualifi ed dietician. how and when care was delivered, who delivered it, and how it ○ The facility must employ suffi cient support personnel was tolerated by the elder patient. The resident, family, or legal competent to carry out the functions of the dietary service. representative should have access to that documentation at any time. ○ The facility must provide food that is palatable, attractive and ● 483.25 at the proper temperature. ○ Based on a resident’s comprehensive assessment, the facility ○ The facility must provide substitutes of similar nutritional must ensure that a resident maintains acceptable parameters value to residents who refuse the food served. of nutritional status, such as body weight and protein levels, ○ The facility must provide at least three meals daily at regular unless the resident’s clinical condition demonstrates that this is times comparable to normal meal times in the community. not possible. ○ There must be no more than 14 hours between a substantial ○ Based on a resident’s comprehensive assessment, the facility evening meal and breakfast the following day. must ensure that the resident receives a therapeutic diet when ○ The facility must offer snacks at bedtime daily. there is a nutritional problem. ○ The facility must provide special eating utensils and equipment ○ The facility must provide each resident with suffi cient fl uid for residents who need them. intake to maintain proper hydration and health. ○ The facility must provide feeding assistance if warranted.
Regulations on physician and therapist care
● 483.25 ○ The facility must ensure that a resident with a limited range of ○ Residents must be seen by a physician at least once every 30 motion receives appropriate treatment and services to increase days for the fi rst 90 days after admission, and at least once range of motion and to prevent further decrease in range of every 60 days thereafter. motion. ○ The facility must, if necessary, assist the resident in (1) making To provide optimum, quality care, a number of professionals should be appointments, and (2) by arranging for transportation to and from available to provide care for routine checks and to consult as needed. the offi ce of a practitioner specializing in the treatment of vision These include dentists, ophthalmologists, audiologists, occupational or hearing impairment or the offi ce of a professional specializing therapists, physical therapists, mental health professionals, podiatrists in the provision of vision or hearing assistive devices. and speech therapists for speaking and swallowing issues. ○ The facility must promptly refer residents with lost or damaged dentures to a dentist.
The facility must provide a safe and homelike environment
This regulation requires the facility to promote an atmosphere that ○ The facility must provide clean bed and bath linens that are in resembles a home rather than an institution. good condition. ● 483.15 ○ The facility must provide comfortable and safe temperature ○ The facility must provide a safe, clean, comfortable and levels. Facilities certifi ed after October 1, 1990, must maintain homelike environment, allowing the resident to use his or her a temperature range of 71-81 degrees Fahrenheit. personal belonging to the extent possible. ○ The facility must provide for the maintenance of comfortable ○ The facility must provide housekeeping and maintenance sound levels. services to maintain a sanitary, orderly and comfortable interior.
Page 29 SocialWork.EliteCME.com ○ The facility must ensure that residents’ environment remains as ○ The facility must maintain an effective pest control program to free of accident hazards as possible. ensure that the facility is free from pests and rodents. ○ The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents.
The facility must have policies against mistreatment
The facility must have policies in place that prohibit mistreatment, for service as a nurse aide or other facility staff to the state neglect, abuse and theft. Most facilities distribute a basic version of nurse aid registry or licensing authorities. these policies to their employees at the time of hire. The following ○ The facility must ensure that all alleged violations involving Nursing Home Reform Act regulations address mistreatment in a mistreatment, neglect, abuse, (including injuries of an nursing home: unknown source) and misappropriation of resident property ● 483.15 are reported immediately to the administration of the facility ○ The facility must develop and implement written policies and and to other offi cials in accordance with state law established procedures that prohibit mistreatment, neglect, and abuse of procedures. residents and misappropriation of resident property. ○ The facility must have evidence that all alleged violations ○ The facility must not employ individuals who have been found are thoroughly investigated and steps are taken to ensure guilty in a court of law of abusing, neglecting or mistreating that the resident is not subjected to further abuse during the residents. investigation. ○ The facility must not employ individuals who have had a fi nding ○ The results of all investigations must be reported to the entered into the state nurse aide registry concerning abuse, administrator or his designated representative and to other neglect, and mistreatment of residents or misappropriation of offi cials in accordance with the state law (including the state their property. survey and certifi cation agency) within fi ve working days of ○ The facility must report any knowledge it has of actions by a the incident, and if the alleged violation is verifi ed, appropriate court of law against an employee that would indicate unfi tness corrective action must be taken.
Addressing resident problems and complaints
A facility must have specifi c procedures for residents and family address the issue. An organized and effective complaint procedure will members to make complaints or discuss a problem. This could include guarantee a response from an identifi able person in authority. There a problem with a particular staff person, a method or type of care, should also be a procedure for registering a complaint or discussing facility rule or condition. problems about a roommate or other resident. The danger of not having an explicit complaint procedure is that a The procedures for addressing residents’ complaints and the legal resident or family member will not know with whom to speak, or may rights of the resident will be discussed further in the following section be dismissed by staff members who claim they have no authority to on laws related to resident rights.
Long-term care ombudsman
The federal government funds a program administered by each state’s the nursing home and the state attorney general’s offi ce to pursue civil agency on aging, which makes available to nursing facility residents an fi nes and criminal charges against abusers and the facilities in which ombudsman. The ombudsman acts as a mediator to address unresolved abuse has occurred. problems between residents or their families and a nursing facility. The victim or someone who suspects that a resident has been abused The ombudsman has regular visiting hours and days at the facility and may also make a complaint directly to the state regulatory agency for is also available by phone. There is no charge for the services of the nursing homes or the state attorney general’s offi ce. State attorney ombudsman. general’s offi ces have Medicaid fraud and control units that are Although the ombudsman does not have the direct authority to required to investigate and prosecute patient fraud, abuse and neglect bring civil or criminal penalties against the nursing home or abusive in facilities that participate in Medicaid. employee, the ombudsman may assist the state agency that supervises
Fingerprinting
Section 483.15 includes regulations requiring fi ngerprinting of These include skilled nursing, intermediate care, home health agencies, designated personnel, including certifi ed nurse assistants (CNAs), intermediate care for developmentally disabled, nurse assistant and home health aides, students enrolling in CNA/HHA training programs, home health training programs, accredited nursing schools, general home health agency owners and administrators in all types of facilities. acute care hospitals and hospices.
Abuse notifi cation procedures
Current regulations in section 483.15 require skilled, long-term certifi cation agency and either the ombudsman program or the local care facility staff to report suspected abuse immediately to the police department, within fi ve working days. A detailed description of administrator, and the administrator’s investigation must be reported 483.15 was provided in the last section. to the state agency, including to the department of health licensing and
SocialWork.EliteCME.com Page 30 Residents’ rights
In 1987, the federal government approved the Nursing Home Reform ● To examine results of the most recent survey of the facility Act in response to public concern over the poor quality of care the conducted by federal or state surveyors and an any plan of elderly were receiving in nursing homes across the nation. The correction in effect with respect to the facility. new law provided rights to all nursing home residents and required ● The resident or his/her legal representative has the right, upon facilities that accept payments from Medicare and Medicaid to abide oral or written request, to access all records which pertain to by these rules. These were designed to improve the quality of care for him/herself, including current clinical records within 24 hours residents in all care facilities. (excluding weekends and holidays). ● To refuse to perform services for the facility. The law created a set of rights for residents and a set of specifi c ● To privacy in written communication. guidelines for nursing home operation. A portion of the act gave ● To resident has the right and the facility must provide immediate residents clear, enumerated entitlements and was named the Residents’ access to any resident by the following: Bill of Rights. On the wall of every nursing care facility, the Residents’ ○ Any representative of the state. Bill of Rights should be posted for all to see. ○ The resident’s individual physician. The formal source of these rights is the Code of Federal Regulations ○ The state’s long-term care ombudsman. (CFR), Title 42-Public Health, Part 483, Requirements for States and ○ Immediate family members. Long-Term-Care Facilities (Reed, 2009). These laws can be divided ○ Others who are visiting with the resident’s consent. into two sections: ● To use a telephone where calls can be made without being overheard. ● The rights of residents. ● To retain and use personal possessions, including some furnishings ● The responsibilities of a nursing facility. and appropriate clothing as space permits unless to do so would 483.10 The resident has a right to a dignifi ed existence, self- infringe upon the rights or health and safety of other residents. determination, communication with and access to persons and services ● To share a room with his/her spouse when married residents live in inside and outside the facility. A facility must protect and promote the the same facility as long as both consent to the arrangement. rights of each resident, including each of the following rights: ● To self-administer drugs if the interdisciplinary team has ● To exercise his/her rights as a resident of the facility and as a determined that the practice is safe. United States citizen. ● To refuse a room transfer to another room within the institution ● To be informed of his/rights and responsibilities, both orally and in if the purpose of the transfer is to relocate a resident of a skilled- writing, in a language that the resident understands. nursing facility (SNF) to a distinct part of the institution that is ● To mange his/her fi nancial affairs, and the facility may not require not a SNF, or a resident of a nursing facility (NF) to a distinct part residents to deposit their personal funds with the facility. of the institution that is a SNF. This regulation ensures that the ● To choose a personal attending physician and participate in resident cannot be moved to a part of the facility that provides a planning treatment. different level of care unless it is part of the care plan designated ● To be fully informed in advance about care and treatment and by the interdisciplinary team. of any changes in that care and treatment that may affect the ● In a case of a resident adjudged incompetent under the laws of resident’s well-being. the state by the court of competent jurisdiction, the rights of the ● Unless adjudged to be incompetent or otherwise found to be resident are exercised by the person appointed under state law to incapacitated under the laws of the state, to participate in planning act on the resident’s behalf. care and treatment or changes in care and treatment. ● In the case of a resident who has not been adjudged incompetent ● To personal privacy and confi dentiality of his or her personal and by the state court, any legal surrogate designated in accordance clinical records. with state law may exercise the resident’s right to the extent ● To voice grievances without discrimination or reprisal and have provide by state law. the facility respond to those grievances. ● To refuse treatment, to refuse to participate in experimental ● The resident has the right to prompt efforts by the facility to research, and to formulate an advanced directive. resolve grievances the resident may have, including those with ● To have access to stationery, postage and writing implements at the respect to the behavior of other residents. resident’s expense.
Medication control
Overmedication is a serious problem for elderly individuals. Some For these reasons, it is important to have the facility monitor all elders have diffi culty keeping track of when and how often they take medications using the following procedures: various medications or the correct dosage to take. Sometimes one or ● Keep a written record that can be reviewed by physicians and family. more physicians may prescribe medications that may interact adversely ● Have a policy for periodic review of all medications the resident is with other drugs the person is taking. Long-term care facilities can taking. add to this problem by encouraging residents to take “as-needed” ● Have a policy that the physician clear all new medications or medications, such as sedatives, relaxants and sleeping medications. supplements and inform the family. ● Have a clearly stated policy about residents’ right to refuse unwanted medication and a system to inform the physician and family.
Right to be free from restraints and abuse
483.13 ● The resident has the right to be free from verbal, sexual, physical ● The resident has the right to be free from any physical or chemical and mental abuse, corporal punishment and involuntary seclusion. restraints imposed for purposes of discipline or convenience and not required to treat the resident’s medical symptoms.
Page 31 SocialWork.EliteCME.com Quality of life 483.15 ● The resident has the right to receive notice before the resident’s ● The resident has the right to reside and receive services in the room or roommate in the facility is changed. facility with reasonable accommodation of individual needs and ● The resident has the right to organize and participate in resident preferences except when the health or safety of the resident or groups in the facility. other residents would be endangered. LEGAL REQUIREMENTS AND REGULATING THE NURSING HOME The Nursing Home Reform Act requires nursing homes to assume the regulations dictate the specifi c actions the facility must take to ensure responsibilities of meeting individual needs of each resident. These proper care is delivered to each resident.
The facility must inform the resident and family 483.10 status, deterioration in health, mental or psychological status in ● The facility must inform each resident of the name, specialty and either life-threatening conditions or clinical complications. method of contacting the physician responsible for his or her care. ● The facility must immediately inform the resident, consult with ● The facility must immediately inform the resident, consult with the resident’s physician, and if known, notify the resident’s legal the resident’s physician, and if known, notify the resident’s legal representative or interested family member when there is a need representative or an interested family member when there is an to alter treatment signifi cantly or a need to discontinue an existing accident involving the resident that results in injury and has the form of treatment due to adverse consequences, or to commence a potential for physician intervention. new form of treatment. ● The facility must immediately inform the resident, consult the ● The facility must record and periodically update the address and resident’s physician, and if known, notify the resident’s legal phone number of the resident’s legal representative or interested representative or an interested family member when there is a family member. signifi cant change in the resident’s physical, mental or psychological
The facility must post information 483.10 ● The facility must furnish a written description of legal rights that ● The facility must furnish a written description of legal rights that includes a statement that the resident may fi le a complaint with the includes the posting of names, addresses and telephone numbers state survey and certifi cation agency concerning resident abuse, of all pertinent state client advocacy groups such as the state neglect, misappropriation of resident property in the facility and survey and certifi cation agency, the state licensure offi ce, the state noncompliance with advanced directives requirements. ombudsman program, the protection and advocacy network, and ● The facility must allow representatives of the state ombudsman to the Medicaid fraud control unit. examine a resident’s clinical records with the permission of the resident or the resident’s legal representative, and consistent with state law.
The facility must assess the needs of the resident 483.20 ● The facility must maintain all resident’s assessments completed ● The facility must conduct initially, and periodically, a within the previous 15 months in the resident’s active record and comprehensive, accurate, standardized, reproducible assessment of use the results of the assessments to develop, review and revise the each resident’s functional capacity. resident’s comprehensive plan of care. ● At the time the resident is admitted, the facility must have physician orders for the resident’s immediate care.
Nursing home surveys “I love working here when the state is here. We always have all the investigation on the later shift. Rarely do they inspect in the middle of staff we need.” the night or on weekends. – A nursing assistant during a three-day inspection. (Reed, 2009) A follow-up inspection is conducted when a facility has failed a The Nursing Home Reform Act requires facilities that accept Medicaid previous inspection and corrective action was required. The corrective and Medicare reimbursement payments to undergo regular inspections action indicates the need to rectify a failing grade or address a called surveys of the facility to ensure compliance with the laws set forth situation deemed potentially dangerous for residents. This inspection in the act. Each state has a designated agency in charge of inspecting the is conducted to determine whether the facility has appropriately facilities within its jurisdiction. The contact information for this agency identifi ed and completed the necessary action to bring the facility into must always be posted in the facility for all to see. The state agency compliance with all regulations. is responsible for conducting several types of surveys, with the most An inspection will also take place if a complaint is fi led with the common type being the annual survey. Other surveys are follow-up inspecting agency and it is determined that the complaint warrants inspections and inspections that are conducted in response to a complaint. additional inspection. Inspectors may perform an additional inspection The annual survey takes place within 12 to 18 months (although it is to investigate specifi c allegations of: called “annual”). This type of inspection is typically performed during ● Abuse. the same time frame each year, usually on a weekday. Inspectors ● Neglect. occasionally stay into the evening shift so they can conduct part of the ● Mistreatment. ● General complaints of poor care.
SocialWork.EliteCME.com Page 32 Complaints may be made by residents, family members, staff or way. In order to verify such allegations, the agency will conduct an anyone with knowledge or suspicion that a facility is not in compliance investigation, which may include an additional inspection. with regulations that results in potentially placing residents in harm’s
The annual survey process
For this inspection, the facility administrator knows in advance when legal requirement during the inspection, a defi ciency is issued. Each the inspection will take place and so is able to prepare. Before their defi ciency is broken into two parts (GAO, 2005): arrival, the surveyors have gathered necessary information about their 1. Severity. subject. They review previous survey results to determine whether the 2. Scope. facility has any pattern of citations and review any complaints reported A defi ciency is categorized as one of four possible levels of severity: to the state ombudsman’s offi ce. ● Level 1 defi ciency – Potential for minimal harm. This is the lowest Once the surveyors arrive at the facility, they conduct an entrance grade with the potential to cause harm. conference. The team of inspectors, usually three to fi ve people, meets ● Level 2 defi ciency – Potential for more than minimal harm. with the administrator and begins the inspection. Inspectors request ● Level 3 defi ciency – Actual harm noted and cited. information from the administrator and review written policies and ● Level 4 defi ciency – Immediate jeopardy. This is the highest level procedures, mealtimes and staffi ng information. of severity and requires the implementation of an emergency plan of correction to avoid eminent danger to residents. The surveyors assign themselves to the areas of the facility that require inspection: The scope of the defi ciency refers to the number of residents affected ● They check for cleanliness, including the kitchen and dining areas. by the defi ciency and is reported using the following terms: ● They observe and speak to residents. ● Isolated. ● They observe an entire medication pass to ensure compliance with ● Pattern. physician orders and federal regulations. ● Widespread. ● They inspect the building for compliance with building codes. A defi ciency may affect as few as one or two residents or it can be ● They observe eating and feeding practices. widespread, affecting every resident in the facility. ● They monitor wound care techniques and procedures. The fi nal part of the inspection process is the exit conference. The At the end of the inspection, they will analyze all of the information administrator and other members of management meet with the they have collected. If any of the areas of the facility failed to meet the inspectors at the conclusion of the fi nal day of the inspection. During this meeting, the defi ciencies issued against the facility are disclosed.
Interpretation of the annual survey results
The results of all Centers for Medicare and Medicaid Services (CMS)- ● High-risk residents with pressure sores. mandated nursing home inspections are available at http://www.medicare. ● Low-risk patients with pressure sores. gov. Copies of the inspection results can also be obtained directly from the ● Long-stay residents who are physically restrained. state survey agency or from the nursing home facility administrator. ● Long-stay residents who are depressed or anxious. ● Low-risk, long-stay residents who lose control of bowel or bladder. The annual survey results include staffi ng data divided into three ● Long-stay residents who have had a catheter inserted or left in categories: ● The amount of nursing time the facility provides each resident their bladder. ● Long-stay residents who spend most of the day in their chair or bed. each day. ● The comparison of the facility’s average nursing time per resident ● Long-stay residents whose ability to move about in and around per day and the state average. their room has decreased. ● The comparison of the facility’s average and the national average. ● Long-stay residents with urinary tract infections. ● Long-stay residents who have lost weight. Reed noted that some researchers conclude this data is misleading ● Short-stay residents given fl u and pneumococcal vaccinations. because it does not indicate whether the nursing care is exclusive to the ● Short-stay residents with delirium. resident. The facility nursing time is determined by dividing the number ● Short-stay residents with moderate to severe pain. of nursing hours in the facility by the number of residents in the facility. ● Short-stay patients with pressure sores. A nurse who spends much of his time in an offi ce but delivers some The next part of the inspection report reviews the results of the nursing care may be factored into this equation. Inappropriately adding standard health inspection and compares the average number of these eight hours of nursing care results in a misleading fi gure. defi ciencies in the facility to the averages for the state and the national Another issue to be considered is the level of care provided in the level. This section also lists the dates of any complaint investigations facility that is not considered in the calculation of nursing time per and any mistreatment defi ciencies and includes: resident in the three categories. In a facility that accepts skilled-care ● The type of mistreatment and corrections the facility failed to residents, researchers note that most of the nursing hours are dedicated complete. to treating skilled-care residents because they are more dependent and ● The severity of harm from Level 1 to Level 4. require a more intense level of care than the long-term-care residents. ● The scope of the mistreatment, which is measured by the After nurse staffi ng time calculations, the annual inspection includes number of residents in terms of isolated (few), pattern (some), or a comparison of 19 quality control measures of the facility with state widespread (many). and national averages. The next section of the inspection report reviews defi ciencies related to These quality measures include the following percentage areas: fi re safety: ● Long-term residents given fl u and pneumococcal vaccinations. ● Inspections of the walls and doors. ● Number of residents who require help with daily activities. ● Vertical opening defi ciencies, such as stairways and vertical shafts. ● Residents who have moderate to severe pain. ● Hazardous area defi ciencies.
Page 33 SocialWork.EliteCME.com ● Emergency plan and fi re drill defi ciencies. ● Mistreatment. ● Fire alarm system defi ciencies. ● Quality care. ● Automatic sprinkler defi ciencies. ● Resident assessment. ● Results of the severity of harm from Level 1 to Level 4. ● Resident rights. ● Scope of residents affected. ● Nutrition and dietary. ● Pharmacy service. Finally, the inspection report ends with the number of defi ciencies ● Environmental. for the previous three annual inspections for the facility. Each of the ● Administration. annual reports from the past three years are compared in the following defi ciency categories: ● Number of complaints between inspections.
After the inspection: Sanctions and enforcement study by the Government Accountability Offi ce (GAO) 2000-2005
A comprehensive nationwide study was conducted to review The GAO noted that ensuring the quality and safety of nursing home care federal enforcement efforts and sanctions to address nursing home has been a focus of considerable congressional attention since 1998. With defi ciencies. Four states with the highest level of defi ciencies the Omnibus Budget Reconciliation Act of 1987 (OBRA87), Congress and sanctions were identifi ed and studied to determine whether focused on the requirements of quality care provided in the nursing home. the sanctions resulted in a decrease in defi ciencies and thus an OBRA87 also established the range of available sanctions. improvement in the quality of elder care. CMS contracts with the state survey agencies to assess whether The states reviewed were Texas, Michigan, Pennsylvania and homes meet federal quality requirements through inspections, known California. The study was conducted by the Government Accountability as standard surveys, and complaint investigations as discussed in Offi ce (GAO), which is the audit, evaluation and investigative previous sections. Registered nurses, social workers, dieticians and other arm of Congress. It was developed to support Congress in meeting specialists are normally included on the state survey teams. Defi ciencies constitutional responsibilities and to help improve the performance identifi ed during the surveys are classifi ed in 1-12 categories according and accountability of the government. The study was conducted to to the scope, based on the number of residents potentially and actually determine whether sanctions were effective in encouraging nursing affected, and the level of severity. The A-level defi ciency is the least homes to maintain compliance with federal quality requirements. The serious, and an L-level defi ciency is the most serious and considered GAO study analyzed sanctions from 2000-2005 against 63 nursing to be widespread throughout the nursing home. Throughout the GAO homes previously reviewed and assessed by the Centers for Medicare study, the term “serious defi ciency” is used to refer to care problems that and Medicaid Service’s (CMS) overall management of enforcement. were at the level of actual harm or immediate jeopardy. When the state The 63 homes had a history of harming residents and were located surveyors identify a B-level or higher, the home is required to prepare a in four states. Those states account for about 22 percent of homes plan of correction, and the surveyor will conduct a repeat visit to ensure nationwide and were located throughout the country. the plan has been implemented and the defi ciency has been corrected. Below is the breakdown of severity and scope as outlined by the CMS.
Scope and severity of defi ciencies identifi ed in nursing home surveys
Severity Scope affect the home’s revenue and provide fi nancial incentives to correct Isolated Pattern Widespread defi ciencies and maintain compliance. Two sanctions, CMPs and DPNAs, represented 80 percent of federal sanctions between the years Immediate jeopardy* J K L of 2000 to 2005. The following list outlines the different types of Actual harm G H I sanctions and their descriptions (Table 1). Potential for more than DE F From 2000 to 2005, about 54 percent of the sanctions were CMPs, minimal harm which range from $50 to $10,000 per day for each day the home is out Potential for minimal harm** A B C of compliance. If the CMP cannot be collected, Medicaid/Medicare * Actual or potential for death/serious injury. payments are withheld. ** The facility is considered to be in substantial compliance. Although nursing homes can be terminated, which can result in the Homes with A, B and C level defi ciencies are considered to be in home’s closing, it is used infrequently. When a home is terminated, it substantial compliance with the federal regulations required for loses all Medicaid/Medicare income, which accounted for 40 percent of quality. D level or higher defi ciencies are considered to be out of nursing home payments in 2004. If termination occurs, residents must be compliance or noncompliant. The noncompliance period begins when moved to other facilities. A terminated home can apply for reinstatement the survey inspection rating notes noncompliance and continues until if it corrects defi ciencies. Termination is required if the home fails to the nursing home either achieves the required compliance rating by correct immediate jeopardy defi ciencies within 23 days, or within six correcting the defi ciency or when the home is terminated from the months if the home fails to correct nonimmediate jeopardy defi ciencies. Medicaid or Medicare agency. According to CMS, substandard quality of care exists when a home is Since 1998, the defi ciencies cited during the surveys have been cited for a defi ciency at the F, H, I, J, K, or L level in any of the three summarized on CMS’s Nursing Home Compare website (see last following areas: section), and CMS has added data on the results of complaint ● Quality of care – Defi ciencies such as inadequate treatment or investigations. In addition to federal sanctions, states also impose prevention of pressure sores. sanctions under their state licensing or certifi cation agencies, and those ● Quality of life – Defi ciencies such as failure to accommodate the are located on the individual state department of health websites. needs and preferences of residents. CMS and the states use a variety of federal sanctions to help encourage ● Resident behavior – Defi ciencies such as failure to protect nursing homes to meet compliance with quality requirements. These residents from abuse. range from less severe sanctions, such as indicating specifi c actions needed for correction within a specifi c time frame, to sanctions that
SocialWork.EliteCME.com Page 34 Table 1: Sanctions and Descriptions
Sanction Description Civil Monetary Penalties fund. The home pays a fi ne for each day or incidence of CMP noncompliance. Denial of payment for new admissions. Medicaid/Medicare payments for all DPNA newly admitted residents may be denied.* The home is required to provide training to staff on the specifi c noncompliance Directed in-service training issue. The home must take action within a specifi c time frame to plan corrections Direct plan of correction developed by CMS, the state or a temporary manager. An on-site monitor is placed in the home to help ensure that the home achieves State monitoring and maintains compliance. The nursing home accepts a substitute manager appointed by the state with the Temporary management authority to hire, terminate and reassign staff, obligate funds and alter nursing home procedures. Termination Loss of Medicare/Medicaid funds for benefi ciaries residing in the nursing home. * CMS may also deny payment for all Medicare- or Medicare-covered residents, but seldom does so because it would severely limit the home’s revenues for patient care.
Enforcement of nursing home quality of care is a shared federal-state correct defi ciencies but only temporarily, and were found to be out of responsibility. In general, sanctions are: compliance in subsequent inspections. 1. Initially proposed by the state agency based on a cited defi ciency. A number of factors seemed to decrease the effectiveness of sanctions 2. Reviewed and imposed by CMS regional offi ces. implemented against the nursing homes studied: 3. Implemented by the same CMS regional offi ce. ● Civil money penalties were often imposed at the lower end of the 4. State inspectors make follow-up visits. allowable dollar range, with the median CMP ranging from $350 5. The CMS regional offi ce implements the sanctions if defi ciencies to $500, signifi cantly lower than the maximum of $3,000 per day. are not corrected. ● CMS favored the use of sanctions that gave homes more time to 6. In the case of an appeal, an informal dispute resolution at the state correct the defi ciencies; therefore, fewer sanctions were imposed. level may occur or there may be a hearing before an administrative ● There was no record of a sanction for about 22 percent of the law judge as well as before the Department of Health and Human nursing homes reviewed that met CMS’s criteria for immediate Services Appeals Board. sanctions, which was identifi ed as a problem by GAO in 2003. The GAO study addressed the issue of the effectiveness of federal ● 60 percent of the DPNAs imposed as immediate sanctions were not enforcement as a deterrent to repeated harm committed by nursing implemented until one to two months after the defi ciency was cited. homes on their residents. ● Involuntary termination of homes was rare because of concerns over locating nearby homes and resident trauma over the transfer. The number of sanctions did decrease for the 63 nursing homes studied Only two of the 63 homes were terminated over quality problems. over the fi ve-year period, which is consistent with nationwide trends. ● CMS’s management of enforcement was hindered by the The decline may refl ect improved quality or changes in enforcement complicated immediate sanctions policy and by inconsistent and policy, or may mask weaknesses in the inspection process, which the incomplete data collection. This might explain why the 63 homes GAO has reported on since 1998. Although the number of sanctions reviewed only had 69 cases of immediate sanctions despite 444 declined, the homes generally were cited for more defi ciencies that citations for defi ciencies that harmed residents. caused harm to more residents than other homes in their state. Almost ● Although CMS developed a new enforcement policy six years 50 percent of the nursing homes studied continued to cycle in and out ago, it is still plagued by a fragmented and incomplete system of compliance; 19 homes did so four times or more. These homes did for national reporting. Many researchers, as noted in previous sections, repeatedly reference this.
GAO recommendations
The GAO recommends that the CMS administrator: noted that state offi cials often use state rather than federal sanctions 1. Develop an administrative process for collecting civil money for G-level or higher defi ciencies because the state penalty amount that penalties in a timely and effective manner. may be imposed may be greater than the amount of the federal CMPs 2. Strengthen its immediate sanctions policy so that issues that cause that may be imposed (Horn, 2007). harm to residents can be addressed quickly and uniformly to Michigan recommended that termination compliance deadlines of less provide assistance to remedy quality-care issues expediently. than six months be implemented for all specialized, high-end care facilities 3. Expand its oversight of homes with a history of harming patients. and facilities that had recently completed an enforcement cycle and failed 4. Improve the effectiveness of its enforcement data systems. to maintain compliance. State offi cials noted that decreased time frames Beyond the recommendations of the GAO to improve the enforcement provide a clear incentive for the early correction of defi ciencies. of sanctions to improve the quality of nursing home care, the four Under Michigan’s state enforcement, offi cials noted that facilities states cited in the study made signifi cant reforms of their own. that continue to harm residents or to provide substandard care receive Texas initiated language as a result of the report that included a state more severe enforcement commensurate with their compliance history, maximum penalty amount that could be assessed per violation, per day repeat citations and scope and severity of the citations in the current at $20,000, exceeding the federal amount of $10,000 per day. It was survey. In addition to the “double D” determination that mandates
Page 35 SocialWork.EliteCME.com remedies, a survey that results in two or more harm levels will result Finally, they noted one facility cited in the Michigan study had 95 in a CMP recommendation. If the facility had a CPM imposed during D-level defi ciencies and cycled out of compliance seven times in the preceding 24 months or two standard survey cycles, the next CPM the fi ve-year period of 2000-2005. Because the number of citations imposed will be at least as high as the previous CPM. exceeds the state average, it was to be given a special review to This progressive sanction approach works to stop the cycle of homes determine whether it should be terminated without further opportunity adopting temporary compliance and works to increase quality to avoid to correct because of poor surveys in 2006 (Dankert, 2007). increasing sanctions. Some of Michigan’s “voluntary terminations” California addressed its data communications as recommended in the were situations in the facility that warranted severe sanctions. The GAO study and implemented a monitoring alert function. ASPEN progressive sanctions served to remove the poorly performing home (automated survey processing environment) enforcement manager because the owner made the decision to voluntarily terminate before (AEM) was not functional or available to California until January facing serious sanctions or closure. 2007. State offi cials point out that the workload to copy, e-mail or send survey documents overnight is now diminished, and expedited reviews and recommendations can now occur (Billingsley, 2007).
Legal representation
Residents should have one of the following types of representation in The resident has the right to revoke the authority of the agent by effect while in the nursing home: notifying the agent or the treating physician, hospital or other health ● POA (power of attorney) care provider orally or in writing of the revocation. The agent has the A document created by a mentally competent individual to appoint right to examine the resident’s medical records and to consent to their another person to handle his or her affairs. disclosure unless the resident has limited this right in the document. ● DPOA (durable power of attorney) Unless otherwise specifi ed in the document, the agent has the power A document created by a mentally competent individual to appoint after the resident dies to: another person to handle his or her affairs. This document retains ● Authorize an autopsy. its agency power even if the mentally competent individual who ● Donate the resident’s body or parts thereof for transplant or issued the authority becomes incompetent. therapeutic, educational or scientifi c purposes. Sandell and Hudson (2000) in their book “Ending Elder Abuse,” ● Direct the disposition of the resident’s remains. describe the details of this important document. The person ○ The document revokes any prior power of attorney for health designated by the resident as agent will make health care decisions care. Particular attention should be given to the witnessing and must be trusted to act consistently with the resident’s desires procedure described at the end of the document because the as stated in the document. Except as otherwise specifi ed in the document will not be valid unless the witnessing procedure document, the document gives the agent the power to consent to is done correctly. It is important that the resident understands the physician not to give treatment or to stop treatment necessary everything in the document and asks for an explanation from to keep the resident alive. an attorney if anything is unclear. ○ The agent may need access to the document immediately in case The document gives the resident the right to make medical and of an emergency that requires a decision concerning health care. other health care decisions for themselves so long as they can The document should be kept where it is immediately available give informed consent with respect to the particular decision. In to the agent and alternative agents, and all parties should be addition, no treatment may be given over the resident’s objection given executed copies of the document. The physician also may at the time, and health care necessary to keep the resident alive be given an executed copy of the document. may not be stopped or withheld if the resident objects at the time. ● MPOA (medical power of attorney) The document gives the agent authority to consent, to refuse to A document created by a mentally competent individual to appoint consent, or to withdraw consent to any care, treatment, service another person to make health care decisions on his or her behalf or procedure to maintain, diagnose or treat a physical or mental in the event that the mentally competent person becomes incapable condition. The power of the document is subject to any statement of making those decisions for himself or herself. of the resident’s desire and any limitations that the resident ● Guardian includes in the document. The resident may state in the document An individual appointed by the court to act on behalf of a resident any types of treatment he or she does not want. In addition, the who is incapable of managing his or her fi nancial or medical court can take away the power of the agent to make health care affairs. The guardian can be a lawyer, a nurse, a social worker, a decisions for the resident if the agent: family member or a friend. ○ Authorizes anything illegal. ○ Acts contrary to the resident’s known desires. A social worker and/or an eldercare attorney can assist the elder resident ○ If the resident’s desires are not known, does anything clearly and/or family to determine which type of representation is appropriate. contrary to the resident’s best interests.
Conclusion
The implementation of the Nursing Home Reform Act laws improved society and a culture of respect for our older adults. It will require that nursing home care in many areas, but 24 years later, the quality everyone becomes educated about aging to establish the resources of nursing home care remains far from satisfactory. Rights and needed to provide quality care for aging Americans. regulations for quality care are often not adhered to because the “It is not enough for a great nation merely to have added new years facilities do not always have adequate resources and staff to provide to life. Our objective must always be to add new life to those years.” the level of care the law requires. – John F. Kennedy, 1963 A common thread among elder advocates and researchers is that the prevention of elder abuse will require eradication of ageism in our
SocialWork.EliteCME.com Page 36 More information
The following list of organizations has publications and information National Association of Home Care available: Website: www.nahc.org National Council on Aging National Family Caregivers Association Website: www.ncoa.org Website: www.nfcacares.org The National Center on Elder Abuse National Aging Information Resource Center Website: www.elder abusecenter.org Website :www.aoa.gov/NAIC/Notes/caregiverresourcehtml National Center for the Prevention of Elder Abuse National Association of Professional Geriatric Website: www.preventelderabuse.org Care Managers National Health Information Center Website: www.caremanagers.org Dept. of Health and Human Services National Association of Elder Law Attorneys Website: www.health.gov/ncih Website: www.naela.com Family Caregiver Alliance National Caucus and Center on Black Aged Website: www.caregiver.org Website: www.ncba.org Federal Administration on Aging Nation Senior Citizens Law Center Website: www.aoa.dhhs.gov Website: www.nsclc.org Visiting Nurses Association of America National Citizen’s Coalition for Nursing Home Reform Website: www.vnaa.com Website: www.nccnhr.org National Parkinson’s Foundation American Association of Homes and Services for the Aging Website: www.parkison.org Website: www.aahsa.org Alzheimer’s Association American Association of Retired Persons (AARP) Website: www.alz.org Website: www.aarp.org Children of Aging Parents The Offi ce of Geriatric Medicine/Gerontology Website: www.caps4caregivers.org Email: brp@[email protected] National Hispanic Council on Aging The Eldercare Locator Telephone: 800-677-1116 9 a.m. to 11 pm (EST)
References
Administration on Aging. National Ombudsman Reporting System Data Tables. Frolik, A. & Whitton, S. (2010), Everyday Law For Seniors, Boulder, CO: Paradigm (2003), Retrieved from http://www.elderabusecenter.org. Press. Administration on Aging (2011) Statistics on Aging. Retrieved from http://www.aoa. Gallup Poll (1995) Retrieved from http://www.Gallup.com org. October 21, 2011. Hetzel, L. & Smith, A (2001) Recognizing and Reducing Elderly Abuse in Long Alecxih, L. M. (1997) Demographics and Service Need Projections for the Aging Term Care Facilities. Bonnie, R.J. & Wallace, R.E., (Ed.), Elder Mistreatment: Abuse, Population. Retrieved from http://www.academyhealth.org.October, 21, 2012. Neglect, and Exploitation in an Aging America. Retrieved from http://www.nap.edu/ Alecxih, L.M., Corea, J., Gross, D.J., Gibson, M.J., Caplin, C.F., Brangan, N. Out catalog/10406.html. of Pocket Health Spending by Medicare Benefi ciaries Age 65 and Older: 1997 Himes, C.L., Hogan, D.P., Eggebeen, D.J. (1996) Living Arrangements of Minority Projections. Washington D.C. American Association of Retired Persons. Elders. Journal of Gerontology: Social Sciences.S1B:42-48. Almost Home (2006) http://www.pbs.org. Retrieved October, 21, 2011. Horn, A. (2007)Comments from the Texas Department on Aging and Disability. Billingsley, K. (2007) Comments from the State of California Health and Human GAO-07-241 Report on Nursing Home Enforcement. Services Agency Department of Health Services. In GOA-07-241Report on Nursing Jogerst, Gerald J. (2003) Domestic Elder Abuse and the Law. American Journal of Home Enforcement. Public Health.93.12:2131-2136. Blencker, M., Bloom., M., Weber, R. (1974) Benjamin Rose Institute Study. Jones, J., Dougherty, J.D., Scheelbie, D., & Cunningham, W. (1998)Emergency Room Cleveland, OH. Protocol for the Diagnosis and Evaluation of Geriatric Abuse. Annals of Emergency Bonnie, R. J. & Wallace, R.E. (2003)Elderly Mistreatment, Abuse, Neglect, and Medicine, 17, 1006-1015. Exploitation in Aging America: A Panel to Review Risk and Prevalence of Elder Kennedy, J.F. (1963) Quote In Sandell, D.S., & Hudson, L. Ending Elder Abuse. Ft. Abuse and Neglect, National Research Council, National Academy of Sciences. Bragg, CA: Cypress House. Retrieved from September 30, 2011.htpp://www.nap.edu/catalog/10406.html. Lachs, M.S., & Pillemer, K. (2004) Elder Abuse, The Lancet, 364, 1192-1263. Brookmeyer, R. (1998) Forecasting the Global Burden of Alzheimer’s. Retrieved Lichtenstein, B. & Gildehaus, L. (2006) Nursing Home Reform. Retrieved from from http://www.works.bepress.com/rbrookmeyer/doctype.html. http://www.ITVS.org: October 20, 2012. Burgess, A. Hanrahan, N. (2006) Identifying Forensic Markers in Elder Sexual Abuse Lindbloom, E., Brandt, C .Hawes, C. Phillips, D. Zimmerman, J., Robinson, B., & Final Report. National Institute of Justice, 255, 1-7. McFeeley, P. (2005) The Role of Forensic Science in Identifi cation of Mistreatment Caregiver Stress and Elder Abuse (2002) htpp://www.elderabusecenter.org. Retrieved Deaths in Long-Term Care Facilities, Retrieved October 1, 2011, from http://www. October 21, 2011. ncjrs.gov/pdffi les1/ NIJ/grants/209334.pdf. Dankert, M. (2007) Comments from the Michigan Department of Community Health. Matthews, J. L., (2003). Choosing the Right Long Term Care, Berkeley, CA : Nolo. In GAO -7-241 Nursing Home Enforcement. McNamee, C.C. & Murphy, M.B. (2006) Elder Abuse in the United States. Journal of Daschle, T. (2008), What Can We Do About The Health Care Crisis, New York, NY: the National Institute of Justice, 255, 1-7. St Martin’s Press. Mosqueda, L., Burnight, K., Liao, S. (2006) Bruising in the Geriatric Population, fi nal Dyer, C.B., Connolly, M. T., & Mc Feeley, P. (2003) The Clinical and Medical of report submitted to the National Institute of Justice, Washington, DC: Retrieved from Forensics of Elder Abuse and Neglect. In Bonnie, R.J. & Wallace, R., (Ed.) Elder http:// www.ncjrs.gov/pdffi les1/nij/grants/2146499.pdf. Mistreatment: Abuse, Neglect,, and Exploitation in an Aging America (344-360). National Center on Elder Abuse. (2003) A Response to the Abuse of Elder Adults: The Washington, D.C. National Academies Press. 2000 Survey of Adult Protective Services. Retrieved from http://www.ncea@nasua. Eberhardt, M.S., Ingram, D.D., Makuc, D.M., (2001) Urban and Rural Chartbook. org.October1, 2011. National Center for Health Statistics. Retrieved from http://www.nap.edu/ National Center on Elder Abuse. (2005) Elder Abuse Prevalence and Incidence. catalog/10406.htlm. Retrieved from http://[email protected]. October 5, 2011. Efforts to Strengthen Federal Enforcement Have Not Deterred Some Homes National Ombudsman Reporting Systems Data Tables (2003) Washington, D.C.:U.S. from Repeatedly Harming Residents (2007) http://www.gao.gov/cgi-bin/ Administration on Aging. getrpt?GAO-07-241. Retrieved October 21, 2012
Page 37 SocialWork.EliteCME.com NBC Nightly News (2011) October, 27, 2011.Obama Administration Approves Partial Rice, D.P., Fillit, H.M., Max, W., Kropman, D.S., Lloy, J.R., & Duttagupta, S. (2001) Cuts to California Medicaid. Prevalence Costs, and Treatment of Alzheimer’s disease and Related Dementia. Nelson, T.D. (1984) Ageism in Stereotyping and Prejudice Against Older Adults American Journal of Managed Care.7 (8)809-818. (Ed.). Cambridge, MA:MIT Press. Sandell, D. & Hudson, L.(2000) Ending Elder Abuse, Fort Bragg, CA: Cypress House Nursing Home Reform Act (1987) Code of Federal Regulations, Title 42- Public Steigerwalt, K. ( 2007) Resources 4 Nursing Home Abuse. Retrieved October 21, Health, 483, Requirements for States and Long –Term-Care Facilities. 2011, from http://www.legalchatonline.com. Pepper, C. & Okar, M.R. (1981) Elder Abuse: An Examination of a Hidden Problem. Stone, R.L (2000) Long-Term Care for Elders with Disabilities. Retrieved from http:// Report Issued to the Select Committee on Aging U.S. Congress. Comm. Pub No.97- www.milbank.org/0008stone/ 277. Washington, D.C.: U.S. Government Printing Offi ce. United States Offi ce of Health and Human Services (2011) Retrieved from http:// Pillemer, K. & Finkelhor, D. (1998)The Prevalence of Elder Abuse. The www.hhs.gov. Gerontologist, 28, 51-57. United States Social Security Administration (2011) Retrieved from http://www.ssa.gov. Platt, A. M. (1969) The Child Savers. Chicago, IL. University of Chicago Press. Volderheide, B. (2008) Action Agenda For Nursing Home Reform In Kentucky. Population Projections of the United States by Age, Sex, Race, Hispanic Origin, and Retrieved October, 21, 2012, from http://www.kynursinghomereform.org. Nativity: 1999-2100. Retrieved from http://ftp.census.gov/population/projections/ Wasik, J.F. (2000) The Fleecing of America’s Elderly. Consumer’s Digest. March/ nation /detail/np-d5-cd.txt. April. Quigley, T. (2004) Suspicions of Cullen Arose in 1993. The Express Times, May 30, Whitton, L.S., (2007) Durable Powers as an Alternative to Guardianship: Lessons We 2004. Retrieved from http://www.nij.gov/journals/255/elder_abuse. html have Learned. Stetson Law Review, 37, 7. Reed, D. (2009). An Insider’s Guide to Better Nursing Home Care, Amherst, NY: Wolf, R.S. (1986). Major Findings From the Three Model Projects on Elder Abuse. In Prometheus Books. Pillemer, K.A. & Wolfe, R.S., (ED.) Elder Confl ict in the Family. (218-238). Dover, MA, Auburn House
ELDERLY ABUSE IN AMERICA: PREVALENCE, ETIOLOGY AND PREVENTION Final Examination Questions Select the best answer for each question and then proceed to SocialWork.EliteCME.com to complete your fi nal examination.
6. There is no “gold standard” test for abuse and neglect to identify 9. Under the Nursing Home Reform Act of 1987, a facility can refuse elder abuse. a request for staffi ng data from the public. a. True. a. True. b. False. b. False.
7. The best estimate of for elder mistreatment is the between 1 10. Resident’s rights do not include the right to prompt efforts by the million and 2 million Americans age 65 and older have been facility to resolve grievances the resident has with respect to the injured, exploited or mistreated by someone they depended on for behavior of other residents. care or protection. a. True. a. True. b. False. b. False.
8. Neglect in care facilities is not considered abuse. a. True. b. False.
SWCA05EA14
SocialWork.EliteCME.com Page 38 CHAPTER 3: Ethics in Social Work and Counseling and HIPAA Privacy Rules
6 CE Hours
By Deborah Converse, MA, NBCT with Kathryn Brohl, MA, LMFT
Learning objectives
Describe fi ve primary purposes of the codes of ethics for mental Identify four factors in an ethical decision-making model. health practitioners. Explain the impact of technology and a protocol for ethical use in Explain the fi ve professional values and related principles that mental health practice. inform ethics for social work practitioners. Identify fi ve ethical guidelines to follow when fi ling, managing Recognize and discuss problematic nonprofessional behavior that and storing client data covered by HIPAA. could lead to ethics violations. Describe confi dentiality and privileged communication as it affects Describe ethical best practices that mental health practitioners use ethical practice. each day to avoid unethical or illegal behaviors. Describe two current issues that involve the ethical decision- Identify issues of multicultural diversity in mental health practice. making process in counseling. List examples of informed consent as applied to clients, supervisees and other professionals.
Introduction
Those who pay attention will often see ethics violations reported in laws are enforced by government defi nitions of the minimum standards the media. Teachers, politicians, coaches, physicians, nurses, college acceptable to society. presidents and clergy, all professionals in their fi eld, are a few who To guide professional counselors and social workers, their professional have made national headlines recently. Ethics violations occur in all organizations have developed guidelines in the form of a code of professions, making the study of ethics a critical issue for all professionals. ethics. Recent revisions to these codes of ethics will be discussed. Today, professionals in the fi eld of mental health face many complex The Standards for Privacy of Individual Identifi able Health Information, ethical considerations. Managed care requires practitioners to consider (the Privacy Rule) establishes a set of national standards for the protection issues of confi dentiality, informed consent and multiple relationships with of health information. The U.S. Department of Health and Human clients in a constantly changing culture with many diverse populations. Services (HHS) issued the Privacy Rule to implement the requirement of In an increasingly litigious society, strict adherence to a code of ethics the Health Insurance Portability and Accountability Act of 1996 (HIPAA). by all mental health professionals and their staffs is essential. The Privacy Rule standards address the use and disclosure of individuals’ Ethics refers to the beliefs individuals hold about what is “right.” health information by organizations subject to the rule (HHS, 1996). Ethical conduct refers to the behaviors exhibited by the counselor The major goal of the Privacy Rule is to assure that health information and social worker. Good ethical conduct is grounded in sound moral is properly protected, while allowing the fl ow of information to principles, understanding the ethical codes, and having the desire to do promote quality health care and protect the public health. what is right. Morality informs proper ethical conduct and involves an The HIPAA Privacy Rule and the codes of ethics for mental health evaluation of behavior based on standard expectations often infl uenced practitioners compliment each other, as both were developed to ensure by culture and religion. privacy, confi dentiality and the well-being of individuals and society. Laws and ethical codes regulate the practice of social workers and counselors. Professional organizations do not enforce the law; instead,
Historical perspectives
Standards of practice and the idea of accountability can be traced back choice as one that falls between two extremes. For example, Aristotle to ancient Egypt around 2000 BC as found in the code of Hammurabi believed that trust is a virtue that lies between suspicion and foolish (American College of physicians, 1984), which contained a description faith (Stanford, 2010). of physician responsibilities and the consequences and punishments if After World War II, the American Psychological Association (APA) the patient’s health did not improve. saw the need to develop a code of ethics because of a change in the Later, around 400 BC, the Hippocratic oath was an early example of type of professional activity requested of their members. Psychologists a code of ethics to guide the practice of medical professionals and were called upon to address the mental health needs of many highlighted obligations to their profession, practice and patients. This soldiers returning home from the war and responsible for developing oath contains many of the same values and ethical principles that we psychological assessments that would be used to determine eligibility see today in current codes of ethics (Sinclair et al., 1996). for the draft. A committee was formed to identify ethical issues that The writings of Aristotle concluded that ethics provide guidelines for would be effective in guiding psychologists’ practice as well as their virtuous action. In his rule the “Gold Mean,” Aristotle defi ned ethical behavior. It covered such concepts as the psychologists’ responsibilities
Page 39 SocialWork.EliteCME.com when treating clients, their relationships with their clients, students and from confi dentiality between therapist and client (Epstein, Steingarten, colleagues and ethical research practices (Hobbs, 1948). Weinstein and Nashel, 1977). They proposed the ideas that the Through the years, the APA and other mental health organizations therapeutic relationship must be based on confi dence and trust so clients developed codes of ethics and subsequent revisions to address changes are willing to openly and honestly communicate emotions, fears, in society and the needs of their clients. perceptions and actions. The complex, sensitive and serious nature of the information that is shared may be painful or shameful for the individual. One shared belief among social workers and counselors is that If the client believes that this information will be kept confi dential, there professionals will do the right thing or make the right decision in the is a greater possibility of developing an effective relationship with the best interest of the client. therapist and therefore a positive outcome for the client. Trust appears to be the common thread throughout ethical counseling Over the last decade, ethical issues faced by counselors have received and social work practice. Tremble and Fisher (2006) note that it is not an increased attention in counseling literature (Corey, Corey, and Callahan, external force that directs ethical practice; instead the focus is on internal 2003). Counselors are often faced with situations that require sound resources such as trust and respect as a foundation for the counselor/ ethical decision-making. Determining the appropriate course of action to client relationship. Ridley (2001) provides an ethical decision-making take when faced with a diffi cult ethical dilemma can be a challenge. model based on trust and respect in an effective counseling relationship which is referred to as “goodness of fi t.” The counselor/client Codes of ethics were developed by professional associations to provide relationship affects ethical decision-making that considers the cultural guidelines for practice by counselors and mental health professionals. context of the relationship as applied to general ethical principles. These codes are designed to protect the professional practitioner, client and public. In their practice, counselors constantly encounter ethical Confi dentiality is essential in developing an effective relationship issues and dilemmas that require decisions and should be not only between mental health practitioners and clients. Some researchers have familiar with ethics codes for their organization but also should know noted that therapy may not be effective at all without the trust that comes the areas and issues that are problematic for counselors.
Overview
Ethical professional behavior includes (Meara, Schmidt and Day, 1996): ● Realizing the importance of intuition, integrity, honest self- ● Understanding and implementing ethical codes. evaluation and ethical decision-making models. ● Always doing what is best for the client. ● Placing client welfare as paramount in all ethical decisions. ● Practicing the four core virtues: prudence, integrity, respectfulness and benevolence.
Moral principals
Kitchener (1984) identifi ed fi ve moral principles that are viewed as ● Benefi cence – The counselors’ responsibility to contribute to the foundations of components that make up ethical decision-making. The welfare of the client by preventing harm by being proactive and guiding moral principles described by Kitchener and adopted by other attempting to benefi t the client. researchers include the following: ● Justice – The principle of providing equal treatment for all clients. ● Autonomy – The concept of freedom of choice for the client is ● Fidelity – Honoring commitments. Counselors must guard clients’ stressed. Counselors encourage the client to make decisions that trust and therefore not threaten the therapeutic relationship. are consistent with their values and to think and act in autonomous Ethics in counseling focuses on the ideal rather than the obligatory rules ways. The counselor must consider whether the client is capable of and emphasizes the character of professionals and their relationships making sound choices. If the client is incapable of making sound with clients rather than on solving a specifi c ethical or legal dilemma. choices, the counselor will help the client as much as possible. Although ethics codes speak to many issues, counselors must recognize ● Non-malfeasance – The concept of “do no harm.” Though this that these codes are broad and do not cover all ethical issues faced language has been recently revised, it refl ects the concept of not by counselors. Professionals’ ethical awareness and problem-solving infl icting pain on others and refraining from actions that risk harm skills will determine how they translate these general guidelines into to others. professional day-to-day behavior. Welfel (2002) concludes that “ethical codes are not cookbooks for all ethical problems, and in fact, the codes are silent on many ethical issues.”
Client focus
Counselors need to be aware that their focus must be on putting the and defenses, and how this may affect the client. Professionals have a client’s needs before their own. Counselors must understand their responsibility to work actively toward expanding self-awareness and own needs, areas of unfi nished business, potential personal confl icts recognizing areas of bias, prejudice and vulnerability.
Right of informed consent
Informed consent is an ethical and legal requirement and is an integral of clients in their counseling plan. By educating clients about their part of both therapeutic processes. Providing clients with information rights and responsibilities, the counselor builds empowerment and a they need to make informed choices promotes the active cooperation trusting relationship.
Confi dentiality
Cullar (2001) conducted a study in which clients were questioned relationship. The survey revealed that the two most critical were “a to determine what was most important to them in a therapeutic feeling of safety and security” and “the chance to talk to the therapist
SocialWork.EliteCME.com Page 40 in a safe environment without fear of repercussion.” Aspects of Confi dentiality is the foundation of the professional-client relationship informed consent and confi dentiality included in the in HIPAA Privacy and is consistent with the mission to serve as an advocate for the Rule will be discussed later in this course. client and the greater society. Confi dentiality as it is addressed in Today the social stigma surrounding mental illness and seeking therapy ethics codes and case study examples of violations of confi dentiality, has decreased – but those perceptions still exist in some areas. In the will be presented here. The Tarasoff vs. University of California case 1996 decision by the U.S. Supreme Court in Jaffe v. Redmond (1996, and the legal action that resulted led to the revisions in the American p.8), the court said, “Disclosure of confi dential communications made Counseling Association (ACA) Code of Ethics in 2005. during counseling sessions may cause embarrassment or disgrace,” and Some research found that only 1 percent to 5 percent of complaints “the mere possibility of disclosure may impede development of the registered with ethics committees and state licensing boards of confi dential relationship necessary for successful treatment.” counselors and psychologists involved confi dentiality violations Confi dentiality is also based on our society’s belief that individuals (Pope and Vasquez, 1998). However, a national study that interviewed have a right to privacy and the right to decide what information they psychologists reported that 69 percent revealed they had violated will share and with whom. Confi dentiality is an ethical principle, client confi dentially unintentionally, and clients may not have known which holds the practitioner responsible for respecting the client’s (Tabachnik, & Keith-Spiegel, 1987). privacy and protecting information disclosed during therapy. Both the Today, codes of ethics and the HIPAA Privacy Rule must address code of ethics and the HIPAA Privacy Rule provide explicit, detailed the use of new technology to prevent unintentional and intentional provisions that cover client consent for disclosure of information and breaches of confi dentiality that may occur in managing therapy notes which entities can receive information. Privileged communication and patient fi les electronically. resulting from a therapy session is a legal concept that protects clients from having confi dential information disclosed without their consent.
Multicultural issues
A major focus of the ACA Code of Ethics revision of 2005 was The counseling theory or methodology must provide a valid multicultural diversity competency. Cultural bias is an ethical dilemma explanation for the origin and maintenance of the behavior to inform facing many counselors today. Our culture infl uences our lives and the counseling process. The racial or cultural identity of both the defi nes reality for us in many ways. A culturally centered approach counselor and the client infl uences how problems are defi ned and recognizes that culture is central, not marginal, to effective counseling infl uences counseling goals and methods. Counselors must expand relationships. Cultural issues have given rise to a variety of counseling their repertoire of helping responses to be effective in a variety of styles that are complex and ever changing. cultural contexts. An ethical dilemma in multicultural diversity may begin with the Problems may also arise when making a diagnosis in a multicultural diffi culties with assessment because appropriate evaluation tools may context when using the Diagnostic and Statistical Manual of Mental not be available. It is diffi cult, if not impossible, to locate a culture- Disorders (DSM-IV). There are many cultural beliefs and experiences fair or culture-free test for all specifi c cultural contexts. The counselor that are normal for the client’s culture, but viewed from a “western” must be trained to interpret data from tests in ways appropriate to the perspective, may seem pathological (Pedersen, 2007). client’s cultural context (Paniagua, 2001).
Revised ethical codes
The American Counseling Association (ACA) developed a independence of all people within their social and cultural contexts. professional code of ethics that has been adopted by licensing boards All of these associations have ethics codes that apply to their scientifi c, in 22 states that use the code as the basis in counseling decision- educational, and professional roles. They share common terms and making on ethical issues. defi nitions and are based on the foundational premise that the client’s A major revision of the ACA Code of Ethics was completed in October welfare always has the highest priority. 2005 and contains signifi cant changes that will impact professional These codes clarify the ethical responsibilities of the practitioner and counselors across all settings and specialties. The code contains new identify relevant considerations when professional obligations confl ict ethical directives in the areas of confi dentiality, dual relationships, or ethical uncertainties arise. The code for each organization includes multiculturalism and diversity, technology, end-of-life care, and the information in the following areas: selection of counseling interventions. ● The client relationship. ● Communication and privacy, and confi dentiality. Revisions in the ACA code also include obligations for protecting ● Professional responsibility. the confi dentiality of a deceased client, ethical use of technology in ● Evaluation, assessment and interpretation. the practice of counseling, permission to refrain from making a new ● Training, teaching and supervision. diagnosis and mandates for selecting new or innovative interventions, ● Research and publication. and the importance of always consulting professional colleagues in the ● Relationships and ethical responsibilities to colleagues and other ethical decision-making practice. professionals. A review of the Code of Ethics for the American Mental Health ● Ethical responsibilities to society. Counseling Association (AMHCA), American Counseling Association ● Resolving ethical issues, complaints or inquiries. (ACA), the American Psychological Association (APA), American This course will review and discuss key elements of the codes of Association of Marriage and Family Therapists (AAMFT), and the ethics for social work and counseling and the application of an National Association of Social Workers (NASW) reveals similarities in ethical decision making process. It is not a comprehensive guide to the values, principals and standards that guide their professions. compliance or a source of legal information or advice. All have the mission to enhance human development and well-being, recognize diversity and promote the worth, dignity, potential and
Page 41 SocialWork.EliteCME.com Terms and defi nitions
Counseling and social work organizations, including ACA, NASW, views on biological, psychosocial, historical, psychological and APA, AAMFT and AMHCA, have terms and defi nitions in common, other factors. and these are seen throughout their ethics codes. Some of the most ● Diversity – The similarities and differences that occur within and commonly used terms and their defi nitions are: across cultures, and the intersection of cultural and social identities. ● Advocacy – Promotion of the well-being of individuals, groups ● Documents – Any written, digital, auditory, visual or artistic and the profession within systems in organizations. Advocacy recording of the work within the counseling relationship between seeks to remove barriers and obstacles that inhibit access, growth counselor and client. and development. ● Multicultural/diversity competence – A capacity whereby ● Assent – To demonstrate agreement when a person is otherwise practitioners possess cultural and diversity awareness and knowledge not capable or competent to give formal consent or informed about self and others, and how this awareness and knowledge is consent to a plan of service. applied effectively in practice with clients and client groups. ● Client – An individual or group of individuals seeking services or ● Psychosocial – Involves aspects of social and psychological referred for professional services to help with problem resolution behavior and development. Related to the infl uences of life or decision-making. experiences combined with cognitive and behavioral processes. ● Competency – Only services that are within the boundaries of ● Student – An individual engaged in formal educational social workers’ and counselors’ education, training, license and preparation to be a counselor or social worker. certifi cation shall be offered. ● Supervisee – A professional counselor or counselor in training ● Culture – Membership in a socially constructed way of living that who is being supervised by a qualifi ed professional in a formal incorporates collective values, beliefs, norms, boundaries and the supervisory relationship. lifestyles that are co-created with others who share similar world
Code of Ethics of the National Association of Social Workers
The NASW approved a Code of Ethics in 1996 at its Delegate ● Identify relevant considerations when professional obligations Assembly, and the same group revised it in 2008. The Code is based confl ict or issues concerning ethics occur. on a set of core values that are the foundations for the principals and ● Provide ethical standards to which the general public can hold the standards of the profession. The core values are: social work profession accountable. ● Service. ● Articulate standards that the social work profession can use to ● Social justice. assess whether unethical conduct has occurred. ● Dignity and worth of the person. ● Introduce new practitioners to the mission, values, ethical ● Importance of human relationships. principles and ethical standards. ● Integrity. The NASW Code of Ethics is used by individuals, agencies, ● Competence. organizations, licensing and regulatory boards, professional liability The NASW Code of Ethics proposed these values, principles and insurance providers, courts of law, agency boards of directors, standards to guide social workers’ conduct. The code is relevant to all government agencies and other professional groups that choose to social workers and social work students regardless of the type of work, adopt it as a frame of reference. setting or population they serve. No code of ethics can ensure ethical behavior or resolve all ethical issues The NASW Code of Ethics was developed to: and disputes. The NASW code refl ects the commitment of all social ● Identify core values on which social work is based. workers to uphold professional values and to act ethically. Principles and ● Summarize broad ethical principals that refl ect the profession’s standards must be applied by individuals, who identify moral questions core values and establish a set of specifi c ethical standards that and must make reliable ethical judgments (NASW, 2011). guide the social work practice.
Ethical principles
The following principles are based on the six core values identifi ed respect, aware of individual differences and cultural and ethical by the NASW and set forth ideals to which all social workers should diversity. They promote clients’ social responsibility and self- aspire and are the foundation of the NASW Code of Ethics: determination to change and address their own needs. ● Value: Service. ● Value: Importance of human relationships. Principle: Social workers’ primary goal is to help people in Principle: Social workers recognize the central importance need and address social problems. Social workers elevate service of human relationships. Social workers seek to strengthen to others over self-interest. Social workers are encouraged relationships among people in a purposeful effort to promote, to volunteer their professional skills with no expectation of restore, maintain and enhance the well-being of individuals, signifi cant fi nancial return (pro bono). families, social groups, organizations and communities. ● Value: Social justice. ● Value: Integrity. Principle: Social workers pursue social change on the behalf of Principle: Social workers behave in a trustworthy manner. Social vulnerable oppressed individuals and groups of people. Efforts workers act honestly and responsibly to promote ethical practices of social change may be focused on poverty, unemployment, on behalf of their organization. discrimination and other forms of social injustice. Social workers ● Value: Competence. promote sensitivity and knowledge about oppression and cultural Principal: Social workers practice within their areas of and ethnic diversity. competence and enhance their professional expertise. Social ● Value: Dignity and worth of the person. workers strive to increase their professional knowledge and skills Principle: Social workers respect the inherent dignity and worth to apply them in practice. They should aspire to contribute to the of the person. Social workers treat each person with care and knowledge base of the profession.
SocialWork.EliteCME.com Page 42 Ethical standards Ethical standards concern social workers’ ethical responsibilities to ● Competence. their clients, colleagues, the profession as a student or professional, ● Multicultural diversity. and to the broader society. ● Confl ict of interest. ● Disputes, referrals, termination of service. These standards cover the following general areas. Contact the NASW for ● Records. the code of ethics for each section below and procedures for enforcement. ● Supervision. Section 1: Ethical responsibilities to clients. ● Unethical conduct. Section 2: Ethical responsibilities to colleagues. ● Evaluation and research. Section 3: Ethical responsibilities in practice settings. ● Education and training. Section 4: Ethical responsibilities as professionals. ● Administration. Section 5: Ethical responsibility to the social work profession. ● Continuing education and staff development. Section 6: Ethical responsibility to the broader society. ● Labor management disputes. Each of the six sections includes extensive and specifi c details that ● Social welfare. cover such topics as: ● Public emergencies. ● Privacy and confi dentiality. ● Social and political action. ● Informed consent.
Counselor Code of Ethics The American Counseling Association (ACA) Code of Ethics was approved settings and serve multiple capacities. Members are dedicated to the by the ACA governing council in 2005. Every section of the code was enhancement of human development and serve individuals of all ages. revised during the three-year process. Since it was fi rst adopted in 1963, Association members recognize diversity and embrace a cross-cultural the ACA Code has been revised every seven to 10 years. It is currently approach in support of the worth, dignity, potential and uniqueness of under revision, and a revised code is planned for publication in 2014. people within their social and cultural context. The American Mental Health Counseling Association (AMHCA) Professional values represent the ethical commitment of the counseling governing board revised its Code of Ethics in 2010.The mission of profession and are the foundation for principles that guide professional both counseling associations is to enhance the quality of life in society behavior and the counseling practice. The practice of the counselor by promoting the development of professional counselors, advancing is developed out of personal dedication rather than mandatory the counseling profession, and using the practice of counseling to requirements of an external organization or legal system. promote respect for human dignity and diversity. The codes of ethics for the two counseling associations mirror each The ACA and AMHCA serve as educational, scientifi c and other and in purpose and content and will be summarized. professional organizations whose members work in a variety of
Purpose The ACA Code of Ethics and AMHCA Code of Ethics outline the The ethics code sections above contain specifi c details covering the following purposes: following topics: 1. The code enables the association to clarify to current and future ● Informed consent. members and to those served by the members the nature of the ● Professional competence. ethical responsibilities held by all counselors. ● Cultural sensitivity/diversity. 2. The code supports the mission of the association. ● Advocacy. 3. The code establishes principles that defi ne ethical behavior and ● Group work. best practices for counselors. ● End-of-life care. 4. The code serves as an ethical guide to help counselors construct ● Fees and bartering. a professional course of action that best serves the client and best ● Termination and transfer. promotes the values of the counseling profession. ● Technology services. 5. The code serves as a basis for processing ethical complaints and ● Privacy and confi dentiality. inquiries initiated against members in the counseling profession. ● Shared information. ● Records. The complete ACA Code of Ethics and the AMHCA Code of Ethics ● Parents and guardians. must be reviewed to study the specifi c guidelines for each section: ● Counseling relationship. ● Research and publication. ● Confi dentiality, privileged communication and privacy. ● Continuing education. ● Professional responsibility. ● Assessment and evaluation. ● Relationships with other professionals. ● Supervision and training. ● Evaluation, assessment and interpretation. ● Standards and the law. ● Supervision, training and teaching. ● Research and publications. ● Resolving ethical issues.
American Nurses Association: Code of Ethics for Nurses The following summary is from the American Nurses Association ● Nurses in all professional relationships have respect for the uniqueness Code of Ethics for Nurses with Interpretive Statements, published in of every individual, regardless of social or economic status. 2001. Please refer to this document for specifi cs of the code. ● Nurses’ primary commitment is to the patient, regardless of the setting for treatment of their health problems.
Page 43 SocialWork.EliteCME.com ● The nurse always advocates for the health and safety of the patient. ● The nurse participates in the advancement of the profession. ● The nurse is responsible and accountable for nursing practice to ● The nurse collaborates with other health professionals to meet provide optimal patient care. health needs throughout the community. ● Nurses are responsible to maintain competence and personal and ● Those in the profession of nursing are responsible for articulating professional growth. nursing values to maintain integrity of the profession, its practice ● The nurse strives to maintain and improve health care and for shaping social policy. environments and conditions conducive to quality care.
Public education code of ethics
Most states and local school systems throughout the states have a code ● Responsibilities to students. of ethics for teachers and counselors. The American School Counselor ● Confi dentiality academic, career/college, post-secondary and Association (ASCA) is a professional organization whose members personal/social counseling plans. are school counselors, certifi ed or licensed in school counseling with ● Appropriate referrals. unique qualifi cations and skills to address all students’ academic, ● Danger to self or others. personal, social and career development needs. ● Student records. ● Evaluation, assessment and interpretation. In their role as school counselors, they are advocates, leaders, ● Technology. collaborators and consultants who work to ensure equity in access ● Student peer support. and success in educational programs. In all situations, the educational ● Responsibilities to parents/guardians. professionals must align their programs with the mission of the school ● Parental rights and responsibilities. and school district. As with other codes of ethics, the ASCA Ethical ● Responsibilities to colleagues. Standards were developed to: ● Specify the principles of ethical behavior. ● Sharing information. ● Maintain high standards. ● Collaborating and educating as the counselor. ● Clarify the nature of ethical responsibilities. ● Responsibilities to school communities and families. ● Serve as a guide for ethical practice. ● Responsibilities to self. ● Provide self appraisal and peer evaluation. ● Multicultural and social justice advocacy. ● Inform others, including students, parents, guardians, teachers, ● Responsibilities to the profession. ● Supervision of school counseling candidates. administrators, community members and courts of justice, of the ● Maintenance of standards. best ethical practices in the profession of school counseling. ● Resulting ethical confl icts. The following major sections are included in the ethical standards for school counselors. Specifi c details for each section are included in the document last revised by ASCA in 2010. The sections are:
An ethical decision-making model
Ethical decision-making is a process and involves the informed professional codes of ethics is an eight-step model (Corey, Corey, and judgment of the social worker or counselor. There are many situations Callahan (2004). The eight steps are: in which simple answers are not available for ethical issues. The 1. Identify the problem or dilemma. practitioner should consider how the issues would be judged in a peer 2. Identify the potential issues. review process where the ethical standards would be applied. 3. Look at relevant codes of ethics for general guidance. In all cases, practitioners must review all values, principles and ethical 4. Consider applicable laws and regulations, and determine how they standards that are relevant to the situation. They must have thorough may have bearing on an ethical dilemma. knowledge of the code of ethics for their organization or employer. 5. Seek consultation from more than one source to gain multiple perspectives on the dilemma. When codes do not contain information on a particular issue, the 6. Brainstorm various courses of action. practitioner is still responsible for making correct ethical decisions. If 7. Enumerate consequences of various decisions. practitioners are faced with ethical dilemmas that are diffi cult to resolve, 8. Implement the course of action. they are expected to engage in a carefully considered ethical decision- making process. Reasonable differences of opinion can and do exist School counselors must become familiar with an ethical decision- among individual counselors or social workers about values, ethical making model such as Solutions to Ethical Problems in Schools principles and ethical standards to be applied when they confl ict. (STEPS) (Stone, 2001). This model follows nine steps to help the school counselor work through solutions to ethical problems in Because there is no specifi c ethical decision-making model that is schools. It includes the following steps: most effective, professionals are expected to be familiar with credible ● Defi ne the problem emotionally and intellectually. models of decision-making that involve the professional team and ● Apply the code of ethics for the school system and any school law will stand public scrutiny. In the absence of a clear answer in the that applies. particular ethics code or confl icts arise among the team concerning ● Consider the student’s chronological and developmental level. interpretation, they must implement an ethical decision-making model. ● Consider the setting, parental rights and minors’ rights. Through an ethical decision-making process and evaluation of the ● Apply the moral principles. context of the situation, counselors are empowered to make decisions ● Determine potential courses of action and their consequences. that help expand the capacity of people to grow and develop. ● Evaluate the selected action. Cottone and Claus (2000) described nine decision-making models. ● Consult with other professionals and administrators within the These models are grounded in Kitchener’s fi ve ethical principles. school system. The model that is used most frequently and complements most of the ● Implement the course of action.
SocialWork.EliteCME.com Page 44 The implementation of the decision-making model provides a means simple tests to the course of action selected to be sure it is appropriate. by which the counselor can implement a standard of care in making The three tests are: ethical decisions (Grant, 2010). 1. Justice – In this test, you assess your own sense of fairness and It is important to realize that different professionals may implement whether you would treat other people the same way in this situation. different courses of action in the same situation. There is rarely one 2. Publicity – Ask yourself if you want your ethical decision or right answer to complex ethical dilemmas, but if practitioners follow a course of action to be reported by the press. systematic model, they will be able to give a professional explanation 3. Universality – Could you recommend the same decision and for the course of action they choose. course of action to another counselor in the same situation? The decision-making model presents a format for balancing risks and If the course of action or decision seems to present new ethical issues, benefi ts of a course of action. In accordance with professional codes of then the counselor will go back to the beginning and re-evaluate each conduct, the models provide a means for counselors to consult with others step of the process. The course of action or decision may be incorrect, or and refl ect on the process, which minimizes the likelihood of an arbitrary the problem, situation or context may have been identifi ed incorrectly. decision. The model will help counselors select an action that includes the If the counselor can answer in the affi rmative to Sadler’s three tests rights, responsibilities and welfare of the client (Corey, et al, 2004). questions above and is satisfi ed with course of action they selected, he After a counselor or team has selected a course of action, the plan or she is ready to move to implementation. should be reviewed to see whether it presents any new ethical After implementation the counselor would follow up to assess whether considerations. Stadler (1986) suggests a counselor should apply three the course of action had the anticipated effect and consequences.
Evaluating ethical practice
Van Hoose and Paradise (1979) suggest practitioners are probably ● Can justify their actions as the best judgment of what should be acting in an ethically responsible way with a client if they: done based on the current state of the profession. ● Maintain personal and professional honesty. ● Can demonstrate and document their competency in their area or ● Clearly have the best interest of the client as a priority. practice. ● Act without malice or personal gain. ● Employ a sound decision-making model. ● Consult with other professionals in the fi eld. ● Follow their code of ethics.
Current ethical issues
Many counselors have consulted ACA staff and leaders about ethics same-sex attractions and behaviors as abnormal and unnatural, and in the practice of conversion therapy. The ACA ethics committee therefore in need of “curing.” shared its formal interpretation of specifi c sections of the Code of The belief that same-sex attraction and behavior is abnormal and in Ethics concerning the practice of conversion therapy and the ethics need of treatment is in opposition to the position taken by national of referring clients for this practice in (Whitman, Glosoff, Kocet mental health organizations, including ACA, APA and the AMHCA. &Tarvydas, 2011). The ACA Governing Council resolution of 1998 specifi cally notes Ethics case study 1: Reparative/conversion therapy that the ACA opposes the portrayals of lesbian, gay and bisexual During the third session of counseling, a client reports that he is gay and individuals as mentally ill due to their sexual orientation. states, “I want to change my way of life and not be gay anymore. It’s not In addition, the resolution supports dissemination of accurate information just that I don’t want to act on my sexual attraction to men. I don’t want about sexual orientation, mental health and appropriate interventions and to be attracted to them at all except as friends. I want to change my life instructs counselors to report research accurately and in a manner that so I can get married to a woman and have children with her.” minimizes the possibility that results may be misleading. At the suggestion of a friend, the client had read about reparative/ In 1999, the ACA Governing Council adopted a statement “opposing conversion therapy and has researched this approach on the Internet is the promotion of reparative therapy as a cure for individuals who convinced this is the route he wants to take. are homosexual.” In fact, in 1973, the American Psychological Thee counselor listens carefully to what the client has to say, Association Diagnostic and Statistical Manual (DSM–IV-TR) stated asks appropriate questions and engages in a clinically appropriate that homosexuality is not a mental disorder in need of being changed discussion. The counselor informs the client that although she is (APA, 2011). happy to continue working with him, she does not believe reparative/ The ACA found the majority of the studies on this topic have conversion therapy is effective and tells him she can fi nd no scientifi c been expository in nature with no scientifi c evidence published in evidence or support for the approach. She will not offer that as a psychological peer-reviewed journals that state the effectiveness treatment, and the client says he is disappointed that the counselor will of conversion therapy. They did not fi nd any longitudinal studies not honor his wishes. conducted to follow the outcomes of those individuals who have He then asks for a referral to another counselor or therapist who will engaged in this type of treatment. They did conclude that research help him to change his sexual orientation. The ethical question is published in peer-reviewed counseling journals indicates that whether the counselor should make a referral for conversion therapy. conversion therapy may harm clients. Interpretation Ethical questions The ACA Ethics Committee considered many factors and derived a These fi ndings bring several questions to the forefront: consensus opinion that addresses several sections of the Code of Ethics ● Is a counseling professional who offers conversion therapy and moral principles of practice presented in this scenario. practicing ethically? ● Since ACA has taken the position that it does not endorse Members started with the basic goal of reparative/conversion therapy, reparative therapy as a viable treatment option, is it ethical to refer which is to change an individual’s sexual orientation from homosexual a client to someone who does engage in conversion therapy? to heterosexual. Counselors who conduct this type of therapy view
Page 45 SocialWork.EliteCME.com ● If the client insists on obtaining a referral, what guidelines can a supervised experience, state and national professional credentials, and counselor follow? appropriate professional experience.” ● If professional counselors do engage in conversion therapy, what It continues, “Counselors practice in specialty areas new to them only must they include in their disclosure statements and informed after appropriate training, education, and supervised experience. While consent documents? developing skills in a new specialty area, the counselor takes steps Ethical decision to ensure the competence of their work and to protect others from ● ACA committee members agreed that it is of primary importance possible harm” (ACA, 2005). to respect the client’s autonomy to request a referral for services Any professional engaging in conversion therapy must have received not offered by counselor. appropriate training in such a treatment modality with the requisite ● If counselors determine an inability to be of professional assistance supervision. There is no professional training condoned by ACA, APA, to clients, they must avoid entering or continuing the counseling AMHCA or other prominent mental health associations that would relationship. prepare counselors to provide conversion therapy. ● Counselors are knowledgeable about culturally and clinically appropriate referral resources and suggest alternatives (ACA, The ACA Code requires counselors to “recognize history and social 2005). prejudices in the misdiagnosis and pathologizing of certain individuals ● The ACA Code reminds the counselor “to be respectful of and groups and the role of mental health professionals in perpetuating approaches to counseling services that differ from their own” these prejudices through diagnosis and treatment.” (ACA, 2005). Historically, mental health professions viewed homosexuality as ● “The primary responsibility of counselors is to respect the dignity a mental disorder. But with the revision by the APA, removing it and to promote the welfare of clients” (ACA, 2005). from the Diagnostic and Statistical Manual as a mental disorder, ● “Counselors act to avoid harming their clients, trainees, and professional communities of counseling, social work and psychology research participants and to minimize or to remedy unavoidable or no longer diagnose the client who has an attraction to people of the unanticipated harm” (ACA, 2005). same sex as mentally disordered. Referring a client to a counselor who engages in a treatment modality However, within some religious and cultural communities, same-sex not endorsed by the profession and that may in fact cause harm does attractions and behaviors are still viewed as pathological. not promote the welfare of clients and is opposition to the basic purpose of the code. Referring a client to someone who engages in conversion therapy communicates to the client that same-sex attraction and behaviors are The ACA Code clearly states that counselors “practice only within disordered and need to be changed. This contradicts the dictates of the the boundaries of their competence based on the education, training, 2005 ACA Code of Ethics and APA Diagnostic Manual, so the ethical decision in this case would be to refuse the referral request.
The use of technology
Today, computer networks are used to manage records concerning ● Always use privacy screens to shield monitors or other screens assessment and evaluation, treatment, billing and payment, and from view. communications between therapist and client. The use of these ● Protect the physical security of portable devices such as laptops, systems may lead to breaches in confi dentiality given the rising use small computers, personal digital devices and smartphones. of new technologies such as the computer, e-mail, faxes and cellular ● Update virus protection software and other security systems. phones. Technology in counseling settings requires special security ● Remove all information when disposing of computers or other considerations to avoid new risks for unintentional confi dentiality electronic devices because information may remain after erasing fi les. breaches. Gelman et al. (1996) advise that secure computer systems be ● Consult technology specialists when disposing of information developed that: electronically. ● Block unauthorized users from accessing information. Practitioners must always consult their organizations’ code of ● Provide ongoing security of data to prevent alteration or lost. ethics, which address the maintenance, dissemination and disposal ● Verify the source of information to confi rm authenticity. of confi dential records of professional and research work stored or ● Keep a record of communications to and from the system. communicated electronically. ● Recover quickly and effectively from anticipated disruptions. The following cases concern confi dentiality issues using modern Koocher and Keith–Spiegel (2008) suggest the following safeguards to technology as described by Koocher and Keith–Spiegel (2008). manage electronic records: ● Apply encryption software to protect data transmission. Ethics case study 2: Technology breach of confi dentiality ● Protect stored information with complex passwords. A therapist sent a third billing notice to a slow-to-pay client’s fax ● Apply Internet fi rewalls. machine in her offi ce. On that day, however, the client did not report ● Discuss security measures with professionals when storing fi les to work. The bill was titled “Psychological Services Rendered” and with the common server or backing them up on an institutional handwritten in large print was “Third Notice – Overdue!!” with the system. client’s name also on the cover. This notice sat in an open access mail ● Keep removable data storage media in secure places or use tray of the busy offi ce all day. complex passwords to encrypt them. Analysis: The therapist should have considered that many people ● Protect passwords, changing them frequently and never share would have access to a common fax machine in a business offi ce. passwords with others. Private material should not be faxed unless it is known that the ● Be knowledgeable about security measures when using wireless intended recipient will be there to immediately receive the information. devices. In fact, a message relating to billing or payment sent to a client’s offi ce ● Never reveal confi dential information in an e-mail or instant might violate debt collection laws as well as confi dentiality (Koocher messaging without encryption. and Keith-Spiegel, 2008).
SocialWork.EliteCME.com Page 46 Ethics case study 3: Technology breach of confi dentiality Ethics case study 5: Technology breach of confi dentiality A therapist updated numerous cases on her laptop computer while on A mental health practitioner received a faxed complaint release of a fl ight. As she completed a treatment summary on a client, she was information form from a counselor in another city. The form requested directed to turn off all electronic equipment and prepare for landing. information about one of the practitioner’s former clients. The She saved the fi le to a hard disk, backed it up on a removable drive, practitioner noticed an e-mail address indicated on the new counselor’s put the stick in the seat back pocket, and packed up her computer. letterhead to which he transmitted the requested fi les. During the At that moment, the plane hit some turbulence, which caused her e-mail transmission, the practitioner was interrupted by a phone call to become anxious and confused. She left the plane without the that resulted in him sending the confi dential material to the wrong removable drive and though she called the airline, the drive was not e-mail address – and 3,500 subscribers on the International Poodle recovered and the confi dential material was not retrieved. Fanciers list server received the confi dential client fi les. Analysis: The use of readily available encryption technology for Analysis: When sending information by e-mail, the practitioner must confi dential fi les would have protected the contents. always determine the security and accuracy of the recipient e-mail Ethics case study 4: Technology breach of confi dentiality address and carefully execute the transmission of confi dential material A therapist who managed an offi ce bought new desktop computers and by e-mail, fax or any electronic means. donated the old computers to a local community center. She deleted Ethical principles and codes and the HIPAA Privacy Rule remain all of the word processing and payment fi les before donating the in place even though technology is constantly changing. Therapists computers. are always responsible for protecting client privacy and information Analysis: Just deleting fi les on a hard drive will not permanently remove disclosed to them in confi dence. They must be especially careful when the information, so the confi dential fi les remained on the donated using electronic communication methods to protect client welfare. computers. In some cases, reformatting a drive may not prevent some Extra precautions must be taken to ensure confi dentiality of information from being recovered. Professional computer consultation information transmitted through the use of computers, electronic mail, must be considered when disposing of computer equipment containing fax machines, telephones, voice mail, answering machines, video and client data. The counselor must consider special confi dentiality issues audio recording devices, and other electronic or computer technology. when using modern technology. The use of encryption technology for confi dential fi les would have protected the contents also.
Dual relationships
When reviewing revised codes of ethics, considerable information multiple relationship, the practitioner must take immediate action relates to dual relationships that counselors may have with a client. and show evidence of attempting to remediate the harm. Gabbard (1994) discussed the need for maintaining boundaries, Kitchener and Harding (1990) identifi ed three risk factors that may which requires therapists to set aside their own needs in the service of result in harm to clients involved in multiple or dual relationships with addressing the patient’s needs. Mental health professionals must have their therapist: guidelines, often referred to as boundaries, that are designed to minimize ● The more incompatible the expectations in the roles within the the opportunity for therapists to use clients for their own gain. dual relationship, the greater the potential harm. These boundaries can identify a set of roles for those involved in ● The greater divergence of responsibilities and obligations the therapy process and serve as a “limit that promotes integrity” associated with the dual roles, the more potential for divided (Katherine, 1991). loyalties and loss of objectivity. ● The larger power and prestige differential between a therapist Boundaries serve to ensure the well-being of clients who disclose and client in a dual relationship culminates in greater potential confi dential information to their therapist. Dual relationships are for client exploitation because power is generally assigned to the sometimes referred to as multiple-role relationships, which occur when therapist in most societies. the counselor assumes two or more roles concurrently or sequentially that involve the client (Herlihy and Corey, 1997). Herlihy and Cory (1997) outlined four problematic and complicated characteristics of dual relationships: The dual relationship may include a second role that could be social, ● Dual relationships can be diffi cult to identify because they develop fi nancial or professional. The practitioner may also be a friend, in a subtle fashion without a clear danger sign alerting the therapist supervisor, teacher, associate or employer. that the behavior in question might lead to an unprofessional In all codes of ethics there are key elements in the guidelines relating relationship. to dual relationships as summarized below: ● The potential for harm broadly ranges from extremely pernicious ● A dual relationship exists when a mental health practitioner is to neutral or even benefi cial. Sexual dual relationships can be in a counseling relationship at the same time he or she is in a extremely harmful to the client, whereas attending a client’s relationship with the client. graduation may be benign or therapeutic. ● Guidelines also govern a promise or agreement to enter into ● Except for dual sexual relationships, there is little consensus another relationship in the future with the client or a person among mental health practitioners concerning the appropriateness associated with the client. of dual relationships. ● Mental health practitioners should not take on a dual role with the ● Some dual relationships cannot be avoided, such as those facing client if it would impair their assessment, objectivity, competence, clinicians living in rural areas and small towns where they are effectiveness, communication or confi dentiality as a therapist. more likely to have social and other relationships with clients. ● Mental health practitioners should not enter into a dual relationship Within an urban environment, political affi liations, ethnic identities, if the possibility exists that it could exploit or harm the client. pastoral counseling and substance abuse status can promote dual ● Mental health practitioners are responsible for establishing clear, relationships because clients may seek a therapist with similar values appropriate, sensitive and ethical boundaries before entering into (Lerman and Porter, 1990). any dual relationship with a client. ● If a mental health practitioner becomes aware that potential harm Borys and Pope (1989) surveyed 1,600 psychiatrists, 1,600 may occur or that unintentional harm has occurred because of a psychologists, and 1,600 social workers with a 49 percent return rate.
Page 47 SocialWork.EliteCME.com They examined a number of the beliefs and behaviors related to dual This would explain the number of revisions and the specifi city relationships, such as the practitioners’ gender, type of profession, in the detailed descriptions of dual relationships in mental health area of residence, marital status, experience, practice setting, practice organization’s current codes of ethics. The above section represents location, size of the community, therapeutic orientation, and clients’ only a brief view of complex dual relationships. Practitioners must ages. Their results found: carefully study their organization’s code of ethics in its entirety. ● There was not a signifi cant difference between the three Ethics case study 6: Dual relationships professions relative to sexual intimacy with clients before or A client worked as a records clerk for a community mental health after termination, nonsexual dual professional roles, social center and a therapist supervised her work. The client experienced involvements, or fi nancial involvements with clients. some personal problems that she asked the therapist to treat, and ● More therapists rated each dual relationship behavior as “never he agreed. The client ultimately fi led an ethics complaint against ethical” or “ethical under only some rare conditions” than a rating the therapist, charging that he blocked her promotion based on the of “ethical under most or all conditions.” evaluation of her as a client rather than an employee. ● Psychiatrists, as a whole, rated such dual relationships as less ethical than psychologists or social workers. Analysis: It is diffi cult to determine exact cause and effect in this situation, but the client can now interpret the cause of any work-related Herlihy and Corey (1997) developed a decision-making model for negative outcomes as related to the therapy. Dual relationships with therapists faced with a potential dual or multiple relationship. Their a client/employee can become problematic in many ways and can model gives following guidelines: produce career and economic hardships for the client. The therapist ● Determine whether the dual relationship is avoidable or violated ethical standards because of the clear and foreseeable risk of unavoidable. harm to the client (Koocher and Keith-Spiegel, 2008). ● If avoidable, the practitioner should explore potential problems and benefi ts with the client. Ethics case study 7: Dual relationships ● The practitioner must judge whether benefi ts outweigh the risk or A professional artist complained to an ethics committee that the vice versa by assessing issues that establish potential harm. therapist did not carry out her promises. The therapist had treated the ● The differences in the client’s expectations of the therapist in the artist for more than one year, during which the therapist complemented two roles must be examined. the client’s art work, attended art shows with him and promised to ● The therapist’s divergent responsibilities in the two roles must be introduce her art gallery contacts to the client. The client stated he determined. began to feel so self-confi dent that he terminated therapy and expected ● The power differential in the therapist and client relationship must the therapist’s interest in his career to continue. The therapist stopped be considered. returning the ex-client’s phone calls, which left the client frantic. ● If the practitioner’s assessment concludes that client risk of harm An ethics committee contacted the therapist, who explained that she is greater than the potential benefi ts, the counselor should not enter always provided unconditional positive regard to her clients, but since the dual relationship, and if necessary, refer the client to another this particular individual was no longer a client, she felt no further therapist. obligation to him. ● The client should be informed of the rationale for not participating Analysis: The ethics committee found in favor of the client. The in the dual relationship. therapist maintained a dual relationship by entwining their lives ● If the therapist feels that client benefi ts are substantial and the risk together, rendering confusion in the client. The therapist did not of harm is minimal or that the dual relationship is unavoidable, resolve the potential consequences of the dependency she established then the dual relationship can exist with the following safeguards: and maintained with the client Koocher and Keith-Spiegel, 2008). ○ Obtain the client’s informed consent and initiate the dual relationship. The practitioner and client should discuss Ethics Case Study 8: Dual relationships potential problems and possible methods of resolution. A therapist and her ex-client decided they would become friends ○ Seek ongoing consultation because the therapist can lose because the past therapeutic relationship was very harmonious. objectivity in managing a dual relationship’s potential for harm Unexpectedly, the ex-client perceived the therapist to be controlling to the client. and overbearing in the new relationship. She then questioned the ○ Maintain ongoing communication and monitoring with the therapist’s overall competence to the point of distancing herself from client about potential problems and potential resolutions. This the post-therapeutic friendship. The ex-client decided that the therapist step refl ects the dynamic and ongoing, rather than static, nature was incompetent, causing her to feel exploited and confused. She then of informed consent. consulted another therapist, who told her to press charges against the ○ Document the dual relationship and self-monitor throughout previous therapist. the process. If the dual relationship becomes a complaint Analysis: An ethics committee determined that incompetence could before a licensure board or court of law, those adjudicating the not be conclusively proven, but both the complainant and respondent complaint will expect an open reporting of all information. were surprised at the fi ndings on a dual role violation. ○ The practitioner is advised to document the dual relationship, The investigation uncovered that the therapist mistakenly planned their providing evidence of vigilance toward client risks, benefi ts developing relationship and its longer-term continuation while the and protection. client was still in active therapy. The therapist had actually presented ○ Obtain ongoing supervision, beyond simple consultation, these facts as a defense against the client’s accusations. during the dual relationship if risks are high, the relationship is complex, or if practitioners are concerned about maintaining This case shows how personas may change from one context to objectivity. another, and the change may be viewed as negative. The client responded well to the therapist’s authoritative personality in therapy Ethics violations related to dual relationship comprise the majority of but not socially. Also, ex-clients may choose to reenter therapy, and a ethics complaints and licensing board actions (Montgomery and Cupits, neutral relationship combined with the positive effects of continuing 1999; Neukrug, Milliken, and Walden, 2001). Lawsuits and the cost of transference is advised (Koocher and Keith-Spiegel, 2008). defending licensing board complaints led to increased liability insurance rates, which affect everyone in the mental health professions.
SocialWork.EliteCME.com Page 48 Bartering: A common boundary issue
Bartering with the client for goods or services is not ethically Establishing a friendship or social relationship when bartering prohibited but is not recommended as a customary practice. All codes with clients produces a confl ict of interest that impairs the required of ethics for mental health practitioners include major sections on objectivity necessary for professional judgment (Pope and Vasquez, regulations surrounding bartering. 1998.) The friendship dual relationship forms a new set of interests beyond those of the client, namely those of the therapist. For example, There is much disagreement among practitioners regarding whether a therapist may hesitate to raise a certain issue with the client who is bartering is ethical as evidenced by Gibson and Pope’s (1993) survey also a friend because of concerns about damaging the friendship. fi nding that 53 percent judged accepting services and 63 percent rated accepting goods instead of payment as ethical. Therapists generally enter Ethics case study 9: Bartering bartering arrangements with clients with the good intention of offering A counselor presented an unemployed landscaper the option of services to those with limited fi nances. However, potential problems exist. designing and redoing his yard in exchange for psychotherapy. The counselor charged $100 per hour and credited the client with $15 an Often, client services do not equal the monetary value, on an hourly hour, thus the client worked more than six hours for each therapy basis, to that of therapy (Kitchener and Harding 1990). Therefore clients session. The client protested to the therapist that the time required for fall further behind in the amount owed and may feel trapped or resentful. the yard work prevented him from securing full-time employment. The The quality of barter services might also become problematic as therapist countered that the client could choose to terminate therapy therapist or client may feel short-changed, resulting in resentment and and resume when he could pay the full fee. therapeutic damage. Analysis: The therapist calculated a below fair-market value for a The exchange of goods instead of payment may elicit the same quality profi cient landscape artist’s labor. The bartering contract is assumed to issues inherent in service exchange, and negotiating the equivalent have contributed to the client’s diffi culties. The therapist interrupted number of therapy sessions for the bartered goods can become an issue. the agreement and abandoned the client upon hearing the client’s The following list provides general guidelines that are summarized complain. The client sued the therapist for considerable damages and held in common from the various codes of ethics for mental health (Koocher and Keith-Speigel, 2008). practitioners: Most professional liability insurance policies exclude coverage ● Bartering arrangements create the potential for confl icts of interest pertaining to business relationships with clients (Canter et al., 1994; and inappropriate boundaries with clients. Bennett et al., 2007). Liability insurance carriers may construe ● Bartering should occur only in limited circumstances and if it is an bartering arrangements between mental health professionals and accepted practice in the community. clients as business relationships and therefore refuse to defend covered ● The mental health practitioner assumes the full burden of therapists if bartering complications arise. Koocher and Keith-Spiegel demonstrating that this arrangement will cause no harm to the client. (2008) believe that bartering arrangements have the propensity to ● Bartering arrangements should not put the mental health be problematic, actually or perceived as exploitive, unsatisfactory in practitioner at an unfair advantage. outcome to both parties, and should be used sparingly, if at all. ● Bartering agreements should be discussed and a clear written contract should be signed by the counselor and client.
Sexual dual relationships
One of the oldest ethical mandates in the health care profession is the the sections of their organization’s code of ethics that govern sexual prohibition of sexual intimacies with health seekers, and it predates contact with clients in their entirety. the Hippocratic Oath. The ethics codes of mental health professions, The following list contains information held in common among major however, did not address this behavior until research revealed its codes of ethics regarding regulations for sexual contact between prevalence and harm to clients (Pope and Vasquez, 1998). It is mental health practitioners and clients: estimated that 7 percent of male counselors and 1.6 percent of female ● Mental health practitioners do not engage in sexual intimacies with counselors reported sexual relationships with former or current clients current therapy clients. (Salisbury & Kinnier, 1996; Thoreson, Shaughnessy, & Frazier, 1995). ● Mental health practitioners do not engage in sexual contact with Holroyd and Brodsky (1997) discovered that 80 percent of former clients that according to the limits set in their organization’s psychologists who reported sexual contact also reported sexual code of contact. intimacy with more than one client. ● Sexual intimacy with former clients is likely to be harmful. ● Even after the appropriate time period allowed in the Approximately 90 percent of clients who experienced sexual professional’s code of conduct, the burden shifts to the therapist to intimacies with their therapist are damaged by the relationship demonstrate there has been no exploitation or injury to the client or (Bouhoutos, Holroyd, Lerman, Porter, & Greenberg, 1983). the client’s immediate family. Clients are likely to suffer reactions similar to victims of rape, spouse ● Whether such contact is consensual or forced, under no abuse, incest and post-traumatic stress disorder. Feelings of guilt, rage, circumstances will the counselor engage in sexual activities or isolation, confusion and impaired ability to trust often ensue. Other sexual contact with current clients. clients have symptoms of post-traumatic stress disorder, including ● Mental health practitioners should not engage in sexual activity attention and concentration issues, overwhelming emotional reactions with anyone associated directly with a client, such as friends, upon sexual involvement with the partner, nightmares and fl ashbacks. family members or colleagues. Such harm is currently well recognized, and there are no credible opinions The indecency of sexual conduct with clients is widely acknowledged, in the profession that defend therapist-client sexual relationships. and clients who sue for damages have an excellent chance of winning The codes of ethics for all mental health organizations include their lawsuits if allegations are true. established moratorium time frames and strict regulations concerning Jorgenson (1995) lists the broad array of causes of action that sexual contact with clients. Mental health practitioners must review victimized clients may allege in their civil lawsuits:
Page 49 SocialWork.EliteCME.com ● Malpractice. Clients who sue must prove the sexual relationship harmed them, but ● Negligent infl iction of emotional distress. harm is broadly defi ned as emotional, fi nancial or physical. ● Battery. Feeling sexually attracted to a client is not unethical, but acting on ● Intentional infl iction of emotional distress. the attraction is unethical. Upon feeling a sexual attraction to a client, ● Fraudulent misrepresentation. Remley and Herlihy (2007) recommend various measures, including: ● Breach of contract. ● Consulting with clients. ● Breach of warranty. ● Considering client welfare issues. ● Spousal loss of consortium. ● Obtaining supervision. Some state legislators have passed laws that automatically make ● Self-monitoring feelings. it negligent for certain categories of mental health professionals to ● Seeking counseling to help the practitioner resolve issues. engage in sexual relationships with their clients – which encourages ● Referring the clients to another therapist. victimized clients to sue.
Confi dentiality and duty to warn Anyone familiar with the previous 1995 ACA Code of Ethics will notice Interpretation the omission of “clear and imminent danger” and the substitution of Resulting court opinions form the basis for general acceptance of “serious and foreseeable harm” in the 2005 revisions. This was a direct the notion that treating professionals have a duty to protect known outcome from the legal case Tarasoff vs. the University of California. intended victims. This is important and relates to the general principles This case from 1969 concerned a counselor working with a client who of benefi cence, meaning “strive to benefi t,” and non-malfeasance, or confessed an intention to kill a partner (Grant, 2011). taking care to “do no harm.” Ethics case study 10: Duty to warn In Tarasoff v. Regents of the University of California it was ruled In this case study, a student named Prosenjit Poddar came from India, that if the patient poses a signifi cant risk of violence to another party, where he had been born into the Harijan “untouchable” caste. He the therapist “bears a duty to exercise reasonable care to protect the came to UC Berkeley as a graduate student in September 1967, and he foreseeable victim of the danger.” States differ in their requirements briefl y dated a fellow student named Tatiana Tarasoff. for identifying foreseeable danger or intended victims and the scope or degree of possible danger. These are important factors to be considered She was not interested in a serious, exclusive relationship, and during and acted upon to protect individuals and society. the summer of 1969, she went to South America. Poddar felt betrayed, became depressed and went to a psychologist for counseling at UC Ethical decisions Berkeley University’s Health Service Department. During counseling, Key points resulting from the Tarasoff case (Grant, 2011): ● A belief that therapists have special knowledge that, when coupled Poddar confi ded his intent to kill his former girlfriend to his counselor. with the “special relationship” of therapist and client, gave rise to The psychologist requested that the campus police detain the duty to protect in such cases. Poddar, writing that, in his opinion, Potter was suffering paranoid ● The Tarasoff case and the line of cases that followed do not stand schizophrenia, acute and severe. The psychologist recommended the for that proposition that psychotherapists have a duty to warn defendant be civilly committed as a dangerous person. unknown, intended victims. Instead they have a duty to protect the Poddar was detained, but then quickly released, because he appeared intended victim. rational. The psychologist’s supervisor then ordered that Poddar not be ● Counselors must keep current in methods and procedures to handle subject to further detention. violent clients and evaluate the level of danger. ● If a patient poses a signifi cant risk of violence to another party, the Poddar then befriended Tatiana’s brother and even moved in with therapist “bears a duty to exercise reasonable care to protect the him. In October, after Tatiana had returned, Poddar stopped seeing his foreseeable victim of danger.” psychologist. Neither Tatiana nor her parents received any warning of ● One standard by which the breach of confi dentiality and the the threat he had made as revealed to the counselor. Several months duty to warn will be judged is the standard of what a reasonable later, on October 27, 1969, Poddar carried out his plan, killing Tatiana professional in the community under the circumstances would do. Tarasoff by stabbing her with a kitchen knife. ● Counselors must be competent to work with clients with those Tatiana Tarasoff’s parents sued the psychologist and other employees diagnoses that may include violent behavior. of the university. Poddar’s original sentence was overturned, and he ● Thorough records are critical to document that the therapist was allowed to avoid a second trial by agreeing to return to India. understood the nature of the situation in relation to the client’s Some reports indicate he is married and living happily in India today. diagnosis. ● Counselors must take reasonable steps in light of the facts. Ethical questions ● Counselors should consult with colleagues if they unsure of how to This case brings several ethical questions to mind: proceed according to their code of ethics and the law of their state. ● Should the counselor have informed the police or Tarasoff or her ● A therapist is liable for a negative outcome if their actions fall family? below the expected level of care. ● Does the counselor have a duty to warn or to protect? ● What information concerning cultural contexts existed, and should Therapist liability either to the client for slander or defamation or to they have been reviewed? the person warned for intentional infl iction of emotional distress is ● Was the counselor competent to deal with the cultural aspects and extremely unlikely under the doctrine of “qualifi ed privilege” (Grant, the mental health diagnoses? 2011). Elements of this doctrine are: ● Was the counselor competent to deal with dangerous or violent ● Good faith. clients? ● Legitimate interest in their duty to “protect from harm” to be ● If confi dentiality is the cornerstone of patient-counselor furthered by statement or action. relationships, can the counselor violate this ethical standard if he is ● Statements limited in scope to that purpose. no longer seeing the client? ● Proper location and communication in a proper manner and to ● In what circumstances is breaching the sanctity of confi dentiality proper parties. necessary or allowed?
SocialWork.EliteCME.com Page 50 Subsequent cases
● Some cases have recognized the duty to warn all foreseeable ○ Have the parties participate in other partner notifi cation programs. victims, not just those clearly identifi ed. ● States differ in the breathe of requirements concerning the ● Legislative and regulatory bodies have attempted to clarify and identifi able victim versus the scope of the danger. As stated defi ne this duty across numerous states. throughout all codes of ethics, counselors must be familiar with ● In child abuse cases, parents must be notifi ed despite client their state statutes. confi dentiality rules. Other circumstances dictate the counselor MUST legally report ● All 50 states have mandatory reporting requirements for child abuse. information in the following cases as outlined by law: ● In cases of communicable diseases, HIV in the relevant case, ● Counselors believe a client under 16 is a victim of incest, rape or the counselor may attempt to diffuse the risks before making some other crime. an exception to the confi dentiality rule if the levels of risk or ● Counselors believe the client needs hospitalization to prevent harm foreseeable harm allow it. Examples would be to: to self or others. ○ Have the client present when the partner is notifi ed. ● When information is required as an issue in a court action. ○ Including this in part of the therapy. ● When clients request that their records be released to themselves ○ Have the partner or client voluntarily divulge. or to a third party (HIPAA, 1996).
Discussing confi dentiality laws with a minor or incapacitated client
Federal and state laws mandate reporting of suspected child abuse or According to the APA, psychologists should disclose confi dential neglect, and statutes require the protection of others who may not have information without the consent of the individual only as mandated by the ability to protect themselves, such as elderly individuals or those law or where permitted by law for a valid purpose such as to: who reside in institutions. ● Provide needed professional services. ● Obtain appropriate professional consultations. A report by Taylor and Alderman (1995) included a statement to ● Protect the client/patient, psychologist or others from harm. inform minor clients about the counselor’s obligations to report ● Obtain payment for services from a client/patient, in which information that may breach confi dentiality between the counselor disclosure is limited to the minimum necessary to achieve the and client. Taylor and Alderman provided an example of the type of purpose (APA, 2002). statement that could be used in this situation: “Most of what we talked about is private, but there are three kinds To have thorough knowledge about the above situations, the complete of problems that you might tell me about that we would have to APA Code of Ethics and HIPAA Privacy Rule must be studied. share with other people. If I fi nd out that someone has been hurting NASW (1999) highlights on duty to warn include: or abusing you, I would have to tell the police about it. If you tell ● Social workers should protect confi dentiality of all information me you plan to hurt yourself, I would have to let your parents obtained in the course of professional service, except for know. If you tell me you have made a plan to hurt someone else, I compelling professional reasons. would have to warn that person. I would not be able to keep these ● The general expectation that social workers will keep information problems just between you and me because the law says I can’t. Do confi dential does not apply when disclosure is necessary to prevent you understand that it is okay to talk about things here, but that serious, foreseeable, imminent harm to a client or identifi able person. these are things we must talk about with other people?” ● In all instances, a social worker should disclose the least amount of They further suggest adding a buffer statement along the lines of the confi dential information necessary to achieve the desired purpose. following: ● Only information that is directly relevant to the purpose for which “Most of what we talked about is private. If you want to talk about the disclosure is made should be revealed. any of the three problems that must be shared with others, we will This summary above is not compete information, and contains also talk about the best way for us to talk about the problem with concepts that cannot be fully understood without studying NASW others. I want to be sure I’m doing the best I can to help you.” Code of Ethics in its entirety. As previously outlined, the confi dentiality requirement does not The ACA (2005) general requirement that counselors keep information apply when imminent danger to the client or others exists. This duty confi dential does not apply when: to warn from the Tarasoff case in California has been added to many ● Disclosure is required to protect clients or identifi ed others from states’ laws across the nation. The laws on therapists’ obligation vary. serious and foreseeable harm. Variations across the states include: ● When legal requirements demand that confi dential information ● Language such as whether the therapist must warn of imminent must be revealed. danger or may warn of imminent danger. ● The counselor is in doubt as to the validity of the exception and ● Information about which individuals must be given a warning of must consult other professionals. imminent danger. ● Additional considerations apply when addressing end-of-life issues ● What circumstances warrant the therapist’s obligation to warn of (ACA, 2005). imminent danger. The statements above are addressed in detail in the ACA Code Therapists must know their state laws on their duty to warn, and if of Ethics, which must be studied in its entirety to understand the they are communicating across state lines in the course of therapy, they complexities of confi dentiality between the client and the counselor. must also be knowledgeable of the laws of that state or country. Case study 11: Duty to warn The requirement that counselors keep information confi dential as A PhD and MFT therapist had treated a client, who was a former defi ned in the code of ethics governing their organization must also policeman, for three years. Therapy centered on work-related injuries be reviewed in relation to state and federal laws, including HIPAA, and the breakup of a 17-year relationship with a woman who had governing disclosure. begun to date someone else.
Page 51 SocialWork.EliteCME.com On June 21, 2001, the client allegedly told the therapist that he was A judge dismissed the case against the therapist, who asserted that his having suicidal thoughts. The therapist recommended hospitalization, client did not disclose a threat to the new boyfriend directly to him. and he asked for permission to speak with the client’s father. The Ultimately, the California Court of Appeals reinstated the case, father told the therapist that his son was deeply depressed, had lost explaining, “When the communication of a serious threat of physical his desire to live, and contemplated harming the new man his former harm is received by a therapist from the patient’s immediate family, partner was dating. and is shared for the purpose of facilitating and furthering the patient’s The client checked himself into the hospital as a voluntary patient on treatment, the fact that the family member is not technically the the evening of June 21, 2001. ‘patient’ is not crucial.” The court expressed that psychotherapy does The therapist received a phone call from the client’s father the not occur in a vacuum, and that for therapy to be effective, therapists next morning, who said the hospital would soon release his son. must be aware of the context of a client’s history and personal The therapist then called the admitting physician and urged him to relationships. The court advised that communications from clients’ maintain the client’s hospitalization for further observation through the family members in the context comprised a “patient communication.” weekend. The psychiatrist disagreed and released the client, who did When therapists must testify in court and their clients request that they not contact his therapist after he was released from the hospital. not disclose information revealed in therapy, therapists may ask the On June 23, 2001, the client shot the boyfriend of his ex-partner and court not to require the disclosure and explain the possible harm to then killed himself with the same handgun. the therapeutic relationship if such a disclosure is made. If the judge requires the therapist disclose the information, the therapist should The parents of the new boyfriend fi led a wrongful death lawsuit naming only reveal information directly related to the request. Under the the therapist as one of the defendants (Ewing v. Goldstein, 2004), circumstances, counselors are not in violation of privacy rules because claiming he had a duty to warn their son of the risk from the client. they are complying with a judge’s order. This is a defense against any charge of wrongdoing if the counselor is later sued over a breach of confi dentiality (Prosser, 1971).
Confi dentiality in group counseling
When counseling groups or families, confi dentiality cannot be ● Must disclose to clients the nature of confi dentiality and the guaranteed because the counselor cannot control the behavior of group possible limitations of the clients’ right to confi dentiality. members. In all codes of ethics there are statements that guide the ● Review with clients the circumstances where confi dential counselor to: information may be requested and when it can be disclosed. ● Inform all clients in the group of the rules of confi dentiality. ● Explain circumstances that may necessitate repeated disclosures. ● Defi ne the parameters of the specifi c group. ● May not reveal any individual’s confi dences to others in the ● Identify who the client is in the counseling setting. client unit without the prior written permission of that individual ● Discuss how confi dentiality matters will be addressed. (AAMTF, 2001). ● Determine how information provided by one member may be As noted above, this information serves as a guideline only. The entire disclosed to other members by the counselor. AAMFT Code of Ethics must be reviewed to understand the complex ● Discuss how to disclose information that was previously held as nature of confi dentiality in group therapy. secret in the group counseling session. ● Explain that confi dentiality cannot be guaranteed in the group setting. The American Counseling Association offers confi dential ethical and professional standards consultation fi ve days a week during business The ACA suggests that counselors seek agreement and document in hours. Most inquiries are answered within 24 hours, but may take up to writing agreements among all parties involved in the group counseling three days when inquiries require specifi c research. setting. These documents should include consent agreements concerning the rights of each individual to confi dentiality and any obligation to As noted above, the ACA Code is currently being revised, and one of preserve the confi dentiality of the information disclosed (ACA, 2005). the newest areas of concern is social media. ACA President Marchetta Evans noted in June 2011, “with Twitter and Facebook, there are some The AAMFT notes that as with other information shared in a ethical boundary issues just fl oating out there with counselors.” counseling setting, marriage and family therapists: ● Do not disclose client confi dences except by written authorization, Evans continued, “Revising our ethics code periodically is part of our waiver or when mandated by law. professionalization. We want it to be as extensive and as inclusive as it ● May accept verbal authorization only in an emergency situation, or can be while also looking at issues that pop up in the future. The ACA when permitted by law. Code of Ethics helps defi ne who we are, how we operate and who we ● Do not disclose information outside the treatment context without are as counselors” (Glosoff & Kocet, 2011). a written authorization from each individual competent to execute the waiver.
Confi dentiality in research
There are many ethical standards in the code of ethics for mental would. Because of the formal, superfi cial nature of research, a researcher health practitioners that govern the confi dentiality rights of subjects likely would not know the research subject as well as a therapist does. or clients in research projects. The standards also govern research Information obtained about a participant during a research project must conduct and the differences between the client-therapist relationship be kept confi dential unless an agreement has been made in advance and the participant-researcher relationship. (Keith-Spiegel and Koocher, 1985). Therapy clients usually realize that they are receiving services. Research Some laboratory ethics don’t translate well to recent research studies subjects may not always know this. The goal of therapy is healing the outside the laboratory. New ethical dilemmas may occur when social client. The goal of research is the dissemination of information. The psychologists use what are called nonreactive methods in which therapist, because of the close relationship, would probably have a better research subjects are not aware they are being observed. This would understanding of what would be harmful to the client than a researcher preclude advanced informed consent and voluntary contracts. People
SocialWork.EliteCME.com Page 52 may be observed in a social setting, contrived or changed setting. permission to interview Jane Doe and review records. The university Without consent, ethical principles allow for only minimal-risk cleared the psychologist, but she was required to take an ethics class research. Yet, minimal risk may be hard to defi ne, because the invasion and to get permission from the IRB before talking to any of the of privacy and some level of deception may be involved. Both of research subjects again. these situations may be considered suffi cient conditions to cause risk. The psychologist is facing an impending lawsuit fi led by Jane Doe. Ethical problems in these cases may be minimized if the data cannot She and several others are accused of defamation, libel, negligent and be linked to those observed. intentional infl iction of distress, emotional invasion of privacy, and When participants believe they are in a private setting, such as damages. Jane Doe alleges that the psychologist’s research disclosed their own homes, added ethical issues arise when a researcher her private information and disclosed her identity. Her lawsuit claims surreptitiously intrudes into the settings. that this has subjected her and her family to additional emotional The responsibility is solely on the researcher to develop research distress from past events. She also claimed that the psychologist conditions and procedures that engage in compassionate, sensitive did not plan the research with regard for her safety and welfare, and work that provides accurate data. A researcher must also be sure that those procedures were not in place for other researchers, or her, to actually being studied has not harmed the group or subject. observe the project and report possible problems. Jane Doe states that the psychologist purposefully mischaracterized the records and Researchers may deem it necessary to violate the confi dentiality of information they received. a subject to improve their data to help others. But with sensitive and advanced planning, ethical problems can be minimized. Mental health The psychologist in her defense claims she always called the subject practitioners are responsible for seeking advice whenever scientifi c Jane Doe in the publication and that the lawsuit was an attempt to stifl e values may cause a confl ict and compromise ethical principles. her freedom of speech. Investigators are also responsible for removing any negative Though the psychologist’s article did not include names, other details consequences as a result of research-related participation (Keith– were included that could break confi dentiality. This information included Spiegel & Koocher, 1985). Jane’s parents’ wedding date, name of the hospital Jane was taken to Ethics case study 12: Research violations and the emergency room director’s name, Jane’s age and the date of the A research article was published concerning a child abuse case. It incident, details of her injuries and information on a custody case. centered on a videotaped discovery of a reportedly forgotten memory This information and other details in the article would make it in a child sexual abuse case, which was compared to the childhood relatively easy for a researcher to ascertain Jane’s identity. interview videotaped 11 years before. The woman, known as Jane Doe, Analysis: In this particular case, it appears the psychologist may have had agreed to this publication of the article (Caridad, 2003). violated at least three ethical codes: research subject confi dentiality, A psychologist on staff with a university and a private investigator informed consent and dual relationships. Psychologists are only discovered the real identity of Jane Doe. They interviewed her mother, allowed to reveal the information with the consent of the person or brother, stepmother and foster mother. The investigator also tried to their legal representative, with the exception of when this information contact Jane Doe, but failed. The psychologist and the investigator did could cause a clear danger to the person or others. not contact the original publisher of the article or Jane for their consent The code of ethics further states that psychologists who present to confi rm her identity or to talk to her caregivers. personal information obtained during their professional work are As a result of their investigation, two articles were published, entitled required to obtain adequate prior consent or adequately disguise the “Who abused Jane Doe?” information. The psychologist did not get prior consent or adequately The psychologist did not respond to the university’s Institutional disguise the information (Keith-Spiegel & Koocher, 1985). Review Board (IRB) in response to questions about their research of The 1992 APA guidelines for disclosure of information say Jane Doe. This was because the psychologist claimed the IRB had psychologists are only allowed to disclose confi dential information given the permission to proceed with the research. The IRB had no without the individual’s consent in the following cases: record of approval for research in this case. The university decided that ● To help provide the client services. the study didn’t fall within its scope. ● To get appropriate professional consultation. ● To protect clients or others from harm. The psychologist believed she was justifi ed in exposing Jane’s identity ● To get payment for services provided, but disclosure is limited to because she believed that the secrecy rules used to protect patients or the minimum information necessary. research subjects should not be used to hide the truth about a child abuse case. The psychologist admitted befriending Jane’s mother and The psychologist’s rationale for violating confi dentiality was to expose that she was largely motivated by the a desire to reunite the mother and the truth, but this does not fall under one of the APA’s guidelines for daughter. violating confi dentiality. Jane Doe told the IRB that she disagreed with the psychologist’s decision However, scientifi c merit and ethical issues may sometimes confl ict. and actions to fi nd her mother and her stepmother for interviews. A researcher may deem it necessary to violate confi dentiality of the subject to improve the data to help others. But with sensitive advance Meanwhile, the psychologist’s actions damaged her relationship with planning, ethical problems can be minimized. the university. Her colleagues questioned the methods she used in her challenge of the initial published research. University offi cials began a Psychologists are responsible for seeking advice whenever scientifi c 21-month investigation of the psychologist’s research in this case. values may cause a confl ict and compromise the APA standards. The investigator is also responsible for removing any necessary negative The dean at the university stated that university rules for research consequences as a result of research-related participation. on human subjects were primarily written for medical school examinations. The offi ce of scholarly integrity stated that the Stricker (1982) defi nes informed consent as the subject agreeing to psychologist would have had to seek the university’s permission to participate in research after receiving an explanation of the research interview people and probably would have been required to give and its risks. The elements of informed consent include competency, the IRB a list of questions being asked and a form explaining to the voluntariness and knowledge. subjects the risks of being interviewed. The psychologist would have One issue in the research concerns existing records that were collected for been required to have the researcher who wrote the initial article get clinical or administrative purposes. Patients may have given initial consent
Page 53 SocialWork.EliteCME.com for this data to be collected, but they probably didn’t give consent for researcher is merely observing the subject to obtain accurate data, while the data to be used in research. Many records may be old, and a patient’s a therapist is attempting to help the client make a change. permission would be diffi cult to obtain. In these cases, retaining A researcher must also be sure the group or subject has not been patient anonymity is crucial. Permission should be obtained from a harmed by being studied. A case could be made that because of the person acting on the patient’s behalf. The data should not be used in any breach of confi dentiality and intrusion into Jane Doe’s private life and way beyond that for which permission was granted (Stricker, 1982). the life of her family, Jane’s informed consent before research of this Jane Doe gave consent to the initial study, but she did not give case would be ethically mandated. Jane also alleges she was harmed consent for the second study. The psychologist admits she could by the research. As noted, it is a researcher’s ethical responsibility to have contacted Jane Doe to interview her, but chose not to do so. The ensure such harm is not occurring to anyone during the research. psychologist did not call the original researcher until the middle of her The right to freedom of speech and academic debate does not allow for research of the Jane Doe case. the kind of ethical breaches that were made in the Jane Doe case. The As previously noted, the psychologist admitted to befriending Jane’s violation of Jane Doe’s confi dentiality without her written consent around biological mother and that she was largely motivated by the desire such a sensitive issue appears to have been unnecessary and inappropriate. to reunite the family. Dual relationships are defi ned as having two Furthermore, discussing such a sensitive issue publicly without a or more roles with the client at the same time. In this situation, the person’s consent appears to be extremely insensitive. There may have psychologist had two or more relationships with research subjects. The been other ways to contradict the initial case study that would not have psychologist acted as researcher and friend to the mother. necessitated publishing extremely personal details about Jane Doe The psychologist’s objectivity may have been diminished by her without her permission. friendship with Jane’s mother. The psychologist’s desire to unite mother The hazards and inconveniences that the research caused Jane and her and daughter may have made her biased to the mother’s perspective. family were not well mediated. The psychologist admitted having a dual A mental health practitioner needs to maintain a certain distance to relationship with Jane’s mother, which shows poor judgment on her part. watch for transference and counter transference issues. The psychologist’s excuse that she should reunite the mother with Therapists may not need to be as objective as a researcher when trying to Jane is not strong enough to counteract the possible damage that could come to a conclusion about the data or clients there they are studying. A result from her dual relationship with the mother (Claridad, 2003).
Summary of the HIPAA Privacy Rule
The U.S. Department of Health and Human Services (HHS) created A major goal of the Privacy Rule is to assure that individuals’ health the Standards for Privacy of Individually Identifi able Health information is properly protected while allowing the sharing of health Information, known as the Privacy Rule, to establish a set of national information to provide high-quality health care and to protect to public standards for the protection of certain health information. The Privacy health. Rule was needed to implement the requirements of the Health The health care marketplace is diverse, so the rule is designed to be Insurance Portability and Accountability Act of 1996 (HIPAA). fl exible and comprehensive to cover the variety of disclosures that The Privacy Rule standards address the use and disclosure of need to be addressed. individuals’ health information called “protected health information” The following summary of key elements in the Privacy Rule is by organizations subject to the rule, which are called “covered not a complete or comprehensive guide to compliance. Covered entities.” HIPAA also includes standards for individuals’ privacy rights entities regulated by the rule are obligated to comply with all of its to understand and control how their health information is used. requirements and should not rely on this summary as the source of Within HHS, the Offi ce for Civil Rights (OCR) has responsibility for legal information or advice. To view the entire rule, and for other implementing and enforcing the Privacy Rule, including voluntary information about how it applies, review the OCR website included in compliance activities and civil money penalties. the resource information section at the end of this course.
Background information
The Health Insurance Portability and Accountability Act of 1996 did not enact privacy legislation within three years of the passage (HIPAA), Public Law 104-191, was enacted on August 21, 1996, and of HIPAA. Because Congress did not do so, HHS developed a sections 261 through 264 required the secretary of HHS to publicize proposed rule and released it for public comment on Nov. 3, 1999. The standards for the electronic exchange, privacy and security of health department received more than 52,000 public comments. The fi nal information. These are known as the administrative simplifi cation regulation, the Privacy Rule, was published Dec. 28, 2000. provisions. In March 2002, the department proposed and released modifi cations to HIPAA required the HHS secretary to issue privacy regulations the Privacy Rule. The department received more than 11,000 comments, governing individually identifi able health information if Congress and the fi nal modifi cations were published on Aug. 14, 2002.
Covered entities
The Privacy Rule, as well as all of the administrative simplifi cation health, dental, vision, prescription drug insurers and health rules, applies to health plans, health care clearinghouses, and to any maintenance organizations (HMOs). health care provider who transmits health information in electronic ○ Medicare, Medicaid, Medicare Plus Choice, and Medicare form in connection with transactions that are called “covered entities.” supplement insurers, and long-term care insurers are covered ● Health plans entities. ○ Individual and group plans that provide or pay the cost ○ Health plans also include employer-sponsored group health of medical care are covered entities. The plans include plans, government- and church-sponsored health plans, and multi-employer health plans.
SocialWork.EliteCME.com Page 54 ■ There are exceptions; a group health plan with less than certain transactions is a covered entity. These transactions 50 participants that is administered by the employer that include claims, benefi t eligibility inquiries, referral established and maintains the plan is not a covered entity. authorization requests and other transactions for which HHS ○ Two types of government-funded programs are not health plans: has established standards under the HIPAA Transaction Rule. 1. Those whose principal purpose is not providing or paying ○ The Privacy Rule covers a health care provider regardless the cost of health care, such as food stamp programs. of whether it electronically transmits these transactions 2. Those programs whose principal activity is directly directly or uses a billing service or other third party to do so providing health care, such as a community health center, or on its behalf. Health care providers include “all providers of to provide grants to fund the direct provision of health care. services” and “providers of medical or health services” as ● Health care providers defi ned by Medicare and any other person or organization that ○ Every health care provider, regardless of size, who furnishes, bills or is paid for health care. electronically transmits health information in connection with
Protected information
The Privacy Rule protects all “individual identifi able health ● Identifi cation of the individual or information for which there is a information” held or transmitted by a covered entity or its business reasonable basis to believe can be used to identify the individual. associate, in any form or media, whether electronic, paper or oral. The ● Individually identifi able health information that includes many Privacy Rule calls this information “protected held information (PHI).” common identifi ers such as name, address, birth date and Social Security number. “Individually identifi able health information” is information, including demographic data, that relates to: The Privacy Rule excludes from protected health information ● The individual’s past, present or future physical or mental health employment records that a covered entity maintains in its capacity as condition. an employer, and education and other records subject to or defi ned in ● The provision of health care to the individual. the Family Educational Rights and Privacy Act, 20 U. S. C. 1232G. ● The past, present or future payment for the provision of health care to an individual.
De-identifi ed health information
There are no restrictions on the use or disclosure of de-identifi ed health ● Telephone numbers. information. De- identifi ed health information neither identifi es nor ● Fax numbers. provides a reasonable basis to identify the individual. There are two ● Electronic mail addresses. ways to de-identifying information: ● Social Security numbers. ● A formal determination by a qualifi ed statistician. ● Medical record numbers. ● The removal of specifi ed identifi ers of the individual and of the ● Health plan benefi ciary numbers. individual’s relatives, household members and employers is ● Account numbers. required, and is adequate only if the covered entity has no actual ● Certifi cate and license numbers. knowledge that the remaining information could be used to ● Vehicle identifi ers and serial numbers, including license plate identify the individual. numbers. ● Device identifi ers and serial numbers. The following identifi ers of the individual or of relatives, employers or ● Web universal resource locators (URLs). household members of the individual must be removed to achieve the ● Internet protocol (IP) addresses. “safe harbor” de-identifi cation: ● Names. ● Biometric identifi ers, including fi ngerprints and voice prints. ● All geographic subdivisions smaller than the state, including street ● Photographic images and any comparable image. ● Any other unique identifying numbers, characteristics or code. address, city, county, precinct and zip code, except for the initial three digits of the zip code unless the ZIP code is for a geographic In addition to the removal of these identifi ers, the covered entity may unit containing 20,000 or fewer people. In that case, the initial not have actual knowledge that the remaining information could be three digits are changed to 000. used alone or in combination with any other information to identify an ● All elements of dates, except a year, directly related to the individual, individual who is the subject of the information. including birth date, admission date, discharge date and date of death.
Principles for uses and disclosures
Basic principles ● To HHS when it is undertaking a compliance investigation or A major purpose of the Privacy Rule is to defi ne and limit review of enforcement action. In these cases, refer to the OCR circumstances in which an individual’s protected information may be Government Access Guidance. used or disclosed to covered entities. A covered entity may not use or Permitted uses and disclosures disclose protected health information, except: A covered entity is permitted, but not required, to use and disclose ● As the privacy rule permits or requires. protected health information without an individual’s authorization for ● As the individual who is the subject of the information or the the following purposes or situations: individual’s personal representative authorizes in writing. 1. To the individual, unless required for access or accounting of Required disclosures disclosures. ● To individuals, or their personal representatives, specifi cally when 2. Treatment, payment, and health care operations. they request access to, or an accounting of, disclosures of their ○ Treatment is the provision, coordination, or management protected health information. of health care-related services by one or more health care
Page 55 SocialWork.EliteCME.com providers, including consultation between providers regarding Covered entities may rely on professional ethics and best judgment in a patient, and referral of a patient by one provider to another. deciding which of these permissive uses and disclosures to make. ○ Payment encompasses activities of the health plan to obtain Most uses and disclosures of psychotherapy notes for treatment, premiums, determine or fulfi ll responsibilities for coverage, payment and health care operations purposes require an authorization provisions of benefi ts, and furnish or obtain reimbursement for as described below: health care to an individual. ● Obtaining consent, which is written permission from an individual ○ Health care operations may include any of the following to use and disclose information for treatment, payment and health activities: care operations, is optional under the privacy rule for all covered ■ Quality assessment and improvement activities, including entities. case management and care coordination. ● The content of a consent form and the process for obtaining consent ■ Competency assurance activities, including provider or are at the discretion of the covered entity electing to seek consent. health plan performance evaluation competency assurance ● The counselor should refer to the ethics sections or their activities, credentialing and accreditation. organization to determine how to proceed in disclosures of ■ Conducting or arranging for medical reviews, audits or psychotherapy notes. legal services, including fraud and abuse detection and compliance programs. Informal permission may be obtained by asking the individual ■ Specifi ed insurance functions. outright, or by circumstances that clearly give the individual the ■ Business planning, development, management and opportunity to agree, acquiesce or object. administration. Where the individual is incapacitated, in an emergency situation or ■ Business management and general administrative activities not available, covered entities generally may make such uses and of the entity, including de-identifying protected health disclosures, if in the exercise of their professional judgment the use of information, creating a limited data set, and certain fund- disclosure is determined to be in the best interest of the individual. raising for the benefi t of the covered entity. 3. To provide the opportunity to agree or object. Refer to the code of ethics for the counseling or social work 4. Incident to an otherwise permitted use and disclosure. organization to address issues in the decision-making process related 5. For the public interest and benefi t activities. to these disclosures. 6. For limited data sets for the purposes of research, public health or health care operations.
Facility directories
It is common practice in many health care facilities, such as hospitals, may then disclose the individual’s condition and location in the facility to maintain a directory of patient contact information. A covered health to anyone asking for the individual by name, and also may disclose care provider may rely on the individual’s informal permission to religious affi liation to clergy. Members of the clergy are not required to list in its facility directory the individual’s name, general condition, ask for the individual by name when requiring about patient religious religious affi liation and location in the provider’s facility. The provider affi liation.
Notifi cation and other purposes.
A covered entity also may rely on the individual’s informal permission permission to use or disclose protected health information for the to disclose to the individual’s family, relatives, friends or other purpose of notifying family members, personal representatives or persons whom the individual identifi es, protected health information others responsible for the individual’s care, the individual’s location, directly relevant to that person’s involvement in the individual’s care general condition or death. or payment for care. This provision, for example, allows a pharmacist In addition, protected health information may be disclosed for to dispense fi lled prescriptions to a person acting on the behalf of notifi cation purposes to the public or private entities authorized by law the patient. A covered entity may rely on the individual’s informal or charter to assist in disaster relief efforts.
Public interest and benefi t activities
The Privacy Rule permits use and disclosure of protected health other governmental agencies authorized to receive reports of child information without an individual’s authorization or permission for abuse and neglect. national priority purposes. These disclosures are permitted, although ● Entities subject to FDA regulations – Entities involved with not required, by the rule in recognition of the important use made of FDA regulated products or activities may disclose information for health information outside the health care context. Specifi c conditions purposes such as adverse event reporting, tracking of products, or limitations applied to each public interest purpose, striking the product recalls and surveillance. balance between the individual privacy interest and the public interest ● Individuals – When notifi cation is authorized by law, information for this information, are as follows: may be released on people who may have contracted or been ● Required by law – Covered entities may use and disclose exposed to a communicable disease. protected health information without individual authorization as ● Employers – Information on employees about a work-related required by law, including statute, regulatory, or court orders. illness, injury or related medical surveillance may be sought and ● Public health activities – Covered entities may disclose protected disclosed because such information is needed to comply with the health information to public health authorities authorized by Occupational Safety And Health Administration (OHSA) and Mine law to collect or receive such information for preventing or Safety and Health Administration (MHSA) regulations or similar controlling disease, injury or disability and to public health or state law.
SocialWork.EliteCME.com Page 56 Victims of abuse, neglect or domestic violence
In certain circumstances, covered entities may disclose protected health information to appropriate government authorities about victims of abuse, neglect or domestic violence.
Health oversight activities
Covered entities may disclose protected health information to help activities, such as audits and investigations necessary for oversight of oversight agencies for purposes of legally authorized health oversight the health care system and government benefi t programs.
Judicial and administrative proceedings
Covered entities may disclose protected health information in a may be disclosed in response to a subpoena or other lawful process judicial or administrative proceeding if the request for the information if certain assurances regarding notice to the individual or a protective is through an order from a court or administrative tribunal. Information order are provided.
Law enforcement purposes
Covered entities may disclose protected health information to 5. When a covered entity believes that protected health information is law enforcement offi cials for law enforcement purposes under the evidence of a crime that occurred on its premises. following six circumstances, and subject to specifi c conditions: 6. By a covered health care provider in a medical emergency not 1. As required by law, including court orders, court ordered warrants, occurring on its premises when necessary to inform law enforcement subpoenas and administrative requests. about the commission and nature of a crime, the location of the 2. To identify or locate a suspect, fugitive, material witness or crime or crime victims and the perpetrator of the crime. missing person. Covered entities may disclose protected health information to funeral 3. In response to a law enforcement offi cial’s request for information directors as needed, and coroners or medical examiners to identify the about a victim or suspected victim of a crime. deceased person, determine the cause of death and to perform other 4. To alert law enforcement of a person’s death, if the covered entity functions authorized by the law. suspects that criminal activity caused the death.
Research
“Research” is any systematic investigation designed to develop or research purposes has been approved by an Institutional Review contribute to general knowledge. The Privacy Rule permits a covered Board or Privacy Board. entity to use and disclose protected health information for research ● That the use or disclosure of the protected health information purposes, without an individual’s authorization, provided the covered is solely to prepare a research protocol or for similar purpose entity documents: preparatory to research, that the researcher will not remove any ● That an alteration or waiver of individuals’ authorization for the protected health information from the covered entity, and that use or disclosure of protected health information about them for information is necessary for the research.
Serious threats to health and safety
Covered entities may disclose protected health information that they believe can prevent or lessen the threat, including the target of the threat. believe is necessary to prevent or lessen a serious and imminent threat Covered entities may also disclosed to law enforcement if the information to a person or the public, when such disclosure is made to someone they is needed to identify or apprehend an escapee or violent criminal.
Essential government functions
Authorization is not required to use or disclose protected health making determinations of medical suitable for U.S. State Department information for certain essential government functions. These employees, protecting the health and safety of inmates or employees in functions include assuring proper execution of a military mission, a correctional institution, and determining eligibility for or conducting conducting intelligence and national security activities that are enrollment in certain government benefi t programs. authorized by law, providing protective services to the president,
Workers’ Compensation
Covered entities may disclose protected health information to comply with workers’ compensation laws and other similar programs providing benefi ts for working-related injuries or illnesses.
Limited data set
A limited data set is protected health information from which certain public health purposes, provided the recipient enters into a data use specifi c direct identifi ers of individuals and their relatives, household agreement promising specifi c safeguards for the protected health members and employers have been removed. A limited data set information within the limited data set. may be used and disclosed for research, health care operations, and
Page 57 SocialWork.EliteCME.com A limited data set excludes the following direct identifi ers of an ● Health plan benefi ciary numbers. individual or of relatives, employers or household members of the ● Account numbers. individual: ● Certifi cate and license numbers. ● Names. ● Vehicle identifi ers and serial numbers, including license plate ● Postal address information, other than town or city. numbers. ● State and zip codes. ● Device identifi ers and serial numbers. ● Telephone numbers. ● Web universal resource locators (URLs). ● Fax numbers. ● Internet protocol (IP) address numbers. ● Electronic mail addresses. ● Biometric identifi ers, including fi ngerprint and voice identifi ers. ● Social Security numbers. ● Full-face photographic images or any comparable images. ● Medical records numbers.
Authorized uses and disclosures
A covered entity must obtain an individual’s written authorization for life insurer for coverage purposes, disclosures to an employer of the any use or disclosure of protected health information that is not for results of a pre-employment physical or lab tests, or disclosures to a treatment, payment or health care operations, or otherwise permitted pharmaceutical fi rm for its marketing purposes. or required by the Privacy Rule. A covered entity may not condition All authorizations must be in plain language and contains specifi c treatment, payment, enrollment or benefi ts eligibility based on whether information about the information to be disclosed or used, the persons an individual grants an authorization, except in limited circumstances. disclosing and receiving the information, expiration, right to revoke Any authorization must be written in specifi c terms. It may allow use in writing, and other data. The Privacy Rule contains transition and disclosure of protected health information by the covered entity provisions applicable to authorizations and other express legal seeking that authorization or by a third-party. Example of disclosures permissions obtained prior to April 14, 2003. that would require an individual’s authorization are disclosures to a
Psychotherapy notes
The covered entity must obtain an individual’s authorization to use or analyzing the contents of the conversation during a private counseling disclose psychotherapy notes with the following exceptions: session or a group, joint, or family counseling session and that are ● The covered entity who originated the notes a may use or separated from the rest of the individual’s medical record. disclose the psychotherapy notes for his or her own training with Psychotherapy notes exclude medication prescription and monitoring, an individual’s authorization, and as part of a defense in legal counseling session start and stop times, the modalities and frequencies proceedings brought by the individual. of treatment furnished, results of clinical tests, and any summary of the ● For HHS to investigate or determine the covered entity’s following items: compliance with the Privacy Rules. ● Diagnosis. ● To avert a serious and imminent threat to the public health or safety. ● Functional status. ● To a health oversight agency for lawful oversight of the originator ● Treatment plan. of the psychotherapy notes, for the lawful activities of the coroner ● Symptoms. or medical examiner or as required by law. ● Prognosis. “Psychotherapy notes” are notes recorded in any medium by a health ● Progress to date. care provider who is a mental health professional documenting or
Limiting uses and disclosures to the minimum necessary
An essential aspect of the Privacy Rule is the principle of “ minimum Access and use: For internal uses, a covered entity must develop and necessary” use and disclosure. A covered entity must make reasonable implement policies and procedures that restrict access and uses of efforts to disclose and request only the minimum amount of protected protected health information based on the specifi c roles of the members health information needed to accomplish the intended purpose of the working within the covered entity. These policies and procedures disclosure or requests. A covered entity must develop and implement must identify the persons, or classes of persons, in the workforce who policies and disclosures to reasonably limit uses and disclosures to the need access to protected health information to carry out their duties, minimum necessary. When the minimum necessary standard applies to the protected health information to which access is needed, and any a use or disclosure, a covered entity may not use, disclose or request the conditions under which they need the information to do their jobs. entire medical record for a particular purpose unless it can specifi cally Disclosures and requests for disclosures: Covered entities must justify the whole record as the amount reasonably needed for the purpose. establish and implement policies and procedures for routine, reoccurring The minimum necessary requirement is not imposed in the following disclosures or requests for disclosures that limit the protected health circumstances: information disclosed to that which is the minimum amount reasonably ● Disclosure to order a request by a health care provider for treatment. necessary to achieve the purpose of disclosure. Individual review of ● Disclosure to an individual who is the subject of the information. each disclosure is not required. For nonroutine, nonrecurring disclosures ● The individual’s personal representative. or requests for disclosures that it makes, covered entities must develop ● Use or disclosure made pursuant to an authorization. criteria designed to limit disclosures to the information reasonably ● Disclosure to HHS for complaint investigation. necessary to accomplish the purpose of the disclosure and review each ● Compliance review or enforcement. of these requests individually in accordance with established criteria. ● Use of disclosure that is required by law. Reasonable reliance: If another covered entity makes a request for ● Use of disclosure required for compliance with the HIPAA protected health information, a covered entity may rely, if reasonable Transaction Rule or other HIPAA administrative simplifi cation rules. under the circumstances, on the request as complying with the
SocialWork.EliteCME.com Page 58 minimum necessary standard. Similarly, a covered entity may rely ● A professional, such as an attorney or accountant who is a covered upon request as being the minimum necessary protected health entity’s business associates seeking information to provide services information from: to or for the covered entity. ● A public offi cial. ● A researcher who provides the documentation or representation required by the privacy rule for research.
Privacy practices notice
Each covered entity, with certain exceptions, must provide a notice of for the acknowledgment. The provider must document the reason its privacy practices. The privacy rule requires that the notice contain for any failure to obtain the patient’s written acknowledgment. The certain elements: provider is relieved of the need to request acknowledgment in an ● The notice must describe the ways in which the covered entity may emergency treatment situation. use and disclose protected health information. Access: Except in certain situations, individuals have the right to ● It must state the covered entity’s duty to protect privacy, provide review and obtain a copy of their protected health information in notice of privacy practices, and abide by the terms of the current covered entities’ “designated record set.” The designated record set notice. is that group of records maintained by or for a covered entity that is ● The notice must ascribe individual’s rights, including the right to used, in whole or part, to make decisions about individuals, or that is complain to HHS and to the covered entity if the person believes a provider’s medical and billing records about individuals or health his or her privacy rights have been violated. plan’s enrollment, payment, claims adjudication and case of medical ● The notice must include a point of contact for further information management records systems. The rule excepts from the right of access and for making complaints to the covered entity. the following protected health information: ● Covered entities must act in accordance with their notices. ● Psychotherapy notes. ● The Privacy Rule also contains specifi c distribution requirements ● Information compiled for legal proceedings. for direct treatment providers and all other health care providers ● Laboratory results to which the Clinical Laboratory Improvement and health plans. Act (CLIA) prohibits access to information held by certain Notice distribution: Since April 14, 2003, a covered health care resource laboratories. provider with the direct treatment relationship with individuals must ● For information included within the right of access, covered entities deliver a privacy practices notice to patients, as follows: may deny an individual access in certain specifi c situations, such ● Not later than the fi rst service encounter by personal delivery, as when a health care professional believes that access could cause by automatic and contemporaneous electronic response, and by harm to the individual or another. In such situations, the individual prompt mailing. must be given the right to have such denials reviewed by a ● By posting the notice at each service delivery site in a clear and licensed health care professional for a second opinion. prominent place where people seeking service may reasonably be ● Covered entities may impose reasonable, cost-based fees for the expected to be able to read the notice. cost of copying and postage. ● In emergency treatment situations, the provider must furnish its A covered entity may deny access to individuals, without providing notice as soon as the emergency is resolved. the individual an opportunity to review, in the following protected ● Covered entities, whether direct treatment providers or indirect situations: treatment providers such as laboratories or health plans, must ● The protected health information falls under an exception to the supply notice to anyone on request A covered entity must also right of access. make its notice electronically available on any website it maintains ● An inmate request for protected health information under certain for customer service or benefi ts information. circumstances. ● The covered entity in an organized health care arrangement may ● Information that a provider creates or obtains in the course of use that joint practice privacy notice, as long as each agrees to research that includes treatment for which the individual has abide by the notice content with respect to the protected health agreed not to have access as part of consenting to participate in information created or received. the research, as long as access to the information is restored upon ● The health plan must distribute its privacy notices to each of its completion of research. enrollees by its compliance date. ● For records subject to the Privacy Act, information to which access ● A covered health care provider with a direct treatment relationship may be denied under the Privacy Act. with individuals must make a good-faith effort to obtain a written ● Information obtained under a promise of confi dentiality from a acknowledgment from patients of receipt of the privacy practices source other than a health care provider, if granting access would notice. The privacy rule does not prescribe any particular content likely reveal the source.
Restriction and request
Individuals have the right to request that a covered entity restrict death. The covered entity is under no obligation to agree to a request use of disclosure of protected health information, payment or health for restrictions. A covered entity that does agree must comply with the care operations, disclosure to persons involved in the individual’s agreed restrictions, except for the purposes of treating the individual in health care or payment for health care, or disclosure to notify family a medical emergency period. members or others about the individuals general condition, location or
Confi dential communications requirements
Health plans and covered health care providers must permit the disclosure of all or part of the protected health information individuals to request an alternative means or location for receiving could endanger the individual. The health plan may not question the communications of protected health information. Health plans must individual statement of endangerment. accommodate reasonable requests, especially if the individual indicates
Page 59 SocialWork.EliteCME.com Administrative requirements
HHS recognizes that covered entities range from the smallest provider appropriate for their environment. This may depend on the nature of to the largest multistate health plan. The rules are intended to allow the covered entity’s business, as well as its size and resources. covered entities to analyze their own needs and implement solutions
Privacy policies and procedures
A covered entity must develop and implement written privacy policies documents containing protected information before discarding them and procedures that are consistent with the HIPAA Privacy Rule. or securing medical records with a lock, key or pass code, and limiting Privacy personnel: A covered entity must designate a privacy offi cial access to key user pass codes. responsible for developing and implementing its privacy policy and Complaints: A covered entity must have procedures for individuals procedures, and the contact person or offi ce responsible for receiving to make complaints regarding its privacy policies and procedures. The complaints in providing information on the covered entity’s privacy covered entity must explain those procedures in its privacy practices. practices. The covered entity must identify to whom individuals can submit Workforce training and management: Workforce members include complaints to at the covered entity, and advise that complaints also can employees, volunteers and trainees and may also include other persons be submitted to the Secretary of the HHS. whose conduct is under the direct control of the entity. A covered Retaliation and waive: A covered entity may not retaliate against a entity must train all workforce members on its privacy policies and person for exercising rights provided by the Privacy Rule for: procedures as necessary and appropriate for them to carry out their ● Assisting in an investigation by HHS or another appropriate functions. A covered entity must have and apply appropriate sanctions authority. against workforce members who violate its privacy policies and ● Opposing an act or practice that the person believes in good faith procedures or the privacy rule. violates the Privacy Rule. Mitigation: A covered entity must mitigate, to the extent practicable, A covered entity may not require an individual to waive any right any harmful effect it learns was caused by the use or disclosure of under the privacy rule as a condition for obtaining payment, treatment, protected health information by its workforce or associates in violation an enrollment or benefi t eligibility. of its policies and procedures or the Privacy Rule. Documentation and records retention: A covered entity must Data safeguard: A covered entity must maintain reasonable and maintain until six years after the latter of the date of their creation or appropriate administrative, technical and physical safeguards to last effective date its privacy policies and procedures, privacy practices prevent intentional or unintentional user disclosure of protected notices, disposition of complaints and other activities and designations health information. For example, a safeguard might include shredding that the Privacy Rule requires to be documented.
Personal representatives and minors
Personal representatives: The privacy rule requires a covered exercise individual rights, such as access to the medical records, on entity to treat a personal representative the same as the individual behalf of their minor children. In certain exceptional cases, the parent with respect to uses and disclosures of the individual’s protected is not considered the personal representative. In these situations, the health information, as well as the individual’s rights under the rule. Privacy Rule defers to state and other law to determine the rights of A personal representative is defi ned as a person legally authorized to the parents to access and control the protected health information of make health care decisions on an individual’s behalf or to act for a their minor children. deceased individual or the estate. If state and other law is silent on parental access to the minors’ The privacy rule permits an exception when a covered entity has a protected health information, a covered entity has discretion to provide reasonable belief that the personal representative may be abusing or or deny a parent access to the minor’s health information, provided the neglecting the individual, or that treating the person as the personal decision is made by a licensed health care professional in the exercise representative could otherwise endanger the individual. of professional judgment. For further information, review the OCR Special case – Minors: In most cases, parents are the personal Personal Representatives Guidance. representatives for their minor children. In those cases, parents can
State law preemption
requirements will apply. “Contrary” means it would be impossible for a covered entity to comply with both the state and federal requirements, or that the provision of state law is an obstacle to accomplishing the full purposes and objectives of the administrative simplifi cation provision of HIPAA. The Privacy Rule provides exceptions to the general rule of federal preemption for contrary state laws that: ● Relate to the privacy of individually identifi able health information and provide greater privacy protections or privacy rights with respect to such information. ● Provide for the reporting of disease or injury, child abuse, birth or In general, state laws that are contrary to the Privacy Rule are death, or for public health surveillance, investigation or intervention. preempted by the federal requirements, which mean that the federal ● Requires certain health plan reporting, such as for management or fi nancial audits.
SocialWork.EliteCME.com Page 60 Exception determination: In addition, preemption of a contrary state ● Is necessary for purposes of serving a compelling public health, law will not occur if HHS determines, in response to a request from a safety or welfare need, and if the Privacy Rule provision is at state or other entity or person, that the state law: issue, if the secretary determines that the intrusion into privacy is ● Is necessary to prevent fraud and abuse related to the provision of warranted when balanced against the need to be served. or payment for health care. ● Has as its principal purpose the regulation of the manufacture, ● Is necessary to ensure appropriate state regulation of insurance registration, distribution, dispensing or other control of any and health plans to the extent expressly authorized by statute or controlled substance as defi ned in 21 U.S.C.802, or that is deemed regulation. a controlled substance by state law. ● Is necessary for state reporting on health care delivery or costs.
Enforcement and penalties for noncompliance
Consistent with the principles of achieving compliance provided in ● For violations due to willful neglect that were corrected within the the rule, HHS will seek the cooperation of covered entities and may required time period, a minimum fi ne of $10,000 up to $50,000 provide technical assistance to help them comply voluntarily with may be imposed, with an annual maximum of $1.5 million. the rule. The rule provides processes for persons to fi le complaints ● For violations due to willful neglect that were not corrected, a with HHS, describes the responsibilities of covered entities to provide minimum fi ne of $50,000 per violation may be imposed, with an records, compliance reports, and to cooperate with and permit access annual maximum of $1.5 million. to information for investigations and compliance reviews. However, courts have in some cases have treated multiple violations However, she American Recovery and Reinvestment Act of 2009 put as separate cases, allowing the maximum fi nes to be much higher than new teeth into the laws and penalties for HIPAA violations when it $1.5 million. implemented tiered penalties refl ecting the circumstanced surrounding In addition, criminal penalties may apply in some cases. A person the violation. These acknowledged whether the violator did not know who knowingly obtains or discloses individually identifi able health about the violation, had reasonable cause, allowed the violation information in violation of HIPAA faces a fi ne of $50,000 and up to because of willful neglect but subsequently corrected it or allowed the one year imprisonment. The criminal penalties increase to $100,000 violation because of willful neglect and did not correct it. and up to fi ve years imprisonment if the wrongful conduct involves ● For violations that the entity did not know about, minimum fi nes false pretenses, and up to $250,000 and up to 10 years imprisonment if are $100 per violation up to $50,000 may be imposed, with an the wrongful conduct involves the sale, transfer or use of individually annual maximum of $1.5 million. identifi able health information for commercial advantage, personal ● For violations that had reasonable cause and were not due to gain or malicious harm. Criminal sanctions are enforced by the willful neglect, a minimum fi ne of $1,000 up to $50,000 may be Department of Justice. imposed, with an annual maximum of $1.5 million.
Compliance dates
All covered entities, except “small health plans,” were required to be receipts. Health plans that do not report receipts to the Internal compliant with the privacy rule by April 14, 2003. Small health plans Revenue Service (IRS), for example, group health plans regulated by had until April 14, 2004, to comply. the Employee Retirement Income Security Act 1974 (ERISA) that are Small health plans: A health plan with annual receipts of not more exempt from fi ling income tax returns should use proxy measures to than $5 million is a small health plan. Health plans that fi le certain determine their annual receipts. federal tax returns and report receipts on those returns should use the The entire HIPAA Privacy Rule as well as guidelines and additional guidance provided by the small business administration at Number materials may be found on the government website www.hhs.gov/ocr/ 13 Code of Federal Regulations (CFR) 121.104 to calculate annual hipaa.
Client Education: Confi dentiality and privacy rights
Clients may feel betrayed when therapy records become part of their The council recognized that utilization and quality assurance reviews general medical or health records in an HMO or other managed-care are functional in a health care system, but it also promotes safeguards facility and may be disclosed to third-party resources and eligibility to protect confi dentiality of patient/client data and practitioner clinical compliance. Not all clients understand that submitting a claim for materials, and to obtain client consent. mental health services leads to the provider of services sharing It concludes, “The rationale for this position is founded on the patient’s information such as diagnosis, types of services offered, dates of autonomous right to control sensitive personal information. It is service, duration of treatment and so on. further based upon historical recognition of the Oath of Hippocrates, Sometimes, insurers or companies assigned to manage mental health and corroborated throughout the centuries, on the enduring value of benefi ts may be authorized to seek detailed information from case fi les, preserving confi dentiality in order to enhance mutual trust and respect such as client current symptoms status, treatment plan specifi cs or in the patient provider relationship” (1997). other personal information. Insurance companies may not protect such All mental health practitioners, their employees and students must information as diligently as a provider of services, so confi dentiality have a thorough and working knowledge of their organization’s ethics lies beyond the control of the therapist in this circumstance. code and the HIPAA Privacy Rule as it applies to their practice. The Council of the National Academies of Practice, which includes In addition, they should inform clients about issues of confi dentiality medicine, dentistry, nursing, optometry, osteopathic and podiatric governing their practice and help them gain understanding of the medicine, psychology, social work and veterinary medicine, adopted HIPAA Privacy Rule as it may apply to disclosure of their health care the “Ethical Guidelines for Professional Care in a Managed Care information. They should be prepared to answer questions on these Environment,” and confi dentiality is one of the fi ve guidelines issues in a manner best suited for their individual client’s needs. indicated as a primary concern.
Page 61 SocialWork.EliteCME.com Resources for information
● American Association of Marriage and Family: www.aamft.org/ ● HIPAA Privacy Rule: www.hhs.gov/ocr/hipaa. resources/LRMPlan/Ethics/ethicscode2001.asp. ● National Association of Mental Health Counselors: www.namhc. ● American Counseling Association: www.counseling .org. org. ● American Psychological Association: www.apa. org. ● National Association of Social Workers: www.socialworkers.org.
References
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Code of Ethics of the National resources/LRMPlan/Ethics/ethicscode2001.asp Association of Social Workers. Retrieved on November 15,2011 from http://www. American Psychological Association (2002). Ethical Principles of Psychologists and socialworkers.org/pubs/code/code.asp Code of Conduct. American Psychologist, 57,1060-1073. Montgomery, L.H., & Cupit, B.E. (1999) Complaints, malpractices, and risk American School Counselor Association (2010) Ethical Standards for School management: Professional issues and personal experiences. Professional Psychology, Counselors. Alexandria, Virginia 30,402-410. Bennet, B.E., Bricklin, P.M., &VandeCreek, L. (1994) How certain boundaries and National Academies of Practice. (1997). Ethical guidelines for professional care in a ethics diminish therapeutic effectiveness. Ethics and Behavior, 4,263-266. managed care environment. Washington, DC: Author Borys, D.S. (1998). 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(1996). A comparison of codes of professional conduct and ethics. In L.J. http://www.csun./edu/psy460. Bass, S.T. Demers, J.R.P. Ogloff, C. Peterson, J.L. Petifor, R.P. Reaves, T. Retfalvi, Health Insurance Portability and Accountability Act, Pub.L. No.104-191 (1996). N.P. Simon, C. Sinclair, & R.M. Tiptons (Eds.) Professional Conduct and Discipline Herlihy, K.C. & Corey, G. (1997) Code of ethics as catalysts for improving practice. in Psychology (pp. 53-71). Washington, DC: American Psychological Association. In Ethics in Therapy (pp 37-56). New York: Hatherleigh. Stanford University (2010). Aristotle on Ethics. Retrieved on November 19, 2011, Hobbs, N. (1948) The development of a code of ethical standards for psychology: from http://www.plato.standford.edu/entries/aristotle/ethics/ American Psychologist, 3,80-84. Sticker. & Fisher, M. (Eds.) 1990. Self-disclosure in the therapeutic relationship. New Holroyd, J.C. & Brodsky, A.M. (1977). Psychologists’ attitudes and practices York: Plenum Press. regarding erotic and nonerotic physical contact with patients. American Psychologist, Tabachnik, B.G., Keith-Spiegel, P., & Pope, K.S. (1987). Ethics of Practice: The 32,843-849. Beliefs and Behaviors of Psychologists as Therapists. American Psychologist .46,501- Jaffe v. Redmond et al., 1996 WL 3`4841 (U.S. June 13,1996) 515. Jorgenson, L.M. (1995) Sexual conduct in fi duciary relationships in J.C. Gonsioorek Tarasoff v. Regents (1976). 17Cal.3d 425,551 P.2d 334,131 Cal.Rptr.14. Retrieved (Ed.) Breach of trust: Sexual exploitation by health care professionals and clergy November 15, 2011, from http://www.csun./edu/psy460 (pp.131-134). Alexandria, VA: American Counseling Association. Thoreson, R.W., Shaughnessey, P., & Frazier, P.A. (1995). Sexual contact during Katherine, A. (1991) Boundaries: Where you end and I begin. New York: Simon & and after the professional relationship: Practices and attitudes of female counselors. Schuster. Journal of Counseling and Development, 74,84-88 Keith-Spiegel. & Koocher, G.P. (1985) Ethics in Psychology: Professional Standards Trimble, J.E. & Fisher, C. (2006). Handbook on Ethical Considerations in Conducting and Cases (1st ed.). New York, NY: McGraw Hill. Research With Ethnocultural Populations and Communities. Thousand Oaks, CA: Kitchener, K.S. (1984) Intuition, Critical Evaluation, and Ethical Principles. Sage Publishing. Counseling Psychologist, 12(3), 43-55. Van Hoose, W.H. & Paradise, L.V. (1979). Ethics in Counseling and Psychotherapy: Kitchener, K.S. (2000). Foundations of ethical, research, and teaching in psychology. Perspectives in Issues and Decision Making. Cranston, RI: Carroll Press. Mahwah, N.J.: Lawrence Erlbaum Associates. Welfel, E.R. (2002) Ethics in Counseling and Psychotherapy: Standards, Research, Kitchener, K.S. & Harding, S.S. (1990) Dual role relationships. In B. Herlihy & and Emerging Issues. (2nd Ed.) Pacifi c Grove, CA: Brooks/Cole. L.Golden (Eds.) Ethical standards casebook (4th Ed., pp.145-148). Alexandria, VA: Whitman, J.S., Glosoff, H.L., Kocet, M.M. & Tarvydas, V. (2011). Retrieved on American Association for Counseling and Development. November 26,2011, from http://www.counseling.org/PressRoom/NewsRelease.aspx/ Koocher, G.P., & Keith-Spiegel, P. (2008). Ethics in Psychology and the Mental AGuid=b68aba97 Health Professions Standards and cases (3rdEd). New York: Oxford University Press.
SocialWork.EliteCME.com Page 62 ETHICS IN SOCIAL WORK AND COUNSELING AND HIPAA PRIVACY RULES Final Examination Questions Select the best answer for each question and then proceed to SocialWork.EliteCME.com to complete your fi nal examination.
11. The HIPAA Privacy Rule and codes of ethics for mental health 16. NASW highlights on duty to warn include the following practitioners share all of the following EXCEPT: statements EXCEPT: a. Both compliment each other. a. Therapists must know their state laws on the duty to warn, and b. Both were developed to ensure privacy, confi dentiality, and the those of other states if they are communicating across state well-being of the individual and society. lines. c. Both have enforcement agencies and structured monetary b. Social workers should disclose all confi dential information and penalties sanctioned by the Federal level of government. patient records in all cases where there is potentially imminent d. None of the above. harm. c. Only information that is directly relevant to the purpose for 12. The following statements about confi dentiality are true EXCEPT: which the disclosure is made should be revealed. a. Confi dentiality is based on society’s belief that individuals d. The general expectation that social workers will keep have a right to privacy and the right to decide what information confi dential does not apply when disclosure is information they will share and with whom. necessary to prevent serious, foreseeable, imminent harm to a b. Confi dentiality is an ethical principle. client or identifi ed person. c. Both codes of ethics and the HIPAA Privacy Rule provide explicit, detailed provisions the cover client consent for 17. The Privacy Rule applies to “covered entities,” which include the disclosure of information. following EXCEPT: d. Privileged communication from a therapy session, however, a. Health plans - individual and group. is not a legal concept that protects clients from having b. Medicare and Medicaid. confi dential information disclosed without their consent. c. A group plan with less than fi ve participants that is administered by an employer. 13. Multicultural diversity competency includes: d. Church-sponsored health plans. a. A capacity where by practitioners possess cultural and diversity awareness. 18. “Individually identifi ed health information” excludes which of the b. Knowledge about self and others. following? c. How this awareness and knowledge is applied effects the a. Name, address, birthday and Social Security number. practice with clients and the client group. b. Present physical and mental health information. d. All of the above. c. Past, present, and future payment information for the provision of health care. 14. Which statement below about dual relationships is TRUE? d. Health information employment records that a covered entity a. They can be social, fi nancial or professional relationships, keeps in its capacity as an employer. and the practitioner may be the friend, supervisor, associate, supervisor, teacher or employer. 19. To achieve “safe harbor” de-identifi cation, all of the following b. A dual relationship exists when a mental health practitioner should be removed except: is counseling at the same time he or she is in another a. All geographic subdivisions smaller than the state except for relationship with the client. the initial three digits of a Zip Code or the numbers 000 in c. Mental health practitioners should not enter in to a dual some cases. relationship if the possibility exists for exploitation or harm to b. The year of death. the client. c. Medical records numbers. d. All of the above. d. License plate numbers.
15. Codes of ethics address behaviors among practitioners that may 20. In the special case of minors, which of the following statements is result in ethical violations. All of the situations below represent FALSE? Jorgenson’s list of causes of action that clients may allege in civil a. In most cases, parents are the personal representatives for their lawsuits EXCEPT: minor children. a. Negligent infl iction of emotional distress. b. When the parent is not considered the representative, the b. Setting rates higher than the local average. Privacy Rule defers to the state and other law to determine the c. Breach of contract. rights of the parents to access protected health information. d. Intentional infl iction of emotional distress. c. If the state or other law is silent on parent access, a covered entity may not use its own discretion to provide or deny a parents access to the minor’s health information. d. All of the above.
SWCA06EH14
Page 63 SocialWork.EliteCME.com CHAPTER 4: Internet Addiction to Cybersex and Gambling: Etiology, Prevention and Treatment
8 CE Hours
By Deborah Converse, MA, NBCT, Clinical Ed.
Learning objectives
Identify three criteria necessary for a DSM-IV diagnosis of Describe four negative aspects of social networking. Internet addiction. Identify prevalence rates of Internet addiction by age, gender and List and explain three similarities between Internet addiction and socioeconomic variables. obsessive/compulsive disorders. List and discuss biological, social and environmental factors that Defi ne three factors that may lead to the development of an may predispose an individual to an Internet sexual addiction. Internet addiction. Compare and contrast the unique factors of Internet sexual Explain four examples of inappropriate thought patterns that may addictions to other forms of addiction. lead to Internet sexual and gambling addictions. Explain four prevention strategies for Internet addiction. Discuss pharmacological and psychotherapy treatments that Discuss federal laws and sanctions on Internet child pornography. have proven effective for treating Internet sexual and gambling Identify and defi ne biological, social and environmental infl uences addictions. on the development of an Internet gambling addiction.
Introduction
Many individuals today are drawn by the power of the Internet to life personalities. Reality may reinforce responsibilities, obligations, expand their world. The Internet can be a positive tool in business, personal weaknesses and failures. By going online, these realities can education, research and communication, and has revolutionized quickly disappear into an exciting virtual life based on imagination, opportunities to establish social networks worldwide. However, desires and grandiose thinking, all in the privacy of cyberspace. this unlimited access can also lead to self-destructive behaviors and Aboujaoude (2011) studied heavy Internet users and found that they addictions in many areas. Some individuals like to escape into novel experienced dissociation phenomenon as demonstrated by high scores experiences, and they develop alternative personalities that are more on dissociation questionnaires. Other scientifi c studies noted biological aggressive, less inhibited, more sensual, and more likely to take risks. changes that occurred in the brain during excessive online use. The Internet may lead to dramatic changes in behavior and identity in PET scans have been used to measure the level of the neurotransmitter some individuals. Excessive use of the Internet can lead to addiction dopamine during excessive Internet use (Renshaw, 2007). Dopamine with characteristics similar to obsessive-compulsive disorders and the is released in the brain during pleasurable and rewarding experiences same type of euphoria reported during impulse control disorders. such as sex, eating or gambling, as well as during use of addictive Internet addiction is a relatively new phenomenon, and research substances like alcohol and drugs. The euphoric state that occurs studies into problematic Internet use are in the beginning stages. during the use of cocaine and other addictive substances correlates One study by Elias Aboujaoude (2011) reviewed Internet habits of with the level of dopamine released in several pleasure centers in the more than 2,500 U.S. adults and found signifi cant rates of online brain. Studies of the brain during online gambling or during sexual pathological behavior across all geographic, socioeconomic, age and encounters have shown effects on the brain’s reward system that are gender groups. similar to those of substance abuse. The data from this study indicated that Internet use often interfered A study by Dr. John Suler (2004) identifi ed dynamics of Internet with the individual’s personal relationships, career goals and family use that enhance its appeal and may lead to addiction. These factors responsibilities, and altered the self-concepts and personalities of many include disinhibition, anonymity, accessibility, the loss of balance or individuals. This study showed that in the virtual world, individuals control, and the lack of any real hierarchy in cyberspace. Suler notes developed an exaggerated sense of their abilities, a superior attitude that “People have the opportunity to separate their actions online from toward others, new moral codes, increased impulsive behavior, and a their in-person lifestyle and identity; they feel less vulnerable about tendency to develop a totally different persona. These characteristics self disclosing and acting out.” may lead individuals to indulge in activities online that they would Anonymity allows individuals to believe their online behavior is separate never consider in real life. from who they really are and thus does not refl ect on their character The Internet has been described as a gateway drug, which has opened and absolves them of responsibility for their actions. These fallacies the door to many addictions. With the development of video games, of thinking allow them to abandon moral and societal boundaries and smart phones, iPads, personal daily planners and wireless computers, behave in ways they would never have considered in real life. some individuals spend more time and are more preoccupied with The invisibility and anonymity online leads to disinhibition because online experiences than real-world ones. Their communications and the individual is able to be alone to engage in risky online activity interactions in every aspect of life are linked to the online virtual world. without judgment or censorship. The person or activity they choose Described by some researchers as the “e-personality,” many individuals is easily accessible 24 hours a day and is often designed to the fi nd themselves in a daily battle between their virtual life and their real- individual’s specifi c requirements or desires.
SocialWork.EliteCME.com Page 64 Aboujaoude (2011) has identifi ed fi ve psychological forces that also ● Darkness, or the ability of the Internet to nurture the sinister, contribute to Internet addictive personalities: morbid side of their personality anonymously. ● Grandiosity, or the feeling that one is more important, more ● Regression, or the marked immaturity that is sometimes seen in impressive and more capable during activities online than in real life. the behavior of individuals online. ● Narcissism, because individuals can think of themselves as the ● Impulsivity, the urge-driven lifestyle that may occur with center of their world on the Internet. excessive online use. SOCIAL NETWORKING
The fi ve psychological forces mentioned above can be found among ● Looking for news online – 60 percent. the seemingly harmless pastime of social networking. As with any ● Finding product information – 43 percent. activity taken to extremes, excessive time on social network sites may ● Connecting to online banking and other fi nancial services – 38 cause problems in the everyday lives of the users. percent. ● Instant messages – 37 percent. The Digital Future Project is the annual identifi cation and examination ● Playing online games – 35 percent. of the social impact of online technology conducted by the University ● Searching for humorous content – 35 percent. of Southern California. The project found the number of hours that ● Membership in online social networks has more than doubled in the Americans spend online has increased in the past few years to an last three years with more than half of online network members, 54 average of 15.3 hours per week, and Internet users reported being percent, logging into their community at least once a day. involved in the following activities at least weekly: ● E-mail – 96 percent. ● Seventy-one percent of members said that their online network is ● Internet surfi ng without a specifi c destination – 71 percent. very important to them or extremely important to them. ● Fifty-fi ve percent said they feel as strongly about their online network friends as they do about their offl ine ones.
The online personality
The Internet provides endless opportunities to reach out to old and off a relationship over the Internet can be quick, to the point, and new friends. For some users, a new identity develops as a result of avoids the unpleasantness of a face-to-face encounter. the novel and diverse online interactions. The online personality But the e-personality, which can remain anonymous without the rules may be very different when compared to what they thought was their and boundaries of the offl ine world, may encourage the online user personality. The result may be an e-personality that despite not being to be irresponsible and act in sinister or morbid ways without caution real, is full of life and vitality (Aboujaoude, 2011). or control. Some may pursue unrealistic and unhealthy goals and be The ability to create and modify the e-personality can allow users to encouraged to behave in more selfi sh and reckless ways. let go of inhibitions and forge new connections and friendships that As exciting as this virtual experience may be, it can lead to real- would have been impossible otherwise. In many cases, the virtual life problems. Beyond changes in the brain dopamine levels and personality compliments and is an extension of their offl ine self. They neurotransmitters that may lead to Internet addiction, online personality may be more effi cient, and more likely to voice opinions. It could characteristics can be carried over into the offl ine interactions where make standing up against injustice by instant messaging or voicing boldness, feelings of power, narcissism, or need for adventure and unpopular ideas over a social network site much easier. Even breaking excitement may interfere with family, school or work activities.
Narcissism and social networking
Whether the new self-image emerges unintentionally or by design, can use the site to gather as many followers as possible and spend even online users can exaggerate their most attractive characteristics and more time soliciting new friends. post them on Facebook with its more than 500 million subscribers. Certainly, the Internet allows people with narcissistic traits to reach a huge audience for their self-promotion. Aboujaoude (2011) says the focus of the letter “i” on Internet URLs and electronic “apps” matches the rise of self-absorbed online narcissism. The “i” is everywhere in what is now called personal social media. From iTunes, iPod, iPad, iChat and iPhone, the cyberspace world revolves around the fi rst-person singular pronoun. Technology is constantly upgrading social networks to satisfy users’ every desire and gives them a sense of control and creativity at lightening speed. Social networking sites provide the perfect media for narcissists because users can spend all day revising their profi les, In a study by Buffardi and Campbell in 2008, 129 undergraduate posting fl attering photographs, infl ating biographies and “tweeting” Facebook users were interviewed, and their Facebook pages were with hundreds of people who have “friended” or “followed” them. analyzed. Researchers administered The Narcissistic Personality Inventory, or NPI, which is a 40-item personality test designed to Twitter uses the term “followers,” a more accurate description of social measure narcissistic traits by asking the recipient to choose between sites that have been extensively used by celebrities in pop culture two statements, for example, “I think I am as attractive as other to build their fan base. A large number of Web-based relationships people,” or “I am more attractive than other people.” In the sample and statements such as, “I have 1,000 friends on Facebook,” set the pairs, the second statement is awarded one point and the fi rst statement standard for popularity on social networks. Facebook had to increase is awarded no points. A high total score on the NPI indicates a high its 5,000-friend limit because people reached it so quickly. Now people degree of narcissism.
Page 65 SocialWork.EliteCME.com The study also included independent raters who did not know the individuals and self-promotion could become the norms for expression undergraduate participants to analyze the students’ Facebook pages on social network sites. Members who want to keep up with their using a number of subjective and objective criteria. The objective Facebook peers will have to increase their self-promotion, which could criteria were based on Facebook components, such as the number of lead to more narcissism, to gather more friends and followers. friends listed, the number of virtual groups they belonged to, the number Mark Leary (2008), a Duke University psychologist, expressed similar of lines of text in the “About Me” section, and the number of wall posts, concerns about the results of this study. He described Facebook’s use which are messages posted on virtual bulletin boards. The hypothesis of self-promotion as a “self presentational vehicle” that resembles was that the participants with the greatest number of friends, virtual advertising. Because ads are made to be self-promoting, it appears that the group connections, wall posts, and lines of self description were more rules of advertising are applied to people when they use social network likely to be narcissistic in life, as judged by their NPI scores. sites. Users select and highlight their most attractive characteristics, then The subjective criteria included the content of the “About Me” advertise them on the network. Facebook and many online dating sites section, rated as self-absorbed, self-important, self-promoting or self- turn into virtual ads, often promoting false profi les that over time may conscious. The type of clothing worn in the main photo was rated as translate into rising levels of narcissism and deception. attractive, self-promoting, sexy, vain or modest. For example, it would be diffi cult to keep a positive self-image with Scores of the objective and subjective measures of narcissism from only fi ve Facebook friends when a friend at school or work has more the Facebook page were then totaled and compared to the participants’ than 500. To prevent feelings of inferiority, some users would have to NPI profi le scores. The results showed that users with high NPI scores enhance their online identity to seem more attractive to increase the were more narcissistic in real life and were seen as sexier and more number of their friends or followers. If Betty and Bob represent the self-promoting in their photograph. The independent raters were able normal, everyday, real life of the average person but feel their profi les to accurately detect the owner’s level of narcissism based solely on are boring, they can reinvent themselves to have a captivating and the profi le content. The higher scores on the NPI were linked to higher stimulating virtual online life. numbers of Facebook interactions and the more interactive, the more The Internet can provide a place for self-conscious or inhibited narcissistic. individuals to connect with each other and gain confi dence. Buffardi and Campbell concluded that because narcissists have more Unfortunately, it also can be diffi cult to tell whether people are social contacts on Facebook than non-narcissists, the average user presenting their real attributes and personality, which ultimately can on Facebook will fi nd social networks have a high representation of result in disappointment or rejection. narcissism. The study also suggests that interaction with narcissistic
Attention span
With instant messaging, texting and Twitter, speed and brevity are Then they send their replies to our Facebook accounts, which send the most important factors. Twitter, the micro-blogging service, us e-mails, which then prompt us to log back in. compacts conversations into 140 characters so no one has to read long Children and teenagers often have diffi culty understanding that facts messages or give long responses. Dictionary.com says the defi nition in real life may be different from what they read on the Internet. The of Twitter is “to talk lightly and rapidly, especially of trivial matters.” overabundance of content on the Internet, which includes facts and Twitter followers can send or receive thousands of micro-messages opinions, is diffi cult for young people to decipher. Information posted simultaneously, and like Facebook, the friend counter shows the on health issues and drug use may be dangerous for young people who number of followers for all to see. It is commonly accepted on the do not have the experience, knowledge and decision-making skills to social network that the more followers you have, the more important, sort fact from opinion. smarter, and popular you are because people want to read your tweets and interact with you online. The increasing problems with attention span and distractibility have researchers questioning whether excessive Internet use may be a Because online encounters using Twitter are quick and to the point, factor in ADHD, which is the most commonly diagnosed behavioral this rapid-fi re communication style can interfere with slower paced disorder. Prescriptions for Ritalin, which is used to treat ADHD, have offl ine reading and writing and decrease attention span and increase signifi cantly increased over the last decade. This disorder leads to distractibility when trying to focus on learning or completing tasks. impairment at home, school and work, and is found in adults as well. College instructors have noted shorter attention spans among students who often skip class to post on Facebook. Several studies have shown a link between ADHD and excessive Internet use. The largest of the studies involved 752 elementary students Nicholas Carr (2008) writes about the problems with attention span in South Korea and found that 33 percent of those who suffered from on sites like Twitter, which highlight superfi cial social network ADHD were addicted to the Internet. A study of 216 college students communication. Carr noted diffi culty concentrating among people in Taiwan compared the rate of ADHD in those who met criteria for who spent excessive time on Facebook activities. Many users reported Internet addiction to the rate of ADHD in those who were moderate feeling trapped by Facebook, unable to focus their attention elsewhere users of the Internet. The results showed that 32 percent of Internet for any signifi cant length of time. Martha Brockrenbrough writes about addicts had ADHD compared to only 8 percent of non-addicts. this worldwide cultural trend: For many, the year passed in a blue-and-white blur of Facebook These studies do not prove that Internet use is the cause of ADHD, but status updates, inane friend comparisons, and awkward they do show a signifi cant correlation between ADHD and excessive “poking” situations with complete strangers. We spent hours Internet use. throwing cupcakes at people we barely spoke to in high school. With the 140 key stroke-limit set by Twitter before reaching We compared our tastes in movies with our ex-boyfriends’ new information overload, it is not surprising that youngsters who use this girlfriends. We let everybody know we were fans of Starbucks and form of communication exclusively will have a short attention span for “Battlestar Galactica,” and pants. Worse, where we used to just longer, more traditional texts and responses. send e-mail messages, now we send messages through Facebook so everyone can see what we have written. Just as someone might spend too much time at home working on the computer, studies have shown that many people spend too much time
SocialWork.EliteCME.com Page 66 at work being distracted by social network sites, which is called “cyber ● According to a 2005 America Online study, 45 percent of 10,000 loafi ng.” This can have high costs for employers: workers listed Internet use as the number one distraction at work. ● A New Zealand security fi rm estimated personal Internet use at ● The Harris Interactive Web Sense study reported the cost to U.S. work to be as high as 25 percent of the total online time. employers from cyber loafi ng at $178 billion dollars annually.
Privacy and security
There have been numerous accounts of tragedies that have occurred loss of privacy, the security of all kinds of information on the Internet because of the lack of privacy on the Internet. Anyone can write and is also at risk. send almost anything they want, making it impossible to maintain Many people choose simple passwords and use them on many different privacy in cyberspace. This was shown recently when an 18-year- sites. Even if a Facebook account is closed, it will not permanently old freshman committed suicide by jumping from a bridge after his remove archived user content that remains on the company’s servers. roommate posted a video of the freshman having sex with another Content delivery networks (CDN), which are used to manage data and man. He thought he was in the privacy of his dorm room and did not distribution, copy the data to multiple intermediate devices to speed up know that his roommate had a remotely activated webcam running access to fi les when millions of people are trying to access the service and was streaming live video of him and sharing it with others. Two at the same time. Changes are not refl ected across the content delivery days later, the roommate sent his 148 Twitter followers another network immediately and copies of fi les can still be found. message that anyone with iChat should video chat him between 9:30 and midnight because the young man was having another visitor in his This was scientifi cally demonstrated in 2009 in a Cambridge University room that night, and the camera would be rolling. study where a group of computer scientists found that nearly half of 16 social networking sites they tested did not immediately remove pictures The incident ended with a criminal trial, but the roommate received when a user requested they be deleted. During the experiment they only probation because his actions were conducted through cyberspace uploaded photos to each of the sites then deleted them, recording the and he could not be held accountable for the suicide. direct URL addresses to the pictures from the site’s CDN. When they Most online users are not driven to suicide, but detailed and permanent checked 30 days later, those links continued to work for seven of the online records can ruin reputations and have devastating effects when sites, even though users would assume the pictures had been removed. embarrassing or incorrect information is posted online. Along with the If the pictures had gone beyond the boundaries of the social network site, they would be impossible to delete.
Online dating and sex
The Internet has revolutionized the dating world with numerous encounters and is especially harmful for youth who are not fully aware relationships sites and an unlimited number of subscribers. The six- or capable of understanding the dangers online encounters may hold. month subscription to Match.com includes a warranty that if a person The Internet, with its false sense of security coupled with disinhibition, does not fi nd someone special in six months, he or she will get an impulsivity, grandiosity and accessibility, can lead to increased risks initial six months free. of acting outside the bounds of normal behavior. The feeling of Plentyofi sh.com is one of the fastest growing relationship sites on the anonymity and false sense of control trump common sense, inhibition, Internet, and eHarmony advertises a compatibility matching system judgment or fear. When individuals are struggling with self-concept, that claims to fi lter millions of potential matches to a specifi c group of gender identity issues, loneliness, or just beginning to experiment with singles who are compatible based on 29 characteristics of personality. dating or sex, they are especially vulnerable. According to eHarmony, the matches are based on scientifi cally The real-life dangers of Internet encounters can be life altering in determined characteristics of long-term relationships. a negative way. It is impossible for people to verify that the online More than 15 million people are estimated to be subscribers to dating profi les they have selected are real or truly represent the individual. websites, and many people fi nd themselves in dating relationships as a One study led by Dr. Jeffrey Klausner (1999) revealed that 67 percent result of their participation. The Internet has changed social norms and of patients surveyed with syphilis, compared to only 19 percent of all of the rules of traditional communication, romance and dating. healthy control subjects, said they found their sexual partners online. Many of the sites include pictures, although people still exaggerate This shows one negative outcome of the online search for sex and off- their attributes and misrepresent every aspect of their profi le in some line sexual behavior and sexually transmitted diseases. cases. It is impossible to have success meeting someone online Paige M. Padgett (2007), Ph.D, of the University of Texas School of without including a picture, which points to the importance of physical Public Health, studied the effect of the Internet on the health and safety appearance. On some dating sites, just the picture of the match comes of women seeking men through online sites. The 740 women who up fi rst with the idea that if the person’s appearance is not acceptable, completed the study survey included 568 women who reported having there is no need to read the profi le. Helen A.S. Popkin (2009) wrote an met in person with a man who had contacted them as a result of their article entitled “The Internet Makes Me Feel Fat,” which includes the online dating ads. Their ages ranged from 18 to 78 years of age, with following passage: an average age of 38. The results of the study showed: In the Internet age with its endless playground for re-invention ● Women relied heavily on their online communication with men and resources for human understanding, it’s painfully clear just when considering safety and boundary issues, such as sexual how fond we are of appearances. Even in the world, especially in a preferences, STD history and condom use. world where computers control our illusions, nobody wants to feel ● 77 percent of the women did not use protection during their fi rst like, let alone be seen as, anything less than and “8.” That many sexual encounter with men they met online. people use enhanced cyberspace images is making many people ● Women in this study felt they knew the men quite well because more self-conscious than ever. they had an Internet relationship with them already and did not see the sexual encounter as a one-night stand. Beyond increasing individuals’ ability to socialize with like-minded ● They relied heavily on instinct, intuition and feelings, and felt people, the Internet may also facilitate casual and random sexual overly confi dent in their online opinion of the men.
Page 67 SocialWork.EliteCME.com ● They believed they could sense whether it was safe to meet the ● One-fourth of the teenage girls and young women said they had men by analyzing how they communicated via e-mail. seen sexual images intended for someone else. ● One-fourth of the teens admitted that technology makes them feel This data points to the false sense of security the women had based on more forward and aggressive. their online communication, which led them to engage in at-risk sexual ● More than one-third of the respondents agreed that exchanging behavior. sexual content makes real-life sex more likely. There are not many studies among teenage girls and young adults, ● Nearly one-third of the girls believed that exchanging explicitly but the young generation is growing up with different feelings sexual content was expected to get a date. about sexual encounters that were not seen prior to the Internet Based on the research presented so far, it would seem that the digital social networking craze. The 2008 survey of 1,280 participants, age makes dating, long-term relationships and the pursuit of true love commissioned by the National Campaign to Prevent Teen and more diffi cult as people try to search on the constantly changing, Unplanned Pregnancy, illustrates this point. According to the survey: ● Electronic exchange of sexual content, called sexting when using a dubious online social networks. With Twitter, as with online dating cell phone, has become very common among teenagers and young sites, users power-date with few words, which can complicate real adults. romance and long-term relationships. ● Of all teenage girls surveyed, 22 percent said they had posted According to Charles M. Blow (2008), there seems to be a major online, e-mailed or sexted nude or semi-nude images of change in the way teens view sex and dating, citing a report that noted themselves. more high school students said they have never dated than said they ● Of teen boys, 18 percent reported posting or sending such pictures dated frequently. Blow writes, “Under the old model, you dated a few of themselves. times and, if you liked the person, you might consider having sex. ● Young adults ages 20 to 26 are even more likely than teens to have Under the new model, you ‘hook up’ a few times, and if you like each sent nude or semi-nude images, with 36 percent of women and 31 other, you might go on a date.” percent of men reporting this behavior. The rules people have followed for years have changed due in part to ● Two-thirds of the teenage girls said it was fun or fl irtatious to send Facebook, online dating sites, Craigslist’s sexually explicit personal these pictures to boys. ads, and easy access online to sexually explicit pornographic materials ● 50 percent said it was a sexy present for their boyfriends. that are outside the boundaries of decency for adults who did not grow ● 40 percent said they sent the pictures as a joke. up experiencing dating and sexual experimentation online. ● One-third of the teen boys and 40 percent of the young men said they have seen sexually suggestive images intended for someone else. For many adults and youths, social networking on the Internet creates confusion and feelings of inadequacy because of the emphasis on appearance over honest interactions.
Case study: Rick
Pleasant and well mannered, Rick was a 25-year-old man with good online matches result in confrontations that will be damaging to both looks and an engaging personality. He went to see a psychologist individuals depending on the amount of commitment, length of the because of symptoms of depression that had occurred after a long- online relationship, and the emotions of both parties. term relationship ended. He had become socially isolated from others Rick had to learn about the often false, self-promoting profi les on the and was spending excessive amounts of time looking for a romantic Internet and how they had contributed to his feelings of inferiority, relationship on a popular classifi ed website. which were unwarranted, based on false social networks profi les. Along Rick became discouraged because he saw nothing but profi les of other with his therapy sessions, he came across an article that explained in a men with perfect bodies, great incomes and graduate level degrees. humorous way the exaggerated terms used on social networks and what Rick fi gured he was no match when it came to attracting women when they often represent. That gave him the confi dence to take some initial compared to his competition online. He felt too inhibited to post a steps in more open, traditional venues for meeting others. truthful ad about himself, let alone a made-up one. He felt that he According to the University of Southern California 2008 Digital would never have a chance to meet a match online and became more Future Project, as many 50 percent of Internet users believe most isolated and depressed. or all of the information online is reliable. Their research found that His psychologist suggested that he should try to meet someone the exaggerations like those listed in online personal ads, dating profi les traditional way at church or by joining a group with others of similar and social network sites are likely to generate more interest than doubt interests, but his lack of confi dence prevented him from joining any or avoidance of the Internet. social groups. Just as online advertising works, online self-promotion works, too, The online profi les were actually holding him back because of his lack and people who live more online than off turn to the cyberspace for of confi dence in his ability to attract someone online. The psychologist relationships. Cyberspace relationships work until the fi rst contact told Rick that people often exaggerate or make up their characteristics with reality and often end negatively, which may cause more serious and attributes, but eventually, they will have to come in contact problems if the online users have underlying mental disorders. with reality when they meet an individual. He told Rick that many
Case study: Yvette
Yvette, a 45-year-old with a history of bipolar disorder, thought Neither of them had the money to travel overseas to meet, and one day she had found her perfect love online after meeting a 38-year-old during a manic episode, Yvette thought she remembered a conversation Frenchman named Pierre on a singles website. She did not mind the with Pierre the previous night in her bedroom. She noticed some long-distance relationship, and that he appeared to live in southern scratches and believed that they, along with the exhaustion and night France seemed exotic and romantic to Yvette as she fantasized about sweats she was having, were the result of many passionate, all-night strolling along the sea, hand-in-hand with Pierre. lovemaking sessions with Pierre. She believed those physical symptoms were evidence that her online love affair with Pierre was real.
SocialWork.EliteCME.com Page 68 The sinister side of social networking
In addition to social networking designed to promote friendships and emergency and may order the disconnection of any federal government dating, many radical groups use social networks to recruit online. or United States critical infrastructure information system or network.” Neo-Nazis, Skinheads, Ku Klux Klan (KKK) and various extremist, It would give the president what has been called an “Internet kill racist, militia and gang organizations are growing in number from switch” to go along with the nuclear defense activation switch. online networking and promotion. The number of such groups in the Many statistics show the sinister side of the Internet, where engaging U.S. is on the rise, according to the Southern Poverty Law Center. The in objectionable material for sexual fantasies, identity theft, cyber worldwide Jihadist movement Al Qaeda has networks in cyberspace fraud or other cybercrimes can enable the violent and criminal side of called As-Sahab, Arabic for “the cloud.” The website comes with human personality and behavior. More than 20 million Americans were instructional videos and text on building bombs, fi ring surface-to-air victims of online identity theft in which their personal information missiles, obtaining fake documentation, and directions on how to leave was stolen from a website transaction. Many companies fell victim to and enter the country unnoticed. Its terrorist members have grown computer hacking and information theft, with trillions of dollars lost from less than 100 in 2000 to more than 5,000 today. and extensive costs incurred to repair the cyber damage. In 2009, President Obama added a high-level cyber security position to The U.S. government is not completely secure either, with more coordinate the response to cybercrime by the Pentagon, The National than 5,000 security breaches of government computers, including Security Agency, and the Department of Homeland Security. The hackers breaching White House computers to intercept offi cial president said the goal would be to “detour, prevent, detect, and defend e-mails as recently as June 2012. No individual or agency is safe from against cyber attacks.” The Protecting Cyberspace as a National Asset cybercrime, which occurs anywhere data is posted online. Act proposes to give the president the power to “declare a cyberspace
Case study: Carl
Carl graduated from school and was excited about making money in There are many examples of deceptive and harmful behavior on the his new online investment company. He proposed to focus on retirees Internet every day. The online culture regularly reinforces the cruel on fi xed incomes that he met on social networks or from lists he side of the social networking. An example of that is the Megan Meier retrieved online from marketing sites. He encouraged the seniors to case. The 13-year-old Missouri girl was the victim of a hoax when she invest their savings in high-risk Internet stocks, including investing believed she had found an Internet boyfriend – who turned out to be money in his new company. the 49-year-old mother of a girl with whom Megan had argued. The Internet makes it easier for some users to ignore rules of ethics Lori Drew, the mother of the other girl, had posed as the boy on that govern conduct and behavior in real life. Carl had always been MySpace, and for weeks told Megan she was beautiful and sexy and well-respected in the community and was a member of a number of led her on, only to later began a vicious online attack with hurtful civic organizations that completed service projects for the betterment insults posted on Megan’s site for all to see. One day, the “boy” told of the community. This well-mannered, sociable, respected member of Megan he hated her, and that the world would be better off if she were the community was able to work outside of ethical or moral codes when dead. Later that day her mother found her hanging dead in her closet. it came to his Internet investment company. Protected by anonymity and Drew was accused of cyberbullying and convicted of a misdemeanor the lack of laws governing online trading and investments, he could run a for fraudulent use MySpace. Two years later, a federal judge threw out company that violated community standards and ethics in the offl ine world. the conviction. CYBERBULLYING
Children are often victims of cyberbullying on social networks, among the victims who do not know who the bully is, when and where and the number of cyberbullies is increasing. According to Dr. they might strike, and who therefore cannot protect themselves. Robin Kowalski, Clemson University psychologist and author of The victims often become socially isolated, avoiding playgrounds, school “Cyberbullying: Bullying in the Digital Age,” cyberbullying occurs buses and any area where they could be attacked. But cyberbullies can through e-mails, chat rooms, instant messages, social networking sites, strike 24 hours a day, seven days a week through a social network. Children digital images and messages sent via cell phones. It is different from are often afraid to tell their parents about the behavior for fear the parents traditional playground and school bullying, and data suggest higher will take away their cell phones and Internet capability. victimization rates, as much as 50 percent of children. Kowalski also notes that when people tease or bully face-to-face, the Because of the anonymity of the Internet, more individuals are victim can usually fi gure out the intent behind the behavior with verbal cyberbullies than schoolyard bullies. Not only is the number of and nonverbal clues. Cyberbullies do not acknowledge the pain that cyberbullying cases increasing, but so is the severity of the threats and they cause their victims because it’s invisible to them, and the victims the aggressiveness and violence of the content, according to data from cannot tell whether their bullies are serious about their threats. The National Institute on the Media and the Family. A number of negative consequences can occur from the bullying, Unlike traditional bullying, the identity of the cyberbully is unknown including bad grades, school phobia, fear, social withdrawal, to at least half of the victims. This leads to higher levels of anxiety depression, suspicion, anxiety and suicide. Many families move or change schools to try to end the cyberbullying. ONLINE VIOLENCE
Ninety percent of U.S. children aged 8 to 16 play virtual video games logical to expect that these children will become more violent offl ine or visit online sites that are classifi ed as being appropriate for their as well as online because of the violent, mature content of the online age but contain violence. Amazingly, 80 percent of underage children material easily accessible to them. who try are able to purchase mature-rated material online. It could be
Page 69 SocialWork.EliteCME.com One of the largest studies to address this issue was led by psychologist accidents and unspeakable acts of cruelty and violence are shared Craig A. Anderson of the Center for the Study of Violence at Iowa online and through YouTube. Some view these sites out of curiosity, State University. The study included three groups of young people but others enjoy view them as entertainment. ages 9 to 18 from the United States and Japan, totaling more than It does not take much to progress from thinking virtual violence is 1,500 participants. The study evaluated over time whether repeated entertaining to fi nding it sexual. The Philip Markoff case illustrates the exposure to violence online leads to an increase in physical aggression. online curiosity, attraction and correlation between sex and violence. Results showed that children involved in violent online activity early In 2009, Philip Markoff, a 23-year-old Boston medical student, became in the school year were twice as likely to show aggressive behavior known as the fi rst “Craigslist Killer.” Markoff was charged with killing later in the year compared to those who were not accessing violent a masseuse and aspiring drug counselor, Julissa Brisman. Markoff online sites. The difference was still there after researchers corrected allegedly had booked a “sexual release” massage with Brisman. for gender differences and differences in baseline aggressiveness. Four days before Brisman’s slaying, Markoff had bound and robbed The study offered two types of evidence to show a connection a Las Vegas hooker at the Boston hotel, police said, and robbed an between aggression and excessive exposure to virtual online violence. exotic dancer in Rhode Island. In 2010 while in custody, Markoff The study supports the theory that increased aggression occurred in committed suicide. individualistic cultures with high societal levels of physical aggression and violence, like the United States, and in more mutualistic or With his good looks, credentials, intelligence and status, Markoff did collectivistic cultures with low levels of physical violence and not fi t the profi le of someone who could hire prostitutes or commit aggression, like Japan. It also found that the power of virtual violence murders and violence. He was described as well dressed, handsome, to affect children’s development in an aggressive way is not altered by blond and intelligent with no criminal record. He was a student at a culture that has a low overall tolerance for violence. Virtual violence Boston University Medical School and was engaged to a medical seems to cause increased violence in cultures with very low baseline student he met while volunteering in a local emergency room. levels of aggression and different parenting practices. Markoff had met all of the victims through Craigslist. According to The study also contradicts alternative hypothesis that only children with attorneys general from 40 states, a section that was called “erotic aggressive tendencies will have problems with aggression in the future, services” on Craigslist violated anti-prostitution laws, but the site still and it points to a need to use caution and develop preventative measures lists “adult services.” Markoff might have felt he could evade law and restrictions to address the spread of violence online and off. enforcement and his crimes would be diffi cult to trace. The ads gave him easy access online to women who were desperate for money and in an The studies of the dangers of online violence show greater impact environment that works outside of the law. The Internet had enabled him on personality and behavior than violent TV shows, movies, graphic to assault, batter, rob and murder because he appeared to have the profi le novels and violent music lyrics, which have been studied over the of a man with a bright future, anything but a serial killer. years. The interactive nature of virtual violence, the total immersion in the activity, the capacity to reward and punish others with violent acts, Media coverage of the story revealed that Markoff also used Craigslist and the fact that the user is totally focused for long periods of time, to meet men for sex, trading nude photos and e-mails that were makes online violence more powerful than other form of media and sexually explicit and graphic. He described himself as “quite a catch” potentially more addictive. as an unattached medical student. No male victims came forward, but a number of men commented online that Markoff was sexy and hot, Dr. Vladan Starcivic, a psychiatrist at the University of Sydney and that they would like to see the nude photographs and wished they Australia writes: had met him. One man even expressed regret that they had not gotten In the virtual world, a violent player may kill or injure computer- together because “he liked bad boys.” generated characters or other online gamers without any consequence, including punishment. While many video games Elias Aboujaoude (2011) writes about the ordinary, everyday provide a story that primes the player to kill, there is very little viciousness found on the Internet: room for moral consideration of killing, and to kill invariably Less inhibition in the virtual world means that the threshold to benefi ts the player more than exercising restraint. The players are act on violent impulses is lower, but so is the threshold to forgive likely to be rewarded for killing, by means of points, more powerful others or ourselves for such actions. Desensitizing aggression, weapons, or their own survival. and turning it into entertainment, into something thrilling or even “hot,” serves to make amoral or violent online manifestations His studies and others have found that the virtual world can desensitize lesser deals than they ought to be. So besides increasing someone’s users to violence and to what is immoral or indecent. Violent images access to victims, online venues may also provide the person with no longer disgust individuals as they once did, and violence as a psychological out, convincing him that the extreme act will fi nd entertainment adds to the desensitization. There are thousands of an understanding audience online, one willing to absolve the violent posts online, which gain instant notoriety and are watched perpetrator and pardon the offense. around the world. Videos of tragic acts of God, painful, tragic
Case study: John Doe
The case of John Doe is a one example of a tragedy that occurred with the county medical examiner’s offi ce who read the online blog. because of individuals who were desensitized to aggression, violence One viewer wrote to advise Doe that he didn’t take enough pills to kill and the pain of others. John was a lonely, depressed, 19-year-old himself; another called his suicide “Internet Darwinism,” while others community college student who saw online chat rooms and social called him derogatory and obscene names. media as sources of support and substitutes for therapists, friends and As Doe was dying on his bed, faced away from the camera, many family. Message boards are “like a family to me,” he posted on his blog. hours passed. Some viewers mentioned he had not moved in a long In November 2008, he wrote, “Ask a guy who is going to OD again time and questioned whether his body was being shown on a live tonight anything.” Doe started a blog and linked it to a page with a webcam or was a fake still shot. Some believed the whole situation live video streaming website. The cameras recorded his overdose on was a hoax. A viewer in Doe’s online network found a cell phone prescription pills with viewers urging him to go on, taunting him, name number Doe had posted, and several people attempted to call him, but calling, saying, “Go ahead and do it,” according to an investigator
SocialWork.EliteCME.com Page 70 no one called an agency for help. Messages continued to be posted Before Internet access, only medical or scientifi c professionals would using anti-gay slurs and urging him to commit suicide. have had this information, and someone would have to search in Later one person did contact the police, and they tracked him down medical/scientifi c libraries to fi nd methods of suicide. The study through his computer Internet protocol (IP) address. The police described several individuals who committed suicide with unusual arrived, and on the live video stream, 181 viewers watched as police methods they learned online or in chat rooms, which could be traced broke down the teen’s bedroom door and attempted to revive him. to their computers. These studies and others suggest that mental health They watched live and returned to view the video where Doe was practitioners should question clients about their Internet searches for pronounced dead 12 hours after he started his suicide blog and video. suicide, especially if they are depressed or have discussed suicide. The online tragic episode shows the high degree of desensitization and Whether it is a suicide chat room, cyberbullying, hate group recruitment, no regard for the pain of others. The power of online voyeurism and fabricated online dating profi les, cybercrime, or the urge to post and view violence captivated viewers for 12 hours. Unconcerned about Doe’s violent material, cyberspace seems to bring out aggression, violence and online suffering, viewers found it exciting to participate in the suicide, anti-social behavior in some individuals. The Internet has infi ltrated every forwarding it to others online and returning to watch it again. aspect of life, and has the potential to be more dangerous than any other form of media. With its interactive qualities, lightning speed and unlimited Another frightening aspect of social media today is the writing of access, it is easy to understand why Internet addiction is becoming more suicide packs among a number of strangers who “friend” one another prevalent and will be included in the DSM-5. online for the purpose of dying together. Suicide pacts have led to death and near-death and have been documented around the world. Many dangerous and criminal activities occur online that cause serious One case from the Suicide Chat Room for Young People in 2005 and sometimes deadly results. In 2009, the White House made the found depressed participants as young as 12 who were matched up decision to expand cyber security beyond governmental agencies and with people who had access to lethal methods for a mass suicide plan appointed a cyber security czar to address online fi nancial scams, involving 32 individuals. Information from the IP address led police to illegal gambling, child pornography rings, cyberbullying, stalking, arrest a man believed to be the leader. identity theft, and illegal spyware that affects the public. Psychologist Irving Janis (1972) has discussed “a mode of thinking Online gambling and child pornography are two of the most serious that people engage in when they are deeply involved in a cohesive activities that are infl uenced by the anonymity, accessibility, affordability, in-group and when members’ strivings for unanimity override their disinhibition and grandiose thinking that someone can control, win or motivation to realistically appraise alternative courses of action. This experience whatever they desire on the Internet. It was estimated that: ● More than $100 million was wagered daily through online poker group thinking seems to inhibit dissent and the option to counter the sites (Walters, 2005). interest of the group and their single agenda.” This is the online form ● The regulation of online sexual content and child pornography is of the crowd mentality that has been studied and documented. a major area of concern; more than 10 percent of all web pages, Brown University psychiatrist Patricia R. Recuperto and her research 25 percent of all searches, and 35 percent of all downloads are team reported on the type of information a desperate person might pornographic in nature (Family Safe Media, 2006). fi nd through a simple Internet suicide search. Their goal was to assess ● When the subject is a child, the online activity becomes criminal online suicide resources using fi ve popular search engines and four behavior, and one report found that one in fi ve youths has been common suicide-related key word searches. The results found more sexually solicited online (Offi ce of Victims and Crimes). than 50 pro-suicide websites that described methods of suicide that are The growing Internet addiction problems of pornography and not known to the general public. gambling will be covered in detail in the following sections. INTERNET ADDICTION
The debate over whether Internet addiction is an independent disorder ● Negative repercussions, including arguments, lying, poor that deserves to be included in the Diagnostic and Statistical Manual of achievement, social interaction and fatigue. Mental Disorders (DSM) or simply a new manifestation of other mental Some of the most interesting research on Internet addiction has been disorders is currently being debated in the mental health community. published in South Korea, where rates of online use are much higher Some questions that must be answered are what constitutes a legitimate than those in the United States (Choi, 2007). After a series of 10 pathology when it comes to the Internet, what level of Internet use is cardiopulmonary-related deaths in Internet cafés and a video game- excessive, and what negative real-life consequences result. related murder, South Korea considers Internet addiction one of its most The American Psychological Association is currently revising the serious public health issues. In one case, a 28-year-old boiler repairman DSM-5, which is due to be completed May 2013. It has determined suffered a cardiac arrest following a 50-hour Internet gaming binge that Internet addiction does appear to be a common mental disorder during which he did not eat, sleep or take a break. His death prompted that merits inclusion in the DSM-5. an investigation into the problem of Internet addiction in Korea, where The diagnosis of Internet addiction falls in the compulsive-impulsive current estimates are that 4 percent of children suffer from the disorder. spectrum disorder that involves online and offl ine computer usage and Using data from 2006, the South Korean government estimates: consists of at least three subtypes: ● Approximately 210,000 South Korean children ages 6 to 19 are ● Excessive gambling. affl icted and require treatment. ● Sexual preoccupation. ● About 80 percent of those needing treatment may need ● E-mail/text messaging. psychotropic medications. ● An estimated 20 to 24 percent require hospitalization. These subtypes show the following four components: ● Excessive use, often associated with the loss of sense of time, or ● The average South Korean high school student spends about 23 neglect of basic drives. hours each week on online gaming. ● Withdrawal, which includes feelings of anger, tension and ● Another 1.2 million are believed to be at risk for addiction and depression, when the computer is inaccessible. require basic counseling (Ahn, 2007). ● Tolerance, including the need for better computer equipment, more software and more hours of use.
Page 71 SocialWork.EliteCME.com ● In addition, therapists worry about the increasing numbers of ● As of June 2007, South Korea had trained 1,043 counselors in the individuals dropping out of school or work to spend time on treatment of Internet addiction and enlisted over 190 hospitals and computers. treatment centers (Ahn, 2007). ● Preventive measures are now being introduced into schools.
Prevalence
In China, 13.7 percent of adolescent Internet users – about 10 million in the United States games and virtual sex are accessed from home. teenagers – meet Internet addiction diagnostic criteria. In 2007, China Attempts to measure the phenomenon are hampered by shame, denial began restricting computer game use, and current laws discourage more and diminished reporting by recipients. than three hours of game use per day (Peoples Daily Online, 2007). The issue is further complicated by co-morbidity. About 86 percent of Online use by adolescents in European countries ranges from 1 to 9 Internet addiction cases have some other DSM-IV diagnoses present, percent; Middle Eastern countries between 1 and 12 percent; and Asian and in one study, the average patient had 1.5 other diagnoses. In the countries between 2 and 18 percent (NIH, 2010). United States, unless the therapist is specifi cally looking for Internet United States estimates of the prevalence of Internet addiction are not addiction, it is unlikely to be detected. In Asia, however, therapists are consistent. Unlike in Asia, where Internet cafés are frequently used, trained to screen for excessive Internet use.
Etiology
Most researchers currently model Internet addiction criteria on Internet state had an equal chance of being called. Cell phone numbers were gambling addiction. Key components of Internet addiction include: not included to avoid costs to the recipients of the survey. In addition, ● Preoccupation with the specifi c content or behavior. telephone numbers were called 15 times before being disconnected. ● Repeated unsuccessful attempts to reduce or control Internet use. Fifty percent of the people contacted participated in the survey, which ● Mood disturbances from attempts to reduce use. is considered a signifi cant return for a health-related telephone survey. ● More Internet use than anticipated or desired. Individuals responding to the survey were 18 years of age or older ● Problems with employment, relationships or education caused by with the average age of 48, and 51 percent of the respondents fell in excessive use. the middle-class socioeconomic level. ● Hiding or lying about Internet use. An analysis of the data revealed that 14 percent of the general There are signifi cant differences between Internet addiction, substance population shows indicators of problematic Internet use. The survey addiction and gambling addiction. Behaviors or substances that often resulted in the following data: lead to addiction, such as alcohol, gambling, tobacco or drugs, have ● Four percent responded they were preoccupied with the Internet structured legal sanctions governing their use. Drinking alcohol or when they were offl ine. using drugs while driving, at work or school are examples. ● Six percent felt their personal relationships had suffered as a But excessive time searching the Web does not fall under any specifi c consequence of Internet use. legal sanctions unless child pornography or other illegal activity is ● Six percent regularly went online to escape negative thoughts and involved. Using the Internet at work and social networking at home is feelings. a routine and accepted activity. The same cannot be said for gambling ● Nine percent felt they had to hide their Internet use from others. or child pornography. ● Eleven percent regularly stayed online longer than they intended. ● Fourteen percent had diffi culties staying offl ine for several days in With the current understanding of genetic predisposition as well as a row. biological and environmental components to behavioral addictions, a ● There were no signifi cant differences attributed to geographic number of different factors may infl uence the development of Internet locations or ages among the participants. addictions in some people. Existing research on Internet addiction has revealed specifi c subpopulations that are at increased risk, including Genetic studies have indicated a possible predisposition to Internet those with other psychological co-morbidities including obsessive- addiction linked to genes that are known to be involved in the compulsive disorder (OCD), attention-defi cit/hyperactivity disorder transmission of dopamine. In a 2007 study led by a Harvard psychiatrist, (ADHD), post-traumatic stress disorder (PTSD), impulse control teenage boys engaged in excessive online video game play, an average disorders, anxiety, and depression. of 2.3 hours per day, were studied against a control group who were online for only 0.8 hours a day (Renshaw, 2007). By analyzing DNA In a study completed by Aboujaoude (2011), a telephone survey was samples from both groups, the genes involved in dopamine transmission conducted with 2,513 adults from all 50 states. Subjects were selected were studied. The results show that the group who engaged in excessive using a percentage of the population and demographics of each Internet use did have versions of the two genes that are known to be state. Because the DSM-5 diagnosis criteria has not been completed, present in individuals with alcohol and nicotine dependence. diagnostic criteria was taken from well-established psychiatric conditions that share similar features with Internet addiction, including The study suggests that the brain’s neuron pathways and what activates OCD, pathological gambling and substance addiction in the DSM-IV. the neurotransmitters might predispose some individuals to Internet obsession leading to addiction. Scientifi c studies indicate identifi able The sample was developed using random-digit telephone calls of listed changes that occur in brain chemistry as individuals become more and unlisted residential numbers so that the populations within each involved in the online world.
Signs and symptoms of Internet addiction
Researchers have been trying to defi ne the set of symptoms that ● Do you feel preoccupied with the Internet or online services and constitute an Internet addiction. Psychologist Kimberly S. Young from think about it while offl ine? the Center for Online Addiction classifi es people as Internet-dependent ● Do you feel a need to spend increasingly more time online to if they meet the criteria listed below: achieve satisfaction?
SocialWork.EliteCME.com Page 72 ● Are you unable to control your online use? ● Do you risk the loss of a signifi cant relationship, job, and ● Do you feel restless or anxious when trying to reduce or stop your educational or career opportunity because of excessive online use? online use? ● Do you keep returning to the Internet even after spending too ● Do you go online to escape problems or feelings such as much money on online fees? depression, guilt, anxiety or depression, or boredom? ● Do you go through feelings of withdrawal when offl ine, such as ● Do you lie to family, friends, or coworkers to conceal how often increased depression, anxiety, moodiness, or irritability? and how long you stay online?
Case study: Bill
A patient named Bill was a man in his 20s, with fl at affect and a cyberspace world, but the person behind the virtual girlfriend also fell history of treatment anxiety. He went to see a psychologist at the for the fabricated athletic, wealthy, CEO persona without questioning urging of his fi ancée. Bill had secretly joined an online community that his real identity or perhaps just simply enjoyed engaging in the fantasy. promoted dropping out of real life and living in whatever virtual reality Bill felt fulfi lled enough in the virtual relationship to justify breaking or alternate state one wished to design. off with his fi ancée. His virtual life was more satisfying and less For the fi rst time, Bill was free to develop any socioeconomic, complicated than his offl ine relationships. It never occurred to him that psychological or physical profi le he wanted. Bill suffered from social his perfect new girlfriend in real life might be a 49-year-old housewife anxiety, so he designed the most attractive, gregarious and successful with a husband and four children looking for her own fantasy. People online personality he could. On this new life website the user can pick like Bill and his online girlfriend are excited by the virtual world that and choose characteristics to make him- or herself a fantasy individual, gives them all the feelings of living in a thrilling fantasy world. They and Bill developed a new persona as a handsome, former NFL star fall prey to the online life they can never have in reality. player now in his mid-30s. He changed his virtual career to become Lynn Roberts, who has researched cyber psychology, describes some the wealthy CEO of a high-tech company and boasted about living in a of the possible physiological correlates of heavy Internet usage: waterfront condo with great views from his penthouse. ● A conditioned response, including increased pulse and blood As time went on, Bill did not just pretend to have the life he’d always pressure as the modem connects. dreamed of, he became obsessed and told his psychologist he preferred ● An altered state of consciousness during long periods of to live in his virtual life. He spent most of his time online, and when interaction, including total focus and concentration on the screen, talking about his virtual life, he showed enthusiasm and confi dence. similar to a meditation or trance state. ● Dreams that appear in scrolling text. Before long, Bill’s online obsession had become all-consuming, and ● Extreme irritability when interrupted by people or events in real he begin to doubt the value of his real life compared to the one he had life while engaged in cyberspace activities. created in his virtual world. The everyday life he had always known, with its problems and anxiety, was now second to his virtual life. Psychologists often identity patterns that are common to all forms of addiction, and these can be applied to Internet addiction (Suler, 2004). He would check online at least once an hour and often ignored These patterns are: responsibilities at work and home. Bill passed on extra work ● Are you neglecting important things in your life because of this assignments with overtime pay and only did the bare minimum behavior? required. On one occasion, he had a choice to go to a party with his ● Is this behavior disrupting your relationships with important fi ancée or to go online to his virtual penthouse. Because his priorities people in your life? were now held by his virtual life, he skipped the party with his fi ancée. ● Do important people in your life get annoyed or disappointed with Bill became increasingly more agitated when he was not online, and you because of this behavior? his fi ancée grew increasingly hurt and angered by his virtual life and ● Do you get defensive or irritable when people criticize your online hoped that it was a phase he would outgrow. When Bill introduced behavior? her to another virtual resident who had become his virtual girlfriend, ● Do you feel guilty or anxious about what you are doing? she demanded that he seek treatment. He was in a sexually interactive ● Have you ever found yourself being secretive and trying to conceal relationship with this new online girlfriend who had all the features this behavior? and characteristics he had always desired. ● Have your attempts to try to curb your Internet use failed? He later told the psychologist that his real world had become ● If you are honest with yourself, do you feel there is another hidden overrated, and his real-life girlfriend had become too demanding need or problem that drives this behavior? and the relationship was full of problems. Bill had perfected himself People who are addicted to the Internet become disassociated from and his life online, so he made the decision to leave his fi ancée and the reality of life and preoccupied with their Internet cyberspace life discontinued therapy sessions. (Kihlstom, 2005). They may act out pathologically in cyberspace Bill told the psychologist that even though he knew he had crossed because they are dissociated from real life. Their Internet activity into a fantasy world, he did not see that as something bad. He did say becomes a new, separate world, and they may feel too embarrassed, that he would try to live more in the real world even though he found it guilty or ashamed to share it with people in real life. Their Internet dull and uninteresting. He never wanted to completely withdraw from activity becomes an isolated, secretive, alternative life, providing an his virtual life, and Bill did not return to therapy. escape from real-life problems. In their cyberspace world, fantasies are acted out without the constraints or consequences of the real world. Bill was addicted to his online world and met all of Young’s online addiction criteria listed above. Not only was Bill addicted to his
Diagnosing Internet addiction
Powerful social, sexual, and gambling activities can be readily “The Internet is the equivalent of an electronic needle, a potent accessed through the Internet. Dr. Michael Craig Miller of the Harvard and effi cient delivery system that provides ready access to a Mental Health Letter summarized this position in a 2007 editorial: wide range of rewards and pleasures. Shopping, gambling, and
Page 73 SocialWork.EliteCME.com pornography can be infused directly and in the high doses from the experiences signifi cant feelings of heightened anxiety, agitation Internet, anywhere and any time.” and physiological responses similar to substance abusers when they try to cut back or quit. Many mental health professionals, including the APA members who revise the DSM, agree that Internet addiction does meet the DSM’s Internet addiction has a strong similarity to impulse control disorders defi nition of a mental disorder as a “clinically signifi cant behavioral or as listed in the DSM. Some common components between the two are: psychological syndrome that is associated with present distress or with ● An impulse or urge that is diffi cult or impossible to resist. a signifi cant increased risk of suffering death, pain, disability, or an Impulsivity is defi ned by the Clinical Manual of Impulse Control important loss of freedom.” Disorders (2006) as “The failure to resist an impulse, drive, or temptation that is potentially harmful to themselves or others.” Internet addiction fi ts the defi nition of a mental disorder and has ● It is characterized by “carelessness; reduced sense of harm; similarities with other established mental disorders, such as OCD, impatience, including inability to delay gratifi cation; and a tendency ADHD, substance addiction and impulse control disorders. Internet toward risk- taking, pleasure and sensation-seeking behavior.” addicts, like individuals with OCD, have uncontrolled urges to use the ● Performing these behaviors is highly rewarding in the moment but Internet, which is the obsessive component. While on the Internet and often leads to long-term negative consequences. engaged in their activity of choice, they follow repetitive, ritualistic ● Some individuals report that a series of short-lived online behaviors, returning to their Internet sites in predetermined patterns, thrills were followed by increased online activity, which led to which is the compulsive component. relationship confl icts, depression and fi nancial diffi culties that are Despite negative consequences, they return to the same patterns of similar to individuals who have impulse control disorders. behavior, which increase in frequency and level of intensity, on their ● The impulse control disorders, whether online sexual compulsions favorite Internet sites. Internet sexual and gambling addiction has a or pathological online gambling, share basic characteristics. place in the DSM-5, though the DSM avoids the term addiction, using The person feels a repetitive, anxiety-ridden urge to perform an the terms abuse and dependence. Comparisons of Internet sexual act in the moment that leads to long-term dysfunction and guilt and gambling addiction to other forms of addiction are based on the (Chamberlain and Sahrawian, 2007). development of the two states of tolerance and withdrawal: Based on the similarities among impulse control disorders, substance ● Individuals addicted to alcohol and drugs and those in Internet abuse, OCD and Internet addiction, researchers have developed addiction progress through states of tolerance and withdrawal. screening questionnaires using criteria from these conditions adapted Tolerance refers to a condition of needing higher doses of from the DSM. The most commonly used screening tool was the experience or substance, whether it’s OxyContin, online developed, as previously mentioned, by Kimberly S. Young (2007). pornography or gambling, to produce the same effects achieved during initial use, including the same level of euphoria. Tolerance Young developed the Internet addiction test to screen for what she to the Internet occurs when the activity takes more frequent viewed as a new clinical disorder. The test, available online and online visits, greater amounts of time, and the individual fi nds it adapted with scoring instructions, includes questions that are rated on increasingly more diffi cult to disconnect from the Internet. a scale from 1 to 5. A total score of 80 or above is consistent with what ● Likewise, physical dependency, an adaptive physiological state Young terms Internet addiction. Excerpts from the test are found at the that occurs with chronic use, can result in withdrawal symptoms end of this course. when online use is limited or abruptly stopped. The individual
Legal issues
The media and research focused on Internet addiction has contributed He felt that IBM should have offered him support and treatment to a new crop of legal cases in which patients are suing to reverse instead of fi ring him, and noted that IBM workers who have negative consequences, especially termination from work, that are substance problems are referred to specialized treatment programs for brought about by their Internet addiction. rehabilitation. As a decorated Vietnam veteran suffering from a double In one of the most publicized cases, IBM fi red a 59-year-old man for disorder of PTSD and Internet addiction, he felt he deserved at least visiting adult chat rooms at work despite being reprimanded about the that much support from IBM. The case is ongoing, and the judgment behavior. In response, he sued IBM for $5 million, claiming he was an could affect how employers regulate nonwork-related Internet use and Internet addict and the Americans with Disabilities Act protected his treatment of addiction. diagnosis. He attributed his Internet addiction to seeing his best friend They appeal of sex and gambling is recorded in ancient history, but die in Vietnam in 1969, which left him with severe post-traumatic the Internet adds a new, powerful dimension to these behaviors. By stress disorder. He said that the only relief he found was through providing feelings of total control and the possibility of personalized visiting a pornographic online chat room. He stated, “I felt I needed sex or gambling, the Internet provides limitless activity, which can the interactive engagement of the chat room talk to divert my attention lead to addiction. from my thoughts of Vietnam and death.”
INTERNET CYBERSEX ADDICTION
Anonymous, affordable, private and accessible 24 hours a day, the Individuals with online sexual addictions often fall into some or all of Internet offers worldwide access for those with compulsive sexual the following patterns (Carnes, Delmonico, and Griffi n, 2001): behavior. Internet sexual addiction often results in destroyed marriages ● Keeps sexual activity on the Internet a secret from family members. and careers, families torn apart, and lives ruined. ● Carries out sexual activities on the Internet at work. ● Frequently erases computer fi les in an effort to hide online sexual For some individuals, the power of cybersex, like substance abuse, is activity. impossible to resist and control. Men and women fi nd themselves in a ● Feels ashamed and afraid that a loved one might discover the daily struggle with online sexual behavior that has taken priority over sexual activity on the Internet. all relationships. They become isolated and too embarrassed or guilty ● Time on the Internet takes away from or prevents the person from to seek help, and often do not know where to fi nd treatment. doing other tasks and activities.
SocialWork.EliteCME.com Page 74 ● Spends hours captivated in an online sexual experience, losing all ● Sexual chat room friends have become more important then real- concept of time. life family and friends. ● Frequently visits chat rooms that are focused on sexual conversation. ● Downloads favorite pornography. ● Looks forward to sexual activities and feels frustrated and anxious ● Frequently views favorite porn sites. if he or she cannot get to them when planned. ● Visits fetish porn sites or child pornography online. ● Masturbates while on the Internet,
Prevalence
Though populations are diverse and vary worldwide, Internet addiction ● Six percent of the population has viewed pornography on the rates range from 0.3 percent in the U.S. to nearly 38 percent among Internet, and for every three men, there is one woman. Hong Kong teenagers and young adults. Other prevalence rates from ● Two-thirds of junior high school students have looked at the Family Safe Media report are: pornography on the Internet. ● The average Internet user spends 15 minutes a day viewing ● Thirty-four percent of those students are at risk for developing pornography online. compulsive sexual behavior on the Internet. ● One in fi ve men view pornography online at work. ● Eighty-seven percent of university students have virtual sex using ● A quarter of all search engine requests are pornographic. Instant Messenger, webcams and cell phones. ● More than a third of Internet users report unwanted exposure to ● Thirty-two million individuals have visited a porn site; 22.8 sexual material online. million – or 71 percent – were male, and 9.4 million, or 29 percent, ● Twenty-fi ve percent of all Web searches are pornographic in nature. were female. ● Thirty-fi ve percent of all downloads are pornographic in nature. ● Two in fi ve Internet users have visited an adult site. ● Seventy percent of men ages 18 to 38 visit porn sites. ● 63.4 million separate visitors used adult websites reaching 37.2 ● Twenty percent of those sites involved children. percent of the Internet audience. ● The average age of the men viewing pornography on the Internet ● 8.9 million people in the U.S. need intervention to break their was 38. addiction to cybersex. ● Twenty-eight percent of those men were diagnosed as depressed. ● 14.8 million who currently use cybersex moderately are showing the beginning signs of sexually compulsive behavior on the Internet.
Other statistics on Internet sex
According to tracking data by comScore Media Metrix: ● Sixty-six percent do not include a warning of adult content. ● By the end of 2004, there were 420 million pages of pornography, ● Eleven percent included a warning but did not have sexually and it is believed that the majority of these websites are owned by explicit content on the home page. less than 50 companies. ● Twenty-fi ve percent prevented users from exiting the site, called ● The pornography industry generates $12 billion in annual revenue, mouse trapping. larger than the combined annual revenues of ABC, NBC and CBS. ● Only 3 percent of adult sites required adult verifi cation. Of that, the Internet pornography industry generates $2.5 billion in A Stanford/Duquesne study (2000) noted that cybersex is a public annual revenue, according to data released in 2006. health hazard that is exploding because very few health organizations ● The largest group of viewers of Internet porn is children between recognize it as a danger or take it seriously. The study found that at ages of 12 and 17. least 200,000 Internet users are addicted to pornography sites, X-rated ● In 2005, Internet users viewed over 15 billion pages of adult chat rooms, and other online sexual materials. The study completed in sexual content material. 2000 found: ● Sex is the No. 1 searched topic on the Internet. ● Men prefer visual erotica twice as much as women. ● Sixty percent of all Web visits are sexual in nature. ● Women favor sexual chat rooms twice as much as men. ● There are 1.3 million porn sites. ● Women have a slightly lower rate of sexually compulsive behavior. ● Pornographic web pages now top 260 million and are growing. ● Seventy percent kept their cybersex habit a secret. ● 71.9 million people visited adult porn sites in 2005, reaching 42.7 ● Twenty-fi ve million visit cybersex sites between 1-10 hours a week. percent of the Internet audience. ● Another 4.7 million visit cybersex sites in excess of 11 hours per ● From 1998 to 2003, there was a 20-fold increase in porn web week. pages, from 14 million pages of pornography to 260 million pages. ● Students were most at risk for cybersex compulsion because ● The two largest individual buyers of bandwidth are U.S. fi rms in of a combination of increased access to computers, casual the adult online industry. attitudes toward cybersex, more private leisure time, and their Commercial pornography sites: developmental stage, which is characterized by increased sexual ● Seventy-four percent display free teaser porn images. curiosity, experimentation and risk-taking behavior.
Categories of cybersex
Dr. Robert Weiss of the Sexual Recovery Institute describes cybersex 1. Accessing online pornography – Pornography can be found in as the “crack cocaine” of sexual addiction and states that cybersex various forms, including visual, auditory and text stories. Access reinforces and normalizes all forms of sexual disorders. Internet sex is much greater online because many of the sexual content and can be accessed and experienced in many ways, and each has the activity laws that exist in the United States are diffi cult to enforce or potential to cause serious problematic behavior leading to risky or do not apply in other countries. Online pornography can be easily dangerous situations. accessed worldwide on personal and commercial WebPages; it can The term cybersex has become a catch phrase to address a variety be exchanged by e-mail, discussion chat rooms or newsgroups. of sexually related behaviors on the computer, which fall into three These forms allow participants to use their e-mail to post stories, general categories: ideas, photographs or software related to the topic of the group.
Page 75 SocialWork.EliteCME.com These messages can be stored for other groups to retrieve. other electronic device. Compact disc read-only memory (CD- Thousands of sex-related newsgroups exist on the Internet and can ROM) technology allows companies to release software titles with handle high volumes of traffi c. sound and video. 2. In real time with a fantasy partner – This form of cybersex The Internet has become the method of choice for those seeking takes place in what is known as real time, and the experience sexual experiences. Carnes et al., identifi ed fi ve factors that led to the is designed to act out sexual fantasies. Internet chat rooms give popularity and increase in online cybersex: people the ability to hear and discuss sexual topics on the Internet. ● Accessibility – Sites are available seven days a week, 24 hours a There are typically 10,000-20,000 channels available to join. day and available anywhere there is a computer or other electronic Federal Communications Commission laws limit the type of device to access the Internet. The variety of experiences is communication that can take place over the airwaves, but many limitless and available whenever convenient in the privacy of the of the laws do not apply to international cyberspace, so sexual home or offi ce. conversations frequently occur. ● Isolation – The Internet gives users the ability to engage in any behavior they desire without actual contact with others, Cybersex can become part of a person’s arousal pattern, and many eliminating the risk of sexually transmitted disease or any people fi nd eroticism in Internet chat rooms. These can be exciting, responsibilities or entanglements of real world interactions. particularly for women, because they provide opportunities for ● Anonymity – The Internet provides a way to interact romantic intrigue, manipulation, seduction and power. Advanced anonymously, minimizing the risks of recognition, judgment, legal computer technology enables the exchange of images and fi les sanctions or consequences of sexual exploits in public. online during live conversations. These can occur in many virtual ● Affordability – Cybersex provides a low-cost way to obtain locations, so a person can engage in online chatting with others sexual satisfaction. and share voice and video images via the Internet. Live video ● Fantasy – Cybersex sites allow the user to choose the type of feed technology makes it possible to chat online while viewing partner or sexual activity that fulfi lls the individual’s fancy. pornography. These virtual video booths are increasing in number and allow cybersex users to have control over the subject and Cooper, Delmonico, and Berg (2000) conducted a survey of 9,265 sexual activity. With a credit card number, users can view live Internet users and identifi ed three categories of people who use the video cameras that transmit images of men and women performing Internet for sexual pursuits: everything from everyday routines to explicit sexual acts. 1. Recreational users who access online sexual material more out of curiosity or for entertainment and are not seen as having problems Some men and women want to create someone who matches their associated with their online sexual behaviors. idea of perfection, and the Internet provides this opportunity. Live 2. At-risk users who might never develop a problem with online feed video sites and interactive sex sites allow someone to log sexual interaction if not for the availability of the Internet. These on and described the woman or man they want to see and what individuals use the Internet a moderate amount of time for sexual sexual act they want to experience and it appears on the screen. release, but if their type of use or time online increases, it could This provides the individual with the ability to create and engage progress to a sexual compulsion. in personal fantasies. For a small fee, the individual can link to 3. Sexually compulsive users have reached the level of pathological X-rated video feeds or, with CuSeeMe software and camera, watch sexual behavior, and they excessively use the Internet for their others masturbate or engage in sexual activities while they watch sexual activities. For people in this group, the power of isolation, the individual do the same. Though most sites have a fee, some fantasy, anonymity, accessibility and affordability interacts with Internet sites can be accessed for free. certain underlying personality factors to increase their Internet 3. Multimedia software – This category of cybersex does not use for sexual activities. At this level, cybersex use has reached originate online but is accessed there. On the new multimedia the point where it becomes diffi cult if not impossible to control. systems, people can see X-rated movies, play sexual games and The sexual compulsion meets the criteria of an addictive disorder view the latest issues of erotic magazines on their computer or similar to those of substance abuse and other forms of addiction.
Indicators of cybersex addiction
Three criteria are often used to indicate cybersex addiction. They impulses require most of their mental and physical energy. No matter are compulsivity, continued use despite negative often dangerous what is going on at the time, the individual is thinking about the next consequences, and obsession. sexual encounter and how to create the time and secret location for The loss of ability to choose whether to stop or continue a behavior cybersex. indicates a compulsion, which is totally different from normal daily The individual addicted to cybersex lives in three states of mind activities or routine habits. The out-of-control behavior is marked (Schneider, 1994): by deeply held rituals interfering with all aspects of real life, with no 1. Continually planning the next visit to the online sex site. regard for other relationships, activities or negative consequences. 2. Engaging in online sexual activity. They cannot stop obsessing about sexual activity online, and those 3. Coming down from the euphoria of the cybersex activity.
Diagnosis
As with diagnosis of other forms of addiction, there are Internet The 10 criteria are: sex screening inventories that use 10 criteria for problematic online 1. Preoccupation with cybersex. sexual behavior (Delmonico, 1999). No set of criteria or test is an 2. Frequently engaging in cybersex for longer periods of time than absolute measure or predictor of cybersex addiction because they do intended. not address individual differences in behaviors, every type of Internet 3. Repeated unsuccessful attempts to control, limit or stop engaging sexual behavior, or co-occurring mental disorders. Ratings range on a in cybersex. scale from harmless to those that are impulsive or addictive and result 4. Restlessness of irritability when attempting to limit or stop in serious health, relationship and legal risks. engaging in cybersex.
SocialWork.EliteCME.com Page 76 5. Using sex on the Internet as a way of escaping problems or relieving are engaged in sexual behavior on the Internet into fi ve groups, which feelings, such as helplessness, guilt, anxiety or depression. include: 6. Returning to cybersex on a daily basis in search of a more intense ● Recreational cybersex users, who fall into the categories of: or higher-risk sexual experience. ○ Appropriate recreational use. 7. Lying to family, friends, therapists or others to conceal ○ Inappropriate recreational use. involvement with cybersex. The next three groups identifi ed have problematic sexual behaviors on 8. Committing illegal sexual acts online, such as sending or the Internet and fall into one of three groups: downloading child pornography or soliciting illegal sex acts online. ● Discovery group – Those who have no previous problem with 9. Jeopardizing or losing signifi cant relationships, jobs, educational online sex or any history of problematic sexual behavior. or career opportunities because of online sexual behavior. ● Predisposed group – Those who have had their fi rst out-of-control 10. Incurring signifi cant fi nancial consequences as a result of engaging sexual behavior on the Internet after years of obsessing over in cybersex. unfulfi lled sexual fantasies and impulses. In summary, these activities are diagnosed as problematic because ● Lifelong sexually compulsive group – Their out-of-control sexual the online behavior involves excessive time, and the behavior is behavior on the Internet is part of an ongoing and severe sexual uncontrollable and distressing as well as the source of familial, social, behavior problem. professional, educational and fi nancial diffi culties. Diagnosis is based These researchers found that people in the discovery, predisposed and on a comprehensive interview with a physician or therapist, and no lifelong sexually compulsive categories often progress through the other psychiatric disorder can be found to account for the subject’s stages to addiction once they discover the availability, accessibility, Internet sexual addiction symptoms (APA, 2000). variety, and extent of sexual experiences on the Internet. Carnes, Delmonico, and Griffi n (2001) have reviewed and researched types of problematic online sexual behavior. They divided those who
Faulty thought patterns
The addicts’ belief systems contain errors, untruths, delusions and strategies. They do not see their sexual activities as the cause of faulty thought patterns that support their beliefs and reinforce the negative consequences, such as broken families, lost jobs, damaged problematic sexual behavior that leads to Internet addiction (Carnes et relationships, criminal activity and arrests; instead, they blame other al., 2001). These four core beliefs include: factors. Blaming others for their problems is a way to refocus attention 1. I am a bad person and not worthy of anyone’s love. and avoid judgment. They often blame outside factors to justify their 2. I will never be accepted for what or who I am. addictive behavior so those things are responsible for their actions. 3. I cannot trust or count on anyone to meet my needs. Each of these faulty thought processes of denial, rationalization, 4. My most important need is sex. delusion, paranoia and blame block contact with reality, which leads to Core beliefs are formed as individuals grow and develop within their further escape into cybersex. families and community. In a functional, healthy family, children are Online these people become more isolated from the real world, which taught values and receive love and support to grow and develop a positive gives free reign to the cybersex addiction cycle. The addictive cycle self-concept. They know they are valued in the family because their basic has four steps that intensify with each repetition (Carnes, et al., 2001): needs are met and they are able to form close bonds with others. ● Preoccupation – The trance or mood where the person’s mind is In dysfunctional families, children are often ignored, neglected and totally focused and absorbed with thoughts of sex, which creates abused. They grow up without the love and support that leads to a obsessive urges. negative self-image. In this negative and often painful family dynamic, ● Ritualization – The individual creates routines and rituals that children believe that they are not worthy of acceptance, affection or intensify the preoccupation and increases arousal and excitement. love and they are often unable to form healthy attachments to others. ● Compulsive sexual behavior – The actual sex act is the end goal of the preoccupation and ritualization. The individual cannot These beliefs and thought patterns undermine real feelings and control or stop the sexual behavior at this point. connections with others, and such young people feel isolated. They ● Unmanageability and despair – The person feels complete often are responsible for meeting their own basic needs, and many of hopelessness and powerlessness to control his or her sexual behavior. them struggle to survive. The addictive cycle starts with a belief system containing faulty To meet their sexual needs, they take control, and sex may be the only assumptions, myths and distorted values that support impaired thought form of satisfaction and comfort they experience. They view sex as patterns. The resulting delusional thought process leads to a cycle that their most important need and a substitute for relationships with others is completely removed from reality. The four-phase addictive cycle to fi ll their feelings of loneliness and isolation. They often confuse sex repeats itself and consumes the addict’s life. Other support systems, for intimacy and connections with others. including relationships, family, work, fi nances, health and safety rules, People involved in dangerous or illegal activity will develop suspicion are totally abandoned. and paranoia, which will further isolate them from others. The Internet Faulty beliefs are reinforced through continued negative consequences provides a way to interact with others while keeping a barrier between and failures, which cause further withdrawal from reality. The online them and the outside world. People who cannot communicate with sexual experience is the only goal in life, and fi nding sexual pleasure others or trust others may seek anonymity on the Internet. becomes the primary motivation for the addict. Sexual experiences are Sex in real life, no matter how impersonal or unfulfi lling, still involves the source of all energy, pleasure and excitement without the negative physical contact. Cybersex provides sexual satisfaction without a consequences of other high-risk sexual encounters. relationship or connection to anyone and allows people to remain Family and friends of cybersex addicts may observe the out-of-control unattached while fulfi lling sexual needs. behavior, self-degradation, and loss of goals, morals and values. They Faulty belief patterns distort the individual’s view of reality. This may believe that it would be easy to control addictive online behavior results in denial, such as ignoring the problem, blaming others, and by just avoiding the Internet altogether or at least limiting use. But minimizing inappropriate behavior as part of their defensive coping cybersex addicts who may spend up to 11 hours a day online and
Page 77 SocialWork.EliteCME.com another four hours obsessing about online sexual activities cannot through windows or by small hidden cameras in locker rooms or modify or control the behavior. department dressing rooms. At this point, the addiction has evolved into an altered state of Many cybersex users talk about the excitement of fi nding a sex site consciousness in which nothing can compare to the euphoria, release that has particular images they fi nd arousing, and for others, the erotic and escape obtained through online sexual behavior. Cybersex can moment starts when the photos slowly download onto their screen. signifi cantly affect the emotions, sexual arousal and neuro-chemical Some cybersex addicts lose control once they enter the cybersex world reactions in the brain, and the Internet allows people to quickly access after many years of denying or hiding their fantasies and sexuality. sexual experiences that stimulate emotions in new and powerful ways. Through the Internet, sexual stimulation occurs in ways that have Cybersex can capture people’s imagination and draw them into their nothing to do with previous sexual norms, arousal or sexual experiences. fantasy world. It becomes more intense and captivating because they can Before the Internet, sex was confi ned to a relatively small range of create and select their own fantasy experience with the click of a mouse. activities infl uenced by cultural, religious or social background, and These experiences are virtual, but they affect individuals emotionally sexual practices were restricted by morals, values, norms and taboos. and physically and allow for unlimited sexual activities that they Cybersex instantly gives a worldwide view of sexual practices. never imagined were possible. Addicts can create and repeat novel Individuals can fi nd others who have similar sexual desires and arousal sexual fantasies whenever they want and for as long as they want, patterns, so they can share new and unusual methods of gratifi cation. intensifying the arousal and fulfi llment. Finding someone who has similar desires or fantasies without shame There are many examples of erotic experiences that do not involve or guilt can change negative feelings about sexuality and help develop sexual acts. Voyeurs and exhibitionists can experience erotic moments a positive self-image. When the activities are illegal or unhealthy, on the Internet through an endless supply of erotic pictures taken the Internet makes it possible for individuals to reinforce undesirable behavior and strengthen an unhealthy addictive sexual behavior. INTERNET CHILD PORNOGRAPHY
Child pornography is rampant on the Internet with an active and ● More than 20,000 images of child pornography are posted on the sophisticated black market that law enforcement agencies have found Internet every week, and demand for more babies and toddlers is diffi cult to infi ltrate and control. increasing. ● Child pornography is more torturous and sadistic than ever before, The National Center for Missing and Exploited Children says: ● Of those arrested for child pornography possession, 40 percent had according to investigators. ● In the year 2001 alone, over a fi ve-month period there was a 345 sexually victimized children as well. These individuals are known percent increase in child pornography sites. as dual offenders, and both crimes are often discovered in the same ● More than half of all illegal child pornography sites reported to the investigation. ● Another 15 percent of dual offenders had tried to victimize children Internet Watch Foundation are hosted in the United States. ● Illegal sites in Russia have more than doubled from 286 to 706. by soliciting undercover investigators who posed as minors online. ● Overall, 36 percent of dual offenders showed or gave child Demand for pornographic images of babies and toddlers is rapidly pornography to undercover investigators posing as minors online. increasing there as well. ● Of those arrested in the United States for possession of child ● Approximately 20 new children appear on pornography sites every pornography, 83 percent had images involving children between the month, with many kidnapped or sold into sex. ● In the last couple years, Toronto police have seen younger children ages of 6 and 12; 39 percent had images involving children between 3 in regular seizures of child pornography, including babies, 2-, 3- and 5; and 19 percent had images of infants and toddlers under age 3. ● According to The National Children’s Home Report, the number and 4-year-olds. ● The U.S. Customs service estimates that there are more than 100,000 of Internet child pornography images has increased 1,500 percent websites offering child pornography, which is illegal, worldwide. since 1988. ● Approximately 20 percent of all Internet pornography involves ● Revenue estimates for the child porn industry range from about children. $200 million to more than $1 billion dollars per year. These illegal ● Child pornography has become a $3 billion dollar annual industry. online sexual images can be purchased easily. Subscribers typically use credit cards to pay a monthly fee of between $30 and $50 to download photos and videos, or a one-time fee of a few dollars for single images. ONLINE SEXUAL PREDATORS
Statistics ● One in four children participated in real-time chats when solicited ● Internet pedophiles are using counterintelligence techniques to online. protect themselves from being traced. ● Twenty-six popular children’s online characters revealed thousands ● Of people charged with child pornography, 40 percent also of links to porn sites, and 30 percent were hard-core porn sites. sexually abused children, according to police. It is diffi cult to fi nd ● Pedophiles disguise their sites with common brand names, the predators and identify the victims. including Disney, Barbie and ESPN to entice children. ● One in fi ve children who use computer chat rooms has been ● Children are reported missing at the rate of 750,000 per year, or approached over the Internet by pedophiles. 62,500 per month, 14,423 per week, 2,054 per day, 85 per hour, or ● Thirteen million youths use instant messages, and one in fi ve has three children every two minutes. received sexual solicitations. (Source: National Center for Missing and Exploited Children, National ● One out of 33 children who received aggressive sexual Juvenile Online Victimization Study, 2005.) solicitations was asked to meet the person, called by phone, and sent mail, money and gifts. ● Twenty-fi ve percent of youth who received sexual solicitations told a parent.
SocialWork.EliteCME.com Page 78 Paraphilia
Paraphilia is a disorder that is characterized by recurrent intense engaging in sexual activity with pre-pubescent children is the preferred sexual urges and sexually arousing fantasies generally involving or exclusive means of achieving sexual excitement and gratifi cation nonhuman objects, the suffering or humiliation of one’s self or one’s (Fleming, 2007). Mental health professionals defi ne pedophilia as partner, animals, children or other nonconsenting persons (APA, a mental disorder, but the American legal system defi nes acting on 2000). Pedophilia is the paraphilia that involves an abnormal interest pedophilia urges as a criminal act. in children. It is a psychosexual disorder in which the fantasy or act of
Pedophilia
The focus of pedophilia is sexual activity with a child. Many courts The sexual behaviors in pedophilia cover a range of activities from interpret this reference to mean children under the age of 18. Most online child pornography and solicitation to actual contact and may or mental health professionals, however, use the defi nition of pedophilia may not involve the use of force. Some pedophiles limit their behavior as sexual activity with pre-pubescent children, who are generally ages to online contact in chat rooms, exposing themselves or masturbating in 13 or younger. front of the child. Others are compelled to meet the child to participate in oral or genital intercourse. There is no typical pedophile; they may be young, old, male or female, although the vast majority are males.
Etiology
A variety of different theories exist on the cause of pedophilia. A few Some researchers attribute pedophilia to incomplete emotional researchers attribute pedophilia to biology (Wilson, 2002). They hold development, which explains the pedophile’s attraction to children that testosterone, one of the sexual male hormones, predisposes men to because he or she has never matured psychologically (Money, 1989). develop a deviant sexual desire. However, no researchers have claimed Others view pedophilia as a result of distorted needs to dominate a to have discovered or mapped a gene for pedophilia. sexual partner, and because children are smaller and weaker than Most experts believe pedophilia results from psychosocial factors rather adults, they are regarded as nonthreatening potential partners (Carnes, than biological characteristics (Fleming, 2007). They attribute pedophilia 1999). This drive for domination is sometimes thought to explain why to the result of having been sexually abused as a child or from the person’s most pedophiles are males. interactions with parents or guardians during their early years of life.
Symptoms
Pedophiles often have good interpersonal skills with children and can According to the Diagnostic and Statistical Manual of Mental easily gain the child’s trust. They may volunteer with athletic teams, Disorders, DSM-IV, the following criteria must be met to establish a scout troops, schools, religious or civic organizations that serve youth. diagnosis of pedophilia (APA, 2000): In some cases, pedophiles are attracted to children within their extended ● Over a period of at least six months, the affected person family, so they offer to babysit for their relatives or neighbors. experiences recurrent, intense and sexually arousing fantasies, sexual urges or actual behaviors involving sexual activity with Some pedophiles offer rationalizations or excuses that enable them prepubescent children ages 13 or younger. to avoid responsibility for their actions. They may blame the children ● The fantasies, sexual urges, or behaviors cause clinically for being too attractive or sexually provocative. They may maintain signifi cant distress or impairment in social, occupational or other that they are teaching the child about the facts of life, sex or love. This important areas of daily functioning. rationalization is frequently offered by pedophiles who have molested ● The person must be at least age 16 and be at least fi ve years older children related to them. than the child or children who are the objects or targets of attention All of these rationalizations may be found in online child pornography for sexual activity. with pedophilic themes. Pedophilia is one of the more common To establish a diagnosis of pedophilia, the doctor or therapist must paraphilias, and the large worldwide market for child pornography determine whether the pedophilia is exclusive or nonexclusive; that is, suggests it is more frequent in the general population than statistics whether the patient is attracted only to children or to adults as well as indicate. Together with voyeurism and exhibitionism, pedophilia is one to children. of the three paraphilias most often leading to arrests by police. One diffi culty with the diagnosis of the disorder is that persons The onset of pedophilia usually occurs during adolescence. with pedophilia rarely seek help voluntarily from mental health Occasionally pedophiles begin their activities during middle age, but professionals. Instead, counseling and treatment is often the result of this late onset is uncommon. In the United States, about 50 percent of a court order. An interview that establishes the criteria for diagnosis men arrested for pedophilia are married. listed above may be enough to diagnose the condition, or surveillance The frequency of behavior associated with pedophilia varies with or Internet records obtained through the criminal investigation may psychosocial stress. As the pedophile’s stress level increases, so does also be used (O’Donahue, Regev, and Hagstrom, 2000). the frequency of his sexual urges and behavior. Little research has been An additional complication with diagnosis is that paraphilia has a conducted about the incidence of pedophilia in different racial or ethnic high rate of co-morbidity with major depression, anxiety disorders, groups. Pedophiles’ fi rst contact with children often begins online, where and substance abuse disorders. A person diagnosed with pedophilia they befriend children and eventually try to solicit them for sex. may also meet the criteria for exhibitionism, substance abuse or mood disorder (O’Donahue et al., 2000).
Page 79 SocialWork.EliteCME.com Treatment of pedophilia
Cognitive behavioral therapy (CBT) is often used to treat pedophilia as offenders since the 1970s. The anti-androgens in particular have been well as other addictions. It works to change faulty thought processes, shown to be effective in reducing the rate of recidivism. Surgical or which leads to behavioral change. CBT will be covered in the chemical castration is sometimes offered as a treatment to pedophiles treatment section of this course. Berlin (2000) noted that pedophilia who are repeat offenders or who have pleaded guilty to rape. may also be treated with medications, and the three classes of drugs Increasingly, pedophiles are being prosecuted under criminal statutes most often used are: and being sentenced to prison terms. Imprisonment removes them ● Female hormones, particularly medroxyprogesterone acetate (MPA). from society for a period of time but does not usually remove their ● Luteinizing hormone-releasing hormones (LHRH) agonists, which pedophilic tendencies. Many states have begun to publish the names include such drugs as triptorelin (Trelstar), leuprolide acetate and and addresses of persons being released from prison after serving goserelin acetate. time for pedophilia. Many states also restrict whom they may contact, ● Anti-androgens, which block the uptake and metabolism of and where they can live, work and travel. Legal challenges to these testosterone as well as reduce blood levels of this hormone. practices are pending in some states. Most clinical studies of these drugs have been done in Germany, where the legal system has allowed medication use for treating repeat sexual
Prognosis
The prognosis for successfully treating pedophilia is not a positive Their behavior is a set pattern and reinforced often for a very long time one, and there is a high rate of recidivism because pedophiles tend to (Carnes et al., 2001). repeat their acts over time. The rate of recidivism for pedophiles with a The rate of prosecution of pedophiles by the criminal justice system preference for male children is approximately twice that of those who has increased in recent years because of changes in the law and stiffer prefer females. penalties. Pedophiles are at high risk of being beaten or killed by other Historically, the arousal patterns found in pedophilia have been prison inmates, and for this reason they often are kept isolated from viewed as quite rigid and fi xed. Pedophiles who were severely abused other members of the prison population. Knowledge of the likelihood as children developed rigid and narrow arousal patterns that were of abuse by prison personnel and inmates is not an effective deterrent signifi cantly different from normal behavior. It is extremely diffi cult for most pedophiles (National Center for Missing and Exploited for these individuals to make changes in their patterns of arousal Children, 2012). because the damage they suffered is so deep and began so early in life.
Prevention
Other than therapy that works to change thought patterns and medication ● They must be taught to avoid situations that make them vulnerable to help control the pedophile’s sexual compulsions, the main method to pedophiles. for preventing pedophilia is avoiding situations that may enable these ● Children must tell a parent or trusted adult about any unusual or acts. Part of an individual’s therapy would include stress management, threatening contact from an adult or older teen. avoidance and prevention strategies to use if the sexual impulse occurs. ● Parents and guardians must instruct children on Internet dangers and monitor their online use at all times. Families, schools and any organizations that serve children must also ● Rules should be established that govern the amount of access and be involved in prevention: ● Children should never be allowed in one-on-one situations with the online sites they can visit. ● Internet blocks can be installed, but they cannot restrict all any adult other than their parents or trustworthy family members. ● Having another youth or adult as an observer can provide some dangerous material and should not replace careful monitoring. security for all concerned. Likewise, adults who work with youths must be taught to avoid ● Children should be taught and given chances to practice strategies situations that may be construed as pedophilia. Most states have adopted to use if approached online or in person. legislation that requires periodic background investigations of any adults ● Children should be taught to yell or run when faced with an who work with children. This includes individuals who may be paid, uncomfortable situation, and that it is acceptable to scream or call such as teachers, as well as volunteers in any organization serving youth. for help anywhere.
Laws on obscene visual representations of the sexual abuse of children
The National Center for Prosecution of Child Abuse outlines the federal oral to genital, anal to genital, or oral to anal whether between laws that govern any visual representation of child sexual abuse, which persons of the same sex or opposite sex, is illegal. includes Internet representations. The federal law states that: ● Any communication or visual depiction involving a minor made ● Any person who knowingly produces, distributes, receives, or in the furtherance of these offenses communicated or transported possesses with intent to distribute a visual depiction of any kind, by mail or through interstate or foreign commerce by any means including a drawing, cartoon, sculpture, or painting that depicts a including by computer, or that has been shipped or transported minor engaging in sexually explicit conduct, is obscene and illegal. by any means including by computer, committed in the special ● This includes any visual representation that depicts an image that is, maritime and territorial jurisdiction of the United States, or in any or appears to be, of a minor engaged in graphic bestiality, sadistic or territory or possession of the United States, is considered to be masochistic abuse, or sexual intercourse including genital to genital, obscene and therefore illegal.
SocialWork.EliteCME.com Page 80 Defi nitions in the law
The term visual depiction includes: pornography, they will be fi ned under this title and imprisoned ● Undeveloped fi lm and videotape, data stored on a computer not less than fi ve years and not more than 20 years. disk or by electronic means which is capable of conversion into ○ If such a person has a prior conviction under this chapter a visual image, and also includes any photograph, fi lm, video, section or under the laws of any state relating to aggravated picture, digital image or picture, computer image or picture, or sexual abuse, sexual abuse, or abusive sexual contact involving computer-generated image or picture whether made or produced a minor or ward, or the production, possession, receipt, by electronic, mechanical, or other means. mailing, sale, distribution, shipment, or transportation of child ● The term minor means any person under the age of 18. pornography shall be fi ned under this title and imprisoned for ● The child may be recognizable as an actual person by the person’s not less than 10 years nor more than 20 years. face, likeness, or other distinguishing characteristics such as a Sexual exploitation of children – Any person who employs, uses, unique birthmark, or other recognizable feature, and shall not be persuades, induces, entices, or coerces any minor to engage in, or has construed to require proof of the actual identity of the minor. the minor assist any other person to engage in, or who transports any ● The term sexually explicit contact means actual or simulated sexual minor in, or affecting interstate or foreign commerce, or any territory intercourse including genital-genital, oral-genital, anal-genital, or position in the United States, with the intent that the minor will oral-anal, whether between persons of the same sex or opposite sex, engage in any sexually explicit conduct for the purpose of producing sadistic or masochistic abuse, or lascivious exhibition of the genitals any visual depiction of such conduct, or for the purpose of transmitting or pubic area of any person. Online dialog that uses sexually explicit a live, visual depiction of such conduct, shall be fi ned under this title terms or shows the attempt to solicit sex with a minor is also illegal. and imprisoned not less than 15 years no more than 30 years. ● Child pornography is any visual depiction, including any ● If a person has one prior conviction under this chapter they shall photograph, fi lm, video, picture, or computer, or computer- be fi ned under this title and imprisoned for no less than 25 years generated image or picture, whether made or produced by nor more than 50 years. electronic, mechanical, or any other means of sexually explicit ● If a person has two or more prior convictions under this chapter, contact where the production of such visual depiction involves the they shall be fi ned under the title and imprisoned not less than 35 use of a minor engaging in sexually explicit contact. years nor more than life. ● Federal sanctions include but are not limited to the following: ● If in the course of an offense under this section, the person engages in ○ If a person violates, attempts, or conspires to violate laws conduct that resulted in the death of a person, they shall be punished governing the material constituting or containing child by death or imprisoned for not less than 30 years or for life. TREATMENT OF ADDICTION AND INTERNET SEXUAL BEHAVIOR
Few treatment options are available that have been scientifi cally proven Treatment with medication is often applied to problematic Internet use, to be effective. Doctors and therapists often adapt treatments used to including pornography and gambling. Prozac-like medications were address OCD, substance abuse and impulse control disorders because of effective in some patients with problematic Internet use. the similarities among these disorders and Internet addiction. Internet addiction is more complex than an obsessive-compulsive Pharmacological treatments are often used to increase serotonin disorder that often responds favorably to serotonin-enhancing drugs. levels in the brain, which has proven effective in treating impulsive Beyond the rituals that doctors see in patients with OCD, Internet and compulsive disorders. Twelve-step programs such as Alcoholic addictions are also about an interaction with a computer that engages Anonymous and Narcotics Anonymous are effective in some cases, the individual’s personality, frustrations, arousal patterns and need for but scientifi c studies have not been able to prove the effectiveness of stimulation. the 12-step programs with Internet addictions. Today computers are The availability of novel activities on the Internet combined with the an integral part of everyday work and social life, so it is unreasonable characteristics of obsessive-compulsive disorder make the Internet and impossible for individuals to maintain complete abstinence from addiction more complex and diffi cult to treat then the ritual of Internet access as required in 12-step programs. excessive hand washing that might be found in an OCD patient for Medication and cognitive behavioral therapy combined is often the example (Carnes et al, 2001). treatment of choice.
Cognitive behavioral therapy
Cognitive behavioral therapy (CBT) has proven effective in bringing According to Aboujaoude (2011), CBT is the only form of psychotherapy about behavioral change in people dealing with many types of to have been scientifi cally examined to treat Internet addiction, although addiction. CBT addresses the feelings of dissociation that are often only a limited number of studies have been conducted and published. CBT present and the fallacies in thinking that are critical components for for Internet addiction involves bringing the patient to awareness of the treating Internet-addicted individuals. time spent on the Internet by keeping a detailed log of the time spent in CBT focuses on correcting faulty thought patterns that reinforce cyberspace and the type of activity, frequency, duration and predisposing inappropriate behaviors. For example, gambling addicts often conditions or antecedents that led to excessive Internet use. share the belief that they have the knowledge and skills to beat Weekly meetings are held to discuss the journals and develop more the online gaming programs; Internet sexual addicts believe they effective coping skills and ways to manage time more effectively. can use cybersex as an escape and a perfect substitute for real-life Patients are also asked to review their excuses, justifi cations, or relationships. As patients begin to review their thought patterns, rationalizations that they use to explain their Internet use. This helps behaviors and the negative consequences that result, they gradually them identify the faulty thought patterns they have used to justify their learn to address the underlying problems that led to the Internet addiction and the negative consequences of their online addiction. addiction and learn to replace problematic Internet behavior with real- life experiences.
Page 81 SocialWork.EliteCME.com Dr. Kimberly Young (2004) who, as previously mentioned, has ● After reviewing their inventories, individuals should write conducted some of the largest scientifi c studies examining Internet examples that show how unmanageable their lives are because of addiction, reported that CBT was effective in treating Internet their cybersex behavior. addiction symptoms by the eighth session of the program, and that the ● The next step is to list the negative consequences that have been the gains made were in place for at least six months following treatment. result of their behavior. This section should show how their behavior affects family, friends and co-workers. The list should address Carnes, Delmonico and Griffi n (2001) discuss external boundaries that the effects of their addiction on their social life, health, economic need to be set for individuals who have a cybersex addiction. Once status, career, educational goals, emotions, and family and personal people have acknowledged their problem, they need to set boundaries, relationships. The information from this self-assessment should be such as: ● Keeping their computer on the main fl oor of the house rather than shared with everyone involved in the individual’s recovery. ● After the inventory is complete, individuals should be prepared to in a more private home offi ce. ● Choosing a nonsexual screen name. accept that they are powerless to control their behavior, which is a ● Using the computer only when at work for work activities. compulsive or obsessive disorder, and that they need help through ● Not logging on to sexual websites. treatment to overcome their addiction. ● Giving the computer password to a spouse or partner who can A number of changes must be made in order to strengthen the external check computer usage or history fi les. boundaries to limit and control their online addictive behaviors Setting boundaries may be the beginning step to gaining control of (Watzlawick, Weakland, and Fisch, 1988). These include: ● Reduced Internet access. cybersex addiction. The motivation to begin the process often comes ● Move the computer to a high traffi c area. from family friends, therapists or the courts at fi rst. At this point, users ● Don’t go online except when others are at home. must acknowledge their addiction and accept that they are unable to ● Set limits on when, where and how long to use the computer. control it and that they need support through medication, therapy or a ● Use electronic limits to reduce access, such as running software combination to bring about behavioral change and personal growth. They protection such as Net Nanny, Cyber Sitter, Cyber Patrol, or Guard must recognize and acknowledge that their cybersex behavior is causing Dog, which will prevent anyone from getting into sexual websites. negative consequences in their life and the lives of those around them. ● Switch to a safe Internet service provider. A number of family Once individuals have taken the fi rst step, Carnes et al., note that there oriented Internet service providers carefully screen out sexual are eight rationalizations that interfere with recovery and should be sites and provide better protection than software alone. Service addressed as the individual begins to develop a new belief system. providers that are family oriented can be found through Internet Most addicts will fi nd that they have used one or more rationalizations search engines such as Google or Yahoo. in the past and need to understand them as they develop new thought ● If the work site is a temptation, leave the offi ce door open when processes that are inconsistent with cybersex use. using the computer and place the monitor so that others can see it ● Rationalization 1: It is not real. There are no real people, no rules, as they walk by the room. so I can indulge in cybersex without worrying. I’m not going to a ● Avoid any chat rooms that are at all sexual in nature. strip club, seeing a prostitute, or exposing myself to a real person. ● Reduce anonymity by using e-mail addresses and screen names I’m not being unfaithful because I haven’t really done anything. that actually identify the individual so there can be no more hiding ● Rationalization 2: Cybersex doesn’t hurt others. I’m not having under fi ctitious names. skin-to-skin contact, so it’s not sex and not affecting anyone else. ● Share with at least two other people that they have an Internet No one can get a disease, and I can’t hurt anyone. Even when I’m addiction. in a chat room, it is all make-believe. ● Reduce objectifi cation by using various reminders that recipients ● Rationalization 3: Cybersex doesn’t hurt me, I’m just on the of the Internet communication are real people who can be affected computer, so what’s the big deal? It’s no different than using other by the sexual interactions. kinds of websites on the Internet. There are no consequences, and ● Build accountability by allowing a trusted friend, sponsor or I’m not hurting myself at all. therapist to monitor online behavior and access. Give this person ● Rationalization 4: I can stop anytime I want by just turning off access to all computer history. Individuals should be accountable to the computer and everything goes away. this person for the time they spend online and what sites they visit. ● Rationalization 5: I’ve already done a recovery program in the ● Develop healthy online habits so that users can access the past, so why should I go to do another one? computer and Internet. They will need to learn to use the Internet ● Rationalization 6: Cybersex doesn’t have any consequences. for only healthy, positive purposes, which include accessing I’m not going to destroy my marriage. No one has my real name, supportive recovery online resources. phone number, my mailing address, or knows where I live. I use the ● Find an online sponsor and develop e-mail buddies who are computer in private, and no one knows my passwords. When I’m recovering from problematic online sexual behavior. online at work, that’s no different from taking a short coffee break. ● Find and use websites that can support recovery rather than enable ● Rationalization 7: It’s just a game; that’s why it’s called virtual inappropriate behavior. reality. It’s fun entertainment, and who would ever take this ● Find and visit online support groups. seriously? I don’t really mean anything by this, and it’s not really different from a video game. Gold and Edwards (2010) advise that in some cases, inpatient or ● Rationalization 8: I just use it occasionally; it doesn’t interfere residential treatment may be necessary for several weeks. Treatment may with things in my life. I’m not on the computer all the time, I just involve interpersonal therapy or group therapy. Interpersonal therapy can go on when I feel like it and need something to do. I’m still in a deal with factors such as mood disorders, anxiety and depression. Group good relationship with my partner, have a good job, and spend therapy may work on issues such as denial and rationalization. time with my family and friends, so it’s no big deal. Use of medications such as naltrexone and SSRIs have been effective At this point in the process, individuals must complete a self- to address mood disorders and reduce excessive behavior and can be assessment inventory including the following: combined with psychotherapy to enhance the effectiveness. Gold and ● Begin by listing examples that show their inability to stop their Edwards note that 30- to 90-day residential programs are sometimes Internet sexual behavior. The list should provide specifi c details and not effective, and it may take as much as three to fi ve years or 175 examples of behavior and frequency so that the user can see a pattern. hours of therapy to achieve a positive and lasting outcome.
SocialWork.EliteCME.com Page 82 Stages of change
In their book “Changing for Good,” authors James Prochaska, John it. They are still struggling to understand the negative consequences Norcross and Carlos Di Clemente (1995) state that there are six steps, of cybersex, its causes, or possible solutions. Many have indefi nite or stages, that everyone goes through when making changes in their plans in the near future to take action. At this stage, these individuals lives, regardless of their goals. These can be used effectively with are aware that life as they know it is not working, and problems Internet addictions. are beginning to worsen. They are not quite sure how to solve their problems and not quite ready to get started. When contemplating, Each of the steps is predictable, well defi ned, and takes place over they begin to transition to the next stage where they can think more a period of time. Each step includes a series of tasks that must be clearly and begin to focus on a solution rather than the problem. completed before moving onto the next stage. It is possible to stay Their orientation is more to the future than to the past. in one stage longer than another, and by understanding the stages, ● Stage III: Preparation – Most people in the preparation stage are individuals can gain control over the cycle of change and move planning to take action soon, often within the next month, and are through it more quickly and effectively. The stages are: ● Stage I: Precontemplation – People at this stage usually have no making fi nal decisions before they begin the change process. At intention of changing their behavior and often deny even having a this stage, they may still need to convince themselves that this is problem. Their families, friends, neighbors, doctors or coworkers what’s best for them and their family. They’re uncomfortable with see the problem clearly, but the addicted individual in this stage the way things are and want to take action to relieve their anxiety. ● Stage IV: Taking action – At this stage, people want to change their does not. Individuals at this stage resist change, lack information, behavior after years of avoiding their problems. They are working to and are often in denial. They do not take responsibility for their modify their behavior while at the same time changing their level of problems and blame their genetic makeup, family, society, or any awareness, emotions, self-image and thought patterns. other outside infl uence they can name. They often don’t want to ● Stage V: Maintenance – At this stage, they are working to talk or think about their problem because they feel the situation is strengthen the gains they have made during previous stages and hopeless. Individual may have to hit rock bottom, suffering serious are struggling to prevent lapse or relapse. This is a dynamic stage consequences, before they are able to progress from this stage. ● Stage II: Contemplation – At this stage, individuals acknowledge because ongoing effort is needed to maintain the change on a day- that they have a problem and begin to think seriously about solving to-day basis.
Preventing relapse
The recovery process is complex and often includes setbacks and feelings remain unresolved, they can lead to stronger feelings of relapses. As people work through the change process, they may lapse self-pity and entitlement, which may lead to relapse. and return to an earlier stage before getting back on track. Prochaska 3. Self-reliance – Once people have progressed in recovery, they and other researchers note that relapse is a normal part of the change may reach a point where they feel they can handle the situation process. They have found that the average successful individual and are in control. This trap is really an attempt to fi nd ways to relapses several times. participate in the addictive behavior without totally losing the Relapse is never easy, and those who do may feel like a failure, gains they have made. embarrassed, ashamed and guilty and may believe that their hard work 4. Deprivation – Simply stopping problematic or addictive behaviors was for nothing. They may want to give up entirely on the change does not signal recovery. Feelings of deprivation and entitlement process, or they slip back into previous stages and feel as if they’re may occur, and individuals might start other compulsive behaviors, going in a circle. Prochaska advises that individuals should think of the such as drinking or gambling. Until the underlying causes are change cycle not as a circle but as an upward spiral. resolved, recovery will not happen. 5. Stress – Higher-than-normal stress levels can quickly increase the risk Relapses are often the combination of a chain of events that starts of relapse. Stress can occur from negative and positive situations, and days, weeks or even months in advance of their actual occurrence strategies must be developed to handle stress, such as: when individuals engage in rationalization, denial or both. These two ○ Stress management skills. distorted ways of thinking can combine to infl uence certain choices or ○ Relaxation training. decisions as part of a chain of events that lead to a relapse. ○ Meditation or yoga. One of the main relapse prevention goals is to become aware of the ○ Therapy groups. behavior chains that can lead to a lapse or relapse. If people can recognize ○ Contacting support facilitators. the antecedents or triggers to those behaviors and their consequences, they ○ Preplanned activities or hobbies. can take action long before they get to the point of relapse. Individuals in recovery must always stay alert for antecedents or They will be able to plan positive strategies that are incompatible with triggers, such as social pressures, internal challenges and special inappropriate Internet use. Just as people participate in emergency situation that may arise. The following strategies can be used for drills, they can have a relapse drill as part of their prevention plan, maintaining commitment and recovery: and practice skills and strategies ahead of time. Examples of behavior ● List barriers they may encounter. For each barrier listed, strategies chains and specifi c details are included in the next section on Internet should be developed to address that barrier. gambling addiction. ● Take credit for accomplishments, avoid self-pity and self-criticism, and accept responsibility for the positive changes made. Carnes, Delmonico and Griffi n (2001) identify fi ve problematic ● Acknowledge progress month by month, week by week, or day by day. attitudes that they refer to as “relapse traps”: ● Realize there will be temptations and situations that will make 1. Entitlement – In the entitlement phase, individuals who are in a maintenance challenging. Avoid people, places, or activities that struggle to maintain abstinence may feel self-pity and believe they could trigger a relapse. are entitled to some kind of reward for their progress. ● Keep an emergency card in a wallet or purse with a list of negative 2. Resentment – During the recovery process, feelings of anger consequences, strategies to follow, and support people with phone and resentment may come to the surface, and it is important to numbers to call if the urge to relapse occurs. acknowledge and address these feelings with the therapist. If these
Page 83 SocialWork.EliteCME.com ● Substitute a positive, distracting activity, and list the benefi ts of ● Once control is regained, review the incident with a therapist or resisting the Internet. support person to fi nd ways to avoid that situation, or review and ● Seek help and support from support groups, therapist, partner, develop new strategies. spouse and friends.
The next step
This generation of youth is moving toward a totally “paperless” ● One in two parents does not use any blocking or fi ltering software. society, so Internet safeguards and laws must be developed to protect ● Sixty-two percent of parents of teens are unaware that their them against Internet addiction and abuse, which take many electronic children have accessed objectionable websites. forms. There also is a need for more scientifi c understanding of ● Twenty-nine percent of children ages 7 to 17 would give out their Internet addiction, which is limited to a few large-scale studies. name and home address if asked. ● Fourteen percent would give out their e-mail address if asked. Online fee-based subscription material profi ts from designs that will ● Seventy percent of teens 15-17 have accidently accessed encourage continued online activity. Effective prevention strategies pornography online. need to be developed, tested and implemented for the unique needs ● Fifty-fi ve percent of those exposed to pornography said they were of children, adolescents and adults. Internet materials are designed not too upset by it, or not at all upset by it. especially for those populations, but prevention and treatment is not. ● One in four children participate in real-time chat. Limits on Internet access and close monitoring are important for ● Only 34 percent of adults who have children participating in real children, though they are increasingly diffi cult to enforce at home, time chat rooms use technology to monitor where the children chat. libraries and schools. ● One in fi ve children who use chat rooms has been approached over A targeted prevention approach, identifying children who may be at risk the Internet by a pedophile. for addiction, is also important. Children with pre-existing psychological, ● Twenty-fi ve percent of youth who received sexual solicitation told social or familial conditions may be at risk. Internet use by children should a parent. be carefully regulated by parents, guardians and teachers. ● Fifty-eight percent of teens say they have accessed objectionable As indicated by the following statistics, adults are often unaware that websites. children are spending great amounts of time visiting social networks, ● Forty-four percent of children visited X-rated sites or sites with chat rooms, blogs and online sites that expose them to danger: sexual content. ● Parents rely mostly on personal observation and setting guidelines ● Forty-three percent of children say they do not have rules about for their children’s Internet use. Internet use in their home. INTERNET GAMBLING ADDICTION
Defi nition
Internet gambling addiction is gambling behavior that causes that stemmed from personal weakness. The DSM listing changed disruption in any major area of life, psychological, physical, social or gambling addictions from vice to disease. vocational. The term gambling addiction includes the condition known As the DSM-III and DSM-IV were released between 1987 and 2000, as pathological or compulsive gambling (APA, 2010). the defi nition of pathological gambling continued to evolve. It remained A progressive gambling addiction is characterized by: classifi ed as an impulse control disorder, like conditions of pyromania or ● Increasing preoccupation with gambling. kleptomania, rather than directly defi ned as an addiction (APA, 2010). ● A need to bet more money frequently. Under the most recent defi nition, pathological gambling is described ● Restlessness or irritability when attempting to stop. as “persistent and recurrent maladaptive gambling behavior” indicated ● “Chasing” losses. by fi ve or more of 10 symptoms. The perception of problem gambling ● Loss of control manifested by continuation of the gambling has changed dramatically, and in February 2010, a DSM-5 workgroup behavior in spite of mounting serious, negative consequences. recommended that a new category of “behavioral addictions” be There is a certain shame attached to confessing a gambling addiction, formed for the fi rst time and suggested that pathological gambling be in some cases even more than being an alcoholic or cocaine addict. included as the sole disorder on the list. In psychiatry, only disorders Many still believe that people gamble excessively because of a lack involving substances such as alcohol and drugs have been considered of willpower or because they are simply immoral. These beliefs full-fl edged addictions. This proposed change would include gambling are beginning to change, as doctors, scientists and researchers are addiction on the same level with other addictions. Final publication of concluding that pathological gambling is a behavioral addiction that the DSM-5 is scheduled for May 2013 (APA, 2011). affects the brain in much the same way as substance dependency. The DMS-V workgroup has proposed that gambling addiction be Research suggests that about one in two problem gamblers suffer other reclassifi ed from impulse control disorder not elsewhere classifi ed types of addictions (Goudriaan et al., 2006). to substance-related disorders, which will be renamed addiction and Beginning in 1980, modern psychiatry redefi ned gambling addiction. related disorders as described below: The publication of the third edition of the Diagnostic and Statistical A. Persistent and recurrent maladaptive gambling behavior as Manual of Mental Disorders (DSM–III) marked the fi rst time indicated by fi ve or more of the following: pathological gambling was included (APA, 2010). 1. Is preoccupied with gambling, reliving past gambling experiences, handicapping or planning the next venture, This resulted in a major shift in how gambling addiction was seen by thinking of ways to get money to gamble. those in a wide range of fi elds, from doctors to judges, social workers 2. Needs to gamble with increasing amounts of money in order to and religious leaders. The condition was accepted by many as a achieve the desired excitement. medical disorder, as opposed to a moral failing or sinful transgressions
SocialWork.EliteCME.com Page 84 3. Has repeated unsuccessful efforts to control, cut back or stop 8. Has jeopardized or lost a signifi cant relationship, job, gambling. educational, or career opportunity because of gambling. 4. Is restless or irritable when attempting to cut down or stop 9. Relies on others to provide money to relieve a desperate gambling. fi nancial situation caused by gambling. 5. Gambles as a way of escaping from problems or relieving B. The gambling behavior is not better accounted for by a manic episode. negative moods, such as feelings of helplessness, guilt, As discussed in the last section, Internet addiction is characterized by anxiety, or depression. the same types of criteria listed above. The Internet provides a faster, 6. After loosing money gambling, returns for another day to get more accessible, easier, anonymous and private way to gamble, which even (“chasing one’s losses”). can accelerate an individual to addiction. 7. Lies to family members, therapists, or others to hide the extent of involvement with gambling.
Prevalence
Online wagering has turned into the biggest worldwide gambling gambling would add $30 billion in new federal taxes and generate trend. Virtual gambling began in 1995, and since then has grown to 125,000 jobs, the group predicts. more than 2,000 Internet gambling sites. Internet gambling addiction is According to online proponents, the U.S. should follow Europe’s lead, increasing in alarming proportions and results in various dysfunctional where many countries have legalized online gambling. From Denmark behaviors if not treated correctly. to Greece, European governments have legalized and deregulated the Internet gambling has been described as the nation’s foremost “silent online gambling business by allowing private companies to compete addiction.” As one college counselor pointed out, “pathological gamblers with state-sponsored online gambling sites. Some offi cials noting the don’t have track marks on their arms, their speech is not slurred, and they correlation between online gambling and high addiction rates have are not staggering down the street. But on the inside, the emotional churn claimed that legalization is needed because government controls can going on is equally as great as in the substance abuser (Henry, 2003). aid in protecting problem gamblers. But many in the U.S. are concerned The venue of choice for individuals with Internet gambling addiction that legalization and the reliance on gambling revenues, including varies as well. While many prefer gambling online at home, the from addicted gamblers, is distorting the more appropriate role of increasing numbers of Internet cafes contribute to the rates of Internet government and creating dependencies. H2 Gambling Capital explains, gambling addiction that continues to increase as follows: “they regulate a little bit, then they deregulate more. The government ● According to recent research, about 2.5 million adults in America gets more addicted to the tax than the players to the online games.” are pathological gamblers, and another 3 million adults are Young people, especially college students and recent graduates, considered problem gamblers. are at risk for developing online gambling problems. Today young ● Fifteen million adults are at risk of problem gambling, and about people use the Internet as their primary source of communication 148 million are low-risk gamblers. and entertainment. Compared to drugs and alcohol, which have been ● Gambling addiction statistics show that more than 80 percent of around colleges for decades, the addiction to online gambling is a American adults report having gambled at some point in their lives. relatively new addiction on campuses. ● Gambling addiction statistics reveal that more than $500 billion is It is one of the most widespread and serious concerns affecting spent on annual wagers. students today, and online gambling networks in a school can be ● The statistics show that during any year, 2.9 percent of U.S. gamblers disguised as a group of students socializing together. In this Internet are considered to either be pathological or problem gamblers. age, bets can be made online or via cell phones, and the addiction ● Gambling addiction statistics on co-occurrence of gambling and can involve an entire school and be undetected. Because money is alcohol dependence revealed problem drinkers are more likely to something most students need, online gambling seems like a harmless have a gambling addiction (Skolnik, 2011), (Shaffer, 2010) and way to make cash quickly and easily. (Rosenthal, 2010). Being physically and psychologically linked to a campus, college students The rate of online gambling addiction continues to increase: are interested in the outcomes of sporting events, and when combined ● Ten million Americans play poker online for money as opposed to with easy access to alcohol and high-speed Internet, many post-secondary the free, not-for-money games. institutions fi nd their students engaging in online sports gambling at much ● The United States has the highest number of online gamblers in higher rates than the general population (Henry, 2003). the world. ● The country that came closest to the U.S. in the 2009 survey was The University of Kansas director of counseling services noted that the United Kingdom, with 1.9 million players. gambling allows students to feel intimately involved in the game (Aire, ● A survey completed in 2010 estimated that American gamblers 2000). The gambling recovery counselor stated, “The more someone would bet $5.7 billion dollars online by the end of 2010. This is knows about a given sport, the more they believe their decision- down slightly from the $6 billion wagered in 2009. making gives them a signifi cant advantage.” This develops a level of ● Americans comprise 17.2 percent of the worldwide online “emotional invincibility in the addiction” (Henry, 2003). gambling market. With easy access to online gambling and a need to feel part of the Analysts predict that online gambling in the United States will rapidly larger organization, pathological Internet gambling associated with increase if the Unlawful Internet Gambling Enforcement Act (UIGEA) betting on sporting events has risen signifi cantly in the past 10 years is repealed. This act makes it illegal to transfer funds from fi nancial (Jordan, 2009). institutions to online gambling sites. Two U.S. representatives from According to the Annenberg Public Policy Center’s 2005 National Massachusetts and Washington have bills on the table for repeal, as Center of Youth: well as state lawmakers from across the country. If the law is repealed ● There are 2.9 million Americans ages 14 to 22 who gamble online and online gambling becomes legal across the country, it would result once a week. in $67 billion for the U.S. economy over the fi rst fi ve years, according ● About 50.4 percent of male college students gamble online once a to the British consulting group H2 Gambling Capitol. Revenue from month.
Page 85 SocialWork.EliteCME.com ● 26.6 percent of female college students gamble online at least once the lies begin, and gamblers lie to maintain the appearance that a month. they are winning. ● This is half of the entire male student body and a quarter of the ○ Gamblers want to seem fi nancially viable and competent at the female student body. game. They continue to boast about their gambling skills – part ● Gambling is particularly tempting to college students because risk- of the narcissism often seen among Internet addictions. They taking behaviors are common. talk about winning, but not about losses. ● The legal age for gambling is 18 years old in many states, making ○ When they suffer a major setback that causes fi nancial trouble, it a socially permissible behavior. gamblers make up a lie to get a loan. Because they have been In one extreme case, a student at the University of Wisconsin able to hide their online Internet gambling, their deception to murdered three roommates because he owed them thousands in get a loan is much easier. ○ They consider the bailout a win, again because of faulty thought gambling debts. The trio had helped him place bets with an online patterns, and they resume gambling even more aggressively than offshore gambling company. He had lost $15,000 through gambling before. In this phase, there is more losing than winning, time on and withdrawn $72,000 from his bank account to support his habit the Internet increases, and life becomes unmanageable. before he committed the murders (Wexler and Isenberg, 2002). ○ They fi nd it is impossible to persuade others to provide a loan, and Online gamblers are connected to one another and can “chat” with relationships with family and friends are rapidly deteriorating. written posts, but most are sitting alone in a private place while ○ The obsession increases, they cannot stop, debts mount, gambling online. The ability of online gamblers to play considerably irritability and depression may occur, and they drop out of faster than they could at a casino can lead to higher rates of addiction. social, work, and school activities. (These are characteristics The National Gambling Impact Study Commission warned of potential listed in both Internet and gambling addiction as noted in the Internet gambling problems in a 1999 report, issued when the online DSM.) industry was in the beginning stages and much smaller than today. The ● The third phase: Desperation: commission said, “In addition to their accessibility, the high-speed instant This is the point when gamblers become obsessed with Internet gratifi cation of online Internet games and the high level of privacy they gambling and feel compelled to carry it through, despite knowing offer may increase the problem and lead to pathological gambling.” Since they will lose: then, the warning has materialized over the last decade. ○ Life becomes completely out of control, and when others don’t believe their lies, they become angry, blaming others for their Researchers have found pathological online gambling is related to poor problems. physical and mental health even more than other forms of gambling. ○ They need to fi nd money to gamble at all costs, and illegal Internet gambling is very different from the experience of social activity may occur through embezzling and stealing money or gambling, according to Les Bernal, executive director of the group Stop objects to sell or pawn. Predatory Gambling, and he explains the difference. “The speed of the ○ They consider the illegal activity a loan, which they will pay game, the frequency of play, the intensity of the high people get when back from the big win they believe will happen soon. they play, and the enormous amount of money people lose, all of which ○ Still convinced that everyone believes the lies they have told, goes down 24 hours a day, seven days a week – It is the equivalent of these gamblers become furious if questioned by others. putting a Las Vegas casino in every house, apartment and dorm room.” ○ Gamblers outwardly blame everyone else but themselves for Robert L. Custer, M.D., cites the four phases of gambling and has the unfortunate circumstances now occurring. Inwardly, they developed an Adolescent Chart of Compulsive Gambling that can are in severe anguish, truly loves their families, and want apply to adults as well: things to be like they used to be. ● The fi rst phase: Winning: ○ They want to correct the problems they have caused, but are The attraction of compulsive Internet gambling is the immediate compelled to gamble, although they do not know why. gratifi cation. During the winning phase: ○ To pay debts, they sell family valuables, commit crimes, feel ○ Gamblers likely win more than they lose. shame, guilt and panic, and are totally out of control. ○ The wins reinforce the person’s love of the game. ● The fourth phase: Hopelessness: ○ Gamblers may develop the illusion that they are skilled at the Until recently, only three phases of pathological gambling have game. been noted. Many clinicians and experts who treat pathological ● The second phase: Losing: Internet gambling now say a fourth phase exists for both action- Gamblers’ luck does not run forever, and after a while, they start seeking and escape gamblers (Parhami, 2010). Once gamblers losing more money. Ironically, a losing phase does not discourage have been through the desperation phase, it would seem that them. During the losing phase: everything bad had occurred. However, in the hopeless phase, ○ They feel tempted to gamble more and with larger amounts of pathological gamblers have given up: money. ○ They believe nothing can help and many do not care if they ○ They are convinced that they are simply on a losing streak and live or die. just need one win to get back momentum. ○ Many believe suicide is the only way out, and they consider ○ They invest on the “long shots,” which, while having low odds of that during this phase. winning, will pay big, according to their faulty thought processes. ○ Most will commit actions that could place them in jail or prison. ○ They may engage in a behavior called “chasing losses,” ○ They believe no one cares, and no hope is available. meaning they will increase their gambling with larger bets, ○ The hopeless phase is the time when the pathological gambler hoping to win back the losses. In the phase of chasing losses, either gets help or turns to substance abuse or suicide.
Etiology
As with other mental health issues, compulsive online gambling environmental factors. Compulsive gambling affects both men and may result from a combination of biological, genetic, social and women and cuts across cultural and socioeconomic lines.
SocialWork.EliteCME.com Page 86 Risk factors for gambling addiction
Although most people who gamble never develop a gambling People who suffer from compulsive gambling addiction and Internet addiction, certain risk factors are often associated with compulsive addiction often have a tendency to be novelty seekers. Combining the gambling, elements that increase the likelihood that the individual will two forces of gambling and the Internet only adds to the excitement. develop a gambling addiction. Risk factors for developing pathological And the speed of the Internet only increases the frequency of this rush. Internet gambling include schizophrenia, mood problems, antisocial Physiological changes include a surge of blood to the face and a dry behavior, personality disorder, bipolar disorder, and alcohol or cocaine mouth. Concentration narrows, as time seems to slow. The high is addiction as described below (Mayo, 2011): short-lived but is repeated as soon a gambler makes the next bet – ● Behavior or mood disorders: People who gamble compulsively which can happen immediately online. The feeling exists whether the often have mood disorders, such as anxiety and depression, as well bet is won or lost, but can spike, especially if it is more than expected. as attention-defi cit/hyperactivity disorders: The rush experience has been compared to snorting a line of cocaine ○ 37.9 percent of pathological gamblers were also diagnosed (Skolnik, 2011). with mood disorders. ○ 37.4 percent of pathological gamblers were diagnosed with The Internet has provided unprecedented access to online gambling so anxiety disorders (Rosenthal et al., 2010). that rush gamblers can get satisfaction in the privacy of their homes at ● Family infl uences: If a parent had a gambling problem, chances any time. Currently, there are more than 2,000 gambling websites that are greater that children in the family will develop gambling take in more than $4 billion annually (Aire, 2003). problems. Dysfunction in the family and childhood trauma and Here is an example of online gambling as described by one college- abuse are also factors. aged compulsive gambler: ● Personality characteristics: Highly competitive, narcissistic, It’s 2 a.m. I’ve got an economics exam very early in the morning. restless or easily bored individuals have an increased risk of I can stay on for just one more online tournament. This time I developing an Internet gambling problem. can win, I can feel it. I need to make up for what I lost today. I ● A diagnosis of bipolar disorder: Exorbitant spending in the form absolutely have to. Maybe I can buy a new outfi t for this weekend of compulsive Internet gambling may be a symptom. or put a little bit of money toward my credit card bill. I can feel it. ● Parkinson’s disease or restless leg syndrome: Medications used This is the one. Come on. Aces, aces … to treat these disorders have been observed to develop compulsive gambling in some individuals. I am an addict. I’m not alone. This is a new addiction, and my 2 ● Alcohol and cocaine addiction are risk factors for pathological a.m. pre-econ-exam, late-night binging is what I call the “gambling gambling. me.” The reason I didn’t connect this directly to myself is due to ● Biochemical factors: In some addictive individuals, compulsive the fact that I never knew I was capable of an addiction. I’ve never behaviors can be connected to increased activity of the chemical smoked or used drugs and only drink socially. I was the last person messenger dopamine in the brain or low serotonin levels. in the entire world that I thought could be addicted to anything. - Lauren Patrizi, Loyola University-2005, at a Gambler’s For the last decade, researchers have studied how biochemical Anonymous meeting (Jordan, 2009). substances such as dopamine work in gamblers’ brains. Neurotransmitters help the brain learn about pleasure, including Using an MRI scanner, neurologists in Hamburg, Germany, measured predicting when the sensation may return (Goudriaan, et al). the responses of 12 gambling addicts and 12 nonaddicts to a card- guessing game. When participants picked the correct card, they won Addicted Internet gamblers are different from nonaddicted ones in a euro. The non-addicts picked the right card, which increased their the ways their dopamine systems function. Individuals who have a blood fl ow to the ventral striatum, a portion of the brain with dopamine low level of serotonin in the brain are at higher risk for developing receptors that measures rewards. In comparison, the addicted gamblers’ pathological Internet gambling. Some researchers believe that during brains had far less blood fl ow to the area, indicating they needed a the fi rst gambling experience, for some pathological gamblers, a huge reward much larger than a single euro to become excited (Lewis, 2006). dopamine rush can occur that gets planted in their memory. When that happens, the addicted gamblers, like cocaine addicts, develop reward Problem online gambling involves more than one symptom but less than systems that respond to pleasing stimuli differently than nonaddicts. the fi ve symptoms required to qualify for the diagnosis of compulsive or pathological gambling. Binge gambling is a subtype of compulsive An increasingly high level of reward has to be given for many addicted gambling that involves problem gambling, but only during discrete gamblers to continue to feel pleasure, leading to tolerance, dependence periods of time. That is different from an online gambling addiction, and addiction (APA, 2010). Studies have noted that gamblers crave the which tends to involve excessive gambling behavior on an ongoing basis rush, the high or euphoria they feel when they make a bet or when they and includes persistent thoughts or obsessing about gambling, even during anticipate making the bet. times when the person is not engaged in gambling. (UCLA, 2010) TREATMENT OF ONLINE GAMBLING ADDICTION
Cognitive behavior therapy
Cognitive behavior therapy aims at replacing negative beliefs with The goal of treatment is to “rewire” the addicted brain to help the healthy and positive ones as a form of gambling addiction treatment. individual learn to think about gambling in a new way, according to the This therapy focuses on changing unhealthy gambling behaviors and Department for the Mental Health Addiction Services (MHAS, 2011). thoughts, such as rationalizations and false beliefs. It also teaches (Refer to the CBT section in the previous discussion on Internet sexual problem gamblers how to fi ght gambling urges, deal with uncomfortable addiction.) emotions instead of seeking escape through gambling, and solve fi nancial, work and relationship problems caused by the addiction.
Page 87 SocialWork.EliteCME.com Principal errors in thinking among gamblers One way to prevent and control online gambling addiction is to to believe that their actions infl uence their chances of winning. They alleviate fallacies in thinking (Jordan, 2009). The faulty thought maintain the illusion that they will beat the online game by defying the patterns of pathological Internet use were discussed in the previous negative odds to recoup their losses (Jordan, 2009). section and are combined with the faulty gambling thought patterns But because gambling activities are not games of skill, no mental listed below. Internet gamblers must evaluate their patterns of thinking or physical skills are necessary when it comes to betting. However to determine whether they are based on realistic odds. the majority of gamblers believe that it is possible for them to The following are some faulty thought patterns commonly acquire some form of mastery. Familiarity is an important factor misunderstood by compulsive gamblers: in the illusion of control, but often when people familiarize ● Independence of turns. themselves with a task determined by chance, the stronger they It is not unusual for gamblers to think in terms of winning streaks, believe that they can control the situation. which motivates them to continue gambling. They might say, “I The amount of direct exposure to a situation increases the degree will defi nitely win today, I am on a winning streak,” or “I will of perceived control. A number of studies have demonstrated that not place a bet online today because I am on a losing streak.” For when individuals have the opportunity to aggrandize the degree of example, when they get three wins in a row, they interpret that as risk they take, as is the case with online gamblers, they take greater a strong likelihood that the next bet will win. This kind of thinking risks when they make their decisions alone. Wallech explained this runs counter to the principle of the independence of turns. increase in risk-taking as a group process in which the individuals Independence of turns means that events are independent of each share their risk-taking, and therefore, each feels reinforced by other; each is considered as unique and has no links to previous risk-taking behavior. As a result of the group sharing online, the and consequent events. Thus, there is no such thing as a lucky tolerance for risk-taking is increased (Wallech, 2011). streak or catching up on previous losses. Each bet has a 50-50 ● Superstitions. chance of winning. Another common error in thinking among gamblers is the belief in superstitions. Often superstitions support gamblers’ illusions of control Independence of turns is an essential condition of games of by making them think that a ritual can increase their chances of a win. chance. In order to be unpredictable and to obey the rules of chance, all gambling games are structured in a way that each turn The next obvious step would be to address these principal errors is an independent event and in no way determined by the results in thinking through a form of therapy, such as cognitive behavioral of the previous turn. This independence of events, or absence of a therapy, that focuses on thought processes. This could lead addicted or link between events, makes predicting the next result impossible, potentially addicted online gamblers to identify fallacies in thinking, so gamblers can never exert any control over the game. which are directly related to their views on winning. ● Illusions of control. Because these errors in thinking contain concepts commonly The majority of gamblers believe that they accumulate experience and misunderstood by these gamblers, this may provide a cognitive basis learn from their errors when gambling. This follows the patterns of to deal with the realities of gambling and change their thought patterns control, narcissism and grandiosity, which are also characteristics of to develop appropriate strategies for prevention (Jordan, 2009). Internet addiction. This feeling of personal superiority leads gamblers
Four steps program A variation of cognitive behavioral therapy called the four steps program Step 4: Revalue. has been used in treatment of compulsive gambling. The goal is to change Over time, individuals learn to revalue fl awed thoughts about the thoughts and beliefs about gambling in four steps; relabel, reattribute, gambling. Instead of taking thoughts and feelings at face value, they refocus and revalue. Dr. Jeffrey Schwartz outlines the four core steps to realize they have no inherent value or power. They are just “toxic recovery from gambling addiction in his book, “Brain Lock.” waste from the brain” (Schwartz and Beyette, 1996). These four core steps use a variety of psychotherapeutic methods to Treatment helps these people develop tools and support for reframing treat pathological gambling, including cognitive behavioral therapy their thoughts. They learn to change their lifestyles and make healthier and rational emotive severity approaches (Schwartz & Beyette, 1996). choices by analyzing what is needed for online gambling to occur, Step 1: Relabel. work on removing these elements from their lives, and replace them Recognize that the urge to gamble is nothing more than a symptom of with healthier choices (Fong, 2010). the gambling addiction, which is a treatable medical condition. It is not Two elements of problem online gambling to address are: a valid feeling that deserves attention. 1. A decision – Before gambling occurs, the decision to gamble has Step 2: Reattribute. been made. If you have an urge to gamble, stop what you’re doing Stop blaming and try to understand that the urge to gamble has a and call someone, think about the consequences of your actions, physical cause in the brain. People must learn they are separate tell yourself to stop thinking about gambling, and fi nd something from the disease of addiction and not passive bystanders. They must else to do immediately. understand that with practice, they can learn to control the addiction. 2. Money – Gambling cannot occur without money. Get rid of credit cards, let someone else be in charge of money, have the bank make Step 3: Refocus. automatic payments, and keep a limited amount of cash available When the urge to gamble strikes, individuals must shift their attention at all times. to something more positive or constructive. They should plan to do something else, even if the compulsion to gamble is still strong. Medication Medications for online gambling addiction treatment are often from the (Eskalith, Lithobid) and medications used to address addictions like antidepressant group. SSRIs (selective serotonin reuptake inhibitors) naltrexone (ReVia), and antidepressants like clomipramine (Anafranil) have proven to be effective in the treatment of gambling addiction and fl uvoxamine (Luvox) have been effective for some patients. that includes mood swings and anxiety. Mood stabilizers like lithium
SocialWork.EliteCME.com Page 88 Other medications have been helpful in decreasing the urge to gamble or to see whether naltrexone treats pathological gambling among those the thrill involved, including anti-seizure medications like carbamazepine who develop such disorders because they had taken Parkinson’s-fi ghting (Tegretol) and topiramate (Topamax) (Edwards & Shiel, 2011). drugs that may cause addictive symptoms (Dodd, et al.). Naltrexone and nalmefene appear to be two of the most promising drugs A different trial with naltrexolene, unrelated to Parkinson’s disease, being studied today. Primarily used to treat alcohol dependence, both is being conducted and will attempt to determine whether the drug is drugs have proven more effective than a placebo in treating pathological effective in a real-world clinical setting. The trial is scheduled to be gambling in three separate randomized clinical trials (APA, 2010). completed in 2012. These drugs are opioid antagonists. “Opioids regulate dopamine Medication combined with a proven psychotherapy method, such as pathways in areas of the brain linked with impulse control disorders. The cognitive behavior therapy, has been effective in treating a variety of opioid antagonists block opioid receptors in these regions,” according Internet addictions, including online gambling addiction. to the National Institute of Health (NIH, 2011). There is an ongoing trial
Internet boot camps
A controversial strategy that has received increased media attention is government viewed the situation as a national threat and responded boot camp-style rehabilitation programs. These programs can be used aggressively by opening up an extensive network of Internet addiction as an intervention to stop the development of Internet addiction or to outpatient clinics, hospital-based programs and intensive boot camps treat an existing addiction, according to its proponents. Developed and and Internet rescue facilities. used in Asian countries, this treatment program is being widely used in At boot camp, there is no Internet access allowed except for a daily South Korea – one of the most Internet-connected nations with one of cell phone call home. For some youths who had spent upwards of 17 the highest rates of Internet addiction among its population. hours a day on the Internet, this type of treatment produces physical and In Korea, online gaming is a professional sport, and the social life of emotional withdrawal symptoms. The youths are offered substitute games youths revolves around Internet social media. Internet cafés can be and activities to replace the online gaming. Though the results of these found on every corner, and many young people skip school in large programs have not been independently tested through scientifi c studies, numbers to stay online for marathon sessions of virtual games. The some of these programs claim a 70 percent success rate and “cure.”
Illegal activity and severity
Individuals who engaged in illegal behavior in the year prior to treatment other substance abuse, mood disorder or personality disorder, should tend to have more severe symptoms of gambling, have more gambling- be addressed to give the addicted gambler the best chance for recovery related debt, and have more severe symptoms during treatment compared from both conditions (Petry, 2005). to people who are not engaged in illegal activity during that time period. Though one third of pathological gamblers may recover from the People who engage in breaking laws the year before treatment began need disease without treatment, the devastation of Internet gambling addiction more intensive treatment for a longer period of time, sometimes even indicates that positive aspects of treatment outweigh the possible requiring inpatient or residential treatment. complications resulting from intervention (Edwards & Shiel, 2011). Another important fact to consider in treatment is that up to 70 percent One of the challenges of treatment for gambling addiction is that of people with this disorder also have another psychiatric problem two-thirds of addicts who begin treatment for this disorder discontinue (Edwards & Shiel, 2011). It is not enough to just treat the gambling treatment prematurely, regardless of whether treatment involves problem; any coexistent mental health condition, such as alcoholism or medication, therapy or both (Edwards & Shiel, 2011). PREVENTING RELAPSE
Understanding behavior chaining
To understand the sequence of behavior that affects their gambling wants to gamble and feels a craving (thinking initiates feeling). She addiction, gamblers must identify the triggers – the external events – walks into the café, which is dimly lit, and feeling anonymous, she that start the behavioral sequence. After the trigger, people’s thinking enters a room full of colorful online gambling sites ready for play. happens very quickly, and they may not have time to stop and focus at 2. Jan sits down to play, feeling a rush of excitement (feeling initiates the this point. The thoughts that trigger feelings may give the individual behavior). Jan lapses and stays three hours, loses money, and feels energy and direction for action. The trigger initiates the behavior or the defeated, embarrassed and exhausted (the behavior has a consequence). action to occur. Finally, there is always the consequence for the action 3. It is midnight, and Tom is not asleep (the trigger). He thinks, “I will (Fong, 2010). gamble online just a little so I can sleep” (thinking). He feels anxious The following is a behavior chain: about not sleeping two nights in a row (feeling). He gets up, goes to 1. Trigger. the computer and enters his favorite online gambling site (behavior). 2. Thinking. He loses a large amount of money and is so depressed and exhausted 3. Feeling. that he cannot go to work the next morning (consequences). 4. Behavior. In a behavior chain, individuals learn that at every point along the 5. Consequences. chain, they can work on preventing a lapse or relapse. They begin Here are examples of behavioral chains and how they work: by examining triggers carefully to determine what environmental 1. After a stressful day at work, Jan heads home. Jan, a recovering events could lead to gambling. They learn to re-examine high-risk Internet gambler, passes the new Internet café that is open 24 hours a situations to determine what people, places and things may make them day (the trigger). She thinks, “I’m feeling in control, and I think I will vulnerable to lapse or relapse. go in just for a few minutes of fun,” (trigger initiates thinking). Jan
Page 89 SocialWork.EliteCME.com In this way, they can stay away from these triggers as much as possible, This inventory assesses: and if one occurs, they are prepared to use their new coping skills or ● Relapse warning signs. substitute behaviors (Fong, 2010). To prepare for continued recovery, ● Feelings about themselves and others. they develop a daily relapse prevention program, which increases their ● Sleeping, eating, exercise and relaxation habits. chances of success. This plan includes evaluating their recovery daily ● Progress in the total recovery program. and keeping a journal and prevention inventory for continued progress.
Efforts to restrict online gambling
With the increasing incidence of online gambling, a commercially schools, libraries, government buildings and other institutions. This produced computer application has been developed to block access system is installed by many entities to ensure that online gambling to online gambling. GamBlock has been available since 2000 to help cannot be conducted from their facilities by staff, patients or visitors. problem gamblers avoid unrestricted online gambling. The system could be effective in situations where only one computer GamBlock uses a system that continually locates and blocks new is available as well, such as a home computer or controlled therapeutic gambling sites and software as it is developed. It does not require setting to give computer access to an individual in a treatment/ constant updating of website lists and claims to eliminate all access recovery setting. It would not address the underlying issues involved to online gambling. GamBlock cannot be removed, and could be used in a gambling addiction nor serve as a replacement for treatment. at home or in treatment facilities, hospitals, correctional facilities,
Laws to address online gambling
The Unlawful Internet Gambling Enforcement Act (UIGEA) was enacted Agents from the U.S. Justice Department have arrested international in 2006. The measure made it illegal for funds to be transferred from Internet gambling operators for violating the Federal Wire Act. The fi nancial institutions to online gambling sites and made it tougher and illegal Justice Department has maintained that the act makes all Internet for Americans to deposit money on those sites. As noted previously, several gambling illegal, though the issue is under study in the federal courts. bills are being proposed to appeal this act in favor of legalized gambling. YOUNG’S INTERNET ADDICTION TEST
The following 20 questions are examples from K.S. Young’s “Caught Winning Strategy for Recovery.” It is being included here because it in the Net: How to Recognize the Signs of Internet Addiction and a applies to both topics covered in this course.
Young’s Internet Addiction Test Answer each of the following 20 questions on a scale of 1 to 5: 1. Rarely 2. Occasionally 3. Frequently 4. Often 5. Always 12345 1. How often do you stay online longer than you intended? ...... 2. How often do you neglect household chores in order to spend more time online? ...... 3. How often do you prefer the excitement of the Internet to intimacy with your partner? ...... 4. How often do you form new relationships with fellow online users? ...... 5. How often do others complain about the amount of time you spend online? ...... 6. How often do your grades or schoolwork suffer because of the amount of time you spend online? ...... 7. How often do you check e-mail before something else that you need to do? ...... 8. How often does your job performance or productivity suffer because the Internet? ...... 9. How often do you become defensive when someone asks you what you do online? ...... 10. How often do you block out disturbing thoughts about your life with soothing thoughts of the Internet? ...... 11. How often do you fi nd yourself anticipating when you will go online again? ...... 12. How often do you fear that life without the Internet would be boring, empty and joyless? ...... 13. How often do you snap, yell, or become annoyed if someone bothers you while you are online?...... 14. How often do you lose sleep because of late-night Internet use? ...... 15. How often do you feel preoccupied with the Internet when offl ine or fantasize about being online? ...... 16. How often do you fi nd yourself saying “Just a few more minutes” when online?...... 17. How often do you try to cut back on your online time but fail? ...... 18. How often do you try to hide how long you’ve been online? ...... 19. How often do you choose to spend more time online over socializing? ...... 20. How often do you feel depressed, moody or nervous when you’re offl ine, a feeling that goes away once you are back online? ...... A total score of 49 or less suggests typical Internet use by non-addicts; 50 to 79 points correlates with possible Internet-related problems; an 80 or above is consistent with Internet addiction.
SocialWork.EliteCME.com Page 90 Resources for information on gambling addiction and sexual addiction
Gambling addiction resources ● Emotions Anonymous. www.mtn.org/EA. ● American Psychological Association. [email protected]. ● National Council for Couple and Family Recovery. ● Gamble Anonymous. [email protected]. ● National Council on Sexual Addiction and Compulsivity. www. ● Compulsive Gambling Center. www.lostbet.com. ncsac.org. ● Game-Anon International. www.gam-anon.org. ● Recovering Couples Anonymous. ● United States Gambling Hotline. 1-800-522-4700. www.recovering-couples.org. ● UCLA Gambling Studies Program. www.uclagamblingprogram.org. ● Recovery Online. www.onlinerecovery.org. ● Massachusetts Council on Compulsive Gambling. ● The National Center For Prosecution of Child Abuse. www.ndaa.org. www.masscompulsivegambling.org. ● S-Anon. www.sanon.org. ● National Council on Problem Gambling. www.ncpgambling.org. ● Sex Addicts Anonymous. www.sexaa.org. ● Debtors Anonymous. www.debtorsanonymous.org. ● Sex and Love Addicts Anonymous. www.slaafws.org. ● Ernie and Sheila Wexler Associates. www.aswexler.com. ● Sexual Addiction Resources/Dr. Patrick Carnes. Sexual addiction resources www.sexhelp.com. ● American Psychological Association. www.apa.org. ● Sexual Compulsive Anonymous. www.sca.recovery.org. ● Co-Dependents of Sex Addicts. ● Survivors of Incest Anonymous.
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Page 91 SocialWork.EliteCME.com Petry, N.M. (2007). Internet gambling Is Common in College Students and Associated Starcevic, V. & Porter, G. (2010). Effects of Violent Video Games. The Controversy with Poor Mental Health, American Journal on Addictions 16,5. Retrieved December Revisited. Impulse Control Disorders, ed. Elias Aboujaoude and Lorrin M.Koran. 30, 2011 from http://onlinelibrary.wiley.com/articles/october2007/swedenresults.htm. New York: Cambridge University Press. Popkin, H.A.S. (2009). The Internet Makes Me Feel Fat. Newsweek, September 2, Suler, J. (2004) The Online Disinhibition Effect. Cyber psychology Behavior, 7, No.3: 2008. Retrieved May 25, 2012 from http://www.newsweek.com. 321-326. Prochaska, J.O., Norcross, J.C., & DiClemente, C.C. (1995) Changing for Good. New Wallech, D. (2011). Co-addicts, Psycho-education and Support, The Center for York: Avon Books. Recovery. Retrieved on January, 4, 2012 from http://therapists.psychologytoday.com/ Renshaw, P. ((2007) Dopamine Genes and Reward Dependence in Adolescents with rms. /prof.detail. Excessive Video Game Play. Journal of Addiction Medicine I, No. 3, 133-138. Walters, J. (2005). Computer Friendly Gambling Has Found a Growing Fan Base Recupero, P.R., Harms, E.S., & Noble J.M. (2008). Googling Suicide: Surfi ng for Online. Sports Illustrated, Retrieved on June 10, 2012 from http://sportsillustrated. Suicide Information on the Internet. Journal of Clinical Psychiatry 68. No. 6: 878-88. cnn.com/2005 Robert, L. (2004) Excerpt from a Listserv of Cyber psychology. Retrieved on May 25, Watzlawick, P. Weakland, & J.H.,Fisch,R.(1998). Change: Principles of Problem 2012 from http://[email protected]. Formation and Problem Resolution. New York: Norton. Rosenthal, R. (2010) Severity, Gambling, and DSM-5. Journal of Medicine, March, Weiss, R. (2000) When Sex Is Too Important. Retrived on June 1, 2012 from 2010. Retrieved on January 10, 2012 from http://www.uclagamblingprogram.org bpdfamily.com/bpdresources/nk. Schneider, J.P. (2001) A Qualitative Study of Cybersex Participants. Sexual Addiction Wexler, A. & Wexler, S. (2002) Facts on Compulsive Gambling and Addiction. and Impulsivity 7, No. 4, 12-15. Council on Compulsive Gambling, New Jersey ERIC Document reproduction Service Schwartz, J.M. & Beyette, B. (1996). Brain Lock: Free Yourself from Obsessive N.ED372337. Compulsive Behavioral Four-Step Treatment Method to Change Your Brain Wexler, A. & Isenberg. (2002) Blowing the Whistle on Campus Gambling. Chronicle Chemistry. Harper Collins. of Higher Education, p.b19 Shaffer, HJ, Hall, MN, &Vanderbilt, J.1999. Estimating the prevalence of disordered Wilson, W.A. (2002) How Addiction Hijacks Our Reward System. Cerebrum 7:53-66. gambling behavior in the United States and Canada: A research synthesis. American Young, K.S. (1996). Psychology of Computer Use: Addictive Use of the Internet. Public Health. 89: 1369-1376. Psychological Reports 79: 899-902. Skolnik,S. (2011). High Stakes: The Rising Cost of America’s Gambling Addiction. Young, K.S. (1998). Caught in the Net: How to Recognize the Signs of Internet Boston, MA: Beacon Press. Addiction and a Winning Strategy for Recovery. New York: Wiley Southern Poverty Law Center ((2004). Hate Groups, Militias On the Rise as Extremists Stage a Comeback. Retrieved on June 8, 2012 from splcenter.org/center/ splcreport/article
INTERNET ADDICTION TO CYBERSEX AND GAMBLING: ETIOLOGY, PREVENTION AND TREATMENT Final Examination Questions Select the best answer for each question and then proceed to SocialWork.EliteCME.com to complete your fi nal examination.
21. Finish the following statement: Scientifi c studies indicate that 26. Which of the following statements in correct about the APA biological changes occur in brain chemistry during excessive revision of the DSM-5? online use include: a. Internet addiction does appear to be a common mental disorder a. Using PET scans to measure the neurotransmitter dopamine that merits inclusion. levels. b. Sexual preoccupation will not be included. b. CAT scans as the individual withdraws from the offl ine world. c. Internet addiction falls in the spectrum of bipolar disorder. c. Cases when individuals are dual diagnosed with other mental d. None of the above. disorders. d. None of the above. 27. Signs and symptoms of Internet addiction include: a. Going online to escape problems. 22. Five psychological factors that contribute to Internet addiction b. Spending increasing time online to achieve satisfaction. include: c. Risking relationships, jobs or educational opportunities a. Narcissism, regression, surrender, escape, guilt. because of online use. b. Grandiosity, narcissism, dominance, escape, deception. d. All the above. c. Narcissism, grandiosity, impulsivity, regression, darkness (morbid side). 28. Cooper, Delmonico and Berg describe three categories of people d. All of the above. who use the Internet for sexual purposes: a. Sexual perverts, recreational users, and experimenting teens. 23. Lack of attention span and distractibility studies show: b. Recreational users, at-risk users, and sexually compulsive a. A signifi cant correlation in studies in Taiwan between ADHD users. and excessive Internet use. c. Pedophiles, teens, and lower socioeconomic groups. b. There is no correlation between Internet use and attention span. d. None of the above. c. Only children show a correlation. d. None of the above. 29. Paraphilia is characterized by: a. Arousal fantasies involving nonhuman objects, animals, 24. Cyber bullying studies show: children and nonconsenting persons. a. It is increasing. b. Transsexual urges. b. Victimization rates are as high as 50 percent of children. c. Low recidivism rates after treatment. c. The identity of the cyber bully is often unknown. d. All of the above. d. All of the above. 30. The fi ve parts of a behavior chain are: 25. Studies on the danger of online violence show greater impact on a. Obsessions, thoughts, actions, reform and guilt. personality and behavior than: b. Triggers, thinking, feeling, behavior, and consequences. a. Violent music only. c. Stimulus, release, relapse, control and restart. b. Violent TV shows. d. None of the above. c. Violent TV shows, movies, graphic novels and violent music lyrics. d. All media are equally dangerous.
SWCA08IA14
SocialWork.EliteCME.com Page 92 CHAPTER 5: Prescription Drug Abuse: Etiology, Prevention and Treatment
8 CE Hours
By: Deborah Converse MA, NBCT with Kathryn Brohl, MA, LMFT
Learning objectives
Identify and describe the three most abused classes of prescription Identify four factors unique to adolescents that may lead to drugs. prescription drug abuse. Discuss the prevalence of prescription drug abuse in terms of age, Discuss the components of four evidence-based treatment gender, ethnicity and socioeconomic status. approaches for prescription drug addiction. List and explain fi ve factors in the etiology of prescription drug List and describe the fi ve parts of the federal drug abuse abuse. prevention policy. Compare and contrast fi ve symptoms of opioid, CNS depressant Identify and describe three current issues affecting attitudes toward and stimulant drug abuse. prescription drug abuse. Describe the effects of the three classes of drugs on the central Explain fi ve strategies for the prevention of prescription drug abuse. nervous system.
Introduction
The sale of prescription painkillers is increasing throughout the United prescriptions dispensed for opioid pain medications, which include the States, according to the Drug Enforcement Administration (DEA). most potent painkillers, has increased signifi cantly since 2000. From The sale of painkilling drugs has escalated in new parts of the country, 1997 to 2007, the milligram per person use of prescription opioids in the indicating a spread of the prescription drug abuse epidemic identifi ed U.S. increased from 74 milligrams to 369 milligrams, an increase of 402 by a federal government study (ONDCP, 2011). Across the country, percent (Manchikanti et al., 2010). In 2000, retail pharmacies dispensed DEA fi gures show a signifi cant increase from 2000 to 2010 in the 174 million prescriptions for opioids, and by 2009, 257 million distribution of the painkilling drug oxycodone, the main ingredient in prescriptions were dispensed, an increase of 48 percent (FDA, 2010). OxyContin. Similar increases were noted in the sale and distribution In the past, data tracked opiate overdose back to heroin, but today it of hydrocodone, another key ingredient in powerful painkillers. is increasingly attributed to abuse of prescription opioid painkillers Pharmacies across the country reported that in 2010 they had logged (CDC, 2010). This data offers a description of the extent that an equivalent of 69 tons of oxycodone and 43 tons of hydrocodone. prescription drug abuse in America has grown over the last decade. The DEA tracks data on the amount of drugs that are manufactured The federal policy highlights the pivotal role that parents, health care and delivered to pharmacies, hospitals and other prescribers. The data providers, pharmacists and manufacturers share in preventing and shows that in 2000, the abuse of painkillers escalated in two very treating prescription drug abuse. different demographic regions. The highest levels of abuse began in The three classes of powerful prescription medications for relieving the impoverished areas of Appalachia and suburbs in the mid-Atlantic physical and emotional pain often lead to dependence and abuse. and northeast, which show higher than average socioeconomic levels. Acute and chronic pain treatment includes prescription opioids. By 2010, the illegal distribution of painkillers had spread throughout Benzodiazepines are used to treat people with serious anxiety and the Midwest and the South. sleep disorders. Stimulants are used in the treatment of ADHD and Prescription drug abuse is the nation’s fastest growing drug problem. for cognitive enhancement. Federal and state drug policies work While there has been a decrease in the use of some illegal drugs like to eliminate abuse of prescription drugs while providing care for cocaine, data from the National Survey on Drug Use and Health patients with legitimate medical needs. Providing effective drug abuse (NSDUH) showed that nearly one-third of people age 12 and over who treatment is critical to end prescription drug abuse, because only a used drugs for the fi rst time in 2009 begin by using a prescription drug fraction of drug abusers have access to treatment programs today. The nonmedically (NSDUH, 2009). The same survey found that more than federal policy released in 2011, entitled “Epidemic: Responding to 70 percent who abused prescription drug pain relievers got them from America’s Prescription Drug Abuse Crisis,” addresses these problems friends or relatives, while approximately 5 percent got them from a and will be discussed in later sections. drug dealer or the Internet. Although most people take prescription medications as directed by The latest Monitoring the Future study (MTF), the nation’s largest their physician, an estimated 52 million people, 20 percent of those survey of drug use among young people, noted that prescription age 12 and older, have used prescription drugs for nonmedical reasons drugs are the second-most abused category of drugs after marijuana at least once. Prescription drug abuse is the use of medication without (MTF, 2009). In our military, drug abuse increased from 5 percent to a prescription, in a way other than prescribed, or for the experience 12 percent among active-duty service members from 2005 to 2008, or feelings elicited. The prevalence rates for prescription drug abuse primarily attributed to prescription drug use (DOD, 2009). continue to increase, shown by the rate of illegal prescription drug The majority of prescription drug abuse occurs with three classes of sales, arrests, convictions, addiction, treatment admissions, emergency drugs, but the prevention plan developed by the federal government room visits and overdose deaths. only targets the deadly abuse of prescription opioids. The number of
Page 93 SocialWork.EliteCME.com Prescription medications – pain relievers, central nervous system produce serious, harmful, health consequences, including dependence, (CNS) depressants (tranquilizers and sedatives) and stimulants – addiction, overdose, withdrawal symptoms or death. taken by someone other than the patient or other than prescribed can
Dependency versus addiction
Physical dependence occurs because of normal adaptations to chronic relapse can lead to continued dependence. Complications of drug exposure to a drug and is not the same as addiction. Addiction, which abuse and dependence (NIDA, 2011) include: can include physical dependence, involves compulsive drug seeking ● Depression. and use despite devastating consequences. Someone who is physically ● Drug overdose. dependent on the medication will experience withdrawal symptoms ● Bacterial endocarditis, hepatitis, thrombophlebitis, pulmonary when use is abruptly reduced or stopped. These symptoms can be emboli, malnutrition, hepatitis or respiratory infections caused by mild or severe, depending on the drug, and can usually be managed intravenous delivery. medically or avoided by using a slow drug taper (NIDA, 2011). ● HIV infection through shared needles. ● Unsafe sexual practices, which may result in unwanted pregnancy, Dependence is often accompanied by tolerance, or the need to take unviable pregnancy, fetal drug complications, sexually transmitted higher doses of medication to get the same effect. When tolerance diseases and HIV. occurs, it can be diffi cult for a physician to evaluate whether a patient ● Problems with the law. is developing a drug problem or has a real medical need for higher ● Increase in various cancer rates. doses to control his or her symptoms. ● Problems with memory and concentration. Drug abuse and dependence may lead to a fatal drug overdose, often accidental. Some people relapse after they stop using drugs, and
The history of addiction
The term addiction was fi rst used to describe a condition that was more individual rather than fl aws in the design or method of treatment complex and extensive than a simple episode of drug intoxication. (White & McClellan, 2008). Chronic use and the complexity of severe drug problems led to the By the late 1990s, the effectiveness of the AC model began to be development of special institutions in homes and private institutes questioned, and a change in treatment followed that extended the AC hoping to cure addiction (White & McClellan, 2008). Several early model to a more comprehensive treatment that included aftercare pioneers suggested that the treatment of addiction should mirror the for maintenance. One call to redesign addiction treatment was the treatment of other chronic diseases. publication of “Drug Dependence, a Chronic Medical Illness” in the With collapse of the asylum movement at the beginning of the 20th Journal of the American Medical Association (JAMA, 2000). The century, practitioners began to explore the chronic nature of addiction. major fi ndings of this article are summarized below: Many concluded that for complete recovery, treatment must be ● Not all alcohol- and drug-related problems become chronic disorders. continued for years after the patient has been drug-free. The effort ● Clinical research has not been able to clearly predict which cases to promote addiction as a disease continued from the 1940s to the will become chronic. 1960s and led to landmark legislation in 1970 and the development ● Many substance-use problems are developmental and are resolved of community-based, time-limited addiction treatment in the United when adolescents transition to adulthood. States (White & McClellan, 2008). ● Other substance-use problems may occur as a result of major life transitions, such as death of a loved one, divorce, job loss, illness or The next phase of addiction treatment was the acute care (AC) model injury and are resolved by time, natural support, brief professional of intervention. The AC model is characterized by the following intervention or peer-based intervention by others in recovery. central elements: ● A predetermined program delivered through a uniform series ● Substance-use problems are infl uenced by heredity and personal, of related activities, screening, admission, a single assessment, family and environmental risk factors. ● Abuse behaviors may begin as voluntary choices but evolve treatment procedures, discharge and brief aftercare, followed by into deeply ingrained patterns of behavior that are infl uenced by termination of treatment services. ● A professional expert directed the assessment, treatment planning, neurobiological changes in the brain that weaken the individual’s service delivery and decision-making throughout the process. control over abuse behaviors. ● Treatment took place over a short period of time following ● Onset may be sudden or gradual. ● The course of the disease varies from person to person in type, a predetermined, time-limited program to address addiction frequency and intensity of the abuse. treatment as part of a general medical insurance plan. ● The treatment was completed at discharge, and the individual was ● The disease of addiction may result in profound mental and considered addiction free and could maintain long-term recovery physical disability and death. without continued treatment. ● There is effective treatment, prevention, intervention, peer support ● Once treatment was complete, any relapse or readmission for and remission – but no cure. treatment was viewed as a failure or noncompliance of the
Defi nitions
Addiction: A chronic, relapsing disease characterized by compulsive Antagonist: A chemical entity that binds to a receptor and blocks its drug-seeking and use, despite serious adverse consequences, and by activation. Antagonists prevent the natural, or abused, substance from long-lasting changes in the brain. activating its receptor. Agonist: A chemical entity that binds to a receptor and activates it, Barbiturate: A type of CNS depressant prescribed to promote sleep, mimicking the action of the natural, or abused, substance that binds there. used in surgical procedures, or as an anticonvulsant.
SocialWork.EliteCME.com Page 94 Benzodiazepine: A type of CNS depressant prescribed to relieve sensitivity and escalating dependence. In trying to manage pain, the anxiety and sleep problems. Valium and Xanax are among the most patient experiences more pain as a result of the opioid treatment. widely prescribed medications. Pathophysiology: The study of the changes of normal mechanical, Buprenorphine: A mixed opiate agonist/antagonist medication physiological and biochemical functions caused by disease or approved by the FDA in October 2002 for the treatment of opiate resulting from an abnormal syndrome. It includes the biological and addiction, such as heroin. physical manifestations of the disease as they correlate to underlying Central nervous system (CNS): The brain and spinal cord. abnormalities and physiological disturbances. CNS depressant: A class of drugs that slow CNS function, also called Physical dependence: An adaptive physiological state that occurs sedatives and tranquilizers, some of which are used to treat anxiety and with regular drug use and results in a withdrawal syndrome when drug sleep disorders; includes barbiturates and benzodiazepines. use is stopped; often occurs with tolerance. Physical dependence can happen with chronic, even appropriate, use of many medications, and Co-morbidity: The occurrence of two disorders or illnesses in the by itself does not constitute addiction. same person; also referred to as co-occurring conditions or dual diagnosis. Patients with co-morbid illnesses may experience a more Polydrug abuse: The use of two or more drugs at the same time, such severe illness course and require treatment for each or all conditions. as a CNS depressant and alcohol. Detoxifi cation: A process in which the body rids itself of a drug or its Prescription drug abuse: The use of medication without a metabolites. During this period, withdrawal symptoms can emerge that prescription, in a way other than prescribed, or for the experience or may require medical treatment. This is often the fi rst step in drug abuse feeling elicited. This term is used interchangeably with “nonmedical treatment. use,” a term employed by many of the national surveys. Didactic: A teaching method that follows a consistent scientifi c Psychotherapeutic drugs: Drugs that have an effect on the function approach or educational style. of the brain and often are used to treat psychiatric/neurologic disorders; includes opioids, CNS depressants and stimulants. Dopamine: A brain chemical, classifi ed as a neurotransmitter, found in regions that regulate movement, emotion, motivation and pleasure. Respiratory depression: Slowing of respiration that results in the reduced availability of oxygen to vital organs. Epidemiology: The study of the distribution and patterns of health events and their characteristics, causes and infl uences in well-designed Sedatives: Drugs that suppress anxiety and promote sleep; the National populations. Survey on Drug Use and Health (NSDUH) classifi cation include benzodiazepines, barbiturates and any other types of CNS depressant. Hyperalgesia: Abnormal pain sensitivity. Stimulant: A class of drugs that enhance the activity of monoamines, Methadone: A long-acting synthetic opioid medication that is such as dopamine, in the brain, increasing arousal, heart rate, blood effective in treating opioid addiction and pain. pressure and respiration, and decreasing appetite; include some Narcolepsy: A disorder characterized by uncontrollable episodes of medications used to treat attention-defi cit hyperactivity disorder deep sleep. (ADHD), methylphenidates and amphetamines as well as cocaine and methamphetamine. Norepinephrine: A neurotransmitter present in the brain and the peripheral sympathetic nervous system, and a hormone released by the Tolerance: A condition in which higher doses of the drug are required adrenal glands. Norepinephrine is involved in attention and response to to produce the same effect achieved during initial use and often stress, and it regulates smooth muscle contraction, heart rate and blood associated with physical dependence. pressure. Tranquilizers: Drugs prescribed to promote sleep or reduce anxiety; Opioid: A compound or drug that binds to receptors in the brain NSDUH classifi cation includes benzodiazepines, barbiturates and involved in the control of pain and other functions, such as morphine, other types of CNS depressants. heroin, hydrocodone and oxycodone. Withdrawal: Symptoms that occur after chronic use of the drug is Opioid-induced hyperalgia: A phenomenon associated with long- reduced abruptly or stopped. term use of opioids that leads to the development of increasing pain (Defi nitions from: U.S. Department of Health and Human Services National Institute of Health, 2011.) PREVALENCE
According to the national study released in 2009 by the Partnership for involved a prescription opioid pain reliever, a rate more than double a Drug Free America, the Partnership Attitude Tracking Study (PATS), that of the fi ve years prior. Emergency department visits also doubled prescription drugs are more commonly abused then illegal drugs. The for CNS stimulants, involved in nearly 22,000 visits in 2009, as use of these drugs by teens at parties and social situations is increasing. well as CNS depressants, anxiolytics, sedatives and hypnotics, The PATS data shows that 62 percent of teens got prescription drugs involved in 363,000 visits. Of the latter, benzodiazepines and Xanax most recently from someone they knew and that they did not pay for comprised the majority of the visits. Rates for a popular prescribed them. Another 18.1 percent reported that they obtained the drug from non-benzodiazepine sleep aids, Ambien, rose from 13,000 in 2004 one doctor. Only 4.1 percent purchased the prescription drugs from a to 29,000 in 2009. More than half of emergency room visits for stranger, and just 0.5 percent reported buying the drug on the Internet. prescription drug abuse involved multiple drugs (NIDA, 2010). Among those who reported getting a pain reliever from a friend or According to results from the 2010 NSDUH, an estimated 2.4 million relative for free, 81 percent reported in a follow-up question that the Americans used prescription drugs nonmedically for the fi rst time friend or relative had obtained the drugs from one doctor only. within the past year, with averages of approximately 6,600 initiates per The Federal Drug Abuse Warning Network (DAWN), which monitors day. More than one half of the fi rst-time users were females and about emergency department visits in selected areas across the nation, one-third were ages 12 to 17. Although prescription drug abuse affects reported that approximately 1 million emergency department visits many Americans, certain populations such as youth, older adults and in 2009 were attributed to prescription drug abuse. Roughly 343,000 women may be at particular risk.
Page 95 SocialWork.EliteCME.com Youth
Young people are among the increasing numbers of prescription drug half of all substances abused by youth. The national study funded and abusers. The National Institute on Drug Abuse (NIDA) and Monitoring released by the Partnership for a Drug-Free America and MetLife the Future (MTF) surveys found: Foundation in 2009 measured the use of drugs that adolescents are ● One in 12 high school seniors reported past-year nonmedical use likely to use at parties and other social situations. According to the of the prescription pain reliever Vicodin in 2010. Partnership Attitude Tracking Study (PATS) 2009 survey: ● One in 20 reported abusing OxyContin, making these medications ● Teen abuse of prescription and over-the-counter medication among the most commonly abused prescription drugs by remained stable, with about one in fi ve teens in grades nine adolescents. Abuse of prescription drugs is highest among young through 12 – 20 percent, or 3.2 million – reporting abuse of adults ages 18 to 25, with 5.9 percent reporting nonmedical use in prescription medication at least once in their lives. the past month (NSDUH, 2010). ● One in seven teens –15 percent, or 24 million teens – reported ● Among youths ages 12 to 17, 3.0 percent reported past-month abuse of a prescription pain reliever in the past year. nonmedical use of prescription medications. ● More than half, or 56 percent, of teens in grades nine to 12 believe ● According to the 2010 MTF, prescription and OTC drugs are prescription drugs are easier to get than illegal drugs. among the most commonly abused drugs by 12th-grade students ● Sixty-two percent believe most teens get prescription drugs from after alcohol, marijuana and tobacco. their family’s medicine cabinets. ● Past-year nonmedical use of sedatives and tranquilizers decreased ● Sixty-three percent believe prescription drugs are easier to get among 12th graders over the past fi ve years; this is not the case for from their parents’ medicine cabinets, up signifi cantly from 56 nonmedical use of NSAIDs and opioid pain relievers. percent last year. ● When asked how they obtained the abused prescription opioids, ● Adderall, a stimulant used to treat ADHD, showed in 2009 a more than half of the 12th graders surveyed said they were given prevalence rate at 2 percent in grade eight, 6 percent in grade 10, the drugs or bought them from a friend or relative. The number of and 5 percent in grade 12. students who purchased opioids over the Internet was negligible ● Vicodin use has risen and remained high, with 3 percent of eighth (MTF, 2010). graders, 8 percent of 10th graders, and 10 percent of 12th-grade students indicating use in the prior 12 months. Youth who abuse prescription medications are also more likely to use ● At all three grades, OxyContin use is higher today than when its other drugs. Multiple studies have revealed links between prescription use was fi rst measured in 2002. drug abuse and higher rates of cigarette smoking, binge drinking, ● Among teens ages 12 to 17, females exceed males in nonmedical marijuana, cocaine and other illicit drug use among adolescents, use of all psychotherapeutic drugs, including pain relievers, young adults and college students in the United States (MTF, 2010). tranquilizers and stimulants. Monitoring the Future (MTF) is the annual youth survey conducted by ● Among nonmedical users of prescription drugs, females 12 to 17 researchers at the University of Michigan, which measures drug use years old are more likely to meet abuse or dependence criteria for attitudes and patterns among 50,000 eighth-, 10th- and 12th-graders. psychotherapeutic drugs. Prescription and over-the-counter medicines account for more than
Pharming parties
Liz Doup was among the fi rst reporters Shannon slumps in a chair at The Starting Place, a treatment facility to bring the new trend of pharming in Hollywood, Florida, where he’s spending three months trying to parties to national attention. At a end his drug habit. Beside him sits Kyle, a fast-talking, energetic pharming party, teens gather to drink 16-year-old who squirms in his chair. School dropouts at 14, both are and exchange and sample pharming party veterans and addicts. Pharming parties are a new pharmaceuticals that are stolen, or social twist that contributes to the growing problem of prescription “pharmed,” from their parents’, drug abuse, which has spread through pop culture on social media grandparents’ or friends’ medicine message boards, song lyrics and even T-shirts (Doup, 2006). cabinets. According to Doup’s report, Shannon and Kyle routinely mix prescription drugs with illegal drugs. teens gather in abandoned or secluded “You feel like you’re on some kind of truth serum,” says Kyle, who properties where strobe lights fl ash and started smoking marijuana at 10 before moving on to prescription liquor fl ows. Then, from pockets and purses they pull out the pills, drugs as a teenager. “You have no inhibitions or fears, you feel most often Vicodin, OxyContin and Xanax, all legal drugs diverted like you can fi ght the biggest guy,” he says. Getting the drugs is no from unsuspecting family members for illegal use. In 2006, an problem. Shannon and Kyle buy from friends, OxyContin at $12-$15 a estimated 2.3 million students were “pharming,” according to Doup pill or Xanax for $3. Valium goes for $4-$5 a pill. (2006). She provides the following case study of Shannon and Kyle : Sometimes teens trade with each other. For example, a couple of Case study: Shannon and Kyle Valium could be swapped for a more powerful OxyContin. News Shannon, a 17-year-old middle school dropout, was part of the about the pharming parties spreads rapidly through the school and pharming scene. He popped four or fi ve Xanax and washed them down the community. They might meet at someone’s house when the parents with vodka at a party. Not so long ago, teens raided their parent’s are gone, rent a hotel room, or fi nd an abandoned warehouse or other liquor cabinets when they wanted a quick high. Today they turn to location. Shannon was glad to be in the loop, and when he got wind the medicine cabinet. They stock up for pharming parties where teens of a party, he wanted to be there. “You’re much happier when you’re barter and share legal drugs to get high. “It’s better when you’re with (expletive deleted) up,” he says. “It’s all good.” (Doup, 2006). other people, ” says Shannon. “I don’t like doing this stuff by myself.” According to a report by Columbia University’s National Center on Shannon entered the drug world at 10 years old with his fi rst puff Addiction and Substance Abuse (2006), about 2.3 million students 12 of marijuana. He tried many drugs through the years, including to 17 took prescription drugs illegally in 2005, which is a 212 percent Xanax from a family medicine cabinet. Students who to take drugs increase over 1992. “Kids think, it’s not heroin, it’s not crack, it’s not from their families’ medicine cabinets do not fi t into one category. an illegal drug, so how bad can it be?” says Barbara Zoellner, former
SocialWork.EliteCME.com Page 96 executive director of Miami-Dade DFYIT (Drug-Free Youth in Town), make breathing diffi cult or cause a rapid drop or increase in heart rate a school-based drug prevention program (Nelson, 2011, p. 43). and impair senses so that everyday activities such as driving a car are “There is no specifi c group you can pinpoint,” says Doris Carroll, hazardous. community coordinator of the Palm Beach County Substance Abuse About 75 percent of prescription drug users also take other drugs or Coalition, (Nelson, 2011, p. 43). She explains, “It’s not just dropouts. drink, according to the Columbia University report. Teens who abuse It’s not just popular kids. It’s not just football players.” Much of the prescription drugs are: problem is linked to easy access, she says. Indeed, some teens come by ● Twice as likely to use alcohol. drugs legally. Many are taking Ritalin for attention defi cit disorder or ● Five times likelier to use marijuana. painkillers after losing their wisdom teeth or breaking a bone. As well ● 12 times likelier to use heroin. as stealing from medicine cabinets, some buy from other teens, and ● 15 times likelier to use ecstasy. some are purchased on the Internet. At one high school, a student was ● 21 times likelier to use cocaine paying other students to raid their parents’ medicine cabinets, and then (NSDUH, 2009). he sold the drugs to other students at the school. In addition, teens increase the danger factor by taking pills in unsafe ways. OxyContin, for instance, is supposed to be released into the bloodstream over several hours for long-term pain relief. Teens often crush the pills for a quicker, and potentially more harmful, high. Youth see adults who would never touch an illegal drug fi ll prescriptions to treat everything from physical pain to anxiety and weight loss. Meanwhile, pharmaceutical companies use TV and magazines ads to promote drugs that promise a happier, thinner and more energetic body, all by taking a pill you can get from your doctor. But taking powerful drugs without supervision or mixing them with other drugs including alcohol may have devastating results. They can
Stimulants and depression, drug abuse and violence in teens
The 2006 National Survey on Drug Use and Health (NSDUH) The NSDUH includes signs of drug use in children, which include: examined past-year nonmedical use of stimulants among youth ages ● A change in the child’s friends. 12 to 17, their involvement with other drug and alcohol use, illegal or ● Withdrawn behavior. criminal activity, and major depressive episodes (MDE). All fi ndings ● Long unexplained periods away from home. presented in the report are annual averages based on combined 2005 ● Lying. and 2006 NSDUH data. ● Stealing. ● Involvement with the law. The study found that adolescents who abuse stimulants are signifi cantly ● Problems with family relations. more likely to use other drugs, experience MDEs and engage in six types ● Missing medications in the home. of violent or dangerous behavior. In 2006, 2 percent of adolescents ages ● Missing items in the home. 12 to 17, an estimated 510,000 persons, used stimulants nonmedically ● Acting drunk or high (intoxicated), confused, impossible to in the past year, a rate twice as high as observed among adults age 26 or understand. older. Researchers found that stimulant misuse is associated with alcohol ● Unconscious changes in behavior and normal attitude. and drug-use disorders, criminal justice involvement and admission for ● Decreased school performance. mental health treatment. Among youth studied who used stimulants nonmedically in the past year: The youths ages 12 to 17 engaged in the following delinquent ● 70.2 percent also use marijuana, compared with 12.1 percent of activities during the past year: ● Getting into serious fi ghts at school or work. youths who did not use stimulants nonmedically in the past year. ● Taking part in a fi ght where a group of friends fought against ● An estimated 8.7 million, or 34.5 percent, of youth ages 12 to another group. 17 reported that they engaged in at least one of the six types of ● Carrying a handgun. delinquent behaviors in the past year. ● Selling illegal drugs. ● Over 71 percent, approximately 360,000, of youth who used ● Stealing or trying to steal anything worth more than $50. stimulants nonmedically in the past year reported delinquent ● Attacking someone with an intent to seriously hurt them. behavior, compared with approximately 34 percent of youths who did not use stimulants nonmedically in the past year. The NSDUH report also questioned youth ages 12 to 17 to assess past- ● Thirty percent of youth who used stimulants nonmedically in the year major depressive episodes. For these studies, MDE was defi ned past year sold drugs, compared with 2.8 percent of youths who did using the diagnostic criteria established by the American Psychological not use stimulants nonmedically in the past year. Association (APA) in the 4th edition of the Diagnostic and Statistical ● An estimated 2.1 million, or 8.3 percent, of youth ages 12 to 14 Manual of Mental Disorders (DSM-IV), which specifi es the period experienced at least one MDE in the past year. of two weeks or longer where there is either depressed mood or loss ● Youth who use stimulants nonmedically in the past year were more of interest or pleasure, and at least four other symptoms that refl ect a likely to have experienced MDE in the past year than youths who change in functioning, such as problems with sleep, eating, energy, did not use stimulants nonmedically in the past year, 22.8 percent concentration and self image. (See the APA, DSM-IV for a detailed versus 8.1 percent. description of the criteria for this and other mental health disorders related to substance abuse.)
Page 97 SocialWork.EliteCME.com Gender differences
Women are more likely than men to be prescribed one of the three among ages 12 to 17 with young women more likely than young men most abused classes of prescription drugs, in some cases, 55 percent to use psychotherapeutic drugs nonmedically. In addition, research has more likely. Overall, men and women have similar rates of nonmedical shown that women are at increased risk for nonmedical use of narcotic use of prescription drugs. An exception is found, as noted previously, analgesics and tranquilizers such as benzodiazepines (NIDA, 2010).
Older adults
Persons age 65 years and older comprise only 13 percent of the according to the report by the GAO. In one example, an individual population, yet they account for more than one-third of outpatient received prescriptions from 87 different doctors during that year. spending on prescription medications in the United States. Older patients are more likely to be prescribed long-term and multiple Sen. Scott Brown, a Republican from Massachusetts, called it prescriptions, and some experience cognitive diffi culties, which could “taxpayer-funded drug dealing” at a hearing about the issue in 2011. lead to improper use of medications. Brown said oxycodone could sell for more than $5,000 in some areas of the country. Sen. Tom Carper, a Democrat and chairman of the The high rates of co-morbid illnesses in older populations, age- Subcommittee on Federal Financial Management, said Medicare Part related changes in drug metabolism, and the potential for drug D benefi ciaries are abusing powerful drugs to fi ll their own addictions interactions may make abuse of prescription drugs more dangerous or to sell them on the street. He added, “The controls we put in place than in younger populations. A large percentage of older adults also haven’t done the trick (GAO, 2011). use OTC medicines and dietary supplements, which, in addition to alcohol, could compound any adverse health consequences related to The Centers for Medicare and Medicaid Services (CMS) notifi es prescription drug abuse. Elderly persons who take benzodiazepines are doctors and pharmacies about patients who could be abusing at an increased risk for cognitive impairment leading to possible falls prescription drugs. However, some patients with cancer, multiple causing hip and thigh fractures as well as vehicle accidents. Cognitive sclerosis or other diseases with complex treatment or those without impairments related to prescription drugs may be reversible once the a primary care physician may need to see several doctors. Jonathan drug is discontinued (NIDA, 2010). Blum, director of Medicare and Medicaid Services, said, “Some benefi ciaries are bouncing around from emergency room to emergency According to a Government Accountability Offi ce (GAO) 2011 room. We have a very uncoordinated health care system today that report, prescription drug abuse by elderly and disabled benefi ciaries we are working hard to reform. There is a balance between stopping on Medicare cost the U.S. program nearly $150 million in 2008, behavior that is fraudulent and illegal, and ensuring that benefi ciaries highlighting an area where the government can seek to save health have access to medications” (GAO, 2011). care costs. Some of these patients went to at least fi ve doctors to get multiple prescriptions for drugs that are often abused. In all, 170,000 Elderly people on fi xed incomes may sell their remaining medications people enrolled in the Medicare Part D prescription drug program went to make money. Felony convictions for the sales of prescription drugs “doctor shopping” for drugs such as oxycodone and hydrocodone, among elderly individuals have increased in some states.
Prenatal exposure to drugs of abuse
The National Institute on Drug Abuse (NIDA, 2011) notes that detrimental maternal and neonatal outcomes associated with untreated exposure to substances of abuse can affect individuals across the heroin abuse, although newborns exposed to methadone during lifespan and start before birth if prescription drugs are abused during pregnancy typically require treatment for withdrawal symptoms. pregnancy. The combined 2008 and 2009 data from the National Another medication for opioid dependence, buprenorphine, has Survey on Drug Use and Health found that among pregnant women recently been shown to produce fewer neonatal abstinence symptoms ages 15 to 44, the youngest women generally reported the greatest in babies than methadone, resulting in shorter instant hospital stays. substance abuse. Pregnant women ages 15 to 17 had similar rates of drug use as women who were not pregnant, with only a 2.8 percent NIDA-supported research has established that evidence-based lower rate among the pregnant women. treatments to change drug abuse and addiction behaviors in the general population also extend to pregnant women. One example is Drug use during pregnancy has been associated with a variety of contingency management, in which participants are given incentives adverse effects, some of them subtle. Effects generally range from low such as small cash amounts for maintaining abstinence. Compared to birth weight to developmental defi cits and long-term delays affecting a standard treatment conditions, motivational incentive approaches attention span, language acquisition, learning skills, behavior and increase treatment retention and prolonged abstinence in pregnant cognition. women with stimulant and opiate dependence. In general, it is important to closely monitor women who are trying to quit drug use Methadone maintenance combined with prenatal care and a during pregnancy and to adjust treatment as needed. comprehensive drug treatment program can improve many of the
Co-morbidity
Research suggests that pregnant women with food or anxiety disorders young adulthood. They will specifi cally study the structure, function are more likely to have substance disorder as well and vice-versa. and connectivity of the developing brain and how genetics can These studies call for more treatment research on co-occurring infl uence the effects of the drugs on the fetus. The development of psychiatric and substance use problems of pregnant women. interventions for drug-exposed infants and children are also a priority NIDA is supporting multiple research projects examining early (NIDA, 2011). exposure to drugs and increased drug abuse during adolescence and
SocialWork.EliteCME.com Page 98 Drug-endangered children
According to the Offi ce of National Drug Control Policy and the guardians with substance-use disorders and address family issues Federal Interagency Task Force for Drug-Endangered Children (2010): related to drug abuse. Across the country, the DEC movement has ● A drug endangered child is a person under the age of 18 who rescued thousands of children and led to the development of numerous lives in or is exposed to an environment where drugs, including programs that coordinated the efforts of law enforcement, medical pharmaceuticals, are illegally used, possessed, traffi cked, diverted, services and child welfare services to ensure that drug-endangered and/or manufactured and, as a result of that environment: children receive appropriate attention and care. ○ The child experiences, or is at risk of experiencing, physical, The DEC is focused on gathering and producing educational resources sexual, or emotional abuse. that can help law enforcement, child welfare workers, and health and ○ The child experiences, or is at risk of experiencing, medical, educational professionals nationwide protect children and respond to educational, emotional, or physical harm, including harm their needs as well as their caregivers’. By working together with its resulting or possibly resulting from neglect. federal, state and local partners, the task force aims to end this vicious ○ The child is forced to participate in illegal or sexual activity in cycle of drug abuse. exchange for drugs or in exchange for money likely to be used to purchase drugs. Research and statistics. ● Between 2002 and 2007, 2.1 million children in the U.S. lived with As part of the president’s 2010 National Drug Control Strategy, the at least one parent who abused illicit drugs. Department of Justice established the Federal Interagency Task Force ● Studies of children in foster care found that 40 percent to 80 on Drug Endangered Children to support the identifi cation of model percent of families involved with child welfare were having protocols, programming and best practices related to this issue. The substance-abuse problems. website includes resources and practices to assist states, local and ● A 2003 study analyzing administrative data on persons treated for tribal governments in identifying and providing services to endangered substance abuse in California found that 60 percent of those treated children. Through this collaboration, the defi nition of drug-endangered in California’s publicly funded treatment system were parents of children was expanded to include children that face exposure to any minor children. Of those treated, 295,000 parents had one or more type of drug. The DEC movement has sought to assist parents and children removed from their custody by child welfare services.
Native Americans and Alaskan natives
According to the Offi ce of National Drug Control Policy (ONDCP), Treatment, early intervention and recovery. drug abuse is very prevalent among Native Americans and Alaska The president’s Access to Recovery (ATR) grant program natives in the United States. The ONDCP is developing programs and individualizes substance use treatment, recovery, and support services, policies tailored to the Indian country and designed to assist tribal and addresses the unique cultural and geographic needs of American authorities using a strategy of prevention, treatment, recovery support Indian and Alaskan Native communities. In 2010, ATR grants totaling and law enforcement. $15.2 million over fi ve years were awarded to fi ve tribal organizations covering Indian country populations, including: Research and statistics. ● The California Rural Indian Health Board. Research data report high usage of illicit drugs by Native Americans ● Montana Wyoming Tribal Leaders Council. and outlines the need for targeted resources and outreach: ● According to the 2009 NSDUH, Native American and Alaskan ● Intertribal Council of Michigan. ● Oglala Sioux Tribal Council in South Dakota. native populations show high percentages of lifetime use at 64.8 ● Aberdeen Area Tribal Chairman Health Ward in South Dakota. percent. ● Past-year illicit drug use was 27.1 percent. Tribal drug courts, which refer substance users in the criminal justice ● Current nonmedical use of prescription drugs is 6.2 percent. system to treatment and recovery services in lieu of jail, have proven ● 18.3 percent of American Indian and Alaskan natives age 12 or effective in breaking the cycle of drug use and crime. As of December older are current users of illicit drugs or within 30 days prior to the 31, 2009, there were 89 tribal drug courts, nearly twice the number survey. in 2001. Indian tribal governments may apply for drug court funding ONDCP has a number of programs and initiatives that provide through the Bureau of Justice Assistance Drug Court Discretionary support and resources than can help Native American communities Grant Program. be healthy and safe. The National Youth Anti-Drug Media Campaign Partnering with Indian country leadership and law enforcement. researches, develops and delivers relevant and appropriate anti-drug The ONDCP has provided 1.7 million in high-intensity drug messages. Since 2008, the campaign has emphasized Native American traffi cking areas (HIDTA) discretionary funds to Indian country law culture and pride through print, radio and television public service enforcement organizations to detect, interdict and dismantle drug- announcements. The campaign is partnered with the National Congress traffi cking organizations. These funds have been awarded to such of American Indians, the Department of Interior, the Department of areas in Arizona, New Mexico, Nevada, Oklahoma, Oregon, Texas Health and Human Services, and the Partnership at Drug-Free.org to and Washington state. Task forces within these HIDTAs partner with develop a public awareness campaign focusing on preventing drug Indian country law enforcement and tribal offi cials, and work closely abuse among Native American populations. with federal, state and local law enforcement.
Substance abuse among the military, veterans, and their families
The operations in Iraq and Afghanistan have led to signifi cant stress Substance abuse is also a major concern in the 2008 Department for military personnel, returning veterans and their families, according of Defense Health Behavior Survey, which revealed increases in to the National Institute on Drug Abuse (NIDA, 2011). Some have prescription drug abuse and heavy alcohol use. Prescription drug abuse experienced long and multiple deployments, combat exposure, doubled among U.S. military personnel from 2002 to 2005 and almost physical injuries, post-traumatic stress disorder (PTSD) and traumatic tripled between 2005 and 2008. brain injury.
Page 99 SocialWork.EliteCME.com Mental illness among military personnel is a major concern. In a study of exclusively to handling nonviolent crimes committed by veterans, this returning soldiers, clinicians found that 20 percent of active and 42 percent concept has spread quickly, with 65 courts now in 20 states. of reserve soldiers required mental health treatment. Drug or alcohol use Along with the studies mentioned above, NIDA in collaboration impacts mental health problems and was involved in 30 percent of the with the U.S. Department of Veterans Affairs and other entities Army suicide deaths from 2003 to 2009 and in more than 45 percent of within the National Institutes of Health, awarded $6 million in 2010 non-fatal suicide attempts from 2005 to 2009 (DOD, 2009). federal funding to 14 principal investigators to support research To address the social problems caused by and contributing to drug use, on substance abuse and associated problems among U.S. military NIDA-supported researchers are developing and testing new treatment personnel, veterans and their families. The purpose of the initiative approaches with veterans. In one project, researchers are using smart was to enhance and encourage research on the epidemiology, etiology, phones and wearable wireless sensors to record real-time responses identifi cation, prevention and treatment of drug abuse, including illicit to stress among veterans suffering from addiction and trauma. The and prescription drugs. The initiative included associated mental health data will be compiled and analyzed to detect patterns of response problems among active duty or recently separated military troops that predict relapse. Included on the research team are psychologists and their families. Most of the research funded under this initiative working to create interventions that can be delivered by smart phones is focused on substance abuse and related conditions experienced by to help deter drug use as a response to stress. veterans turning from wars in Iraq and Afghanistan. NIDA-supported research is also working to improve veterans’ access These 14 projects will explore a range of topics including: to drug treatment, including adapting currently available Internet- ● Therapies for co-occurring disorders such as depression and based interventions and studying the use of drug courts. Drug courts substance abuse. have proven effective in addressing nonviolent crimes committed by ● The effectiveness of early interventions for recently returning soldiers. drug abusers, getting them into needed treatment instead of prison. ● The impact of a youth substance abuse intervention designed for The criminal justice system is a frequent treatment referral source for parents returning from deployment. veterans, and specialized drug courts for this population give them the By supporting research and initiatives like those mentioned above, the opportunity to access services and supports they may not otherwise NIDA intends to contribute to the design and implementation of effective receive. While New York pioneered the concept of a drug court devoted prevention and treatment interventions that can safeguard the health and well-being of those who protect and serve the nation (NIDA, 2011). SYMPTOMS OF PRESCRIPTION DRUG ABUSE
The following sections list specifi c symptoms of the most commonly ● Weight loss. abused prescription drugs. ● Agitation/irritability. ● High blood pressure. Opiates and narcotics ● Insomnia. Symptoms of opiate and narcotic use include: ● Needle marks on the skin, in some cases called tracks. Symptoms of stimulant withdrawal: ● Scars from skin abscesses. ● Fatigue and malaise. ● Rapid heart rate. ● Depression. ● Small, pinpoint-sized pupils. ● Very clear and unpleasant dreams. ● Relaxed or euphoric state (nodding). ● Anxiety. ● Confusion. ● Intense cravings. ● Constipation. ● Suicidal thoughts and attempts. ● Low blood pressure. ● Paranoia. ● Coma or respiratory depression leading to death in high doses. ● Decreased contact with reality, leading to acute psychosis. Symptoms of opiate and narcotic withdrawal: Central nervous system depressants ● Anxiety and diffi culty sleeping. Symptoms of depressant use: ● Sweating. ● Slurred speech. ● Goosebumps (piloerection). ● Lack of coordination or unsteady gait. ● Runny nose (rhinorrhea). ● Decreased attention span. ● Stomach cramps or diarrhea. ● Impaired or poor judgment. ● Enlarged (dilated) pupils. ● Drowsiness. ● Nausea and vomiting. ● Confusion. ● Excessive sweating. ● Involuntary and rapid eye movements. ● Increase in blood pressure, pulse and temperature. Symptoms of depressant withdrawal: ● Drug cravings. ● Anxiety. ● Depression. ● Sweating. ● Bone and muscle pain. ● Hallucinations. ● Sleeplessness. ● Sleep problems. Central nervous system stimulants ● Shaking (tremors). Symptoms of stimulant use: ● Seizures. ● Exaggerated feeling of well-being (euphoria). ● Increase blood pressure, pulse and temperature. ● Dilated pupils. ● Delirium. ● Fast or irregular heart rate. (NIDA, 2011) ● Restlessness and hyperactivity.
SocialWork.EliteCME.com Page 100 ETIOLOGY
The exact cause of prescription drug abuse and dependence is not prescription drugs are obtained legitimately, teens often believe these known. The person’s genetics, the action of the drug, individual drugs are safe alternatives to street drugs. metabolism, peer pressure, emotional distress, anxiety, depression and In some cases, a doctor’s prescription isn’t even needed. Some countries environmental stress are all possible factors. Peer pressure can lead don’t require prescriptions for opioid painkillers or other commonly to drug abuse, and at least half of those who become addicted have abused drugs, so they can be obtained from some websites without a depression, attention defi cit disorder, post-traumatic stress disorder or prescription. Obtaining drugs online from pharmacies that don’t require another psychological problem. prescriptions is dangerous for a number or reasons. There are no controls Children who grow up in an environment of illegal or prescription to monitor dosage, drug allergies and adverse reactions from other drug abuse may fi rst experience drugs secondhand from seeing drugs, OTC medications, supplements or alcohol that may be used at the their parents using drugs. This may put children at higher risks for same time. Some websites sell counterfeit drugs that contain potentially developing an addiction later in life for both environmental and dangerous, toxic and addictive substances and fi llers. genetic reasons. Risk factors for prescription drug abuse include: Teens and adults abuse prescription drugs for a number of reasons. ● Past or present addictions to other substances, including alcohol. Some of these reasons include a desire to: ● Younger ages of use, specifi cally the teens or early 20s. ● Feel better and get a feeling of euphoria. ● Exposure to peer pressure or a social environment where drugs are ● Relax or relieve tension (painkillers and tranquilizers). used. ● Reduce appetite (stimulants). ● Easy access to prescription drugs, such as working in a health care ● Experiment. setting. ● Be accepted by peers, avoid peer pressure, or be included in a ● Lack of knowledge about prescription drugs, or thinking that social group. taking someone else’s drug is safe because it was prescribed by a ● Be safe because of a false belief that prescription drugs are safer doctor. than street drugs. ● Unknown genetic or metabolic factors leading to increased ● Be legal because of a mistaken belief that taking prescription drugs predisposition to dependence or addiction. without a prescription is legal. Many people fear that they may become addicted to medications ● Satisfy an addiction or dependence. prescribed for legitimate medical conditions, such as painkillers Most prescriptions are written for people who have a true medical prescribed after surgery. However, people who take potentially need for these drugs. But many households have a drawer or cabinet addictive drugs as prescribed rarely abuse prescription medications or fi lled with old prescription bottles containing leftover drugs. Because become addicted (NIDA, 2011).
Addiction as a brain disease
Michael Craig Miller, editor-in-chief of the Harvard Mental Health messenger dopamine into a region of the brain called the nucleus Letter, reports that more than 20 million Americans deal with accumbens. Stimulant drugs can cause this change directly, while addiction that is not a result of a person’s fl awed character but instead other substances act indirectly. In each case, the sensation is of distorted brain function. Addictive substances such as cocaine self-reinforcing, meaning once it is felt, the person wants to feel it weaken a person’s ability to make wise choices by taking control of again. While pursuing better treatment, researchers also worked the brain’s reward systems (Miller, 2005). According to him: to answer the question of who gets addicted, and why. Heredity Scientists completed research on the action of various drugs, and predisposes some people to be more vulnerable to addiction than addictive properties can alter brain function. They developed and others, possibly because they metabolize drugs at different rates tested new treatments for the brain disease of addiction. Addictive or respond more strongly or rapidly to their effects. The research substances take over the brain’s reward system, weakening resolve suggests that different genetics may also affect our response to to make wise choices even when painful consequences are known treatment (Miller, 2005). to result. These substances stimulate the release of the chemical
Genetic and environmental factors
Claudia Wallis writes that genetic variation, personal background researchers like Goldman have begun to pinpoint how specifi c and social factors can shape how one reacts to drug use, including experiences combined with genetic factors lead to addiction (Goldman, becoming addicted. She cites large-scale studies that indicate addiction Oroszi, & Ducci, 2005). is one of the most inherited mental illnesses. Wallis also maintains Many genes have been linked to addiction, though fewer than a dozen that subsets of the population handle the ill effects of certain drugs have been directly identifi ed. Gene patterns may infl uence dual or differently, affecting the likelihood that dependency paired with multiple addictions and are known to alter brain pathways associated genetic traits, childhood trauma and abuse can predispose a person to with pleasure or rewards. Other genes are linked to depression, addictive behavior. “Why do some people get hooked on drugs while anxiety, mood and personality disorders, which are often present others can use drugs and walk away? Some tend to think it’s a matter in people who turn to drugs to escape problems, for stimulation or of willpower or moral fi ber, but it has more to do with the role of the euphoria. “ If you have a twin who uses cocaine, it makes you more genetic dice” (Espejo, 2011, pp. 94-95). likely to use heroin. If you have a twin who uses tobacco, you’re Large-scale studies of twins provide some evidence that addiction more likely to use alcohol,” Goldman explains. He continues, “Even “ranks among the most inheritable of mental illnesses,” says Dr. David the tendency to try dangerous, illegal drugs like crack or heroin is Goldman, who heads the laboratory of neurogenetics at the National partially under genetic control. For instance, an area on chromosome Institute on Alcohol Abuse and Alcoholism. In addition to genetics, 11, associated with taking risks or seeking novel experiences, lies near personal experience and social infl uences matter also. Addiction a region that has been linked to addiction” (Espejo, 2011, p. 95).
Page 101 SocialWork.EliteCME.com Addiction research reported by Michael Craig Miller in 2005 suggests New studies by the National Institute of Health show how this works: that genetic differences may also affect our responses to treatment: Many women who were abused as children are known to have high Studies have found that patients with a family history of rates of alcoholism and drug abuse, yet some show remarkable alcoholism or cocaine abuse are more responsive to naltrexone resilience despite a history of abuse. The difference in vulnerability than people without a family history of addiction. In a recent study, can be traced to variant versions of a gene that controls a key patients who had a gene variant named Asp40 gained more benefi t brain enzyme, monoamine oxidase (MAOA), which helps regulate from naltrexone then those with a different version of the gene. the brain’s response to stress. Wallis cites the 2007 study led by Once genetic markers are better established, it will help doctors Francesca Ducci and reported by the NIH that found that women to determine which treatments are best for which patient. Miller who carry a gene for low MAOA activity are strongly prone to states, “We’re still a long way from pills that will make treatment becoming substance abusers if they were abused as children, while easy.” Long-term strategies are essential even when medication those with high activity MAOA gene are much more resilient. It works because the affected brain circuits don’t return to normal takes both the gene and the childhood trauma for the pattern to right away, if ever” (Miller, 2005). emerge. Among women who were not abused as children, there is Researchers used animal studies to measure the addictive nature of no relationship between MAOA genes and addiction (NIH, 2007). particular drugs. Marijuana and hallucinogens are not very habit- Drug addiction differs from strictly genetic diseases that are not forming, while cocaine and opiates are so compelling that lab rats infl uenced by external factors. Avram Goldstein notes that “Addiction prefer them to food (NIH, 2008). to prescription drugs may be similar to diseases with strong hereditary What is interesting, according to Goldman, is that the more addictive infl uences, like the common kinds of heart disease, or cancers of the the substance, the stronger the role of heredity in causing an addiction. breast or colon, in which environmental factors play a major role.” He explains, “While genetics strongly infl uence your risk of becoming Environmental factors can be modifi ed to reduce addictive behaviors a crack addict, becoming a pothead has more to do with social factors, by prevention education and laws restricting the availability and use of like whether you like rolling joints in the company of other marijuana prescription drugs. Goldstein uses the example of nicotine addiction, users” (Golman, 2009). Responses to drugs also vary enormously, and explaining that “Forty-fi ve years ago, a large majority of young some drugs provide a greater increase in endorphin levels and have Americans began smoking as they entered adolescence, but today been shown in variations of opiate receptor genes. Wallis says genes only a small minority, around one-fi fth, become smokers; moreover alone do not cause an addiction. “Researchers like to point out that, as of all the people who’ve ever smoked, two-thirds are able to quit.” with other ailments linked to lifestyle, heart disease, obesity and lung He concludes that “Genes have not changed in 45 years; the change cancer, for example, genes merely load the gun, while the environment must be due to intensive education about the health consequences of holds the trigger” (Espejo, 2011, p. 97). smoking” (Goldstein, 2007). CURRENT CHALLENGES AND ISSUES IN DRUG ADDICTION
The idea of addiction as a brain disease is relatively new, and drugs, are physicians just replacing one drug addiction with another? historically, people once thought addiction was a personality fl aw and Does the addict simply become addicted to a new, legally prescribed a sign of weakness. This stigma persists in some parts of the country drug? Some physicians and therapists support the use of prescribed today and is a major challenge for addicts and the people who treat alternative drugs as part of the structured treatment plan that would them. Dr. Glen Hanson (2012) states, “An addict can no more stop improve the patient’s quality of life. Pharmaceutical substance abuse their behavior than a Parkinson’s patient can stop their shaking.” treatment can assist the user to begin functioning normally again and Our attitudes about drug use in society are continuously evolving. stop the drug cravings. Many drugs considered dangerous today, like cocaine, marijuana and But many of yesterday’s treatment options were far from perfect, methamphetamine, were prescribed for everything from obesity in and some are still in use today. Methadone for example, was used for adults and insomnia in children in the past. Until its prohibition in treatment of heroin addiction but is now a drug of abuse, and overdose 1937, extract of cannabis was one of the most prescribed medicines in deaths are increasing. New treatments are being developed as the the United States. neurobiology of addiction continues to be revealed, but treating drug One issue being debated today is treating drug addiction with other addiction remains a medical challenge. prescription drugs. When treating drug addiction with alternative
Cultural use of drugs
Some drugs are used in cultural or religious practices. Marijuana has from the U.S. government. There is an active debate today throughout a long history of religious use in India, Africa and Jamaica. Peyote, the United States as to whether the use of illegal drugs should be a cactus containing mescaline, is considered sacred by the Native permitted for cultural, religious or medicinal purposes. American Church and used in spiritual rituals by special permission
Prescribing drugs of abuse
Controlled drugs like ketamine, morphine and codeine are prescribed Another issue is whether clinical trials by doctors for their pain-relieving and anesthetic properties. on illegal drugs like marijuana and Researchers are conducting studies to determine whether controversial ecstasy send the message that the drugs such as marijuana and ecstasy may have some medical use. recreational use of the drug is Ecstasy is currently in clinical trials for treating patients with post- acceptable. Teens are quick to point out traumatic stress disorder. Some researchers think it would lead to that some states have legalized increased abuse of illegal drugs and prefer to look for alternatives to marijuana for medicinal purposes, which illegal drugs for medicinal purposes. they believe supports their use of the drug recreationally.
SocialWork.EliteCME.com Page 102 Mental illness and self-medication
It would be confusing and frightening to function in a world where There is a direct relationship between people with mental illness and one’s thoughts were a rapidly changing series of unorganized the abuse of drugs. Drug use may temporarily relieve the symptoms of perceptions. The world would be a place where it was never clear what mental illness, therefore increasing the likelihood of drug addiction. was reality or hallucination. Some individuals wake up and experience Dr. Glen Hanson notes that more than 70 percent of schizophrenics are days where they have no feelings about anything at all, and they are addicted to nicotine, and there is a signifi cant correlation between mental unable to fi nd any comfort from family or friends. These are just a few illness and alcoholism. Some individuals with mental illness who are of the symptoms that accompany mental illnesses like schizophrenia, not receiving prescribed medications for treatment may abuse drugs in mood disorders and depression. an attempt to self-medicate and escape their symptoms of mental illness. Today there are ongoing debates on whether society should treat drug addicts with mental illness differently than other addicts.
Does Ritalin provide the fi rst step to drug abuse?
The most commonly prescribed medications for attention defi cit they are so similar that Ritalin and cocaine even compete for the same hyperactivity disorder (ADHD) is Ritalin. This treatment helps binding sites on neurons. Ritalin is one of the most abused prescription thousands of people control their symptoms. Ritalin is a stimulant drugs in the United States, and the majority of users are middle-school chemically similar to cocaine and has the potential for abuse. In fact, age youth (MTF, 2009).
Genetic profi les for addiction
What if it was possible to identify which individuals are predisposed to ● Would information on the infl uence of genetics on addiction and addiction by completing a genetic profi le? the research that supports drug addiction as a chronic brain disease ● If the results of the test showed a high predisposition for addictive change how society views and treats addiction? potential, should a person be required to participate in drug abuse ● If people knew they had a predisposition to addiction, would it education or prevention programs? prevent them from using drugs or would they use that knowledge ● If medications or vaccinations were available, should the as an excuse to avoid responsibility for their addiction? individual be encouraged to take the medications and be monitored ● Does the fact that prescription drugs are legal infl uence how by health care practitioners or counselors? society views addiction to them? ● How would the results of the genetic profi le affect insurability? Addiction to prescription medications is occurring at a higher rate ● Would the courts rule more sympathetically or harshly on a drug charge than many illegal drugs bought on the street. All of the issues listed for an individual with proven genetic susceptibility to addiction? above indicate how our society’s attitudes, understanding and response ● What if the test showed an individual had a low level of toward prescription drug addiction and treatment continue to evolve. predisposition to certain drugs? Would the person be more apt to try drugs because of the profi le?
Changing attitudes among youth
The increase in prescriptive drug abuse refl ects a negative shift in ● The number of teens who said “friends usually get high at parties” adolescent attitudes and a growing belief that prescription drug use and increased from 69 percent to 75 percent over the same time period. drinking are safe and accepted, as noted in the 2009 The Partnership/ ● There was a signifi cant drop in the number of teens agreeing MetLife Foundation Attitude Tracking Study (PATS) results: strongly that “they don’t want to hang around drug users,” from 35 ● The percentage of teens agreeing that “being high feels good” percent in 2008 to 30 percent in 2009. increased signifi cantly from 45 percent in 2008 to 51 percent in 2009.
Addressing the unique needs of teen abusers
Adolescent drug abusers have unique needs because of their immature Adolescents are especially sensitive to social clues, with peer groups and neuro-cognitive and psychosocial stages of development. Researchers families being highly infl uential during this time. Treatment programs demonstrated that the brain undergoes a process of continuous that promote positive parental involvement, include other areas of maturation from birth to early adulthood, and a developmental shift the adolescent’s life (such as school and athletics), and recognize the occurs where actions go from impulsive to more reasoned and refl ective importance of positive peer relationships are the most effective. (NIDA, 2009). In fact, the brain areas closely associated with aspects of Access to comprehensive assessment, treatment, case management and behavior, such as decision-making, judgment, planning and self-control, family support services that are developmentally, culturally and gender undergo a period of rapid development during adolescence. appropriate is also crucial when addressing adolescent addiction. NIDA researchers note adolescent drug abuse is also often associated Medications for substance abuse among adolescents may also be with other co-occurring mental illness. These include attention defi cit helpful (NIDA, 2010). hyperactive disorder (ADHD) oppositional defi ant disorder and conduct disorder as well as depressive and anxiety disorders. TESTS AND DIAGNOSIS
The American Psychological Association, DSM-V updates are substance-induced disorder criteria. A list of disorders has been currently under way, and the release date for the completed manual proposed for the diagnostic category substance use and addictive is in May 2013. Within the updated manual is the addition of new disorders. This category contains diagnoses that were listed in the
Page 103 SocialWork.EliteCME.com DSM-IV chapter of substance-related disorders but will be revised. 6. The substance is often taken in larger amounts or over a longer Below is a list of these substance-induced disorders: period of time than intended. ● Psychotic disorder. 7. There is a persistent desire or unsuccessful efforts to cut down ● Bipolar disorder. or control substance use. ● Depressive disorder. 8. A great deal of time is spent in activities necessary to obtain ● Anxiety disorder. the substance, use the substance or recover from its effects. ● Obsessive-compulsive or related disorder. 9. Important social, occupational or recreational activities are ● Dissociative disorder. given up or reduced because of substance use. ● Sleep-wake disorder. 10. The substance use is continued, despite knowledge of ● Sexual dysfunction. persistent or recurrent physical or psychological problems, that ● Delirium. is likely to have been caused or exacerbated by the substance. ● Mild neuro-cognitive disorder associated with substance use. 11. Craving or a strong desire or urge to use a specifi c substance. ● Major neuro-cognitive disorder associated with substance use. Severity specifi ers: Many categories are still under revision, but some have been released. ● Moderate: 2-3 criteria positive (from the list above). The following information gives an example of the criteria for ● Severe: 4 or more criteria positive. diagnosis of a substance use disorder as the DSM-V revisions are in When making a diagnosis, specify if the disorder occurs: progress: ● With physiological dependence: evidence of tolerance or ● A maladaptive pattern of substance use leading to clinically withdrawal, item 4 or 5, see list above, is present. signifi cant impairment or distress, as manifested by two or more of ● Without physiological dependence: No evidence of tolerance or the following occurring within a 12-month period: withdrawal, neither item 4 or 5 is present. 1. Recurrent substance use resulting in a failure to fulfi ll major role obligations at work, school or home. This includes neglect The revision process under way seeks input from current APA of children or the household. members. Other proposed revisions can be reviewed on the APA, 2. Recurrent substance use in situations in which it is physically DSM-IV Revision website (APA, 2012). hazardous, such as driving an automobile or operating a Doctors generally base a current diagnosis of prescription drug abuse machine when impaired by substance use. on a medical history and answers to other questions. In some cases, 3. Continued substance use despite having persistent or recurrent there are signs and symptoms that may also provide clues. The use social or interpersonal problems caused or exacerbated by the of many types of drugs can be detected by blood or urine tests. These effects of the substance (e.g., arguments with a spouse about tests can help track the progress of a person undergoing treatment. consequences of intoxication or physical fi ghts). Drug tests, toxicology screens on blood and urine samples, can show 4. Tolerance as defi ned by either of the following: many chemicals and drugs in the body. How sensitive the test is a. A need for markedly increased amounts of the substance to depends upon the drug itself, when the drug was taken and the testing achieve intoxication or desired effect. laboratory. Blood tests are more likely to detect a drug than urine tests; b. Diminished effects from the use of the drug and the need however, urine drug screens are done more often. to use increasing amounts of the substance. Tolerance is not counted for those taking medications under medical Opiates and narcotics are usually in the urine 12 to 36 hours after the supervision. last use, depending on the amount and frequency of the drug used. 5. Withdrawal, as manifested by either of the following: CNS stimulants such as cocaine can be found in urine for one to 12 a. Characteristic withdrawal syndrome for the substance. days, depending on frequency of use. CNS depressants such as Valium b. The same, or closely related, substance is taken to relieve and Xanax are found up to seven days after the last use, depending or avoid withdrawal symptoms. Withdrawal is not counted on the substance used and how quickly the body eliminates the drug for those taking medications under medical supervision. (half-life). Most hallucinogens can be found in the urine up to seven days after the last use. Marijuana can be found up to 28 days in regular users (SAMHSA, 2006).
Alcohol and other drugs (AODs) and psychiatric disorders
The U.S. Department of Health and Human Services (2006) notes The symptoms of a coexisting psychiatric disorder may be that determining a diagnosis for patients in addiction and mental misinterpreted as poor or incomplete recovery from AOD addiction. health settings is a multifaceted process. Clinicians must discriminate Psychiatric disorders may interfere with patients’ ability and motivation between acute primary psychiatric disorders and psychiatric symptoms to participate in addiction treatment as well as compliance with caused by alcohol and other drugs (AODs). Clinicians must complete a treatment guidelines. For example, patients with anxiety and phobias thorough history of AOD use and psychiatric symptoms and disorders. may fear and resist attending group meetings. Depressed people may There are several possible relationships between AOD use and be too unmotivated or lethargic to participate in treatment. Patients psychiatric symptoms and disorders. AODs may induce, worsen or with psychotic or manic episodes may exhibit bizarre behavior and diminish psychiatric symptoms, complicating the diagnostic process. poor interpersonal relations during treatment, especially during group- oriented activities. Such behaviors may be misinterpreted as signs of treatment resistance or symptoms of addiction relapse (HHS,2006).
AOD and psychiatric symptoms
● AOD use can cause psychiatric symptoms and mimic psychiatric ● AOD withdrawal can cause psychiatric symptoms and mimic syndromes. psychiatric syndromes. ● AOD use can initiate or exacerbate a psychiatric disorder. ● Psychiatric and AOD use disorders can independently coexist. ● AOD use can mask psychiatric symptoms and syndromes. ● Psychiatric behaviors can mimic AOD use problems. Source: The U.S. Department of Health and Human Services, 2006.
SocialWork.EliteCME.com Page 104 The terminology of dual disorders
The term dual diagnosis is a common term that indicates the ● Patients with schizophrenia and alcohol addiction are frequently simultaneous presence of two independent medical disorders. Recently seen in psychiatric units, mental health centers and programs that within the fi elds of mental health, psychiatry and addiction medicine, provide treatment to homeless patients. the term has been used to describe the coexistence of a mental health ● Patients with mental disorders have an increased risk for AOD disorder and AOD abuse. The equivalent phrase “dual disorders” disorders, and patients with AOD disorders have an increased risk also denotes the coexistence of two independent but interactive for mental disorders. For example, about one-third of patients who disorders and is the preferred term in treatment improvement protocols have a psychiatric disorder also experienced AOD abuse at some (HHS,2006). Acronyms used to describe dual disorders include: point (Regier, 1990), which is about twice the rate among people ● MICA, which represents the phrase “mentally ill chemical without psychiatric disorders. abusers,” is sometimes used to designate people who have an ● More than half of the people who use or abuse AODs have AOD disorder and markedly severe and persistent mental disorders experienced psychiatric symptoms signifi cant enough to fulfi ll such as schizophrenia or bipolar disorder. A preferred defi nition is diagnostic criteria for a psychiatric disorder (Regier, 1990; Ross et “mentally ill chemically affected.” al., 1988). ● MISA – Mentally ill substance abusers. ● Patients with dual disorders often experience more severe and ● CAMI – Chemical abuse and mental illness. chronic medical, social and emotional problems. Because they ● SAMI – Substance abuse and mental illness. have two disorders, they are vulnerable to both AOD relapse and a Common examples of dual disorders include: worsening of the psychiatric disorder. ● Major depression with cocaine addiction. ● Addiction relapse often leads to psychiatric decompensation, and ● Alcohol addiction with panic disorder. worsening of psychiatric problems often leads to addiction relapse. ● Alcoholism and polydrug addiction with schizophrenia. Thus relapse prevention must be specially designed for patients ● Borderline personality disorder with episodic polydrug abuse. with dual disorders. ● Patients with dual disorders often require longer treatment, have The National Institute of Health explains that some patients have more more crises and progress more gradually in treatment. than two disorders, such as cocaine addiction, personality disorder ● Psychiatric disorders most prevalent among dually diagnosed and alcoholism. The principles that apply to dual disorders generally patients include mood disorders, anxiety disorders, personality apply also to multiple disorders. The combinations of AOD problems disorders and psychotic disorders. and psychiatric disorders vary along dimensions, such as severity, Among patients with a psychiatric disorder, any AOD use can have chronicity, disability and the degree of impairment in functioning. For dangerous consequences. This is especially true for patients with example, the two disorders each may be severe or mild, or one may be severe psychiatric disorders and patients who are taking prescribed more severe than the other. Indeed, the severity of both disorders may medications for psychiatric disorders. For patients with psychiatric change over time. Levels of disability and impairment in functioning disorders, even occasional use of alcohol can lead to serious problems, may also vary (HHS, 2006). such as adverse medication interactions, decreased medication Patients with similar combinations of dual disorders are often found in compliance and AOD abuse. Screening questions can determine certain treatment settings and exhibit the following characteristics: evidence of AOD use and the frequency, dose, and duration (HHS, ● Methadone treatment programs see a high percentage of opiate- 2006). The DMS-IV developed by the APA and currently under addicted patients with personality disorders. revision describes the criteria that must be present to make a diagnosis of an AOD addiction and dual diagnosis of dependence. COMMONLY ABUSED PRESCRIPTION MEDICATIONS
Although many prescriptions can be abused, the following three ● Central nervous system (CNS) depressants – used to treat classes are most commonly abused (NIDA, 2011): anxiety and sleep disorders. ● Opioids – usually prescribed to treat pain. ● Stimulants – prescribed to treat ADHD and narcolepsy.
Opioids
Opioids are analgesic, or pain relieving, medications. NIDA studies codeine. Hydrocodone is prescribed for a variety of painful conditions, have shown that with properly managed medical use and taken including dental and injury-related pain. exactly as prescribed, the opioid analgesics are safe, can manage pain Abuse of opioids can occur when taken orally, or the pills may be effectively and rarely cause addiction. crushed and the powder snorted or injected. A number of overdose Among the compounds in this class are hydrocodone (Vicodin), death have resulted from snorting and injecting opioids, particularly oxycodone (OxyContin) and Percocet. OxyContin is an oral, controlled with OxyContin, which was designed to be a slow release formulation. release form of the drug used to treat moderate to severe pain through Snorting or injecting opioids results in the rapid release into the a slow, steady release of the opioid. Morphine, fentanyl, codeine bloodstream, exposing the person to high doses and causing many of and related medications are also opioids. Morphine and fentanyl are the reported overdose reactions, including death. used to alleviate severe pain before or after surgery, or with oncology Opioids act by attaching to specifi c proteins called opioid receptors, patients experiencing severe pain, while codeine is use for milder which are found in the brain, spinal cord and gastrointestinal tract. pain. Other examples of opioids prescribed to relieve pain include When these compounds attach to certain opioid receptors in the brain propoxyphene (Darvon), hydromorphone (Dilaudid), and meperidine and spinal cord, they can change the way a person experiences pain. (Demerol), which is used less often because of its side effects. In addition, opioid medications can affect regions of the brain that In addition to their pain-relieving properties, some of these interpret and communicate the perceptions of pleasure. This explains medications can be used to relieve severe diarrhea, such as Lomotil the initial feeling of euphoria or false sense of well-being that many (also known as diphenoxylate), or to address severe coughs, such as
Page 105 SocialWork.EliteCME.com opioids produce. The feeling of euphoria results from the drug’s affect the desired effect compared to when it was fi rst prescribed. Physical on the region of the brain involved in reward. dependence is a normal adaptation to chronic exposure to a drug and is Opioids can produce drowsiness, mental confusion and constipation, not the same as addiction. People taking prescribed opioid medication and large doses can depress respiration to the point of severe respiratory should be given these medications only under appropriate medical distress or death. Prescribed opioid medications are only safe to use supervision and should be medically supervised when decreasing or with other substances under physician supervision. They should not stopping use to reduce or avoid withdrawal symptoms. Symptoms of be used with alcohol, antihistamines, barbiturates or benzodiazepines withdrawal can include restlessness, muscle and bone pain, insomnia, because these substances slow breathing, and their cumulative effects in diarrhea, vomiting, cold fl ashes with goose bumps, and involuntary leg combination with opioids could lead to life-threatening respiratory failure. movements (NIDA, 2011). Regular use several times a day for several weeks or more, or long- Street names for opioids include: ● China girl or China white. term abuse of opioids can lead to physical dependence and in some ● Vike, dance fever, friend, good fella, jackpot, murder 8, TNT, cases, addiction and death. hillbilly heroin, percs,Watson-387, juice, smack, footballs, dillies, Repeated exposure to opioids causes the body to adapt, sometimes D, biscuits, blue heaven, blues, Mrs. O, octagon, stop signs, O resulting in tolerance where more of the drug is needed to achieve bomb and demmies.
Central nervous system (CNS) depressants
CNS depressants, tranquilizers and sedatives are medications that slow prescribed. Research is limited on the use of non-benzodiazepine normal brain function. In higher doses, some CNS depressants can be sleep medication, but certain indicators have raised concern about the used as general anesthetics or pre-anesthetics. CNS depressants can be likelihood of abuse or addiction. divided into three groups, based on their chemistry and pharmacology: During the fi rst few days of taking prescribed CNS depressants, a ● Barbiturates, such as mephobarbital (Mebaral) and sodium person usually feels sleepy and uncoordinated. As the body becomes pentobarbital (Nembutal), are used as pre-anesthetics and for accustomed to the effects of the drugs and tolerance develops, the side promoting sleep. They are also used less frequently to reduce effects begin to disappear. Continued use of these drugs long-term may anxiety or sleep problems because of their higher risk of overdose indicate that larger doses may be needed to achieve the therapeutic compared to benzodiazepines. They are still used in surgical effects. Prolonged use can also lead to physical dependence and procedures and for seizure disorders. withdrawal when the drug is abruptly reduced or stopped. ● Benzodiazepines, such as diazepam (Valium), alprazolam (Xanax) and estrazolam (Prosom), can be used to treat anxiety, acute Because all CNS depressants work by slowing the brain’s activity, stress reactions, panic attacks, convulsions and sleep disorders. when an individual stops taking them, there can be a rebound effect, Benzodiazepines, like Halcion and Prosom, are usually only resulting in seizures or other harmful consequences. Although prescribed for short-term relief of sleep problems because of the withdrawal from benzodiazepines can cause serious problems, it is development of tolerance and risk of dependence or addiction. rarely life-threatening, whereas withdrawal from prolonged use of ● Non-benzodiazepine sleep medications such as zolpidem barbiturates can have life-threatening complications. (Ambien), eszopiclone (Lunesta),and zaleplon (Sonata), have It is safe to use CNS depressants with other medications only under different chemical structures, but act on some of the same brain a physician’s supervision. Typically, they should not be combined receptors as diazepam. These drugs are thought to have fewer side with any other medication or substance that causes CNS depression, effects and less risk of dependence than benzodiazepines. including prescription pain medications, some over-the-counter cold Most CNS depressants act on the brain by affecting the neurotransmitter and allergy medications and alcohol. Using CNS depressants with gamma aminobutyric acid (GABA). Neurotransmitters are brain these substances, particularly alcohol, can affect heart rhythm, slow chemicals that facilitate communication between brain cells. Although respiration and even lead to death (NIDA, 2011). the different classes of CNS depressants work in unique ways, their Street names for depressants include: ability to increase GABA and thereby inhibit brain activity classifi es ● Reds, red bird. them as depressants. They produce a drowsy or calming effect benefi cial ● Barbs phennies, tooies. to those suffering from anxiety or sleep disorders. ● Yellows, yellow jackets. Despite their many benefi cial effects, benzodiazepines and ● Candy, tranks, forget-me pills, Mexican valium. barbiturates have the potential for abuse and should be used only as ● R2, rope, and rophies.
Stimulants
The NIDA notes that stimulants, including amphetamines Adderall, norepinephrine. The therapeutic effect is achieved by the slow and Dexedrine and methylphenidate, Concerta and Ritalin, increase steady increase of dopamine that is similar to the natural production of alertness, attention and energy. They increase blood pressure and this chemical by the brain. The doses prescribed by physicians start low heart rate, constrict blood vessels, increase blood glucose and widen and increase gradually until a therapeutic effect is reached. If stimulants the pathways of the respiratory system. Historically, stimulants were are taken in higher doses or administered other than prescribed, the prescribed to treat asthma and other respiratory problems, obesity in stimulant rapidly increases the brain’s dopamine level and intensifi es its children and adults, neurological disorders, and a number of other action on the brain. This in turn distorts the pattern of communication medical problems. As their potential for abuse and addiction became between brain cells, resulting in pleasurable feelings. apparent, physicians decreased the number of stimulant prescriptions. As with other drugs of abuse, it is possible for individuals to become Now stimulants are prescribed for treating only a few health dependent upon or addicted to stimulants. Withdrawal symptoms conditions, including ADHD, narcolepsy and cases of depression that associated with discontinuing stimulant use include fatigue, have not responded to other treatments. depression and sleep disturbance. Continued abuse of some stimulants Stimulants have chemical structures similar to important brain within a short period can lead to feelings of hostility or paranoia, neurotransmitters called monoamines, which include dopamine and even psychosis. Taking high doses of the stimulant may result in
SocialWork.EliteCME.com Page 106 dangerously high body temperature, blood pressure and blood glucose; mixture. Complications can arise from injecting the drug because constricted blood vessels; and a rapid or irregular heartbeat. There is insoluble fi llers in the tablet can block small blood vessels and have also the potential for cardiovascular failure or seizures (NIDA, 2011). even been found in the fl uid in the eye. Young addicts have been found Stimulants should not be used with other medications unless to have vision clouding normally associated with vision problems authorized by a physician. Patients must be aware of the dangers found in elderly patients. Stimulants have been abused for both associated with mixing stimulants in over-the-counter cold medications “performance enhancement” and recreational purposes, such as getting that contain decongestants; the cumulative effects of combining these high (NIDA, 2011). Street names for stimulants include: ● Bennies, black beauties. substances may cause blood pressure to become dangerously high or ● Truck drivers, uppers, speed. lead to irregular heart rhythms. ● Crosses, hearts. When stimulants are abused, they may be taken orally, but some ● LA turnaround. abusers crush the tablets, dissolve them in water and then inject the
Cognitive enhancers
The dramatic increase in stimulant prescriptions over the last two Indeed, reports suggest that the practice is occurring among some decades has led to their greater availability and increase risk for illegal academic professionals, athletes, performers, older people and distribution and abuse. For those who take these medications to improve middle, high school and college students. Such nonmedical cognitive diagnosed medical conditions, they can greatly improve a person’s enhancement poses potential health risks, including addiction, quality of life. However, because they are thought by many to be cardiovascular events, digestive problems and loss of appetite, weight generally safe and effective, prescription stimulants, such as Concerta or loss and psychosis (NIDA, 2011). Adderall, are increasingly abused to address nonmedical conditions. Street names include : ● Jif, mph, R-ball, skippy, smart drug and vitamin R. TREATMENT
Treatment for drug abuse or dependence begins with recognizing enable the person to live as normal a life as possible. Methadone has the problem. The denial of a substance abuse problem used to be serious potential for abuse, which will be discussed in a later section. considered a symptom of addiction. Current research has shown that Research has shown that addiction to any drug, illicit or prescribed, people who are addicted have far less denial if they are treated with is a brain disease that can be treated effectively (NIDA, 2011). empathy and respect rather than told what to do or confronted. Treatment must take into account the type of drug used and the needs Treatment of drug dependency involves tapering off the drug gradually of the individual. Successful treatments need to incorporate several (detoxifi cation), support, and ending the drug use (abstinence). components including counseling, detoxifi cation and sometimes the People with acute intoxication or drug overdose may need emergency use of addiction medications. Multiple courses of treatment may be treatment. Sometimes the person loses consciousness and might needed for the patient to make a full recovery. need to be on a breathing machine such as a mechanical respirator The two main categories of drug addiction treatment are behavioral temporarily. The treatment depends on the drug being used and the and pharmacological. Behavioral treatments help patients stop using severity of the abuse (NIDA, 2011). drugs by teaching them strategies to function without drugs, deal Detoxifi cation is the gradual withdrawal of an abused substance in a with cravings, avoid drugs, identify situations that could lead to drug controlled environment. Treatment may include displacing the drug use, and handle a relapse should it occur. When delivered effectively, with one that has a similar action to reduce the side effects and risks of behavioral treatments, such as individual counseling, group or family withdrawal. Detoxifi cation can be done on an inpatient or outpatient basis. counseling, contingency management and cognitive behavioral If the person also has depression or another mood or psychiatric therapies can help patients improve their personal relationships and disorder, it must be treated as well as the addiction. Very often, people their ability to function at home, work and in the community. start abusing drugs in an effort to self-treat mental illness. For opioid Some addictions can be treated with pharmacological treatments dependence, some people are treated with methadone, a synthetic that counter the effects of the drug on the brain and can be used to opioid, or LAAM to prevent withdrawal and relieve drug cravings. relieve withdrawal symptoms, help overcome drug cravings or treat an Methadone has been used for more than 40 years to successfully treat overdose. Although a behavioral or pharmacological approach alone people addicted to heroin. The goal of methadone treatment is to may be suffi cient for treating some patients, research shows that a combined approach may be best (NIDA, 2010).
Treating addiction to prescribed opioids
Several options are available for effectively treating opioid addiction, These medications can only be used after detoxifi cation is completed which include medications such as methadone and buprenorphine, because they can produce severe withdrawal symptoms if the person which are synthetic opioids. continues to abuse opioids. Naloxone is a short-acting opioid receptor Naltrexone is a long-acting opioid receptor blocker that can be used to blocker that counteracts the effects of opioids and can be used to treat help prevent relapse. It is not widely used because of non-compliance overdoses. In addition to pharmacological approaches to treatment, but is effective with highly motivated individuals such as physicians psychotherapy as well as behavioral counseling approaches combined or other professionals at risk of losing their license or prisoners and with medications has proven to be effective. those on parole or probation who are committed to abstinence to avoid further incarceration.
Page 107 SocialWork.EliteCME.com Agonist maintenance treatment
Agonist maintenance treatment for opioid addicts usually is conducted individual or group counseling as well as other needed medical, in outpatient settings, often called methadone treatment programs. psychological or social services. These programs use a long-acting synthetic opiate medication, usually With continued support and careful monitoring, using sustained methadone or levoalpha-acetylmethodol (LAAM), administered dosages of methadone or LAAM, patients can function normally. They orally for a sustained period at a dosage suffi cient to prevent opioid can hold jobs and rejoin their family and community, avoid the crime withdrawal, block the effects of illicit opioid use and decrease cravings. and violence of the drug culture, and reduce their exposure to HIV by Patients stabilized on opioid agonists can engage in counseling and stopping injection drug use and drug-related, high-risk sexual behavior other behavioral interventions essential for recovery and rehabilitation. (NIDA, 2011). The best, most effective opioid agonist maintenance programs include
Narcotic antagonist treatment
Using naltrexone for opioid addiction usually is conducted in gradually result in breaking the habit of addiction. Naltrexone itself has outpatient settings although it often begins after medical detoxifi cation no harmful effects or potential for abuse and is not addicting. in a residential setting is completed. Naltrexone is a long-acting Patient non-compliance is a common problem, so effective treatment synthetic opioid antagonist with few side effects that is taken orally, outcomes require a positive therapeutic relationship and careful either daily or three times a week, for a sustained period of time. monitoring of medication compliance. Recently, an injectable long- Individuals must be medically detoxifi ed and opiate-free for several acting form of naltrexone (Vivitrol), has also received FDA approval days before naltrexone can be taken to prevent precipitating an opioid to treat opioid addiction. Because its effects last for weeks, Vivitrol is abstinence syndrome (NIDA, 2011). ideal for patients who do not have ready access to health care or who Naltrexone prevents opioids from activating their receptors, although its struggle with taking their medications regularly. use for addiction has been limited due to poor adherence and tolerability Buprenorphine is a partial opioid agonist, containing agonist and by patients. When naltrexone is used correctly, all the effects of self- antagonist properties, which can be prescribed by certifi ed physicians in an administered opioids, including euphoria, are totally blocked. The theory offi ce setting. Like methadone, it can reduce cravings and is well tolerated behind this treatment is that the repeated lack of desired effects will by patients. NIDA is supporting research to determine the effectiveness of these medications in treating addiction to opioid pain relievers.
Treating addiction to CNS depressants
Patients addicted to barbiturates and benzodiazepines should not attempt Inpatient and outpatient counseling can help individuals through this to stop taking them on their own. Withdrawal symptoms from these process. Cognitive behavioral therapy has been successfully used to drugs cause serious physical symptoms, and can be life-threatening. help individuals learn new thought and behavior patterns to adapt to Research on treating barbiturate and benzodiazepine addiction is limited benzodiazepines abstinence. Often barbiturate and benzodiazepine but addicted patients undergo medically supervised detoxifi cation abuse occurs in connection with the abuse of other drugs, such as because the dosage they take should be gradually tapered. alcohol or cocaine. In such cases of polydrug abuse, the treatment approach should address the multiple addictions.
Treating addiction to prescription stimulants
Treatment of addiction to prescription stimulants such as Adderall and ease withdrawal symptoms such as mood changes, sleep and appetite Concerta is based on behavioral strategies used in treating cocaine and disturbances. The detoxifi cation process could be followed by one of methamphetamine addiction. At this time, there are no medications many behavioral therapies. Contingency management, for example, that are FDA approved for treating stimulant addiction, but the NIDA is a system that enables patients to earn vouchers for drug-free urine is supporting research in this area. tests. These vouchers can be exchanged for items that promote healthy Depending on the patient’s type and level of abuse, the fi rst step in living. Cognitive behavioral therapy may be effective for treating treating prescription stimulant addiction is to taper the drug dosage to stimulant addiction and recovery support groups may be helpful when combined with behavioral therapy.
The matrix model
The matrix model provides a comprehensive program for involving self-esteem, dignity and self-worth. A positive relationship with the stimulant abusers in treatment and motivating them to complete the therapist is necessary for success in reaching abstinence. program and progress toward abstinence. Patients learn about issues Treatment materials draw heavily on other evidenced-based critical to addiction and relapse, with direction and support from a treatment approaches. This approach includes elements of relapse trained therapist. They become familiar with self-help programs and prevention, family and group therapies, drug education and self-help are monitored for drug use by urine testing. The program includes for participation. Detailed treatment manuals contain worksheets for education for family members affected by the addiction (NIDA, 2011). individual sessions. Other components include family educational The therapist functions as teacher and coach, developing a positive, groups, early recovery skills groups, relapse prevention groups, urine supportive therapeutic relationship to foster behavior change. The testing, 12-step programs, relapse analysis and social support groups interaction between the therapist and the patient is practical, rational (U.S. Department of Health and Human Services, 2011). and straightforward and never judgmental or imposing. Therapists A number of programs have demonstrated that addicts treated with are trained to facilitate treatment sessions that promote the patient’s the matrix model have statistically signifi cant reductions in drug
SocialWork.EliteCME.com Page 108 and alcohol use, improvements in psychological health, and reduced cocaine users. The reports provided evidence of improved naltrexone risk of sexual behaviors associated with HIV transmission. These treatment among opioid addicts, including peer review support for the reports show similar treatment outcomes for methamphetamine and dissemination of the matrix model (NIDA,2011).
Supportive-expressive psychotherapy
Supportive-expressive psychotherapy is a time-limited, individual Results of supportive-expressive psychotherapy have been tested form of psychotherapy that has been adapted for heroin and related with patients in methadone maintenance treatment who had co- opiates, and cocaine-addicted individuals. The therapy has two main occurring psychiatric problems. In comparison studies with patients components: receiving only drug counseling, groups had similar response rates but ● Supportive techniques to help patients feel comfortable in the supportive-expressive psychotherapy group had more success in discussing their personal experiences. cocaine reduction and used less methadone. Patients who participated ● Expressive techniques to help patients identify and work through in supportive-expressive psychotherapy were able to maintain those interpersonal relationship issues. rates of success. Supportive-expressive psychotherapy, when added to ● Special attention is given to the infl uence of drugs on thoughts, drug counseling, improved outcomes for opiate addicts in methadone emotions and behavior. treatment with moderately severe psychiatric problems (HHS, 2011). ● Strategies are developed to cope with and solve problems without abusing drugs.
Individualized drug counseling
Individualized drug counseling focuses on the patient’s needs in order tools for abstaining from drug use and maintaining abstinence. The to stop the person’s illicit drug use. It also addresses related areas, such addiction counselor encourages 12-step participation and makes as illegal activity, family/social relations and skill development within referrals for needed supplemental medical, psychiatric, employment the content and structure of the patient’s recovery program. and other social services. Individuals are encouraged to attend sessions It works on short-term behavioral goals with individualized drug one or two times per week. counseling and helps the patient develop coping strategies and
Behavioral therapy for adolescents
Behavioral therapy for adolescents follows the principle that by ● Urge control helps patients recognize and change thoughts, identifying behaviors to change, setting clear goals to accomplish feelings and plans that lead to drug abuse. behavior change and delivering consistent rewards at incremental steps ● Social control involves family members and other people toward progress, target behaviors can be changed. important in helping patients avoid drugs. A parent or signifi cant other attends treatment sessions and assists with therapy Therapeutic activities include completing individualized assignments, assignments and reinforcing appropriate behavior. developing strategies to handle drug-related confl icts, rehearsing desired behaviors, and recording and reviewing progress data, with According to research studies, this therapy helps adolescents reinforcement given for goal mastery. Reinforcers are identifi ed for become drug-free and increases their ability to remain drug-free each individual, and reinforcement schedules are defi ned. Urine after treatment ends. Adolescents also show improvements in several samples are collected regularly to monitor drug use. other areas, family relationships, social skills, communication skills, school performance and employment, and lowers depression, This therapy aims to help the patient to gain three types of control: ● Stimulus control helps patients avoid situations associated with institutionalization rates and alcohol use. Such favorable results drug use and learn to engage and commit to substitute activities are attributed largely to including family members in therapy and that are incompatible with drug use. rewarding drug abstinence as verifi ed by urinalysis (HHS, 2011).
Multidimensional family therapy (MDFT) for adolescents
MDFT is an outpatient family-based drug treatment for adolescents. such as decision-making, communication skills, negotiation skills, This method treats drug abuse by addressing all components in effective social/behavioral patterns and problem-solving skills. Youths adolescents’ life that impact their drug abuse. The youth, family, peers, improve skills to communicate their thoughts and feelings to cope with school and community are included and work together to guide healthy life stressors, and learn employment and vocational skills. Counseling behaviors for application in multiple settings. sessions are held with parents to review patterns of behavior and Treatment includes individual and family sessions held in the home, parenting styles. Parents develop positive parenting methods and treatment setting, at the family court, drug court, school or other distinguish effective methods from previous ineffective parenting locations. During sessions, the therapist and adolescent work on tasks, based on control and confrontation (HHS, 2011).
Outpatient drug treatment
This type of treatment costs less than residential or inpatient treatment success. Factors in the choice of outpatient treatment should consider and is implemented for individuals who are employed or who have the type, duration and severity of the abuse; and patients’ medical extensive social supports. Some programs offer little more than drug and psychiatric history, individual needs and support systems in education, but others provide intensive day treatment and could be place. Many outpatient programs use group counseling and some are compared to residential programs in the services offered and rates of designed to treat patients with dual disorders (NIDA,2011).
Page 109 SocialWork.EliteCME.com Long-term residential treatment
This type of treatment provides care 24 hours a day, generally in designed to help residents examine negative self-concepts, destructive nonhospital settings. The best-known residential treatment model is thought patterns and behavior, and develop effective communication the therapeutic community (TC). TCs are residential programs with a skills. The goal is to develop effective ways to face life’s issues and planned length of six to 12 months. They focus on the re-socialization interact with others without substance abuse. of the individual and involve the program’s entire community, Many TCs are quite comprehensive and can include employment including other residents and staff in the treatment. training and other support services on-site. Compared with patients in Addiction is viewed in the context of the individual’s social and other forms of drug treatment, the typical TC resident has more severe psychological defi cits, and treatment focuses on developing personal problems, with more co-occurring mental health problems and more accountability and responsibility for a productive life. Treatment is criminal involvement (NIDA, 2011). highly structured and can at times be confrontational, with activities
Evidence-based drug treatment
Benedict Carey has written about the fi eld of rehabilitation programs, “Then I went right back,” Angella said in an interview. “After which has no standardized set of guidelines and frequently does not a while, you know, you just start missing your friends” (Nelson, track long-term outcomes or attempt to verify effectiveness. He notes 2011, p. 195). that state legislators are mandating that publicly funded programs rely Prescription drug addiction residential treatment programs across on scientifi c evidence to base treatment techniques. Evidence-based the U.S. do not have standard guidelines to follow. Every treatment techniques are the result of recognized scientifi c research investigation, program as well as individual counselors and therapists have their application and reported data. These programs have been replicated own theories about effective treatment approaches based on their and show established track records for positive, lasting results (Nelson, experience and training. Most programs do not have an aftercare 2011, p. 194). program that can track or monitor an individual’s abstinence after they Carey writes that throughout the country, “Some users start early, fall exit the program and resume life in the community. Many programs fast and in their reckless prime can swallow, snort, inject or smoke do not have the resources or a process in place to put a long-range anything available, from crystal meth to prescription pills, to heroin effi ciency study in place. and ecstasy. And the treatment, if they get it at all, can seem like a “What we have in this country is a washing machine model of addiction joke” (Nelson, 2011, p.195). treatment,” said Thomas McClellan, chief executive of the nonprofi t Carey described the “revolving door” aspect of rehabilitation treatment Treatment Research Institute, based in Philadelphia. “You go to Shady programs with the following case study about Angella: Acres for 30 days, or to some clinic for 60 visits or 60 doses, whatever One young addict describes the following experience with it is, and you’re discharged and everyone’s crying, hugging and feeling rehabilitation: proud, and you’re supposed to be cured,” McClellan explained. “After the fi rst couple of times I went through, they basically told He added, “ It doesn’t really matter if you’re a movie star going to some me that there was nothing they could do,” said Angella, a 17-year- resort by the sea or a homeless person. The system doesn’t work well for old from central Oregon, who by freshman year in high school many people with a chronic, reoccurring problem” (Nelson, p. 196). was drinking hard liquor every day, smoking pot and sampling a In 2003, the Oregon legislature mandated that rehabilitation programs variety of hard drugs. receiving state funds use evidence-based practices. The mandate She tried residential programs twice, living away from home was aimed at improving services so that abusers would not become for three months each time. There she learned how dangerous doomed to a lifetime of rehabilitation, repeating the same kinds of her habit was, and how much pain it was causing others in treatment that had failed them in the past. When practiced correctly her life. She worked on strengthening the relationship with and consistently, evidenced-based therapies give abusers their best her grandparents, with whom she lived. For two months or so chance to break drug habits. Among the therapies are prescription afterwards she stayed clean. drugs treatments, like naltrexone for opioid dependence and buprenorphine for narcotics addiction, which have been proven effective (Nelson, 2011, p. 197).
The motivational interview
Another effective evidence-based treatment is called motivational They learn to question and change thought patterns that reinforce their interview, a method to strengthen the client’s commitment to enter drug habits. An example could be an abuser who previously believed and complete treatment. In MI, as it is known, the counselor, through he could not be happy without his drug-abusing friends and would not skilled questioning techniques, has the abuser explain why he or she be accepted by a social group that is drug-free. The program helps the has a drug problem, and why it is important to set goals and develop a addict to learn and participate in activities that do not involve drugs plan to abstain from drug use. and to develop creative interests. Studies show that when clients take responsibility for their addiction, set For Angella, this kind of counseling made a difference. She goals and make a plan instead of listening to a lecture from a counselor spent several months in a program run by Adapt, an addiction as in many traditional programs, they stay in treatment longer. treatment center in Rosenberg, a small city about 175 miles south Psychotherapy techniques help the abuser identify and cope with of Portland. In treatment, Angella said she learned to “just be their inappropriate or drug-related thoughts and feelings. Cognitive with, and feel” bad moods without turning to drink or drugs and to behavior therapy helps abusers to anticipate stress, anxiety, depression throw herself into creative projects like collage and painting. The or mood changes and develop techniques to accept and deal with those program has helped her reconnect with her father and to enroll in feelings without turning to drugs. college beginning in January.
SocialWork.EliteCME.com Page 110 “I want to be a teacher, and someone at the program is advising being swept away by them. The counselors are “always asking me on that,” she said in an interview. “That’s the plan, to just about our stress level, our anger; you become more aware and move out and away from my old life.” A friend of hers in the have a better idea what to do with it,” he said (Nelson, 2011, program, Alex, a 16-year-old from Roseburg, said the therapy p.198). helped him monitor his own emotional ups and downs, without
Adapt treatment services
Adapt has been providing drug abuse treatment using evidence-based The counselors are trained in a variety of treatment programs, such treatment practices in southern Oregon for more than 40 years. The as Seeking Safety, motivational interviewing (MI), and motivational program includes many treatment options and mental health services enhancement therapy (MET) and the matrix model to tailor the for adolescents and adults. Adapt is designed to deliver residential treatment program to meet the specifi c needs of the individual. and outpatient treatment. Different treatment styles and methods are Adapt was developed to provide a full range of mental health services, provided through a number of programs that implement evidenced- including treatment for dual or multiple disorders. The program is based practices that have been studied and verifi ed to be effective with equipped to identify and treat co-occurring mental health conditions a number of diverse populations. that may have been a factor in the substance abuse or addiction. The community reinforcement approach to treatment is the focus of Treating all of the co-occurring mental health conditions is critical to the Adapt program, and it employs a cognitive behavioral therapy achieving success in drug abuse treatment (Adapt, 2004). process using positive reinforcement rather than negative sanctions.
Practice-based evidence
To provide the best treatment services and incorporate effective that those clients met their goals, as measured by both clean urine tests approaches used by veteran counselors, practice-based evidence has and how well they were functioning in school, work and at home. been incorporated into the evidence-based programs. Practice-based “We basically gave them a list of evidence-based practices and told evidence documents the work and results based on counselors’ own them to pick the one they wanted to use; it is up to them to decide what work. In this way, the “tried and true” approaches that counselors want to use,” said Jack Kemp, former director of Substance Abuse Services to continue to use can be incorporated into the mandated evidence- for Delaware. He continued, “For those who were trying not to use based practices. drugs, it doesn’t matter how rehabilitation services are improved, only In 2001, the Delaware Division of Substance Abuse and Mental Health that it happens in time.” A former addict, a 25-year-old from Oregon, began giving treatment program incentives, or bonuses, if they met agreed, “Honestly, you just don’t care how or why something works certain benchmarks. A clinic could earn a bonus of up to 5 percent if it for you, just that it does” (Nelson, 2011, p. 202). kept a high percentage of addicts returning at least weekly and ensure
A note about Oregon
As noted above, Oregon has been on the forefront of treatment because together to create a plan so that the person can move toward becoming of a large number of addicted individuals. This is due in part to the healthy, drug-free and independent and not return to the streets. high numbers of homeless adults and runaway teens living on the The transitional housing program gives youths a safe home streets and under highways. In 2000, Portland had the highest rate of environment as they learn and work through their issues with the homeless teens living on the street, 1,500, and the highest number of support of the staff. The 24-bed housing unit is a place where youths heroin deaths attributed to the low cost of the drug. Since the 1980s, can work on living skills, social skills, employability and educational Portland has seen an increase in the number of runaways and loosely skills. The goal of the program is that when these young people are organized street families. Studies indicate that 57 percent of teens ready to leave New Avenues, they can move on to a self-suffi cient, ran away from foster homes and 81 percent ran from abusive homes independent and productive life, including a permanent living situation (DEC, 2010). off the streets. In an attempt to help these youths and ensure a safe city for everyone, Oregon took the prescription and illegal drug abuse problem in the local business owners and politicians rallied to obtain funds for state seriously and implemented evidenced-based programs proven to programs, which addressed the varied needs of the homeless teens. be effective, as follows: One program, New Avenues for Youth, provides temporary housing ● Almost 54 percent of Oregon’s $94 million budget for addiction and assists teens in locating agencies for help. This program goes treatment services now goes to programs that employ evidence- beyond meeting basic needs and begins with the Day Service Center. based techniques, according to a state report completed in 2008. This is the initial contact point where youths are provided food, The estimated rate of funding before the mandate was 25 percent clothing, showers and have access to various recreational activities. to 30 percent. The purpose is to provide a safe place so these youths can leave the ● Oregon implements the evidenced-based programs mandated by streets and their basic needs can be met. In this way, staff members the state with support from the Robert Wood Johnson Foundation build trusting relationships with the young people and are able to help and the National Institutes of Health. connect them to services that will provide the resources they need to ● By 2006, the state’s rehabilitation programs were operating at 95 leave the streets (New Avenues for Youth, 2012). percent capacity, up from 50 percent in 2001. The New Avenues For Youth case management program provides a ● 70 percent of patients were attending regular treatment sessions, up case manager for each youth in the program. The case managers are from 53 percent, according to an analysis of the policy published Masters-level licensed clinical social workers, and they work with in the journal Health Policy in 2009 (NIH, 2011). youths to identify and connect them to needed services. These services include mental health care, drug and alcohol counseling, as well as education, job training and housing. The youth and case manager work
Page 111 SocialWork.EliteCME.com Treating drug abuse in the criminal justice system
The National Research Advisory Committee (NRAC) has shown that ● Treating the proper criminal justice target population would save criminal justice sanctions to incorporate drug treatment are effective $2.14 for every $1 spent, totaling $1.17 billion in savings annually. in decreasing drug use and crime. Individuals under the legal control Drug courts are one of the most effective strategies to lower the rate of the drug courts attend treatment to avoid a prison sentence. These of recidivism. Roger Warren, president emeritus of the National programs have higher treatment retention rates and abstinence rates Center for State Courts (2010), explains, “Rigorous scientifi c studies that are comparable or higher than non-judicial-based treatment and meta-analysis have found that drug courts signifi cantly reduce programs (NRAC, 2006). Though not by choice, drug abusers enter the recidivism among drug court participants in comparison to offenders in criminal justice system when they would not consider entering other similar treatment programs delivered outside of the drug court system, treatment programs. with effect sizes ranging from 10 percent to 70 percent” (Hora, 2009). The drug court programs provide effective treatment to stop the individual’s Drug courts were among the fi rst to apply evidence-based practices cycle of drug abuse and crime. Drug court sanctions may include treatment on a large scale. In the fi eld of substance abuse and mental health that is delivered before, during or after confi nement. Sanctions may allow treatment, interventions that have been rated through the peer-review individuals to avoid incarceration if they continue to meet the structured process are eligible for inclusion in the National Registry of Evidence- requirements of the drug court program (NRAC, 2006). Based Programs and Practices (NREPP) and the Substance Abuse and A number of criminal justice alternatives to incarceration have Mental Health Services Administration (SAMHSA). The goal of the been tried with offenders who have abused drugs, including limited registry is to “improve access to information on tested interventions diversion programs, pretrial release conditional on entry into and thereby reduce the lag time, currently 12 years, between the treatment, and conditional probation with sanctions. creation of scientifi c knowledge and its practical application in the Drug courts mandate and arrange treatment, monitor progress and fi eld. (NREPP, 2009). assess program effectiveness using evidenced-based practices. The Along with the SAMHSA initiative, evidence-based sentencing court will require and arrange for other services for the offender and implements problem-solving techniques to reduce recidivism and their family that supports treatment success. promote fairness in the courtroom. The chief justices of the 50 states Federal support for planning, implementation and enforcement of drug were surveyed by the National Center for State Courts in 2006, and courts is provided under the U.S. Department of Justice Drug Courts their major concerns were: ● High rates of recidivism. Program Offi ce. As an example, the Treatment Accountability and Safer ● Ineffectiveness of traditional probation supervision in reducing Communities (TASC) program provided an alternative to incarceration recidivism. by addressing the multiple needs of drug-addicted offenders in a ● Absence of effective community corrections programs. community-based setting. TASC programs typically include counseling, ● Restrictions on the judicial discretion that limit the ability of medical care, parenting instruction, family counseling, academic and job judges to sentence more fairly and effectively. training, and legal and employment services. Studies on recidivism rates show that jail or prison is ineffective as a The key features of TASC include: ● Coordination of criminal justice and drug treatment. deterrent for many crimes, and without treatment for the underlying causes ● Early identifi cation, assessment and referral of drug-involved of criminal behavior, recidivism rates are off the charts (Hora, 2009). offenders. She continues, “Seventy percent of drug offenders are rearrested ● Monitoring of offenders through drug testing. within three years of release from custody. One out of every 31 adults ● Use of legal sanctions as inducements to remain in treatment. is under supervision by probation or parole in the United States, and Peggy Fulton Hora is a retired judge who served 21 years in the caseloads exceed every standard that mass supervision is no longer an California Superior Court. She says that drug courts are effective in effective strategy.” dealing with chemical dependency, but incarceration and probation are Evidence-based practices rely on scientifi cally proven risk assessment often not a deterrence to addiction. Hora claims the one-size-fi ts-all tools, so intervention is designed for the individual’s needs and reviews approach of mandatory sentencing is not appropriate, but the fl exibility multiple factors, not just arrest history. Risk assessment instruments of a drug court assesses whether a defendant would benefi t more from measure the likelihood that the defendant will re-offend so that resources treatment and rehabilitation drug courts (Hora, 2009). The fact that can go to the highest-risk offender, and low-risk offenders can be most drug treatment courts are in urban areas has recently been credited managed with fi nes, volunteer work and other low-levels sanctions. with sharply reducing the number of African-Americans who are Substance abusers in the drug court system stay in the program incarcerated. If this trend continues, the large numbers of Americans through completion. This is in sharp contrast to the 80 percent to 90 who are currently disenfranchised in the system they see as racist may percent of conventional drug treatment clients who drop out before 12 be reduced. This will increase trust and confi dence in the judiciary, and months, the period found to be the minimum effective duration. By this situation alone could justify the expansion of such courts. providing a structure that links supervision and treatment, drug courts According to the National Association of Drug Court Professionals exert legal pressure on defendants to enter and remain in treatment (NADCP, 2009): long enough to realize benefi ts. More than two-thirds of participants ● At $250 million, up from $15.2 million in 2008 and an average who begin treatment through a drug court complete the program in a of $40 million since the fi rst federal funding, annual federal year or more, a six-fold increase in retention compared with programs investments would reap staggering savings, with an estimated outside the justice system (Gonzales et al., 2006). annual return of $840 million in net benefi ts from avoided criminal justice and victimization costs alone.
The STOP drug court treatment program
STOP stands for Sanction Treatment Opportunity Progress. Individuals and frequent court appearances in which the drug court judge monitors have the choice of participating in intensive substance abuse treatment compliance. The following clinical services are provided:
SocialWork.EliteCME.com Page 112 ● Assessment and evaluation – Professional evaluation of treatment ● Case management and referrals – Resources are available for needs are provided for alcohol and drug dependence/abuse, and housing, employment and other services that removed barriers to mental health issues. treatment. ● Individual and group counseling – Groups include educational ● Random urinalysis. and process groups in a supportive environment. Funding sources for the STOP program includes the U.S. Bureau ● Naturopathic health evaluation and care – Clients have access of Justice Administration and state criminal justice funds as well as to a team of health care providers who use treatment modes to county-level funds. maintain good health and treat illness. ● Medication management – Psychiatric mental health nurse Outcomes for the fi scal year 2009-2010 STOP program served: practitioners provide evaluation and management of medications ● 995 children. for mental health treatment. ● 534 adults. The program has served more than 8,000 children throughout the U.S. since it began in 2001 (STOP, 2012).
Moral Reconation Therapy in drug courts
Originally developed in the early 1900s by Dr. Gregory Little and Dr. begins with sessions to improve self-esteem by promoting a positive Kenneth Robinson, the program was initially designed to reform and self-image. Participants learn that recovery is an ongoing process of assist prison inmates in developing higher levels of moral reasoning decision -making to develop morality and purposeful behavior. and productive behavior. Many drug courts adopted Moral Reconation Group sessions run approximately 1.5 hours at each step, and Therapy (MRT) in the early 1990s. Today MRT is one of the most participants present their MRT homework assigned in each step. The widely used cognitive behavioral treatment programs with over 100 groups are typically held once a week, and the number of participants drug courts adapting MRT as their primary treatment. in each group varies from four to 15. An MRT-trained facilitator, Many evidenced-based studies have been published over the past usually a drug counselor or probation offi cer, conducts each group 20 years demonstrating positive outcomes with more than 100,000 meeting according to guidelines outlined in the training. individuals completing MRT programs. Rates of effectiveness with Many MRT drug courts studies have reported a 90 percent or higher male and female MRT participants showed similar positive outcomes completion rate, which usually requires six to nine months. MRT in diverse populations in a variety of settings. These included addresses other types of programs, using the cognitive behavioral correctional facilities, probation and parole programs, community- approach, to provide ancillary services, based on the individual’s based correction programs, and drug court programs for juveniles and needs, including: adults. MRT has been implemented successfully in outpatient and ● Relapse prevention. inpatient drug treatment programs. In addition to lower recidivism, ● Character development. improvements in personality variables and enhanced treatment ● Anger management. compliance were noted. ● Family support. MRT is a SAMHSA- and NREPP-registered program. In drug courts, ● Job readiness. MRT is either incorporated into the drug treatment provided or by ● Co-dependency. the probation staff. Participants meet in a group setting and work ● Responsible living. through a 12- to16-step program to help them make the conscious (SAMHSA, 2012) decisions needed to reach higher levels of moral reasoning. This often
Withdrawal therapy
The goal of withdrawal therapy (detoxifi cation) is to end the use of into a formal processes of assessment and referral for drug addiction addicting drugs as quickly and safely as possible. For some people, and mental health treatment (NIDA, 2011). it may be safe to undergo withdrawal therapy on an outpatient basis Withdrawal symptoms but others may require admission to a hospital or residential treatment ● Depressants including barbiturates, benzodiazepines and center. Withdrawal from different categories of drugs produces others: different side effects and requires different approaches. Minor side effects of withdrawal may include restlessness, anxiety, Medical detoxifi cation is a process in which individuals are sleep problems and sweating. More serious signs and symptoms systematically withdrawn from addicting drugs in an inpatient or could include hallucinations, whole-body tremors, seizures outpatient setting under the care of a physician. Detoxifi cation and increased blood pressure, heart rate and body temperature. is considered a prerequisite or the fi rst step of treatment. The Withdrawal therapy may involve gradually tapering the amount of detoxifi cation process must be carefully implemented to treat the acute the drug or adding another medication to help stabilize the nerve physiological effects that occur in the withdrawal process. cells during detoxifi cation. Medications are available for detoxifi cation from opiates, nicotine, ● Stimulants including amphetamines, methamphetamines, benzodiazepine, alcohol, barbiturates and other sedatives. In some cocaine, Ritalin and others: cases, particularly for the last three types of drugs, detoxifi cation may Side effects of withdrawal include depression, fatigue, anxiety be a medical necessity, and untreated withdrawal may be dangerous or and intense cravings. In some cases, signs and symptoms may even fatal. include suicidal thoughts and suicide attempts, paranoia, and decreased contact with reality, even acute psychosis. Treatment Detoxifi cation is not designed to address the underlying psychological, during withdrawal is usually limited to emotional support from the social, behavioral or possible co-occurring mental health problems family, friends, doctors and therapists. The doctor may recommend associated with addiction. Successful detoxifi cation does not produce medications to treat paranoid psychosis or depression. the lasting behavioral changes necessary to maintain abstinence. ● Opioids including heroin, morphine, codeine, OxyContin and Detoxifi cation is most effective when it is followed by immediate entry others:
Page 113 SocialWork.EliteCME.com Withdrawal effects of opioids can range from relatively minor or family sessions. Relapse programs are available in a variety of to severe. Minor effects may include a runny nose, sweating, settings, from outpatient to residential and inpatient programs. yawning, anxiety, and drug cravings. Severe reactions can include Relapse sessions help patients to resist the temptation to resume using insomnia, depression, dilated pupils, rapid pulse, rapid breathing, addicting drugs, develop ways to cope with drug cravings, suggest high blood pressure, abdominal cramps, tremors, bone and muscle strategies to avoid drug relapse, and offer suggestions on how to deal pain, vomiting and diarrhea. Doctors may substitute an artifi cial with the relapse if it occurs. Counseling can also involve talking about opiate, such as methadone, buprenorphine, subutex or LAAM, to the patient’s job, legal problems and relationships with family and reduce the craving for heroin during recovery (NIDA Research friends. Counseling with the patient, family members and friends can Report Series, 2011). help them develop better communication skills and be more supportive All treatment programs generally include sessions focused on of each other. preventing relapse. These may be accomplished in individual, group
Methadone warnings
Jonel Aleccia reports that methadone can be deadly and has resulted Getting the drugs is no problem and children as young as 12 years old in more fatalities than heroin in recent years in Spokane, Wash. The have been admitted to Varner’s program. This can happen as a result long half-life of the substance, how long it remains in the human body, of doctor shopping where doctors unknowing prescribe to a person has led abusers, who do not understand how methadone works, to who is working the system, or sometimes intentionally overprescribe unintentionally overdose. Aleccia writes that the low street price and for their own profi t. “The biggest problem in this community is availability of prescription methadone places the drug abuse out of the diversion,” said Aiken. “It’s not being used by the person it’s medical supervision where it was never supposed to be used (Espejo, prescribed for, and it’s not being used by people who fi t any expected 2011, p.132). profi le for drug abuse,” she added. Users span occupations and Of the 112 people who died from accidental or unintentional geography, often showing up in rural areas rather than urban centers. overdoses in Spokane in 2006, 51 percent were due to methadone Utah, for instant, is showing a growing prescription overdose problem, either alone or in combination with other drugs. In contrast, Aiken noted. “The people that are dying from methadone are not hard- records show the cocaine and methamphetamine killed 36 people core drug users,” she said. “In our society, people think prescription and heroin killed only one. Actual incidents may not be quite as medicines are all okay” (Nelson, 2011, p.133). precise as they appear because of the way drugs and deaths are While all prescription drugs should be taken as directed, methadone is logged, said Dr. Sally Aiken, the medical examiner. But there’s no especially dangerous. Unlike some opiates, it takes longer to have an doubt that deaths from prescription medication overdoses are far effect, and it accumulates in the system with a longer half-life. People outpacing deaths from illegal drugs. “It’s not declining,” Aiken hoping to relieve pain or achieve a high may take more and more of said. Although the average age of victims was 41, the drugs did the drug because they don’t see an immediate reaction. By the time the not discriminate. Victims included boys as young as 16, women methadone takes full effect, the individual may have already taken a and men as old as 70, and people of all ages in between, including lethal dose. many who simply didn’t realize that a substance that came from a medicine cabinet could be so dangerous. “It’s one of those Death from methadone occurs when the drug slows respiration, medications where the difference between what works and what overriding the body’s instinct to breathe. The frequent overdose kills you isn’t that different,” Aikens said. “Just taking a little too deaths point to the fact that abusers do not recognize the potency of much in signifi cant”(Espejo, 2011, p.132). methadone or understand the action of the drug. Five milligrams, one teaspoon, is enough to kill a baby, and 40 milligrams is enough to kill “We have seen a huge shift in prescription drug use in the past two an adult who is just beginning to take opiate drugs. years,” said Traci Varner, whose agency provides inpatient and outpatient services to 1,100 young people annually. Varner explains, The dangers are not confi ned to patient misuse, but sometimes result “There is a huge market for opiates in Spokane, and unlike illicit from inappropriate prescribing from a physician. “From to time, there drugs, methadone and other opiates are easily accessible and fairly is a report in the medical press of doctors who lose their license for inexpensive at $60-$70 for an 80 mg pill.” She continues, “They can negligently believing the lies their parents tell them about the amount chop up that bad boy and that will get them high for days” (Espejo, of methadone they take, amounts that promptly kill their patients” 2011, p.133). (Dalyrymple, 2003).
The addiction vaccine
Vaccines that would strengthen the immune system against addictive abused drug and prevent it from crossing from the bloodstream into drugs and prevent them from making the abuser high are potentially the brain (Interlandi, 2008). The booster shot creates antibodies that the best weapons against addiction. A cocaine vaccine is in the fi rst block the drug from entering the brain and other organs. This prevents large clinical trial, which began in 2008, and vaccines against nicotine, the psychological effects such as euphoria, which can suppress the heroin, methamphetamines, and other opiates and stimulants are also impulsive cravings that in turn may motivate addicts to abandon their in development. abuse of the drug. In theory, these addiction vaccines work the same as traditional Researchers still face the challenge to produce a stronger antibody vaccines used to treat infectious diseases like measles and meningitis. response, and complete recovery requires psychological treatment Instead of targeting bacteria and viruses, the vaccine target addictive and time. Bridgette Martel of Yale University School of Medicine and chemicals. Each of the proposed vaccines consists of drug molecules Thomas Kosten at the Baylor College of Medicine are planning new that have been attached to proteins from bacteria; these proteins trials of improved vaccines. These vaccines could reach the required, set off the immune reaction. Once a person has been vaccinated, sustained antibody levels and prove effective across wider populations the next time the drug is ingested, the antibodies will attach to the of addicts (Kosten & Martel, 2009).
SocialWork.EliteCME.com Page 114 MAINTENANCE AND SUPPORT
Overcoming prescription drug abuse can be challenging and stressful and church or religious organization support groups are available on and often requires the support of family, friends and organizations. The the Internet or in person. Some support groups do not use the 12-step following are resources for support: approach. Most support groups can be found in the phone book or ● Family members and friends that the patient can trust. though a local health organization or county health department. Often patients are embarrassed to ask for help or afraid that their ● Employee assistance programs in the workplace may offer family members will be angry or judgmental. They may worry that counseling services for substance abuse problems. their friends will distance themselves, but patients need to know ● Organizations or groups that promote substance-free healthy that in the long run, the people who truly care will respect their activities will help to prevent relapse. The patient may join a group honesty and decision to ask help. or organization that focuses on healthy recreational activities built ● Support groups. on special interests, community service, volunteer work, special Many support groups are available in the community. A 12-step talents, skills or hobbies. program, such as Narcotics Anonymous (NA), Ala-Teen and Al-anon,
Chronic pain treatment and addiction
Health care providers have struggled with how to effectively treat management, including factors that predispose some patients to patients who suffer from chronic pain, roughly 116 million in this addiction, and to develop measures to prevent abuse (NIDA Research country (NIDA, 2011). The problem is the potential risk involved with Report Series, 2011). long-term treatment using opioid medications. These risks include drug William L White and Thomas McClellan propose that drug addiction has tolerance, which leads to the need for escalating doses, and hyperalgesia, the features of a chronic disease. White and McClellan (Espejo, 2011, which is increased pain sensitivity. Over time the use of opioids become pp.82, 85) note there are striking similarities between substance abuse ineffective and pain sensitivity increases. The cycle continues with and dependence as seen in other chronic illness such as type II diabetes, increasing dosages leading to further dependence or addiction with hypertension and asthma. White and McClellan note that severe substance hyperalgesia increasing in response to the higher dosage. addiction and chronic illnesses share the following characteristics: Some patients may be concerned about taking prescribed opioid ● They are infl uenced by genetic factors and other personal, family medication because they fear becoming addicted. If they try to take less and environmental risk factors. medication than prescribed to avoid addiction, their pain will not be ● Both can be identifi ed and diagnosed using medical testing, well managed. The estimates of addiction among patients taking medication validated screening questionnaires and diagnostic checklists. for chronic pain vary from 3 percent to 40 percent. This variability is ● They are infl uenced by behaviors that begin as voluntary choices a result of differences in treatment duration, insuffi cient research on but evolve into deeply ingrained patterns of behavior that in cases long-term outcomes, and the lack of guidelines and standards to assess, of addiction are further compounded by neurobiological changes measure and record data from diverse populations of abusers. in the brain that weaken control over drug abuse behaviors. ● The pattern of onset may be sudden or gradual for chronic disease To minimize addiction risk, physicians should screen patients for and drug abuse. potential risk factors, including personal and family history of drug ● Both have a prolonged course of the illness that varies from person abuse or illness. Monitoring patients for signs of drug abuse during to person in intensity and pattern. treatment is important in preventing addiction, and yet, some symptoms ● Both are accompanied by risk of profound pathophysiology, can be similar to a variety of medical and psychological conditions. disability and premature death. Complex cases of AOD abuse, dual or multiple disorders, make ● Both have effective treatment, peer support frameworks and diagnosis and assessment of the effects of pain medication diffi cult to similar remission rates, but no known cure. monitor and evaluate. A history of numerous requests for prescription ● Core strategies for achieving long-term recovery from chronic pain medication refi lls from multiple doctors and pharmacies could disorders include: indicate illness progression, the development of drug tolerance or the ○ Stabilization of active episodes. beginning of drug dependence or addiction (NIDA, 2011). ○ Global assessment. The development of effective, non-addicting pain medication is a ○ Enhancement of global health. public health priority (ONDCP, 2011). A growing elderly population ○ Sustained professional monitoring. and an increasing number of injured military personnel only add ○ Early intervention. to the urgency of this issue. Researchers are exploring alternative ○ Continuity of contact in a primary recovery support relationship. medications that can alleviate pain but have less potential for ○ Development of a peer based support network. abuse. More research is needed to understand effective chronic pain PREVENTION
The risks for addiction to prescription drugs increases when the drugs important roles in identifying and preventing prescription drug abuse are used in ways other than prescribed. Health care providers, primary (NIDA, 2011). care physicians and pharmacists as well as patients themselves play
Physicians
More than 80 percent of Americans had contact with a health care taking, physicians can help their patients recognize that a problem professional in the past year, placing doctors in a unique position. exists, set recovery goals and seek appropriate treatment. Physicians not only prescribe medications, but also must include A screening for prescription drug abuse can be incorporated into careful assessments to identify abuse and prevent the escalation to routine medical visits, and doctors should take note of rapid increases addiction. By asking about all drugs and the dosages the patient is in the amount of medication needed. More frequent, unscheduled refi ll
Page 115 SocialWork.EliteCME.com requests should alert doctors to the fact that abusers of prescription drugs Preventing or stopping prescription drug abuse is an important part may engage in “doctor shopping,” moving from provider to provider in of patient care. However, health care providers should not avoid an effort to obtain multiple prescriptions for the drugs they abuse. prescribing stimulants, CNS depressants or opioid pain relievers if needed. Doctors and other prescribers need to secure prescription pads against theft or fraudulent use.
Patients
Patients can take steps to ensure that they use prescription medications ● Check-in with the doctor frequently. Patients should talk with their properly, always following the prescribed directions, be aware of doctor on a regular basis to make sure that the medications they are potential interactions with other drugs, understand side effects, never taking are working effectively and they are taking the right dose. stop or change the dosing regimen without discussing it with a health ● Follow directions for use carefully. A patient should not increase the care provider, and never use another person’s prescription. In addition dose of the medication on his or her own if it does not seem to be to describing their medical problem, patients should always inform their working. For example, if the patient is taking a pain medication that health care professionals about all the prescriptions, over-the-counter isn’t adequately controlling the pain, they should not take more. medications and dietary and herbal supplements they are taking. ● Know what the medication is treating and how it is supposed to work. Patients should ask the doctor or pharmacist about the Prescription drug abuse is rare in people who need pain killers, effects of the medications they are taking so they know what to sedatives or stimulants to treat a medical condition. However, if expect and can identify any harmful side effects. Patients who are patients are taking a commonly abused drug, there are a few things aware of the action of the drug they are taking will be able to help they can do to decrease their risk of prescription drug abuse: ● Make sure they are getting the right medications prescribed at the the provider identify any drug dependence issues early on. ● Never use another person’s prescription. Every patient is different, proper dosages. ● When they see their doctor, they should make sure the doctor and even if the other person has a similar medical condition, it may clearly understands their condition and the signs and symptoms not be the right medication or dosage for anyone else. ● Unused or expired medications should be properly discarded it is causing so they can be distinguished from a developing drug according to U.S. Food and Drug Administration (FDA) guidelines tolerance or dependence. ● They should ask the doctor whether there is an extended release or through the U.S Drug Enforcement Administration (DEA). ● All medications in the home should be secured so that no one but version of a medication or an alternative medication with the patient has access to them. ingredients that have less potential for addiction.
Pharmacist
Pharmacists not only dispense medications but also help patients Prescription drug monitoring programs (PDMPs), which require understand instructions for taking them. By being vigilant for physicians and pharmacists to log each fi lled subscription into a state prescription falsifi cations or alterations, a pharmacist can serve as database, can help medical professionals identify patients who are the fi rst line of defense in recognizing prescription drug abuse. Some getting prescriptions from multiple sources. As of May 2011, 48 states pharmacists have developed hotlines to alert other pharmacists in the and one territory had enacted legislation authorizing PDMPs , 34 of region when a fraudulent prescription is detected. which were operational (NIDA, 2011).
Parents
The new PATS data, discussed previously, indicated students’ growing “We are very troubled by this upswing that has implications not just acceptance of drug use in common social situations, and should for parents, who are the main focus of the partnership’s effort, but the “put all parents on notice that they must pay closer attention to their country as a whole,” said partnership Chairman Patricia Russo. She children’s behavior, especially their social interactions, and parents continued, “The United States simply can’t afford to let millions of must take action just as soon as they think their children may be using kids struggle through their academic and professional lives hindered drugs or drinking,” said Steve Pasierb, president and CEO of the by drug abuse. Parents and caregivers need to play a more active role Partnership For a Drug Free America. in protecting their families, trust their instincts, and take immediate action as soon as they sense a problem” (PATS, 2010). Dennis White, president and CEO of MetLife foundation, added: “The earlier parents take steps to address the child’s drug use, the greater the Discovering that their teen child is using drugs is often a frightening chance of effectively preventing a serious problem. We need to be sure experience for parents. Many feel alone, ashamed, guilty and confused parents know it’s time to act, and how to act when confronted with a about what to do next. The partnership encourages parents of children substance abuse situation” (PATS, 2010). using drugs to take action as soon as they suspect or know their child is abusing drugs. The partnership provides parents with free, Among parents surveyed for the PATS study: ● Twenty percent said their children aged 10 to 19 have already used anonymous access to the most current, research-based information on drugs beyond an experimental level. how to help their children and family take the next steps. ● Among parents of teens 14 to 19, the percentage jumped to 31 Developed in collaboration with scientists from the Treatment percent, nearly one-third of parents surveyed in the study. Research Institute, “A Time To Act” offers step-by-step advice and ● Among those parents of teens who were interviewed, nearly half, sympathetic guidance from substance abuse experts, family therapists, 47 percent, either waited to take action or took no action at all. scientists and fellow parents to help guide families through the process ● Studies show that those children are at greater risk of continued of understanding drug and alcohol use, confronting a child, setting use and negative and sometimes fatal consequences. boundaries and seeking outside help (PATS, 2010). ● Research has shown that students in grades 7 to 12 who learn a lot Parents are encouraged to have frequent ongoing conversations with about the dangers of drugs from their parents are up to 50 percent their children about the dangers of drugs and alcohol and take early less likely to use drugs. action if they think their child is using or might have a problem.
SocialWork.EliteCME.com Page 116 Parents can visit the drugfree.org website to learn strategies to talk ● Let teens know that they need to take the prescribed dose of with their children about drugs and alcohol and take charge of the medication and talk to the doctor before making changes. conversation. Parents can follow these steps to help prevent their teens ● Keep all prescription drugs safe. Keep track of quantities, and keep from abusing prescription medication: them in a locked medicine cabinet. ● Discuss the dangers with the teen. Emphasize that just because ● Properly dispose of medications. Flush opioid painkillers down drugs are prescribed by a doctor does not make them safe, the toilet. It is unsafe to fl ush other a types of medications. Instead, especially if they were prescribed for someone else or if the child take them out of their original containers and mix them with coffee is already taking other prescription medication. grounds, used kitty litter or another undesirable substance, then ● Set rules about the child’s prescription medication. Let the child place them in the trash. Before throwing away medicine bottles, know that it is not okay to share his or her medications with others remove the label or mark out any information such as your name, or to take medications prescribed for others. patient ID or prescription drug name or number (NSDUH, 2009).
Relapse prevention
Cognitive behavioral therapy originated as a method to bring about ● Building a positive self-image, setting attainable goals, and a belief a change in thought patterns that would inform positive behavior and commitment to abstinence. change. The method was applied to a number of behavioral disorders ● Self-monitoring to anticipate and recognize drug cravings and and found to be successful in for the treatment of drug addiction. identify and avoid high-risk situations they may encounter in a Thought processes based on fallacy, unrealistic expectations and lack of variety of settings. decision-making skills lead to the development of damaging behavioral ● Developing strategies for coping with the thoughts and feelings patterns. Through cognitive behavioral therapy, the individual learns to that accompany drug cravings. If they can anticipate the problem, realistically view behavior, and resulting consequences, to identify and patients are prepared with strategies and behavior patterns to avoid change problematic thoughts and behaviors. Many relapse prevention or cope with their urge to relapse. programs use some form of cognitive-behavioral strategies that will help Research indicates that the skills individuals learned through relapse the individual form a realistic, rational view of their drug abuse as they prevention therapy remain after the completion of treatment. In one set goals to reach abstinence and avoid relapse. study, most people receiving this cognitive behavioral approach The relapse prevention includes strategies to build self-control. These maintain the gains they made throughout the year following treatment techniques include: (U.S. Health and Human Services, 2010). ● Exploring the thought and behavior patterns, cause and effect, and positive and negative consequences of their drug abuse. FLORIDA’S BATTLE AGAINST PRESCRIPTION DRUGS
In 2000, In Florida, prescription drug abuse, oxycodone in particular, Law-enforcement agencies are also keeping close surveillance on was primarily concentrated around West Palm Beach, according to pharmacies. The number of applications to open new pharmacies DEA data. However, by 2010, the oxycodone abuse was increasing in in Florida has nearly doubled in the past two years, the result of almost every county in the state. On March 14, 2012, it was reported doctors facing tough laws banning distribution. Requests to open new that seven people die each day in Florida from prescription drug pharmacies in Florida now make up half of all the requests in the entire overdose. In one small rural county in central Florida there is one nation, according to the latest DEA data. death a week attributed to prescription drug abuse. Background checks are required for pharmacy owners and employees. Florida is recognized as the nation’s center for the illegal sales and If violations occur, the pharmacists, doctors or clinic owners face distribution of prescription drugs. Doctors in Florida purchased 89 percent severe penalties if they prescribe or distribute narcotics without medical of all the oxycodone sold to practitioners nationwide in 2010. During documentation of need or without following the required protocol. 2010, Florida was known as the place for criminals to come and get their One indication that Florida law enforcement offi cials are cutting off pills. Ninety percent of the nation’s top 100 oxycodone-purchasing doctors the supply of prescription drugs sold illegally in Florida is that the and 53 of the nation’s top 100 oxycodone purchasing pharmacies were price of oxycodone on the streets there has nearly doubled from last located in Florida. According to the FDLE, in 2011 at its peak, out-of-state year, from $8 dollars a pill to$15 dollars, according to Capt. Eric buyers entered Florida to buy drugs from 1,000 pain clinics that earned the Coleman, commander of the narcotics division of the Palm Beach state the nickname the nickname “Oxy Express.” County Sheriff’s Offi ce. On Commercial Boulevard, a major street With the recent passage of tougher laws, offi cials moved aggressively in Broward County, the number of pain clinics has dropped in the in 2011 to shut down “pill mills” and distribution routes that supply past year from 29 to one. Senior probation and corrections offi cers in drugs to the north. In the past year, more than 400 clinics were either Volusia County, Florida, have reported the same reductions in pain shut down or closed their doors. Prosecutors have indicted dozens clinics, and note that pills can run from $15-$20 on the street. of pill mill clinics, and 80 doctors have had their licenses suspended The penalties for possession of illegally obtained narcotics also are for prescribing large quantities of pills without legitimate, medical tough, and one illegal pill can result in a felony charge. documentation of illness. Treatment centers are also seeing more addicts seeking help. “We have New laws targeted illegal distribution, and in July 2011, Florida patients walking in the door who could not afford prescription drugs doctors were banned from distributing narcotics and addictive anymore,” said Dr. Barbara Krantz, the chief executive and medical medicines from their offi ces or clinics. This resulted in diminished director of Hanley Center, a large treatment clinic in Palm Beach doctor’s purchases of oxycodone from 32.2 million doses in the fi rst County (FDLE, 2011). six months of 2010 to a 97 percent decrease in the same period in 2011. The law contained a strict limit on the number of pills a doctor Federal, state and local enforcement offi cials have worked closely could dispense. “We had no tough laws in place; now we do,” said to increase the number of arrests and major indictments. They Pam Bondi, Florida’s attorney general (FDLE, 2012). are dealing with pill mill operators as they would large criminal enterprises. Federal prosecutors recently used racketeering laws to
Page 117 SocialWork.EliteCME.com indict 32 people, including 20 brothers who prosecutors say operated have made tremendous strides, were just getting started. Prescription drug a widespread prescription drug operation. The brothers, who owned traffi cking remains a signifi cant concern for Florida law enforcement.” four pain clinics, were also charged with kidnapping, extortion and The statewide strike force, under the coordination of FDLE, works assault with a fi rearm under the indictment. Most of the prescriptions with seven regional teams, each led by a police chief and sheriff. were written for patients who travel to Florida from out-of-state, with “Law-enforcement has teamed with city and county government, state Kentucky making up the largest share. regulatory agencies and federal representatives to use all the tools in In one case, a Florida doctor working for several pain clinics was our toolbox to fi ght this battle,” said Winter Park Police Chief Brett charged with murder by Palm Beach County prosecutors after a patient Railey. He continued, “Investigating doctors, pill mills and drug died of an overdose in 2009, a few hours after the doctor prescribed traffi cking organizations can often be long and costly. One important 210 pain pills to him. One of owners of the clinics pleaded guilty to tool has been the availability of strike force funding. Many of the cases second-degree murder. Prosecutors say the clinics were responsible for would go unaddressed without these funds.” 56 overdose deaths. The clinics were shut down in 2010, but more than The next step to curb Florida’s illegal prescription drug traffi cking and a year passed before the case was built, in part because oxycodone is a abuse problems involved the drug court process. The Florida Supreme legal drug, and the new laws were not in place. Court Task Force on Treatment-Based Drug Courts, following the lead In another case in 2011, a south Florida pill mill operator pleaded guilty of the National Center for State Courts (NCSC) developed a proposal for in a Florida federal court to distributing 660,000 oxycodone and other a statewide evaluation of Florida’s drug courts. During the development prescription drugs from eight pain clinics during 2009-2010. He could of the proposal, the NCSC suggested that Florida consider adopting each receive up to 20 years in prison. In addition to his arrest and conviction, of the four National Research Advisory Committee’s (NRAC) core drug 20 other individuals were arrested, and 50 vehicles were seized along court performance measures. The four proposed indicators are: with cash and other assets as part of a month-long pill mill crackdown. 1. Recidivism. Offi cials in Florida acknowledge that the drug problem is still alarming, 2. Retention. with drug overdose rates still at an 8 percent increase from 2009. This is 3. Sobriety. far more than the number who died from illegal drugs. 4. Units of service. Illegal sales of prescription drugs, and oxycodone in particular, Implementing performance indicators will give drug courts the ability to increased in Florida because of the absence of a statewide prescription provide research-based indicators to supplement program evaluations. It drug monitoring system. That changed last October, when the state is critical for drug courts to use performance indicators to demonstrate started a prescription drug monitoring system (PDMP) that will give the effects of a drug court on the clients and the community it serves. pharmacies seven days to record the sale of controlled substances in The task force recognized the importance of Florida drug courts to not a database. Pharmacists will be able to pull up information on how only document performance indicators but also compile data that can be often a patient is prescribed and sold these drugs. The tracking system compared statewide. The Florida Supreme Court Task Force recommended will help prevent pharmacy shopping for drugs. A majority of states that all drug courts in Florida implement, at a minimum, these indicators: already use a monitoring system, which government offi cials say has 1. Recidivism. been crucial to shutting down the oxycodone distribution in Kentucky, The performance indicators should be based on 6-month cohorts, which had one of the highest abuse rates in 2010. that is, everyone exiting from drug court during a specifi ed six-month time period. Recidivism is defi ned as any felony or In Florida, efforts to establish the database were slowed by legal misdemeanor drug or DUI re-arrest resulting in a charge for drug challenges and lobbying over privacy rights. Though federal and state court participants during involvement in the drug court program funds are available to fund the database, the state did not fi nance do and upon exiting from the program for the following time frames: so, leaving private donations to run the program. The fallout from ○ 0 to 12 months after program completion. the tougher laws may include an increase in pharmacy robberies, a ○ 1 to 2 years after program completion. problem that has been worse in Florida than any of the states since ○ 2-plus years after program completion. 2007; there were 65 armed robberies of pharmacies last year in 2011. 2. Retention. “We recognize what a horrible problem we have,” Bondi said. “We The performance indicators should be based on six-month have, of course, many legitimate, good pain-management doctors. We admission cohorts. Each admission will be tracked by type of exit are targeting the drug dealers wearing white coats” (FDLE, 2011). until the person has permanently exited the drug court, including Florida’s Drug Enforcement Strike Force teams have attacked and exits classifi ed as: slowed the out-of-control distribution and abuse of prescription drugs ○ Graduate. in the state. Created by the Florida legislature in March 2012, the ○ Terminations. teams already have had the following impact: ○ Transfers. ● Almost half a million pills have been taken off of Florida’s streets. ○ Voluntary withdrawals. ● They have also made 2,150 arrests, including 34 doctors, and ○ Deceased. seized 59 vehicles, 391 weapons and $4.7 million dollars. 3. Sobriety. ● In 2011, the number of purchasing doctors was reduced by 85 The performance indicator for sobriety should include both the percent, down to 13. percent of positive drug tests and the period of longest continuous ● The number of purchasing pharmacies has declined by 64 percent, sobriety for each participant while in the drug court. The down to just 19. performance indicators should be based on six-month exit cohorts. ● The number of pain clinics has declined from 800 to 508 clinics in Along with the test results that indicate use of illegal or forbidden the state. substance, the following test results will be considered positive: ● The 2011 Interim Drugs Identifi ed in Deceased Persons report ○ Did not show up for drug testing. shows the number of prescription deaths fell nearly 8 percent ○ Did not produce the sample in a reasonable period of time. compared to the same time period in 2010. ○ Tampered with the drug test. Bondi said: “We have made exceptional progress, and we will continue ○ Admitted the use of a forbidden or illegal substance. these efforts that save lives.” FDLE Commissioner Gerald Bailey pointed 4. Units of service. out, “In one year, we’ve gone from being known as the “Oxy Express” The performance indicators should be based on six-month exit to being a role model for other states dealing with this problem. While we cohorts. The dates that those participants received outpatient
SocialWork.EliteCME.com Page 118 or inpatient services should be recorded as well as the dates ○ Mental health. of referrals for ancillary services made by the drug court case ○ Employment services. manager. At the conclusion of the reporting period, the total ○ Educational services. number of units of service received by each participant who exited ○ Medical and dental services. during that period will be accumulated by category. Addiction- ○ Any health-related services. related services would list the number of days of inpatient services ○ Anger management. and a number of sessions for outpatient services. Ancillary ○ Case management. services will record the number of referrals. Ancillary services ○ Drug testing. will address the participant’s needs, and any that are associated ○ AA/NA. with an increased likelihood of reoffending should be targeted for ○ Transportation. intervention. Ancillary services include: ○ HIV counseling and testing. ○ Housing. ○ Day care. ○ Parenting.
The federal government drug policy
The progress that states are making in the fi ght against prescription awareness about the dangers of prescription drug abuse and ways to drug abuse is due in part to the federal policy enacted last year. dispense, store and dispose of controlled substance medications. Entitled “Epidemic: Responding to America’s Prescription Drug Monitoring refers to the use of programs that will help identify doctor Abuse Crisis,” it was distributed in 2011 as the federal government’s shoppers and detect duplications among medications and possible drug Prescription Drug Abuse Prevention plan. This plan expands upon the interactions. To cut down on the problem of diversion, the development administration’s National Drug Control Strategy and includes action of a consumer friendly and environmentally sound prescription drug plans in four major areas to reduce prescription drug abuse: disposal program will be implemented. Is important to limit the ● Education. diversion of drugs because most nonmedical use of prescription drugs ● Tracking and monitoring. occurs because users are getting the drugs from family and friends. ● Proper disposal. ● Enforcement. Finally, enforcement agencies must be given the support and the tools they need to expand their efforts to close down pill-mills and block In the federal prevention policy, education is listed as a critical doctor shoppers who contribute to prescription drug traffi cking. need for both the public and health care providers to increase their
Education
The program identifi es the crucial fi rst step in addressing the problem training, and the number of curricular hours in the required programs of prescription drug abuse is to raise awareness through the education vary from three to 12 hours (Isaacson et al., 2000). A 2008 follow-up of parents, youth, patients and health care providers. The study found survey found that some progress has been made to improve medical that many people are not aware that use or abuse of prescription school, residency and post-residency substance abuse education, but drugs can be as dangerous as the use of illegal drugs and can lead to these efforts have not been uniformly applied in all residency programs addiction and death. or medical schools (Polydorou et al., 2008). One common misperception among parents and youth is that Educating prescribers on substance abuse is critically important, because prescription drugs are less dangerous than illegal drugs because they even brief interventions by primary care providers have proven effective are FDA approved. Many parents do not understand the risks associated in reducing or eliminating substance abuse in people who abuse drugs with giving prescribed medication to a teenager or other family member but are not yet addicted to them. In addition, educating health care for whom the medication has not been prescribed. The study notes that providers about prescription drug abuse will promote awareness of this many parents have medicine cabinets full of leftover prescription drugs growing problem among prescribers so they will not overprescribed and are more concerned about securing alcohol from their teens. medication necessary to treat minor conditions. In turn, this will reduce Some misperceptions can be attributed to the increase in consumer the amount of unused medicines in cabinets in homes across the country. advertising, which may contribute to increased demand for medication. The following action will be taken to improve educational efforts and These mass media representations of prescription drugs make effective to increase research and development: educational programs even more vital, according to the federal studies. ● Health care provider education: ○ Work with Congress to amend federal laws to require practitioners Prescribers and dispensers, including physicians, physician assistants, who request DEA registration to prescribe controlled substances nurse practitioners, pharmacists, nurses, psychologists, psychiatrists to be trained on responsible opioid prescribing practices as a and dentists, have a major role in reducing drug abuse. The federal precondition of registration. This training would include assessing plan notes that these professionals receive little training on the and addressing signs of abuse or dependence. importance of appropriate prescribing and dispensing of opioids to ○ Require drug manufacturers, through the opioid risk evaluation prevent adverse effects, diversion and addiction. Other than specialty and mitigation strategy (REMS), to develop effective addiction treatment programs, most health care providers receive educational materials and initiatives to train practitioners on minimal training on how to recognize abuse in their patients. the appropriate use of opioid pain relievers. The ONDCP studies found that most medical, dental, pharmacy and other ○ Federal agencies that support their own health care systems health professional schools did not provide in-depth training on substance will increase continuing education for their practitioners and abuse, and often this training is limited to classroom or clinical electives. other health care providers on proper prescribing and disposal The federal policy also notes that students in the medical and dental of prescription drugs. schools may only receive limited training on treating pain. ○ Work with appropriate medical and health care boards to A national survey on medical residency programs in 2000 found that of encourage them to require educational curricula in health the programs studied, only 56 percent required substance use disorder professional schools – medical, nursing, pharmacy and dental
Page 119 SocialWork.EliteCME.com – and continuing education programs to include instruction medical boards to promote and disseminate public education on the safe and appropriate use of opioids to treat pain while materials and to increase awareness of prescription drug minimizing the risk of addiction and substance abuse. Work misuse and abuse. with relevant medical, nursing, dental and pharmacy student ○ Require manufacturers, through the opioid risk evaluation and groups to help disseminate educational materials and establish mitigation strategy (REMS), to develop effective educational student programs that can give community educational materials for patients on the appropriate use and disposal of presentations on prescription drug abuse and substance abuse. opioid pain relievers. ○ In consultation with medical specialty organizations, develop ○ Work with private sector groups to develop an evidenced-based methods of assessing the effectiveness and adequacy of pain campaign on prescription drugs targeted to parents in an effort treatment in patient populations to better inform them on to educate them about the risks associated with prescription drug appropriate use of opioid pain medication. abuse and the importance of secure storage and proper disposal. ○ Work with the American College of Emergency Physicians to ● Research and development: develop evidence-based clinical guidelines and establish best ○ Expedite research, through grants, partnerships with academic practices for opioid prescribing in the emergency department. institutions and the New Drug Application Review by FDA on ○ Work with stakeholders to develop tools to facilitate the development of treatments for pain with no abuse potential appropriate opioid prescribing, including development of as well as the development of abuse deterrent formulations of patient-provider agreements and guidelines. opioid medication and other drugs with abuse potential. ● Parent, youth, and patient education: ○ Continue advancing the design and evaluation of ○ Support and promote an evidence-based public education epidemiological studies to address changing patterns of abuse. campaign on the appropriate use, secure storage and disposal ○ Provide guidance to the pharmaceutical industry on the of prescription drugs, especially controlled substances. Engage development of abuse deterrent drug formulations and on post- local anti-drug coalitions and other organizations such as chain market assessment of their performance. pharmacies, community pharmacies, boards of pharmacies and
Tracking and monitoring
Forty-three states have authorized prescription drug monitoring programs physician before reviewing the PDMP data. Thirty-nine percent received known as PDMPs. These programs aim to detect and prevent the more opioid medication than previously planned because the physician diversion and abuse of prescription drugs at the retail level and to allow was able to confi rm the patient did not have a recent history of opioid for the collection and analysis of prescription data more effi ciently than use (Baehren, et al., 2010). PDMPs were associated with lower rates of states without such a program. Only 35 states have operational PDMPs. increase in abuse or misuse over time (Reifl er et al., 2010). These programs are established by state legislation and are paid for by a Reducing prescription drug abuse requires a joint effort by federal, combination of federal and state funds. They track controlled substances state and local agencies. All involved need to be informed on the use prescribed by authorized practitioners and dispensed by pharmacies. of available data sets to identify areas to concentrate their efforts. For PDMPs should serve a multitude of functions, including: example, in Massachusetts, Brandeis University developed geospatial ● Assisting in patient care. mapping of PDMP data combined with data on prescription drug ● Providing early warning of drug abuse epidemics. overdose emergency room visits and prescription drug overdose ● Evaluating interventions. deaths. This data allowed them to identify high concentrations of ● Investigating drug diversion and insurance fraud. overdose hospitalizations and death rates in three suburban areas of the Note: PDMPs cannot be used as evidence in court. state. Agencies and providers could disseminate the data to increase their efforts to address the high rate of abuse in those areas. An analysis in 2006 found PDMPs were associated with lower rates of substance abuse treatment admissions (Simeon et al., 2006). Another A major effort must be undertaken to improve the functioning of study examined the effect of a trial of PDMPs use in emergency state PDMPs, real-time access by clinicians, and to increase interstate departments. It found that PDMP data changed clinical management in operability and communication. Stable fi nancial support must be 41 percent of the cases. Sixty-one percent of the patients received fewer identifi ed to maximize the use of PDMPs, which will help reduce or no opioid pain medication than had originally been planned by the prescription drug diversion and provide better health care delivery.
Proper medication disposal
SAMHSA’s 2009 National Survey on Drug Use and Health found that prescribing privileges by prescribing these medications outside more than 70 percent of people who used prescription pain relievers the usual course of professional practice or for illegitimate nonmedically got them from friends and relatives, while approximately purposes. This has resulted in practitioners’ illegally prescribing 5 percent got them from a drug dealer or from the Internet. The or dispensing prescription controlled substances under the guise of same survey showed the scale of the problem includes more than medical care. These providers not only endanger the individuals 7 million Americans reporting use of prescription medication for receiving medications but pose a serious threat to the communities nonmedical purposes in the past 30 days. A comprehensive plan to where they are located as well. The following actions will be taken address prescription drug use must include proper disposal of unused to assist states to address doctor shopping and pill mills: or expired medications. Individuals must be provided with secure and ○ Continue aggressive enforcement action against pain clinics convenient ways to dispose of medications to help prevent diversion of and prescribers outside the usual course of practice and not for drugs into the community or environment. Prescription drugs collected legitimate medical reasons. from individuals are to be disposed of in accordance with federal, state ○ Work with appropriate groups to write and disseminate a and local laws and regulations. model pain clinic regulation law, including: ● Enforcement: ■ Registration of these facilities with a state entity. Legitimate use of prescription opioid medications in health care ■ Guidance for rules regarding number of employees, settings includes a small group of practitioners who abuse their location and hours of operation.
SocialWork.EliteCME.com Page 120 ■ Penalties for operating, owning or managing a safe use and the proper storage and disposal of schedule II and nonregistered pain clinic. III opioids. Legislation to be passed within 24 months. ■ Requirements for counterfeit-resistant prescription pads. ○ FDA intends to issue guidance on developing abuse deterrent ■ Disciplinary procedures to enforce the regulations. drug formulations and post market assessment of their ■ A procedure must be developed to allow patient records to performance within 24 months. be reviewed during state inspections. ○ Have DOD, VA and IHS provide controlled substance ● Prescription drug abuse plan goals: prescription information electronically to PDMPs in states that National drug control strategy fi ve-year goal for prescription drug operate health care facilities and pharmacies within 24 months. abuse: ○ Increase by 25 percent the number of states reimbursing for ○ 15 percent reduction in nonmedical use of prescription-type screening, brief intervention and referral to treatment (SBIRT) psychotherapeutic drugs in the past year among people 12 within 24 months. years and older. ○ Increase by 25 percent the number of high intensity drug ● Prescription drug abuse prevention goals: traffi cking areas (HIDTA) involved in intelligence gathering ○ Have an approved and implemented risk evaluation and and investigation of prescription drug traffi cking and mitigation strategy for certain long-acting and extended release participation on statewide and regional prescription drug task opioids within 12 months. forces within 24 months. ○ Write and disseminate a model pain clinic regulation law ○ Have legislation in all 50 states establishing prescription drug within 12 months. monitoring programs (PDMPs) within 36 months. ○ Increase the number of collaborative practice agreements that ○ Expand by 10 percent, within 36 months, the available funding involve pharmacists’ prescribing privileges and monitoring of for treatment to increase access because only a small fraction pain medication within 18 months. of drug users currently undergo treatment. ○ Complete rule making and implementation for medication ○ Decrease by 15 percent the number of unintentional overdose disposal within 24 months. deaths related to opioid use. ○ Have legislation passed that requires prescribers applying for DEA registration to complete training on the appropriate and
Summary and call to action
Research and medicine have provided a vast array of medications No one agency, system or profession is solely responsible for this to cure disease, ease suffering and pain, improve the quality of life undertaking. The federal plan states that the all agencies must address and save lives. This is no more evident than in the fi eld of pain this issue as partners in public health and public safety. Therefore, management. However, as with many new scientifi c discoveries and ONDCP will convene a federal Council on Prescription Drug Abuse, new uses for existing compounds, the potential for diversion, abuse, comprised of federal agencies, to coordinate implementation of this morbidity and mortality are signifi cant. prescription drug abuse prevention plan and will engage private parties Prescription drug misuse and abuse is a major public health and safety as necessary to reach the goals established by the plan. crisis. The nation must take urgent action to ensure the appropriate Source: Offi ce of National Drug Control Policy, 2011 balance between the benefi ts these medications offer in improving lives and the risks they pose.
Resources and organizations
● American Council on Science and Health, (ACSH) ● National Council on Alcoholism and Drug Dependency (NCADD) www.acsh.org. www.ncadd.org. ● Drug Policy Alliance (DPA), www.drugpolicy.org. ● National Institute on Drug Abuse (NIDA), http://nida.hih.org. ● Monitoring the Future, www.monitoringthefuture.org. ● Offi ce of National Drug Control Policy (ONDCP), ● Narcotics Anonymous (NA), www.na.org. www.whitehousedrugpolicy.gov. ● National Center on Addiction and Substance Abuse at Columbia ● The Partnership for a Drug Free America, www.drugfree.org. University (CASA), www.casacolumbia.org. ● Rational Recovery, https://rational.org. ● U.S. Drug Enforcement Agency (DEA), www.usdoj.gov/dea.
References
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SocialWork.EliteCME.com Page 122 PRESCRIPTION DRUG ABUSE: ETIOLOGY, PREVENTION AND TREATMENT Final Examination Questions Select the best answer for each question and then proceed to SocialWork.EliteCME.com to complete your fi nal examination.
31. The AC model of intervention has all of the elements below 37. Which of the following statements is NOT TRUE about EXCEPT: prescription opioids? a. Services are delivered as a predetermined program. a. When properly managed and taken as prescribed, use of opioid b. Aftercare is an extended, ongoing process. analgesics rarely cause addiction. c. Relapse or readmission for treatment was viewed as failure or b. Snorting or injecting opioids results in a rapid release of the compliance of the individual. drug, exposing the person to high doses and overdose reactions d. By the late 1990s, this treatment form was being questioned. including death. c. Opioids are used medically only to relieve mild or severe pain. 32. The defi nition for prescription drug abuse includes which of the d. Opioids act by attaching to specifi c opioid receptors in the following statements? brain, spinal cord and gastrointestinal tract. a. The use of medications without a prescription. b. The term is used interchangeably with nonmedical use. 38. The class of drugs that is used to treat attention defi cit c. Using a drug in a way other than prescribed. hyperactivity disorder and was originally prescribed for asthma d. All of the above. and obesity is represented by which of the following statements? a. They are prescribed for many conditions because they a less 33. NIDA studies concerning substance abuse among military veterans addictive than opioids. includes all of the following facts EXCEPT: b. They are treated pharmacologically with naltrexone. a. Rates of prescription drug abuse slowly increased among U.S. c. They are stimulants that can increase heart rate and blood military personnel from 2005 to 2009. pressure. b. Specialized drug courts for this population may give them d. None of the above. access to services and supports they have not otherwise receive. 39. Which statement is NOT TRUE about the development of the c. Drug and alcohol abuse frequently accompanies mental health addiction vaccine? problems and was involved in 30 percent of the Army’s suicide a. Vaccines could strengthen the immune system against deaths from 2003 to 2009. addictive drugs and prevent them from making the user high. d. Federal funding for initiatives to help troops and their families b. Anti-bodies in the vaccine will attach to the abused drug and with the problem is focused on substance abuse and related prevent it from the bloodstream into the brain. conditions experienced by veterans of the wars in Iraq and c. All individuals completing drug court will take the vaccine. Afghanistan. d. A vaccine to treat cocaine addiction is currently in a clinical trial. 34. The etiology of prescription drug abuse includes all of the following risk factors EXCEPT: 40. The 2011 federal Drug Abuse Prevention plan includes all of the a. Unknown genetic and metabolic factors. following goal statements EXCEPT: b. Easy assess to drugs such as working in a health care setting. a. Decrease by 15 percent the number of unintentional overdose c. Character and personality fl aws. deaths from opioids. d. Past or present addictions to other substance including alcohol. b. Expand funding for treatment by 10 percent to increase access for drug users. 35. Adolescent drug abusers have unique needs. All of the following c. Add stimulant and CNS depressants drug classes to the statements describe these unique needs EXCEPT: prevention plan. a. A developmental shift occurs from birth to early adulthood d. Have legislation in all 50 states to establish PDMPs within 36 where actions go from childlike to impulsive behaviors. months. b. The brain areas most closely associated with decision-making, judgment and self-control undergoes a period of rapid development in adolescence. c. Adolescent drug abusers have unique needs due to their immature neuro-cognitive and psychosocial stages of development. d. Adolescent drug use is often associated with co-occurring mental illness.
36. NIDA researchers advise that the most effective addiction treatments for adolescents contain which of the following components? a. Positive parent or family involvement. b. They recognize the importance of peer relationships. c. Comprehensive assessment, treatment, case management and family support. d. All of the above.
SWCA08PD14
Page 123 SocialWork.EliteCME.com CHAPTER 6: Understanding Adolescent Suicide for Mental Health Practitioners
5 CE Hours
By: Dixie L. Casford, MA, LMHC with Kathryn Brohl, MA, LMFT and Rene’ Ledford, MSW, LCSW, BCBA
Learning objectives
List current trends in teen suicide, including prevalence among Describe typical warning signs of suicidal ideation and suicidal diverse populations. behavior. Recognize the correlation between certain mental health diagnoses Identify the relationship between self-mutilating behaviors in and teen suicide. adolescents and adolescent suicide attempts. Identify conventional myths or other misinformation regarding Describe how adolescent suicide affects family and friends. teen suicide. List current suicide prevention and suicide treatment modalities. Be aware of recent research regarding the link between SSRIs and Identify the application of certain treatment modalities with increased suicidal behavior in adolescents. adolescent clients. List and explain action steps that can be taken to help prevent suicide. Introduction
Suicide remains the third-leading cause of death for adolescents, report also indicated that males ages 15-19 were about four times more following motor vehicle accidents and homicide. Despite a decline likely than females the same age to complete suicide. reported in the 1990s, The Science Daily reported in September 2007 Although the fi nancial impact of suicide is diffi cult to measure, the that the adolescent suicide rate for 10- to 14-year-olds increased by 8 National Strategy for Suicide Prevention cites a 1999 study by Miller, percent from 2003-2004, the largest increase in 15 years. et al., that estimated the total cost related to suicide in 1995 was $111.3 The Science Daily report also cited a Centers for Disease Control survey billion, including $3.7 billion in medical expenses, $27.4 billion in of youth in grades 9-12 in both public and private schools in the United work-related losses, and $80.2 billion in quality of life costs (United States that found that 17 percent surveyed reported seriously considering States Department of Health and Human Services). suicide, 13 percent had created a plan for committing suicide and 8 percent Adolescent suicide prevention is of utmost importance, and it begins had attempted a suicide in the 12 months prior to taking the survey. In with early detection. Front-line interventionists, such as primary care addition, the CDC also notes that each year, approximately 125,000 young physicians and mental health professionals who are aware of the people ages 10-24 within the United States are taken to emergency rooms warning signs and understand current screening practices, remain because of self-infl icted injuries from suicide attempts. powerful resources with regard to suicide prevention. Other important The American Association of Suicidology (AAS) reported that in 2005, prevention sources include parents, friends and extended family. the suicide rate for youth ages 10-24 was 10 suicides per 100,000 When more people know about suicide and its warning signs, society people, resulting in a total of 4,212 suicide deaths. AAS reported that benefi ts. Detecting possible problems and intervening early is crucial. one youth completes suicide every two hours and fi ve minutes, leading In addition, suicide does not know racial and ethnic boundaries. to 11.5 suicides each day, and it is estimated that for each completed Prevention must focus on all adolescents in all environments. No suicide by a youth, there are an estimated 100-200 attempts made. This group is immune from suicide. SUICIDE PREVALENCE IN YOUNG PEOPLE OF DIVERSE POPULATIONS
Suicide and ethnicity
According to the National Adolescent Health Information Center’s However, the 2006 fact sheet also shows that statistics related to (NAHIC) 2006 fact sheet: suicide attempts indicate that Hispanic females have the highest rate ● For males 10-24, American Indian/Alaskan native adolescents of suicide attempts among high school students at 14.9 percent. After have the highest suicide rate at 24.3 suicides per 100,000. this group, black females have the next highest rate of attempts at 9.8 ● For males 10-24, white/non-Hispanic, it is 12.7 per 100,000. percent, and then white females at 9.3 percent. ● For males 10-24, black/non-Hispanic, it is 8.6 per 100,000. The male high school student groups revealed male Hispanics with ● For males 10-24, Hispanic, it is 8.0 per 100,000. the highest attempt rate at 7.8 percent, and then black and white males ● For males 10-24, Asian/Pacifi c Islander, it is 6.2 per 100,000. were both at 5.2 percent. These statistics also highlight that females are The American Indian/Alaskan natives also had the highest rate among more likely to attempt suicide, but males are more likely to complete the female groups ages 10-24 at 6.7 per 100,000. After this group were: suicide. (There was no data for American Indian/Alaskan native or ● Asian/Pacifi c Islander females at 2.7 per 100,000. Asian/Pacifi c Islander in this grouping.) ● White females at 2.4 per 100,000. ● Hispanic females at 1.6 per 100,000. ● Black females at 1.5 per 100,000.
SocialWork.EliteCME.com Page 124 Suicide and divorce
Children of divorce represent another group that has been shown to A more recent study found that suicide victims were more likely to have a higher suicide rate. Several studies have found a higher ratio of come from a nonintact family than an intact family, and the rates did suicide among youth who have divorced parents than those from intact not differ signifi cantly between those who were living in two-parent families. One author states, “Death of a parent does not correlate with households (stepparent situations) after the divorce and those who teen suicide, but family instability or disruption is one of the leading remained in single-parent households (Gould, 1998). causes of suicide. Perceived rejection by a parent, not merely the loss of a parent, is apparently the relevant factor” (Nelson, 1988).
Suicide and gay, lesbian, bisexual, transgender youth
Another at-risk adolescent population is the gay, lesbian, bisexual, ● Fearing discrimination when joining clubs, sports, seeking transgender and questioning adolescents. A 1999 study found that admission to college or fi nding employment. 33 percent of gay, lesbian, and bisexual high school students in ● Being rejected and harassed by others (AACAP, 2006). Massachusetts reported attempting suicide in the previous year, However, the surgeon general’s offi ce states the following: compared to 8 percent of their heterosexual peers (Massachusetts “It has been widely reported that gay and lesbian youth are two to Department of Education, 1999). three times more likely to commit suicide than other youth, and A 1995 study found that gay, lesbian and bisexual youth account for that 30 percent of all attempted or completed youth suicides are 30 percent of all teen suicides (Marino, 1995). Added life stressors related to issues of sexual identity. There are no empirical data on could cause the higher rate of suicide. In addition to typical adolescent completed suicides to support such assertions, but there is growing problems, these teens are also: concern about an association between suicide risk and bisexuality ● Dealing with feeling very different from their peers. or homosexuality for youth, particularly males. Increased attention ● Feeling guilty about their sexual orientation. has been focused on the need for empirically based and culturally ● Worrying about the response from their families and loved ones. competent research on the topic of gay, lesbian and bisexual suicide.” ● Being teased and ridiculed by their peers. Although the reports are not conclusive, mental health professionals ● Worrying about AIDS, HIV infections and other sexually working with gay, lesbian, bisexual, transgender and questioning youth transmitted diseases. need to be aware that they may be facing unique challenges that could put them at higher risk for suicide.
Suicide and incarcerated youth
A study conducted in 2000 found that incarcerated youth are at youth have other mental illnesses that contribute to the suicide and that higher risk for suicide attempts (Hayes, 2000). Few studies have it is not an issue with the incarceration, but mental health professionals been conducted with this population, but Hayes found that suicide in working with incarcerated youth should at least be aware that there juvenile detention and correctional facilities was four times greater appears to be a higher suicide rate among those incarcerated. than youth suicide overall. Arguments could be made that incarcerated
Methods of suicide
Within all groups, fi rearms remain the most commonly used suicide has been the leading method of suicide completion in this age group method, accounting for 49 percent of completed suicides in 2006. since 1999. However, in 15- to 19-year-old youths, use of fi rearms has decreased It is also important to note that research has shown that most in the last decade while suicide by suffocation has increased. Suicide adolescent suicides occur after school in the teen’s home. by suffocation has also increased in youth ages 10-14, and suffocation
Common myths
People often don’t know the facts about suicide, leading to a disregard it in some way beforehand. Any mention of suicide, including vague or misunderstanding about potential suicide warning signs. Myths mentions of “not wanting to be here anymore,” “just going away,” or contribute to public misunderstanding about suicidal behavior. These “life being easier without them,” is a strong indication that a youth is include: thinking of taking his or her own life. ● People who talk about suicide are just trying to gain attention. ● Suicide usually occurs with no warning signs. Talking about suicide is one of the warning signs of an attempt, There is almost always a warning sign, but too often people are so it is true that the person is trying to gain attention. However, not aware of them. In fact, one of the best ways to prevent suicide their attempts should not be ignored. This is especially true among is becoming aware of the signs so at-risk teens can be quickly teens who excessively talk about attempting suicide. People will identifi ed and given appropriate support. There are many types of often get tired of the “threats” and not take the teen seriously. warning signs, and not all teens thinking about suicide behave the These teens are seeking attention, and they are often begging same way. for help. Ignoring them can be a deadly decision. Mental health ● Once people decide to commit suicide, there is nothing anyone professionals as well as other adults need to take all talk of suicide can do to talk them out of it. seriously and give these teens the needed attention. People often give warning signs because they desperately want to ● People who talk about wanting to die by suicide don’t usually be talked out of their suicidal plan. More often than not, they don’t follow through. want to die, but they don’t know how to solve the problems they According to the websites www.suicide.org and www.endteensuicide. are facing or they do not know how to stop the psychological pain org, most people who follow through with suicide have talked about they are feeling. Providing immediate attention and help can give
Page 125 SocialWork.EliteCME.com youth hope and help them to recognize that there are other ways to They are, consciously or unconsciously, searching for someone or cope with their experiences. something that will provide them with an alternative or provide them ● Suicide only affects people of a certain gender, race, fi nancial with hope. This is especially true for youth because some teenage status, age, etc. problems considered minor by adults can be devastating for a young Suicide knows no boundaries, and there is no particular group person. In addition, by virtue of their adolescent brain development, that is “safe” from suicide. While some groups have higher rates they are often less equipped to cope effectively with stress. of suicide than others, there is no particular group that is immune ● You should never ask people who are suicidal if they are from suicide. It touches every race, religion and economic class. contemplating suicide, because suicide discussion will prompt ● People who attempt suicide and survive will not attempt them to think that suicide is an option. suicide again. It is best to be direct and honest with a young person. If a person People who have attempted suicide in the past will often make is not contemplating suicide, your question will not make them other attempts, especially if their problems were not addressed consider it. And if they are contemplating suicide, then direct after the fi rst attempt. If these people were treated medically but questions and observational remarks let them know someone cares their mental health needs were not addressed, they will be dealing and is paying attention. with the same mental and emotional pain and the same stress as ● When people feel better, they are no longer suicidal. before the attempt; therefore another attempt can often seem like This is another often-missed suicide warning. Once young people the only plausible way out. In addition, a teen may be dealing with have made a decision to die by suicide, they can feel relief. Loved the additional embarrassment of a failed suicide attempt. ones should be very concerned when they observe a sudden “high” ● People who attempt suicide are crazy. after a period of depression in a young person. And if youth do According to the website www.endteensuicide.org, most suicidal seek help and are “better,” it doesn’t mean the risk of suicide has youth are not psychotic or insane. They are likely feeling disappeared. Previous suicidal thoughts or attempts are predictors depressed, hopeless, distressed and are in deep emotional pain, but for future attempts, so the risk is never entirely gone. this does not necessarily mean they have lost touch with reality. ● Young people seldom think of suicide because they have their Most of these teens continue to function in their daily lives. whole lives ahead of them. ● People who attempt suicide are weak. Suicide is the third-leading cause of death in 10- 24-year-olds. Even youth who are perceived as very strong and/or popular can Adolescence is often a time of turmoil and change, and some attempt suicide. One should never assume that a teen is safe from adolescents are unable to problem-solve or grasp long-term suicide because he or she fi ts into a certain group or has a particular consequences to their actions. It can be dangerous to assume that personality. These teens may fi nd themselves in situations they are any warning sign is “typical teenage behavior” or that someone unable to withdraw from and may face problems they are at a loss to would never do something so drastic. resolve. The warning signs should not be discounted simply because ● There is little correlation between drug and alcohol use and the adolescent is perceived to be a strong individual. suicide. ● People who talk about suicide are trying to manipulate others. According to the National Strategy for Suicide Prevention, between People who talk about suicide are asking for help, not being 40 and 60 percent of those who die by suicide are intoxicated at the manipulative. If they are talking about it, it is an option they have time of death. Substances such as prescription drugs or even over- considered, even if they are not following through at that moment. the-counter cough medicine can lower inhibitions, while alcohol ● People who are suicidal want to die. increases the lethality of some medications. Often these young people just want help. They want to escape from Any mention of suicide by a teenager should be taken seriously, even their current problems or they want to stop their psychological pain, if it has been mentioned numerous times without an attempt. and they believe that dying is the only way to end their current state.
Suicide risk factors
Not all people with suicide risk factors will have suicidal behavior or ● Breaking up with a boyfriend/girlfriend. attempts. Guidelines, however, help people become more aware of ● Moving to a new community. those young people who could possibly be at higher risk for suicidal ● Not feeling accepted by peers. behavior and/or attempts. ● Being ridiculed by classmates. ● Feeling misunderstood. LivingWorks Education Inc. developed a suicide prevention model called ● Any experience perceived to be “humiliating.” the Applied Suicide Intervention Skills Training (ASIST). LivingWorks ● Being bullied by classmates. focuses on training “gatekeepers,” or those who have a great deal ● Pressure to succeed. of contact with youth such as ministers, teachers and counselors, on ● Family problems. identifying suicide warning signs and appropriate interventions. ● Poor self-esteem. In its Suicide Intervention Handbook, LivingWorks states: “There is ● Family history of suicidal behavior. some useful information on high-risk groups. If you use that information ● Someone close to individual has completed suicide. as your only means of recognizing persons at risk, you will miss people ● Parental psychopathology. who are at risk, and you will falsely identify a lot of people who aren’t ● History of physical or sexual abuse. at risk.” Therefore, it is important to understand the risk factors, but they ● Same sex sexual orientation. should not be the only method of prevention. Risk factors include: ● Impaired parent-child relationships. ● Prior suicide attempt. ● Life stressors such as interpersonal loss and legal or disciplinary ● Co-occurring mental and alcohol or substance abuse disorders. problems. ● Having a mental health diagnosis. ● Isolation. ● Death of a parent. Understanding suicide risk factors is the fi rst step in suicide prevention. ● Divorce of parents. Identifying and acting upon warning signs is the next step. There is a ● Feeling like a “pawn” who is being used between feuding, dire need to educate frontline professionals about suicide risk factors. divorced parents. ● Joining a new family with a stepparent and stepsiblings.
SocialWork.EliteCME.com Page 126 In its report “Suicide in Colorado,” The Colorado Trust Report states: indicating that they are planning to end their life.” A report in 1999 “By some estimates, four out of fi ve people who commit suicide have indicated that only 9 percent of health teachers and 33 percent of high tried to warn others of their intent through verbal statements, written school guidance counselors felt they could correctly identify students notes, demonstrating a preoccupation with death or other behavior at risk (King, 1999).
Suicide warning signs
Suicide warning signs are embedded in the following vignettes: is behaving differently. Alex has started taking liquor from his ● Patra, an honor student halfway through her junior year, recently parents’ cabinet and drinks until he is intoxicated when he is with earned four A’s and two B’s on her report card. She is devastated his friends. When they mention their concerns about his behavior, by her report card and tells the teachers in the classes in which she he becomes extremely agitated and will often pick fi ghts with earned a B that she cannot take the report card home. She asks them anyone who mentions his alcohol use. Alex has also started driving if there is any extra-credit work she can do to improve the grade, but his new car extremely fast and almost crashed on numerous both teachers indicate it is too late for that grading period. Patra cries occasions. His friends think he is just working through his feelings and tells them she does not know how she will face her parents. She about the pending divorce. stays after school and meets with her guidance counselor and again ● Amber is in the seventh grade, and her boyfriend of four months stresses that she needs help earning extra credit because her parents recently broke up with her. Everyone at school seems to be talking will not accept this report card. Her counselor reassures her and tells about the breakup, and her ex-boyfriend is spreading rumors about her any parent would be proud of that report card. her. Her classmates have been making fun of her and laughing as ● Raul is a very quiet ninth grader. His teachers and classmates she walks down the hall. She confi des her feelings of humiliation describe him as a loner. He has never been in trouble, and he and shame to one of her teachers, and he tells her that these feelings makes average grades in school. His mother notices that he has no are normal and will pass. She also shares her feelings with her aunt, friends, but Raul tells her he doesn’t care. After coming home from who tells her that she should not worry because there will be plenty school each day, he goes straight to his room. When his mother of other relationships in her life, especially since she is so young. asks him about his school activities and friends, he becomes ● Nick is in the sixth grade, and has been in the principal’s offi ce increasingly agitated and tells her to leave him alone. many times for fi ghting with other students. Recently, his level of ● Jana, a sophomore, has been depressed for about six months. She has violence escalated when he kicked another student in the head after expressed to her friends that she does not know how to make herself pushing him to the ground. The adults in his life are extremely feel better. She dropped out of all of her clubs and stopped going to angry and blame his behavior on defi ance. When he is asked about school activities with her friends. However, her friends and family his behavior, Nick says, “Nothing’s ever going to change. I don’t are very excited because she recently seemed to come out of her care.” School administrators are talking about expelling him. depression. She is extremely happy and appears relieved. Her friends Nick’s father, a single parent raising three children, tells Nick that think she is relieved to be over her depression and back on track. he better “step up” as the oldest child and set an example for his ● Alex, a high school senior, is outgoing and has many friends. His younger siblings. Nick explodes and tells his father that his dad parents recently separated and are talking about getting a divorce. never understands what he is going through. He has said it doesn’t bother him, but his friends notice that he
IS PATH WARM?
Each of these young people is very different, yet they all exhibited at ● Trapped – Young people may feel trapped in their current situation. least one warning sign that family and friends should be able to identify. They may feel like there is “no way out” of their situation. They There is no stereotypical behavior for people who commit suicide, often perceive that there is no solution to their problem and make which is why knowing suicide warning signs is a very important part of statements to that effect. prevention. Although there are many different warning signs, in 2003, ● Hopelessness – Suicidal individuals often feel a sense of the American Association of Suicidology developed a mnemonic device hopelessness and may express that things will remain the same and “IS PATH WARM?” to help people remember the signs. may even appear desperate. ● Ideation – A suicidal person will often express thoughts of suicide ● Withdrawal – Individuals will often withdraw from friends, or threaten suicide before an attempt. Though out of their norm, family and society. Sometimes the change is dramatic and easy a person with suicidal ideation may also talk or write excessively to identify, but sometimes it is very subtle, such as a teenager not about death. They may also seek access to items that would going to school events or not going out with friends. Loved ones help them follow through with a plan, such as obtaining guns or need to be very aware of changes in their young person’s isolating medication. Any of these behaviors indicate suicidal ideation and behavior. Low self-esteem contributes to withdrawal because the should be taken very seriously. youth may feel worthless, shame, guilt or self-hatred and unworthy ● Substance abuse – If a person suddenly increases substance use, of being around other people. this could be a warning sign that the person is contemplating ● Anger – An individual may show signs of rage, uncontrolled anger suicide. Substance use includes alcohol consumption, which or patterns of seeking revenge. These people may act erratically, people may overlook. sometimes hurting themselves or others. ● Purposelessness – Persons contemplating suicide will sometimes ● Recklessness – An individual may begin exhibiting high-risk talk about having no purpose or meaning in life. These individuals behavior or activities. may not specifi cally say they want to die, but they will talk about ● Mood change – Mood changes include dramatic changes in having nothing worth living for or having nothing important to personality, mood or behavior. give their life meaning. These helpful guidelines should not be used as the only method to ● Anxiety – Suicidal people may show signs of anxiousness, recognize a potential suicide. Any changes in behavior should be including agitation or changes in sleep patterns. They may seem investigated, even if they are not drastic. “on edge” for no reason, and might either suffer insomnia or sleep for long periods of time.
Page 127 SocialWork.EliteCME.com Other warning signs include: ● I can’t stop the pain. ● Change in appetite. ● I can’t think clearly. ● Unusual neglect of physical appearance. ● I can’t sleep, eat or do schoolwork. ● Diffi culty concentrating. ● I don’t know how to get out of this. ● Speaking or moving with unusual speed or slowness. ● I am desperate. ● Giving away prized possessions. ● I am so angry/sad/ashamed. ● Saying goodbye to friends or family. ● I feel so guilty. ● Being involved in an unhealthy, destructive or abusive ● People would be better off without me. relationship. ● I am not worth it. ● Unhealthy peer relationships. ● I have nobody. ● Bullying; being bullied as well as bullying others. ● I want to make this all go away. ● I can’t get control. Thoughts and feelings associated with suicide may be expressed at ● Nothing will ever be the same. some point. It is important to be equally aware of suicide-related thoughts and feelings because their expression may be the only Although these are not necessarily observable behaviors, any statements indication of the adolescent’s suicidal ideations. According to the of thoughts or feelings such as the ones above should be red fl ags. Second Wind Fund, some thoughts and/or feelings that may have suicidal implications include:
The suicide warning signs in the vignettes
Patra’s warning sign was her unusual stress reaction related to grades. about their apparent change in mood. However, this type of behavior This is a sign that she felt a great deal of pressure, and pressure to should never be overlooked because a suicidal gesture or actual succeed is one of the warning signs of possible suicidal thoughts or attempt at suicide is most likely imminent. attempts as well. Patra’s teachers and counselor should notice that she Alex is popular with his friends, but when they try to talk to him about became excessively fearful after earning a B on her report card. Her his drinking, he becomes defensive and aggressive. Alex has exhibited teachers and school counselor should speak to her about her extreme quite a few warning signs. He has started using drugs and alcohol, and reaction to the two B’s and offer to share her report card together with is engaging in risky behavior. These are signs that indicate he may her parents if parental abuse and/or retribution are not a consideration. want to “give up on life.” An intervention is necessary to make sure In addition, learning to successfully cope with stress could be another he can more appropriately cope with his parents’ divorce. Alex may discussion. An intervention recommendation and referral to her parents be more challenged because he is perceived as popular and strong. would help them to effectively communicate with their daughter and His peers may not feel comfortable confronting him, and adults may help her to relieve her stress. believe he is strong enough to cope with his stressors. Raul seems to be a typical teenager trying to fi nd his school peer group. Amber was not taken seriously by her teacher and aunt. Adults may His biggest warning sign is withdrawing from his mother. He is already erroneously believe that ending a relationship, particularly in the described as a loner, and in withdrawing further there is the potential seventh grade, is not “the end of the world.” For most young people, for him to isolate and focus on suicidal thinking. His mother should this is true, but for Amber it does seem like the end of the world. She identify this change in behavior and work with him to get through this has lost her boyfriend, classmates are making fun of her, and she feels diffi cult time. If Raul is already receiving mental health counseling, it humiliation and shame. All these experiences are diffi cult stressors for will be important for his counselor to identify and address the continued her to handle. At this point, Amber does not seem to see any way out withdrawal and ask Raul about the possibility of suicide. of her situation. Jana’s friends and family have expressed relief because they believe Nick is familiar to mental health practitioners because they often her to fi nally be over her depression. However, they should be aware work with youth who have been given oppositional defi ant disorder that this could be a sign of imminent danger for Jana. diagnoses. Nick is trying to deal with being the older brother and When a person has been depressed for an extended period and helping to raise his younger siblings. He did exhibit at least two suddenly appears happy, it can be an indication that they have decided warning signs that should have been red fl ags for adults. His level of to follow through with their suicide plan. They may feel relief violence is concerning, but most concerning is his idea that things will following a decision to attempt suicide. This warning sign can be never change. This is a warning that he feels hopeless and trapped. overlooked because people close to the person are usually relieved
Treatment
Developing an appropriate treatment plan for a suicidal youth should “Gatekeepers” are important as well. They should be trained to include a variety of professionals. The Ohio State University Medical identify suicide risk and provide support. Finally, the youth’s family is Center’s report on teen suicide indicates that the youth’s primary essential to treatment. They will be an important part of intervention. care physician is an important member of the treatment team. If the Mental health professionals consider many factors when developing physician is utilized as an integral part of the treatment team, he or a treatment plan for a suicidal youth. The website www.teensuicide. she can help determine whether there are medical factors related to us lists the following factors that mental health professionals need to the youth’s suicidal thoughts or attempts and will be the fi rst person to consider: intervene if a suicide attempt is made. ● The intensity of a teenager’s suicidal symptoms. The mental Licensed mental health professionals are another important part of the health professional needs to determine frequency, duration and treatment team. Mental health professionals will help with diagnosis, number of symptoms the youth is exhibiting in order to determine mental health treatment and youth treatment plans. School counselors the appropriate level of treatment. can also provide support for the youth at school and intervene when ● The overall medical history and health of the suicidal teen. The necessary. mental health professional should have the parent or guardian sign the appropriate releases so the youth’s physician may be consulted.
SocialWork.EliteCME.com Page 128 ● The adolescent’s tolerance for procedures, medications and treatment will be more effective if the plan involves the family and therapies. The mental health professional needs to determine how the youth. The parent or guardian will also be a great source of open the youth and the parents are to different forms of treatment. information and should not be excluded unless it is harmful to the Identifying past interventions and their degree of success can also teen, such as in cases of abuse or neglect. provide important information for treatment planning. Treatment plans for these teens need to be individualized to focus on ● The seriousness of any suicide attempt or warning sign. Any their strengths and on building protective factors. Therefore, a mental suicide attempt is serious, but some attempts are more cries for health practitioner must obtain input and information from many help than attempts to die, and if help is not given, these youth may sources. Gathering information about all aspects of the youth’s life follow up with more serious attempts. Therefore, by examining the leading up to the suicide attempt could provide insight into the youth’s intensity and number of risk factors, the mental health professional decision to attempt suicide and help the treatment team establish the should determine whether the youth’s suicidal ideations can be most effective treatment goals for youth and the family. reduced by outpatient therapy or if hospitalization is necessary for stabilization. Effective treatment modalities for suicidal youth include individual and ● Impressions of the risk for teen suicide at a later time. If the family therapy or hospitalization. Individual therapy can help youth mental health professional determines through risk assessment more effectively regulate emotions, decrease impulsive behaviors, gain that another attempt is imminent, the teen should not be left alone. insight into life stressors, increase self-esteem and establish more effective If the risk assessment determines that the youth has stabilized, procedures for communicating feelings. Family therapy can help youth outpatient treatment may be utilized. and their family members communicate more openly, help resolve family ● The opinion of the parent, as well as the teen, regarding confl ict and establish a supportive environment for the youth. However, treatment preferences. The mental health professional may if a risk assessment indicates a youth is at high risk and a suicide attempt provide guidance and offer suggestions, but the ultimate decisions is imminent, hospitalization is the most appropriate method of treatment. for treatment will be up to the teen and the parent or guardian. The Hospitalization provides a safe environment where the youth is provided constant monitoring in addition to therapeutic intervention. MENTAL HEALTH AND SUBSTANCE ABUSE DISORDERS RELATED/LINKED TO TEEN SUICIDE
Depression
According to the American Foundation for Suicide Prevention, ● Irritable or angry mood – Irritability, rather than sadness, is often researchers believe that two-thirds of people who die by suicide suffer the predominant mood in depressed teens. A depressed teenager may from a depressive illness. The New York State Offi ce of Mental Health be grumpy, hostile, easily frustrated or prone to anger outbursts. reports that mental disorders with impulsiveness, such as borderline ● Unexplained aches and pains – Depressed teens frequently personality disorders, conduct disorder or alcohol and substance abuse complain about physical ailments such as headaches or disorders contribute to the remaining one-third of the deaths by stomachaches. If a thorough physical exam does not reveal a suicide. Teenage depression can be diffi cult to diagnose because the medical cause, these aches and pains may indicate depression. teenage years, by nature, can exacerbate depressive symptoms that are, ● Extreme sensitivity to criticism – Depressed teens are plagued by nature, usually transient. by feelings of worthlessness, making them extremely vulnerable to criticism, rejection and failure. This is a particular problem for Occasional problems are expected, such as bad moods or temper outbursts. “overachievers.” However, when these problems persist, they should not be ignored. The ● Withdrawing from some, but not all people – While adults tend American Psychiatric Association reports that over one-half of children and to isolate themselves when depressed, teenagers usually keep up teenagers suffering depression will have at least one suicide attempt, and some friendships. However, teens with depression may socialize more than 7 percent of them will die as a result of their attempt. less than before, pull away from their parents or start hanging out According to experts, approximately only 20 percent of teenagers with a different group. suffering from depression actually receive treatment (Smith, 2007). In addition, the Child and Adolescent Bipolar Foundation cites the Possible reasons for this include: following symptoms as warning signs of teenage depression: 1. Teenagers’ reluctance to talk about their problems. ● Sad, anxious, or empty mood. 2. Adults’ propensity to attribute depressive symptoms to normal ● Declining school performance. teenage behavior. ● Loss of pleasure or interest in social and/or school activities. 3. Unlike adults, young people must rely on others to identify the ● Sleeping too little or too much. signs and help them seek treatment. ● Changes in weight or appetite. Due to normal adolescent developmental challenges, adults who live Mental health professionals should know the intensity and duration of and associate with youth may fi nd it diffi cult to differentiate between the symptoms and gather information from multiple people involved their normal and abnormal behaviors. For example, some depressed with the youth. Young people may behave very differently in one adolescents never appear sad or withdrawn, but they will display signs setting than in another, so asking multiple people will help paint a more of aggression or rage (Smith, 2007). According to Smith, the following accurate picture of what the adolescent may really be experiencing. behaviors are more commonly displayed in depressed teens than in Although not all depressed teens will attempt suicide, diagnosing and depressed adults. treating depression can be a useful suicide prevention measure.
Substance abuse
According to the American Association of Psychiatry, each day, seniors in high school reported that marijuana was easily accessible approximately 4,700 teens under the age of 18 use marijuana for the to them. The study also found that 50 percent of adolescents had fi rst time. They also report that a 2003 study found that nine out of 10 consumed at least one drink and 20 percent had been drunk by the time
Page 129 SocialWork.EliteCME.com they fi nished the eighth grade. These statistics are alarming due to the suicide, so alcohol use increases the likelihood that the attempt will fact that substance abuse has been linked to adolescent suicide. result in death. In addition, drugs and alcohol affect the teen’s ability It is also important to note that the use of prescription medication to make good judgment, so while under the infl uence, the teen may among teens is increasing. According to a Partnership for a Drug-Free not have the ability to assess risk, make good choices and think of America attitude tracking study in 2003, 20 percent of teens have appropriate solutions to problems. abused a prescription painkiller and 9 percent have abused an over-the- Most adults acknowledge that drug experimentation by youth is counter medication. risky. However, some adults erroneously believe marijuana and The American Academy of Child and Adolescent Psychiatry states that alcohol are not as risky as other drugs and that drinking alcohol and teen drug use is associated with poor judgment that “may put teens at smoking marijuana represent a rite of passage. Statistics highlight that risk for accidents, violence, unplanned and unsafe sex, and suicide.” adolescents who are using drugs and alcohol at a much younger age, Teens at risk for developing serious drug and alcohol problems when their bodies and brains are still developing, are more vulnerable include those with a family history of substance abuse, those who are to their effects. The use of drugs and alcohol can lead to other depressed, those who have low self-esteem and those who feel like problems including: ● Poor school performance. they don’t fi t in with the mainstream. ● Lack of peer support, family problems. The American Psychiatric Association reports that 53 percent of ● Increase in risky behavior. adolescents who die by suicide are substance abusers, and the National ● Increased trouble with the law. Youth Violence Prevention Resource Center reports that 90 percent of Adults need to recognize the warning signs and examine core issues young people who complete suicide have a mental health or substance that prompt youth to experiment with drugs and alcohol. They are most abuse disorder, or both. Substance use also increases aggression, likely using the drug as a way to cope with stress in their lives or to impairs judgment and can increase the lethality of other medications. numb mental and emotional pain related to experiences that produced The National Strategy for Suicide Prevention reports that adolescents shame, humiliation, anger or guilt. Immediate intervention will help who die by suicide are more likely to use a fi rearm if they have alcohol youth adopt more effective coping skills for dealing with these life in their blood at the time of death. This is a far more lethal method of stressors.
Bipolar disorder
The National Institute of Mental Health reports that bipolar disorder ● Frequent mood changes (both up and down) and/or irritability. may be as common in youth as it is in adults, stating that one percent ● Increase in risky behavior. of 14- 18-year-olds meet the criteria for either bipolar disorder or ● Exaggerated ideas of ability and importance. cyclothymia. The report also indicates that an additional 6 percent of The National Institute of Mental Health also adds the following to this adolescents exhibit symptoms of bipolar disorder, although not enough list: indicators are present to warrant a diagnosis. The NIMH states: ● Changes in mood that include overly silly and elated. “Compared to adolescents with a history of major depressive ● Increased energy. disorder and to a never-mentally-ill group, both the teens with ● Decreased need for sleep, including having the ability to go with bipolar disorder and those with subclinical symptoms had very little or no sleep for days without tiring. greater functional impairment and higher rates of co-occurring ● Distractibility, including attention constantly moving from one illnesses (especially anxiety and disruptive behavior disorders), thing to the next. suicide attempts and mental health services utilization. The study ● Hypersexuality, including increased sexual thoughts, feelings, or highlights the need for improved recognition, treatment and behaviors or use of explicit language. prevention of even the milder and subclinical cases of bipolar ● Increased goal-directed activity or physical agitation. disorder in adolescence.” The National Institute of Mental Health (NIMH) states that bipolar Dr. David Brent, a professor of psychiatry at the University of disorder in children and adolescents is more diffi cult to identify than Pittsburgh School of Medicine, believes that the key to identifying in adults, due to the problems and natural reactions of children and suicide risk is a personality characteristic that he calls “impulse adolescents. NIMH indicates that adult symptoms are more clearly aggression” (Gardner, 2006). Dr. Brent defi nes impulse aggression as defi ned than those present in children and adolescents. “the tendency to respond to provocation or frustration with hostility or aggression.” He continues by stating that impulse aggression coupled Children and adolescents with bipolar disorder experience mood with depressed mood increases the risk for suicide in teens, and swings much faster than adults with bipolar disorder. Children and treatment protocol is different than treatment for depression alone. Dr. adolescents can experience swings between depression and mania Brent suggests that the presence of this impulse aggression increases many times each day. Also, mania in children and adolescents shows the chances that an adolescent will act on his or her suicidal thought up more often as irritability and tantrum behavior than the adult because youth who have acquired this characteristic fi nd it more symptoms of overly happy and elated. The NIMH indicates that the diffi cult to assess risk and use more appropriate coping skills. problem is that those behaviors and symptoms are also indicators of other diagnoses in children and adolescents, such as attention defi cit In addition, The Child and Adolescent Bipolar Foundation lists the hyperactivity disorder, conduct disorder and oppositional defi ant following bipolar disorder indicators, especially mania, in teens: disorder, which makes diagnosing even more diffi cult. Because the ● Diffi culty sleeping. suicide rate for those with bipolar disorder is higher that those with ● Excessive talkativeness, rapid speech or racing thoughts. other diagnoses, it is important to make an accurate diagnosis.
Self-injury/self-mutilation and teen suicide
Self-injury/self-mutilation is a phenomenon on the rise in the United population engage in self-injuring behavior (Klonsky, Oltmanns, States. It is diffi cult to identify the exact number of people engaging and Turkheimer, 2003). The most common forms of self-mutilation in self-injurious behavior because many times the behavior is kept a are cutting, branding, picking at skin, hair pulling, hitting, multiple secret. In a 2003 study, it was estimated that 4 percent of the general piercing or tattooing and drinking harmful chemicals.
SocialWork.EliteCME.com Page 130 These behaviors have generally been labeled “maladaptive coping” ● Create a feelings vocabulary. Many who self-injure have problems rather than suicidal traits, but some studies suggest the self-injurer is with verbal expression, so it is important to help clients fi nd words in fact a suicide risk (Stanley, Gameroff, Vanezia, and Mann, 2001). to describe and express what they are feeling. Craigen and Foster Data from a 1997 study indicates a person who self-injures is 18 times say creating a feeling vocabulary list or playing games that promote more likely to eventually die by suicide than nonself-injurers (Ryan, expression of feelings can be very successful with these clients. Clemmett, and Snelson, 1997), and data from a 2001 study suggests ● Help the client establish a support system. Many who self-harm that 55 percent to 85 percent of those who self-injure have had at least feel like they have very little support, and establishing a support one suicide attempt (Stanley, Gameroff, Vanezia, and Mann, 2001). system can be therapeutic for them. In addition, isolation is a risk factor for suicide. Creating a support system can also be a Mental health professionals who help self-injuring or self-mutilating preventative measure for the client. persons should be aware that self-injury is strongly linked to low self- ● Make it clear you care about the person. Craigen and Foster esteem and depression and can cause the self-injuring person to attempt state, “Many times counselors make the mistake of failing to see suicide. Therefore, treatment plan goals for the self-injurer should focus their client beyond their self-harming behaviors. In fact, many on increasing self-esteem and decreasing the depressive symptoms. counselors focus the majority of their sessions on self-harm and do Also, self-harming activities may accidentally infl ict more damage little to get at the true feelings beyond the wounds.” The danger in than the person intended, and a life-threatening injury may result, so doing this is that the counselor does little to help alleviate the pain, treatment plans should also include goals for replacing the self-harming and as the pain increases, it becomes more likely that the person behavior with other behaviors that do not result in bodily injury. could contemplate suicide. While self-injury may not mean a person is at imminent risk of suicide, ● Make statements that demonstrate empathy for what the it should be considered a suicide risk factor. Mental health professionals person is going through instead of becoming irritated with should address this risk factor in treatment, and best practice for their repeated behaviors. counselors suggests conducting a suicide assessment for all self-injuring ● Help them fi nd alternative coping behaviors. Self-harming is individuals. Based on their literature review, Craigen and Foster seen as a coping skill, so counselors need to help the person access compiled the following list of appropriate mental health interventions for and utilize healthier coping skills. self-injurers (Alderman, 1997; Favazza, 1996; Levenkron, 1998). ● Create an atmosphere of openness and trust, and make it ● Conduct a suicide risk assessment. Craigen and Foster indicate clear to the client that it is okay to talk about the self-harming that even though some of the studies have shown little correlation behaviors and that it does not offend the counselor or hurt between self-injury and suicide, it is always best practice for the counseling relationship. Clients who feel more comfortable mental health professionals to conduct a suicide risk assessment talking about their behaviors may be able to get to the underlying when working with self-injurers. issues faster than those who are constantly being judged. ● Understand work/clinical policies for reporting self-harming ● Mental health practitioners who work with these clients behaviors with minors. Some mental health clinics adhere should seek supervision and consultation. This is especially to mandatory reporting for parents while others have different important since there is a possible suicide risk involved, and no philosophies. Consequently, a mental health practitioner should behavior should be overlooked. Talking about the situation and fully understand these policies in order to provide appropriate the behaviors with others will help the counselor sort through the treatment and aid in suicide prevention. issues and better help the client. ● Investigate why the individual is engaging in self-harm. Self- injury may be masking a mental health issue that could lead to Craigen and Foster also state that it is important not to scold or demonstrations of less appropriate coping, including suicidal thoughts reprimand clients who are self-harming, force clients to stop their self- or attempts. Mental health professionals should take the time to harming, let discomfort or uneasiness with the behavior get in the way understand why a client is engaging in the self-harming behavior. of the therapeutic relationship, or miss, cancel, and/or show up late for ● Ask to see the injury if it is in an appropriate location. If a strong client appointments. therapeutic relationship has been established, clients can explain Although there are confl icting conclusions as to whether or not suicide how they were feeling before, during and after the self-harming is directly linked to self-harm, it is a good idea for mental health act. The Craigen and Foster article cites a book by Levenkron that counselors to at least assess the risk. If it is determined that there states, “Routine discussions of injuries and discussing what to do is no suicide risk at the time of the assessment, then follow-up risk about them increases trust, begins to integrate the person’s sense of assessments should be conducted periodically to make sure the client relationship to another person, and can successfully begin to replace is progressing in treatment by adopting healthier coping strategies. self-harm with positive attachment” (Levenkron, 1998).
Selective serotonin reuptake inhibitors (SSRI) and adolescent suicide
The possible link between SSRIs, commonly prescribed According to the New England Journal of Medicine, after this antidepressants, and adolescent suicide caused the United States Food warning was issued, antidepressant prescriptions for children and and Drug Administration to order manufacturers of antidepressant adolescents declined by almost 25 percent, but the rate of follow-up medications to include a “black-box” warning on their medication. The care for children and adolescents who had been diagnosed showed no black-box warning in 2004 stated: improvement. The article also indicated that for every 10,000 children ● Antidepressants increase the risk of suicidal thinking and behavior and adolescents who begin taking antidepressants, about six will die by (suicidality) in children and adolescents with MDD (major suicide and 30 others will be hospitalized for a serious attempt in the depressive disorder) and other psychiatric disorders. six months following the medication fi rst being taken (Simon, 2006). ● Anyone considering the use of an antidepressant in a child or The FDA expanded the warning in May 2007 to include young adults adolescent for any clinical use must balance the risk of increased ages 18-24. Research suggests that the greatest risk is during the fi rst suicidality with clinical need. one to two months of treatment. The FDA website states: “Results ● Patients who are started on therapy should be observed closely for of individual placebo-controlled scientifi c studies are reasonably clinical worsening, suicidality or unusual changes in behavior. consistent in showing a slight increase in suicidality for patients ● Families and caregivers should be advised to closely observe the taking antidepressants in early treatment for most of the medications. patient and to communicate with the prescriber.
Page 131 SocialWork.EliteCME.com Available data are not suffi cient to exclude any single medication The article concludes that while antidepressants “likely have a from the increased risk of suicidality.” Steven Galson, M.D., MPH, potential for provoking suicidal behavior in some vulnerable director of FDA’s Center for Drug Evaluation and Research, states that individuals in the early phases of treatment,” there has been no antidepressants are still an effective mode of treatment for depressive evidence linking increased suicide rates with increased use of symptoms, but people need to be aware of the risks. antidepressants (Science Daily, 2008). Many of the studies that found correlations between teen suicide and The best way to monitor the use of antidepressants is for the treatment SSRIs have not been able to rule out the possibility that the patients in team to be aware of the risks and closely monitor the child or adolescent the studies were more mentally ill than those in the control groups. Dr. taking the medication. According to the FDA guidelines, after starting an David Fassler, M.D., responded to a study in 2006 that found a correlation antidepressant or changing the dose, a teenager should see his doctor: between SSRIs and increased suicidology saying that the results should ● Once a week for four weeks. be “interpreted with caution.” And Dr. Mark Olfson, M.D., M.P.H., the ● Every two weeks for the next month. lead author in the study, stated that while many studies, including his own, ● At the end of the 12th week taking the drug. show correlations, no study has given researchers a “clear indication” ● More often if problems or questions arise. of the risk factors that help clinicians predict which patients could be The FDA has also revised its medication guide related to at increased risk for suicide (Rosack, 2006). antidepressant medications. The new guide states the following: A study in 2007 examined children and adolescents less than 19 years ● Read the medication guide that comes with your or your family old in randomized clinical trials and showed an increase of 0.7 percent member’s antidepressant medicine. This medication guide is only in suicidal ideation or attempts in those who were taking antidepressants about the risk of suicidal thoughts and actions with antidepressant as opposed to those taking a placebo (Bridge et al., 2007). Science Daily medicines. Talk to your health care provider about: reported in 2008 that the evidence was “undisputable” in showing a link ○ All risks and benefi ts of treatment with antidepressant medicines. between antidepressants and increased suicidal ideation and attempts ○ All treatment choices for depression or other serious mental illness. in vulnerable adolescents, especially in the beginning of treatment. It The FDA guide also includes the following statement: is, however, important to note that the article also suggested there are ● What is the most important information I should know about factors present in these types of clinical studies that could distort the antidepressant medicines, depression and other serious mental research fi ndings. illnesses, and suicidal thoughts or actions? The fi rst factor is the amount of time dedicated to the clinical trial. 1. Antidepressant medicines may increase suicidal thoughts or Because the trials are “short-term,” once side effects have been noted actions in some children, teenagers, and young adults when the in the patients, the trials end; however, the effi cacy of antidepressants medicine is fi rst started. related to suicide is seen over longer periods of time. Therefore, 2. Depression and other serious mental illnesses are the most the article suggests that a short-term clinical trial cannot effectively important causes of suicidal thoughts and actions. Some determine both side effects and long-term benefi ts of antidepressant people may have a particularly high risk of having suicidal medications with suicidal patients. thoughts or actions. These include people who have (or have a family history of) bipolar illness (also called manic-depressive The second possible distorting factor is that acutely suicidal people are illness) or suicidal thoughts or actions. not included in the studies of antidepressants. It would be unethical to include this population due to the possibility of them being given a Following this statement, the FDA guide lists possible changes in placebo in the study instead of a true antidepressant, and the omission behavior that could be red fl ags for increased suicidal ideation. It is changes the balance of the studies. The Science Daily article states, also important to note that the FDA advises that people never stop “The antidepressant trials have not been designed to investigate taking an antidepressant without consulting a physician. This can be suicidal behavior, and they cannot provide unbiased information on the initial reaction when somebody notices suicidal behavior in a child their overall effects related to it.” or adolescent, but stopping the medication without the guidance of a physician or psychiatrist can be extremely dangerous. The third factor, which is supported by other studies, is that short-term suicidal ideations or “less severe” attempts do not necessarily increase Finally, the article in Science Daily comes to the conclusion that “While risk for completed suicide. These studies regarding SSRIs have not antidepressants likely have a potential for provoking suicidal behavior had a client complete a suicide, so some experts agree that there is in some vulnerable individuals in the early phases of treatment, from a little indication that there is a link between mildly increased suicidal public health perspective, the epidemiologically much more important ideation and completed suicide. effect of antidepressants is to alleviate depression and thus reduce the risk of suicide.” Finally, the article says short-term clinical trial results are distorted because these types of studies lack the components involved in usual Overall, mental health professionals need to be aware of the fi ndings treatment, such as a treatment team that can evaluate possible side of these studies, but the primary role for the mental health professional effects and change medication as necessary. is to make sure families are aware of the potential side effects, know the warning signs for suicidal thoughts or attempts and have a plan in case their child exhibits warning signs.
Effects of suicide on family and friends
A “survivor of suicide” is the term used to describe a family or from natural causes. The article goes on to say that mental health friend of a person who died by suicide. According to the American professionals should help survivors understand that their grief may never Association of Suicidology, approximately 5 million Americans have go away, but they can learn how to cope with their grief. Mental health become survivors of suicide over the past 25 years. Survivors are left professionals who assist parents, caregivers, siblings or close friends of to cope with their grief, and unlike other deaths, with suicide there are teens who have died by suicide may see emotional responses such as: no “external factors” to blame. ● Guilt – Survivors often feel they could have said or done something to prevent the teen from following through with In their article “Survivors of suicide: Healing after a loved one’s suicide. Survivors of suicide may also feel guilt related to the last suicide,” the Mayo Clinic states that bereavement after a suicide interactions they had with the youth. A negative last experience is “more complicated, intense and prolonged” than after a death
SocialWork.EliteCME.com Page 132 with the person who committed suicide often adds to the survivor’s might engage in self-injurious behaviors (Begley, et al., 2007). As a guilt. When addressing guilt, mental health professionals should mental health professional, it is important to provide ways for a child avoid using clichés with their clients. to express feelings, such as utilizing play therapy and art therapy ● Anger – Anger is often extremely diffi cult for the survivor to admit, techniques, as well as providing developmentally appropriate answers especially when the anger is felt toward the person who died by to questions that may relate to a suicide. suicide. The anger may also be directed at others who came into The effects of teen suicide on their survivors can be long-lasting. Some contact with the teen who died, which may include a therapist. studies suggest that survivors of suicide often deal with emotions Mental health professionals should be aware of the possible related to the grieving process much longer than those grieving other transference issues that could occur when that happens. Caregivers deaths. Feelings of guilt, rejection, shame and isolation are more or parents may be angry with their teen’s friends, especially if they intense than for those who grieve other deaths (Goode, 2003). Studies did not approve of the people with whom their child was associating. have also shown that family members who have survived suicide feel The survivors may also be angry at themselves for not seeing the worse about themselves and are viewed more negatively by others. warning signs, especially if they start reading literature associated with suicide and see that there are often warning signs the suicidal Suicide survivors themselves are at higher risk of suicide. Some person will give. The survivors should be allowed appropriate time studies indicate they are more vulnerable to depression, which is a and an appropriate environment in which to express this anger risk factor for suicide. In a 1996 study, Dr. Brent and his colleagues before working towards moving through the grieving process by found that siblings of adolescent suicide victims had higher levels of resolving their anger. depression six months after the death, and the mothers of the victims ● Grief – Friends, relatives or even acquaintances of a person had higher levels of depression one year after the suicide compared to who has died by suicide are at risk for suicide themselves, so a control group. Dr. Brent also found that three years after the suicide, it is important to conduct a risk assessment with the survivors the siblings were no more depressed than a control group, but the throughout the grieving process. It is natural to feel grief, but if mothers were still experiencing depressive symptoms (Goode, 2003). this grief includes suicidal thoughts and/or a plan, more intense For the survivors of the suicide, quick intervention is critical. According intervention may be necessary. to the Harvard Medical School Guide to Suicide Assessment and ● Shame or embarrassment – There continues to be a stigma Intervention, survivors have a 25 percent chance of experiencing connected with suicide, and survivors can feel embarrassed about the depression, a 40 percent chance of post-traumatic stress disorder, and a 31 teen’s suicide. They may not know what to tell people, they may be percent chance of suicidal ideation. The risk for any one of these increases ashamed of the circumstances surrounding the death and they may if the survivors do not receive immediate intervention (Jacobs, 1999). feel like other parents are judging them or blaming them for their child’s death. This embarrassment and shame can also prevent the Elementary, middle and high schools should also have “postvention survivor from seeking appropriate help; therefore, if they do seek help plans” in place for their students in case of a suicide by a fellow student. from a mental health professional, treatment should includegoals that Schools should be prepared to provide mental health support for these address these feelings of intense shame and embarrassment. students, especially since knowing the person who died by suicide ● Relief – The American Association of Suicidology suggests that places them at higher risk for having suicidal thoughts and/or attempts of a survivor may have feelings of relief following the death of their their own. The postvention should focus on providing education for the loved one. If the adolescent experienced an ongoing mental illness, staff as well as mental health support for staff and students. legal issues or had other excessive and challenging stressors, Often students share the same feelings as family members such as there may be a sense of relief when the person is no longer alive. guilt, rage and confusion. Rumors that surface following a suicide Survivors may not be able to disclose their relief, and mental present another challenge. It is best for school personnel to obtain health professionals may need to approach the subject for them. accurate information as soon as possible in order to dispel any rumors However, once disclosed, it can be very cathartic for the survivor. that may be circulating. Some rumors can be damaging to friends, so ● Confusion – Family members are often left asking questions such it is best to deal with the rumors in the beginning as another way to as “Why?” “How could they?” “What went wrong?” “Could I have provide survivors with support. done something differently?” “What made things so bad?” or Does However, school personnel should be very careful not to glorify the this mean I am a bad parent?” Because survivors are often left with suicide because this can, in some instances, lead to copy-cat suicides so many unanswered questions, they have a very diffi cult time or “cluster suicides” in which multiple teens die by suicide in a brief understanding the suicide. Mental health providers can provide a safe period of time. A 2007 study found that “young people are especially and supportive environment for the survivors to sort out the confusion. vulnerable to imitative suicidal behavior, and this may be encouraged ● Abandonment – Survivors may feel abandoned by those close to by funeral and memorial services that eulogize the young who die them as well as by the person who died by suicide. Often, family by suicide” (Beautrais, et al., 2007). It is believed that glamorizing a and friends do not know what to say or how to comfort a survivor, suicide can cause more to occur. Mental health practitioners should so they may avoid the survivor altogether. quickly identify and intervene with those friends and family members It is also important to note that the parents of adolescents who die by at risk for copy-cat suicide. suicide could experience a sense of “ultimate failure and rejection” Finally, providing family and friends with many external resources because they were expected by society to protect their children, and the and support can be effective in helping them heal. Support groups are suicide could be seen as a failure to do so by society (Parrish, et al., 2005). often a helpful way for families and friends of the adolescent who Mental health professionals must also assist families with how another died by suicide to talk with others who have been through what they child or teen’s suicide affects the children in that person’s life. Often are experiencing. Often people dealing with suicide feel alone and adults feel they need to hide the suicide to protect the child, but the misunderstood. They can experience relief when going to a support American Association of Suicidology (AAS) states it is best to be honest group with others who validate their feelings and concerns. with children about what happened in age-appropriate terminology. Overall, the effects on families and friends can be intense and long AAS states that children “experience many of the feelings of adult lasting. Mental health professionals should be aware of the risks for grief,” especially abandonment and guilt, but they do not have the suicidal behaviors in survivors, develop effective treatment plan goals skills to communicate their feelings effectively. Children should be for survivors and understand that because the emotions tied to suicide told that it is not their fault the loved one died by suicide. The younger may be more intense and longer lasting than those related to other the child, the more diffi cult it is for them to cope with the emotional deaths, the treatment lasts longer. pain and confusion caused by the suicide. Some younger children
Page 133 SocialWork.EliteCME.com SUICIDE RISK ASSESSMENTS AND SAFETY CONTRACT
If a person is assessed “at risk” for suicide, action needs to be taken contract paves the way to negotiate keeping the suicidal person safe to protect the person. Identifying warning signs is only the fi rst step during this critical time. in helping a suicidal person. Once it becomes clear that a person is Suicide risk assessments. experiencing suicidal thoughts, it is important to delve more deeply LivingWorks, in its suicide intervention handbook, identifi es six “risk and conduct a risk assessment to help determine next steps. A safety alerts” to help identify risk levels.
Risk alert No. 1 – an adolescent is having suicidal thoughts.
If a suicidal youth will not literally mention suicide, the mental health ● Have you spoken to anyone about your plans? professional conducting the risk assessment must ask the teen directly ● How does the future look to you? if suicidal thoughts are present. ● What things would lead you to be more/less hopeful about the future? ● What things would make it more/less likely that you would try to For example, if a youth uses statements that indicate he does not kill yourself? know how he will ever resolve or get through his current situation, ● What things in your life make you want to escape or die? it would be appropriate to let him know that sometimes people in ● What things in your life make you want to go on living? his situation consider suicide as a way to cope. The mental health practitioner would then ask if suicide is something that has crossed If it is determined that the teen is, in fact, having suicidal thoughts but has his mind. Young people are sometimes reluctant to say the word no plan, the most important step is to help him refrain from progressing “suicide” because of the implications that they are weak or mentally to a plan. In order to do this, LivingWorks developed four steps: ill, so asking questions that do not include the word “suicide” may be 1. A promise to keep safe – The promise to keep safe requests more appropriate if the youth is guarded or unwilling to talk about his that adolescents promise not to hurt themselves within a specifi c feelings. The mental health professional should persist, even when the time frame. LivingWorks points out that it is important to let the adolescent is reluctant to disclose, by continuing to build rapport and suicidal person know that thinking about suicide is acceptable, client comfort level and continuing indirect questioning. but acting on the thoughts is not. Giving a young person a specifi c time frame also helps because it is not an indefi nite promise but The American Psychiatric Association (APA) suggests the following one that can be monitored. questions to help determine whether suicidal thoughts are present: ● Have you ever felt that life was not worth living? 2. Provide continuously available safety contacts – It is important ● Did you ever wish you could go to sleep and just not wake up? that the suicidal youth have a constant support group. The suicidal ● Is death something you’ve thought about recently? teen must be able to reach help at all hours of the day. Help the ● Have things ever reached the point that you’ve thought of harming suicidal youth establish a list of contacts who are aware of his suicidal yourself? thoughts and willing to be a part of the support group, and then ensure that somebody on the list is available at all times to provide support. If it is determined that suicidal thoughts are present, the APA lists the 3. A promise of safe/no use of alcohol/drugs – Because alcohol next group of questions as helpful in determining the severity of the and drug use can increase the likelihood of a suicide attempt, it is thoughts or whether there are any plans in place: important to eliminate the drug use by a suicidal teen. However, ● When did you fi rst notice such thoughts? at this point, the youth would most likely need more intensive ● What led up to the thoughts (events, actions, thoughts)? services such as an inpatient facility to monitor both the cessation ● How often have those thoughts occurred? of the drug use and the suicidal ideations because drug use may ● How close have you come to acting on those thoughts? have been the only coping skill the youth used. Also, continued use ● How likely do you think it is that you will act on those thoughts in of medication prescribed to the teen should be closely monitored. the future? 4. Link to other support resources – A person with suicidal ● Have you ever started to harm or kill yourself but stopped before thoughts needs to be linked with many supportive community doing something (holding a knife or gun to your body but not resources. Friends and family are good resources, but if the risk doing anything)? is high or the potential exists for the person to become a higher ● What do you envision happening if you actually killed yourself? risk, they should be linked to agencies in the community that can ● Have you made a specifi c plan to harm or kill yourself? provide other levels of support to help reduce suicide risk, such as ● Have you made any particular preparations (purchasing items, support groups and other mental health-related professionals. writing a note, rehearsing the plan)?
Risk alert No. 2 – an adolescent who has had suicidal thoughts has established a plan for following through with the suicide.
When doing a risk assessment, it is important to ask as many questions how determined he is, will be an important part of assessing for risk. as possible to acquire the details necessary for level 2 assessments. In addition, fi nding out if he has taken additional steps, such as writing The suicidal young person should be asked how he or she plans to suicide notes and getting personal affairs in order, is important. The complete the suicide. If the teen knows how he or she is going to more the person has prepared, the higher the risk will be. Finally, fi nd follow through with the attempt, no matter how plausible the plan, the out how soon the person plans to attempt suicide. If he gives you a risk for an attempt is still high. The more detail the person shares, the specifi c time, he should not be left alone, even if that time frame is days greater the risk. away. The fact that the person has a time in mind indicates he is fully For example, the young person who says, “I’m not sure, but I am going prepared to follow through, and the risk is very high. to do it,” is at lower risk than the person who answers, “I will take all of LivingWorks also notes in the risk assessment that if the young person my prescription medication.” The next question to ask is how prepared refuses to share any details about the plan, one should assume it has are they to follow through with their plan. Finding out if the person been planned in great detail. At this point, the most important action has in his possession what is needed for the suicide attempt, as well as step is to disable the suicide plan. The more cooperative the person
SocialWork.EliteCME.com Page 134 is, the less likely he will follow through or change methods once an notes that people should never put their own lives at risk to halt a intervention has occurred. People who are uncooperative are most suicide. When necessary, a person should call for support from local likely at higher risk and should not be left alone. LivingWorks also law enforcement or emergency medical personnel.
Risk alert No. 3 – an adolescent teen with mental pain who is desperate.
The suicidal young person may be suffering from different forms and helpful information. The appropriate step is to help a desperate teen intensity of mental and emotional pain. They may also have physical fi nd ways to relieve the pain. pain that accompanies depression. People who are in a great deal of People fi nd relief in different ways, so it may take a little time to help pain could eventually get to the point where they can no longer cope someone fi nd solutions that work. Voicing aloud one’s thoughts and and are desperate for relief. LivingWorks reports that desperation can feelings often provides a great source of pain relief. A referral to a lead to suicide. psychiatrist for medication intervention, or if the pain is physical, a A desperate, suffering young person should be asked directly if the referral to a doctor, would be appropriate as well. mental or physical pain is unbearable at times. The answer will provide
Risk alert No. 4 – an adolescent who feels as though he has no resources or feels alone.
LivingWorks says that the person most at risk for suicide is one who LivingWorks also points out that even when resources are available, a feels totally alone and cut off from any individual, family, group, suicidal young person may not be able to connect with them for some community or spiritual connection. In general, the closest resources reason. A youth may also think particular resources will not help. are family and friends, but there are other resources that can be helpful While not discounting the young person, it is important to fi nds ways for a suicidal person to utilize as well. Other sources may assist a to connect them with something. If a connection cannot be made, the person with fi nances, physical and mental health, housing issues, person should not be left alone. memberships to clubs or any other resource that will help the person not feel alone or isolated.
Risk alert No. 5 – an adolescent who has attempted suicide before and is familiar with suicide.
Suicide rates for those with a previous attempt are 40 times greater unable to identify the previously used strength-based resources, help him than for those who have had no previous attempts. A young person fi nd new and more appropriate skills to cope with life stressors. who has made an attempt in the past has utilized self-destructive The APA suggests the following questions when gathering information behaviors as a way to cope. A history of a suicide attempt may also in preventing future suicide attempts: indicate that the person is impulsive and may have diffi culty stopping ● Can you describe what happened? a thought from becoming an action. Mental health professionals must ● What thoughts did you have leading up to the attempt? ask about previous suicide attempts in a suicide risk assessment, but ● What did you think would happen (going to sleep versus injury if the suicidal young person is uncomfortable discussing it, the health versus dying, getting a reaction out of a particular person)? professional may need to ask it a number of times in different contexts ● Were other people present at the time? throughout the assessment. ● Did you seek help afterward or did somebody get help for you? Mental health counselors can best help these youth by putting protective ● Had you planned to be discovered or were you found accidentally? factors into place, such as emergency contact lists, and by encouraging ● How did you feel afterward? the youth to utilize past survival skills. Because the young person ● Did you receive treatment afterward? survived a previous attempt, it is helpful to focus on how they managed ● Has your view of things changed, or is anything different since the thereafter. Point out those strengths that led them to survive and attempt? highlight their usefulness during the current suicidal period. If a youth is ● Are there other times when you have tried to harm/kill yourself?
Risk alert No. 6 – an adolescent who has received past mental health care.
If a youth had mental health treatment in the past, they are considered A mental health professional should conduct a thorough risk assessment. at risk. Mental health professionals working with the youth should Many different adolescent suicide risk assessment forms exist. They fi nd out the diagnosis and treatment plan used in the past in order to should include the following: establish the best plan of action for current treatment. Even if a young 1. Clinical factors – A mental health professional should fi nd out person does not remember the diagnosis but does remember receiving as much as possible about any previous diagnosis and current help in the past, the person is still considered at risk because there is symptoms that would reveal a client diagnosis. Again, it is the possibility that the youth had a previous mental health diagnosis or important to fi nd out if a teen suffers from depression, bipolar had diffi culty coping with a life stressor and required intervention. disorder or has a substance-abuse problem because these young Finally, it is important when completing a risk assessment to determine people are at higher risk. whether the teen is having thoughts of hurting others in addition 2. Cognitive thinking – Often the suicidal teen is not thinking clearly to experiencing suicidal thoughts. The APA suggests the following or will have acquired distorted thinking. They may believe that there questions in determining a youth’s potential to harm others: is no escape from their trouble or that no one at school will forget an ● Are there others you think may be responsible for what you’re embarrassing situation. It is important to assess whether the teen’s experiencing? distorted cognitive thinking is interfering with the ability to cope. If ● Are you having thoughts of harming them? this is the case, the teen will be at higher risk for suicide. ● Are there other people you want to die with you? 3. Loss factors – Adolescents who have suffered a signifi cant loss ● Are there others you think would be unable to go on without you? are at higher risk for suicide. Asking about past or recent losses
Page 135 SocialWork.EliteCME.com can help assess current risk. It is important to remember that a burden and that life for their families would be easier without events such as parents’ divorce and a boyfriend/girlfriend breakup them. Teens who are questioning their sexual orientation or who feel can be experienced as signifi cant loss events in a teenager’s life. as if their sexual orientation is not accepted are also at higher risk As a mental health professional, it is important to keep in mind the than other teens. Obtaining a good background history will help the client’s perception of the event. clinician gain a better understanding of the teen’s daily environment 4. Historical factors – Teens who have made prior suicide attempts and protective factors that may need strengthening. or who have family members who have attempted suicide are 6. Risk reduction factors – There are factors that can help lower the at greater risk. Teens who have a history of being impulsive are risk for suicide. Youth who feel a great sense of responsibility to also at higher risk, as well as those who have suffered physical their families, who have a positive social support group, and who and/or sexual abuse. In addition, teens should be asked about have at least one positive family relationship will have a lower risk dates associated with signifi cant losses because anniversaries and for suicidal behavior than teens who do not have these in place. A birthdays can be extremely critical triggers for teens. spiritual community can also be a risk reducer. Uncovering these 5. Demographic/history factors – Ask about the young person’s living risk reduction factors can help determine risk, but they can also environment and upbringing. Of particular interest are youth who assist a therapist to identify key people who can become part of a frequently stay at home alone or do not have a home. Adolescents strong support group in times of crisis. with families that struggle with fi nancial issues sometimes feel like
Safety contracts
A safety contract is also referred to as the “no-suicide contract” or the tool. When forming a contract with a suicidal client, there are certain “no-harm contract.” Study results vary on the effi cacy of these types of elements that should be included. contracts, but some clinicians working with suicidal clients use them. ● Freedom to think about suicide – Often the individuals who The Centre for Suicide Prevention conducted a literature review of the are signing these contracts have been contemplating suicide for a safety contracts in 2002, and found some limitations and benefi ts to the long period of time, so asking them to simply stop thinking about safety contract. it is probably an unrealistic task. It could also add more stress to their already precariously fragile state. By giving a young person Possible contract benefi ts: ● Can be an adjunct to a comprehensive evaluation and treatment plan. permission to think about and discuss suicide, it can relieve some ● Can be a means of evaluating current suicidality. of their anxiety related to the contract. However, it should be ● Can be a means of reducing both patient and therapist anxiety. consistently pointed out to the youth that if they are feeling like ● Can provide specifi c behavioral alternatives to suicide. they are moving from thoughts to possibly actions, they must call somebody on their contact list. Possible contract limitations: ● Specifi city – The agreement should be very specifi c, outlining ● Potential for therapists to believe that a signed contract eliminates a timeline, a support and intervention group, and steps that will suicide risk. be taken if the teen begins to have serious thoughts of a suicide ● Competency level of a younger client to understand what they are attempt. A vague plan gives the teen no real guidance and can add signing or to give informed consent to such an agreement. to an already complicated situation. The agreement should have ● The possibility of implementing a contract to reduce therapist a start date and end date, the order of people to call if the teen is anxiety rather than to benefi t the patient. having suicidal thoughts, and any other details that may help a ● The possibility of therapists substituting a no-suicide contract for young person seek support. the establishment of a sound therapeutic relationship. ● Limited objectives – Be realistic with time frames for the plan. ● Overvaluing the contract as a risk management tool. If a teen is at extreme high risk, it may be realistic to set a goal of ● The propensity to use the no-suicide contract as a safeguard one day without a suicide attempt while appropriate mental health against liability rather than as a part of an overall treatment plan. services are being put in place. If appropriate, sign a contract with In 1999, looking at the legal aspect of the no-suicide contract, Dr. Robert the youth weekly until more effective coping skills are being utilized I. Simon, M.D., wrote the following summary of his article “The Suicide and a risk assessment shows a signifi cantly reduced risk for suicide. Prevention Contract: Clinical, Legal, and Risk Management Issues” in Most importantly, the agreement objectives should be attainable so the Journal of the American Academy of Psychiatry and the Law: the teen can feel a sense of accomplishment and hope. “In the managed care era, mental health professionals increasingly ● Real agreement – LivingWorks states that it is important to ask a teen rely upon suicide prevention contracts in the management of to verbally repeat the plan and demonstrate an understanding about patients at suicide risk. Although asking a patient if he or she is what they are committing to through the agreement. The young person suicidal and obtaining a written or oral contract against suicide can should demonstrate an ownership in the plan by providing input for be useful, these measures by themselves are insuffi cient. ‘No harm’ the objectives. Also, some professionals believe that the act of signing contracts cannot take the place of formal suicide risk assessments. the agreement is empowering for the young person. If a young person Obtaining a suicide prevention contract from the patient tends to be shows little commitment or seems to be “going through the motions,” an event, whereas suicide risk assessment is a process. The suicide the validity of the agreement should be questioned. prevention contract is not a legal document that will exculpate the ● Crisis support – A suicidal teen needs to be aware of steps to clinician from malpractice liability if the patient commits suicide. take if the action plan cannot be followed. For example, if the teen The contract against self-harm is only as good as the underlying cannot stop the suicidal thoughts and an attempt is highly possible, soundness of the therapeutic alliance. The risks and benefi ts of a “safety net” of people should be contacted, and a mental health suicide prevention contracts must be clearly understood.” professional intercession will be an important key to providing safety. There should also be numbers for emergency personnel and Based on the literature review by the Centre for Suicide Prevention suicide hot lines included on the contact list. All numbers should and the work of Dr. Simon, mental health professionals should use be clearly written, and the agreement should be kept in a place a safety plan or no-suicide contract as a tool for treatment but not as easily accessible to the teen when in crisis. the only intervention for a suicidal client. They can be useful, but it is ● Make the environment suicide-safe – A suicidal teen may agree dangerous to believe that the contract is a steadfast suicide prevention to sign the no-harm contract, but mental health professionals and
SocialWork.EliteCME.com Page 136 parents or caregivers need to provide additional support by making LivingWorks states that the no-harm contract can provide a sense sure that the environment is as safe from suicide as possible. This of hope for the youth by identifying the specifi c plan for reducing means making sure the teen has no access to guns, medication or suicide risk and getting the youth additional support. However, mental other instruments that could assist him or her in completing health professionals and family members must follow through on any suicide. The most important thing to remove from the environment promises made in the no-harm contract or the youth will no longer is the suicide weapon mentioned when he or she shared a plan. For value the contract and could feel abandoned or deceived by the support example, if a teen said he was going to take all of his mother’s group. Finally, LivingWorks indicates that during the following week’s medication, it will be especially important to make sure the session with the suicidal youth, the mental health professional should mother’s medication is locked away. Mental health professionals follow up on the safety plan, praise the teen for following the plan and should make sure that people living with the teen are very aware of then design a new safety plan, if necessary. the need to remove these things from the home.
Additional prevention information
The National Alliance on Mental Illness says that suicide is ● Family-focused prevention efforts may have a greater impact than preventable, but it requires educating people about how to identify a strategies that focus only on individuals. youth at risk for suicide and then how to intervene once intervention ● Community programs that include media campaigns and is necessary. NAMI claims that one of the primary goals of a good policy changes are more effective when individual and family prevention program is to reduce risk factors, and this often requires interventions accompany them. seeking professional help to recognize and treat mental health ● Community programs need to strengthen norms that support help- disorders in teens. NAMI states: seeking behavior in all settings, including family, work, school and “According to one recent case-control study (Brent et al., 1999) community. the effective targeting of a handful of risk factors, namely past ● Prevention programming should be adapted to address the specifi c suicide attempt, psychopathology in the adolescent, parental nature of the problem in the local community or population group. psychopathology and gun in the home, is likely to result in a ● The higher the level of risk of the target population, the more substantial reduction in the suicide rate among youth.” intensive the prevention effort must be and the earlier it must begin. According to the American Psychological Association, teen suicide ● Prevention programs should be age-specifi c, developmentally prevention programs throughout the United States have focused appropriate and culturally sensitive. on school education programs, crisis center hot lines, screening ● Prevention programs should be implemented with no or minimal programs that help identify at-risk adolescents, media guides to help differences from how they were designed and tested. educate the media about the prevalence of copy-cat suicides among adolescents to try to minimize the impact of media coverage of teen The National Strategy for Suicide Prevention (NSSP) was established suicide, and limiting access to fi rearms. The APA states: “Currently, with support from the Suicide Prevention Resource Center and the most effective suicide prevention programs equip mental health SAMHSA with the following goals: professionals and other community educators and leaders with ● Prevent premature deaths due to suicide across the lifespan. suffi cient resources to recognize who is at risk and who has access to ● Reduce the rates of other suicidal behaviors. mental health care.” ● Reduce the harmful aftereffects associated with suicidal behaviors and the traumatic impact of suicide on family and friends. Dr. Robert A. King, a professor at Yale University and a psychiatrist ● Promote opportunities and settings to enhance resiliency, at the Yale Child Study Center, told the National Conference of State resourcefulness, respect and interconnectedness for individuals, Legislators in 2005 that he believes suicide prevention should start families and communities. in early childhood, and he even says it could start prenatally with depression screenings for pregnant mothers (National Conference The NSSP supports a public health approach to prevention as opposed of State Legislators, 2005). Dr. King stated that just teaching the to the clinical/medical model of prevention. The public health warning signs or having a “Just Say No” campaign in middle and high approach focuses on prevention in a group or population of people, schools does not generally have a positive effect unless mental health whereas the clinical/medical approach focuses on individuals. The treatment is provided for those determined at risk. He has stated that public health approach uses fi ve basic evidence-based steps in a lawmakers should focus their attention and money on younger children systematic way. The fi ve steps include: and pregnant mothers. He said: “The important thing to focus on ● Step 1 – Defi ne the problem: Surveillance. Suicide surveillance isn’t suicide per se. Instead, legislators may wish to support and fund includes gathering information about suicide behavior in youth. early intervention programs for children, adequate prenatal screening The gathered information should include information regarding programs, nurse visiting programs for mothers of young children at the individuals who die by suicide or attempt suicide and their life risk, and protective services, because child abuse is a big risk factor for circumstances as well as the effect their attempt or death had on adolescent suicide.” others. Surveillance is essential in helping a community defi ne its specifi c problem related to suicidal behavior. The Suicide Prevention Action Network created a booklet “Suicide ● Step 2 – Identify causes. This step should include a thorough Prevention: Prevention Effectiveness and Evaluation” with the goal of analysis of the risk and protective factors for youths attempting utilizing best practices in suicide prevention programs. SPAN reports suicide. Although there is generally no one cause for a suicide that prevention programs should include the following in order to be attempt, there is generally one precipitating event or factor that leads most effective: ● Prevention programs should be designed to enhance protective to a suicide attempt. When gathering information about the cause of factors. They should also work toward reversing or reducing a suicide attempt, mental health professionals should ask appropriate known risk factors. Risk for negative health outcomes can be questions that will help pinpoint the one event or factor that led to reduced or eliminated for some or all of a population. the attempt. This information should be used to identify risk factors ● Prevention programs should be long-term, with repeat specifi c to a community, and then the community can provide interventions to reinforce the original prevention goals. specifi c protective factors that can help reduce suicidal behavior. ● Step 3 – Develop and test interventions. Before utilizing treatment methods, they should be tested to ensure they are safe, ethical
Page 137 SocialWork.EliteCME.com and feasible. It is also important for mental health professionals whether treatment plan goals are being met. A mental health to be mindful of the fact that there is no universal intervention professional may do informal evaluations with clients or more that works for all suicidal clients. However, research has shown formal, statistical based evaluations, but some form of evaluation that programs that are comprehensive and include many different must be conducted to ensure the clients are benefi ting from the community leaders and resources are more effective than prevention model. singularly focused interventions. It is unethical for mental health Overall, the NSSP identifi ed the following components in all effective professionals to utilize treatment methods that have not been tested suicide prevention programs: and proven to be best practice. ● Programs clearly identify the population that will benefi t from ● Step 4 – Implement interventions. The public health approach each intervention and from the program as a whole. emphasizes “fi delity” in this step of the process, which means ● They specify the outcomes to be achieved. implementing programs exactly as they were tested and not ● They are comprised of interventions known to effect a particular changing the program drastically. Small changes to adapt to a outcome. particular community or culture are acceptable, but the consistency ● Sponsors coordinate and organize the community to focus on the of the program design is a vital aspect of implementation. issue. ● Step 5 – Evaluate effectiveness. Mental health professionals ● They are based on a clear plan with goals, objectives and should evaluate the effectiveness of any suicide prevention implementation steps. program. If there is no evaluation, it is impossible to determine
Gate-keeping prevention
The Suicide Prevention Resource Center (SPRC) indicates that ● Recognize behavioral patterns and other warning signs that implementing a gate-keeping program in communities can be another indicate that a young person may be at risk of suicide. effective prevention tool. Gate-keeping programs train people who ● Actively intervene, usually by talking to the young person in ways have regular close contacts with the youth to be able to identify those that explore the level of risk without increasing it. at risk, identify warning signs and implement treatment programs. The ● Ensure that young people at risk receive the necessary services. SPRC states the following as goals of an effective gatekeeper program:
School-based mental health programs
The American Academy of Pediatrics Committee on School Health (mental health) programs offer the promise of improving access to reported that school-based mental health services are an important diagnosis of and treatment for the mental health problems of children aspect of prevention as well. The committee reported, “School-based and adolescents.”
Identifying protective risk factors
One important component in prevention is identifying and, when ● Easy access to a variety of clinical interventions and support for possible, providing protective factors. The protective factors are seeking help. simply guidelines and do not guarantee a suicide attempt will not ● Restricted access to highly lethal methods of suicide. occur. Some of the protective factors identifi ed by the surgeon general ● Family and community support. in a 1999 report include: ● Support from ongoing medical and mental health care ● Genetic or neurobiological makeup. relationships. ● Attitudinal and behavioral characteristics. ● Learned skills in problem solving, confl ict resolution and ● Environmental attributes. nonviolent handling of disputes. ● Effective and appropriate clinical care for mental, physical and ● Cultural and religious beliefs that discourage suicide and support substance abuse disorders. self-preservation techniques.
CARE
Dr. Michael Rayel, M.D., established the CARE approach for ● Remedy with early intervention. For loved ones close to the preventing suicide. The care approach is a four-step process that can be young person, it is important to address the problem and not deny used with suicidal clients or those suffering depression, and the focus that it exists. Family therapy sessions can facilitate communication is on early recognition and intervention. Although the approach was and help the family work through denial and establish a treatment designed for loved ones trying to help the suicidal teen, the approach plan. Dr. Rayel explains that it is important for loved ones to be is also appropriate for mental health professionals working with teens. able to express love and support for the youth, and that family The four steps include: members may need to seek their own mental health counseling ● Check for signs of emotional illness or distress. Dr. Rayel points as part of the intervention. Another important aspect in early out those mental health professionals should always be checking for intervention is providing youth with as many supportive resources signs that show deviation from the teen’s usual mood. He states that as possible, including support groups, legal assistance, tutors or some type of behavior change or emotional turmoil almost always any other service that may help them feel hopeful or believe there precedes suicide, and mental health professionals and loved ones is a solution to their problem. need to be observant and ask the youth about the noted changes. ● Educate yourself. Mental health professionals should educate ● Anticipate complications. Dr. Rayel indicates that once a person themselves and in turn loved ones who are dealing with suicidal has been identifi ed as “in distress,” the mental health providers teens and understand the most appropriate therapeutic methods for and loved ones should anticipate complications, such as denial and treating them. In keeping with best practices in the fi eld, mental possibly escalation in behaviors. At this stage, those close to the health professionals will be better prepared to help reduce suicidal teen should be directly questioning them about suicidal thoughts thinking in youth and help them to establish more appropriate or plans. coping skills.
SocialWork.EliteCME.com Page 138 Summary
There are many approaches when addressing suicide, but the most care physicians and mental health practitioners, are a vital part of important one is early identifi cation and intervention. Identifying those prevention. Early detection can help mental health professionals young people at risk and then providing them with supportive care is establish best-practice therapeutic interventions that could prevent a essential. Educating adults as well as adolescents on suicide risks and suicide attempt. Finally, mental health professionals can assist with warning signs can help ensure that the youth that are struggling receive prevention efforts in their communities by helping educate gatekeepers the appropriate early intervention they need. who are trained on identifying risk factors, warning signs and Suicide attempts among youth have increased over the past few years treatment facilities, and by keeping abreast of current best-practices for after a period of decline, and frontline professionals, such as primary treating suicidal youth.
References
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UNDERSTANDING ADOLESCENT SUICIDE FOR MENTAL HEALTH PRACTITIONERS Final Examination Questions Select the best answer for each question and then proceed to SocialWork.EliteCME.com to complete your fi nal examination.
41. The adolescent suicide rate for 10 to 14-year-olds: 46. The person most at risk for suicide is one who: a. Has decreased in 2000-2001. a. Feels totally alone and cut off from any individual, family, b. Has increased since 2003-2004. group, community or spiritual connection. c. Has not fl uctuated since 2000-2004. b. Feels that his or her parents are too lenient with siblings. d. Has not changed since the 1990s. c. Feels that God is punishing him or her. d. Has lost a pet or family member. 42. A suicidal person will: a. Often express thoughts of suicide or threaten it before an 47. Teens who have made prior suicide attempts or who have family attempt. members who have attempted suicide are: b. Seldom express thoughts of suicide or threaten it before an a. Less at risk because they’ve been there before. attempt. b. At a greater risk. c. Always express thoughts of suicide or threaten it before an c. Are not affected. attempt. d. More reluctant to express their feelings. d. Never express thoughts of suicide or threaten it before an attempt. 48. Mental health professionals should use a safety plan or no-suicide contract as a tool for treatment: 43. Compared with adults with bipolar disorder, children and a. But not as the only intervention for a suicidal client. adolescents with the disorder experience mood swings: b. As the only intervention for a suicidal client. a. At the same rate as adults. c. Seldom, if ever. b. More slowly than adults. d. Only if the client has attempted suicide before. c. Much faster than adults. d. That are less severe than those of adults. 49. A no-suicide contract should be loosely constructed to allow a youth to work out the problem himself. 44. The American Association of Suicidology says it is: a. True. a. Best to hide a suicide from a child. b. False. b. Best to be honest with children about what happened. c. Better to discuss suicide only with adults. 50. The most important thing to remove from the environment is: d. Best to assess the child’s age, maturity and relation to the a. The video games that desensitize youth to violence. victim to decide whether the child should be told. b. The sharp objects in various parts of the home. c. Prescription drugs. 45. If the person’s plan for suicide is not plausible, the risk for an d. The suicide weapon mentioned when he or she shared a plan. attempt at suicide is very low. a. True. b. False.
SWCA05AS14
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