Free Literature Review On A Literature Review Of Two Therapies For Treating Alcoholism
As early as the 1930’s, discussions concerning the identification and treatment of alcoholism have challenged the medical community (Jellinek, 1960). The models for treatment all demanded abstinence; people who drank to access were considered immoral and/or diseased. The health risks associated with excessive drinking include the common cold, cancer, bone density, cognitive functions, high blood pressure, stroke, ulcers, atherosclerosis, and heart disease (Hingson & Rehm, 2013). However, the effect of drinking alcohol is difficult to determine due to under reporting, errors in perception of time or amounts ingested, and methods of data collection.
A literature review was conducted of the topics related to alcoholism and the indications for two types of therapy, Harm Reduction and Motivational Interviewing. A definition of alcoholism establishes the criteria for evaluation, a case study is presented, several articles discussing the health issues of high blood pressure and diabetes are presented, a article concerning the support of Hispanic cultures for drinking, several articles discussed rating and addressing denial, and a number of articles concerning the approaches of Harm Reduction and Motivational Interviewing. In conclusion, the information found in the literature review was found to be supportive of the presented client for Harm Reduction and Motivational Interviewing therapies.
The American Psychiatric Association (1994) defines alcoholism in the Diagnostic and Statistical Manual for Mental Disorders (4th ed.) as two disorders associated with alcohol use: abuse and dependence. Dependence on alcohol results in lifestyle stress, a continuous need to consume alcohol, and physical changes that include increased tolerance and symptoms of withdrawal if the patient stops drinking. Alcohol abuse causes problems meeting obligations and inappropriate drinking patterns, but there is not physical dependence.
Morse (1992) reports that a two-year study was conducted by the National Council on Alcoholism and Drug Dependency and the American Society of Addiction Medicine to create a more current definition. The result was an agreement that alcoholism is a primary and chronic disease and that a physical dependency can develop which can result in withdrawal with attempts at abstinence. Alcoholism is influenced by genetics, environmental, and psychosocial elements. Often progressive and frequently fatal, thought processes are distorted and include denial. Decreased cognitive processes are felt now to be more relevant than the DSM IV previously though. Alcoholics have a loss of control over their drinking habits and become preoccupied with it, even though they may suffer from negative consequences.
The patient is 58 year old Puerto Rican male with a wife and three grown children. He is in denial concerning his alcoholism although he is suffering from hypertension and diabetes. The factors to consider are: cultural influence of his race, his denial about his disease, and his accompanying health problems. A discussion concerning the use of motivational interviewing and Harm Reduction therapy may prove suitable to his case.
Effect of Alcoholism on High Blood Pressure and Diabetes
The patient in the case study is diagnosed with hypertension and diabetes. Klatsky (2004) researched studies concerning alcohol intake and hypertension and concluded that further research is needed in a number of areas including the possible presence of a threshold alcohol dose, if the type of alcohol or pattern of drinking is a factor, the relationship between blood pressure changes and the time sequences of drinking, influence of diet or behavior, and if the usual pattern of high blood pressure is the same as with alcohol-associated high blood pressure readings. The relationship between lighter drinking of alcohol with increased blood pressure has significant public health implications due to the promotion of light drinking socially. This aspect is important when considering health factors later in the discussion and affects on the denial process. When considering the amount of alcohol consumed daily, heavy drinkers will tend to under-report due to the stigma attached to heavy drinking. It is interesting the note that people who are light drinkers have lower blood pressure than people who do not use alcohol at all. The finding would support the Harm Reduction therapy to allow light drinking. The coronary risk increases when alcohol is consumer outside of meals; how often a person drinks is more important than what type of alcohol is used or how much is consumed. In Europe, where even children drink wine, low blood pressure is associated with sipping wine with meals and in moderation.
The affect of alcohol consumption on diabetic measurements has been a matter of debate for some time (Kim & Kim, 2012). Type 2 Diabetes mellitus is a complication of alcoholism. Heavy use of alcohol affects insulin resistance and disrupts the homeostasis of glucose. Glucose tolerance is the gray area between diabetes and normal functions. As with hypertension, there is little evidence that abstinence is more beneficial than light drinking.
There are some research findings that indicate a correlation between alcoholism in Hispanic men and acceptance of the behavior by Latin American families. Fernandez-Pol, Bluestone, Morales & Mizruchi (1985) surveyed 126 male and 25 female alcoholics of Puerto Rican descent using a scale to measure traditional values of Hispanic-American families. The scores were lower than those of 45 males and 71 females of the same descent who were non-alcoholic. Traditionalism appears to be a significant influence and supports the hypothesis that lower-class Puerto Rican cultural attitudes impact alcoholism in that community.
Denial of Alcoholism
In order to address the problems associated with excessive alcohol consumption, therapists must get past the patient’s denial of his disease. Zimberg, Wallace and Blume (1978) state that denial by the alcoholic of his addiction is a major health problem in America. While drinking alcohol is encouraged socially, a chronic alcoholic has a negative stigma attached to him that affects his family, friends, and employment. It is due to these consequences that an alcoholic, and even his family, will deny his problems and not seek help.
DiClemente & Prochaska (1982) used a model of change developed by Prochaska in 1979 to change addictive behavior in smokers. The model is an assessment of the client’s willingness to change a negative behavior, then provides strategies to take him through stages from Action to Maintenance. The Model of Change is a tool that can be used with initial evaluation and during the process of motivational interviewing for insights. A self-anchoring scale can also be used for evaluation of suspected alcoholism; one such scale is the Depression and Anxiety Stress Scale (Depression-test.net, 2015). Clinical research has found that the difference between depressive disorders and normal anxiety can only be a degree. Self-administrated tests contain bias be the person answering the questions and the responses are generally based on a short period of history. Effective evaluation includes administration of other tests and interviews by a professional.
A rating scale for alcoholic denial was developed by Goldsmith and Green (1988) to identify what component of the alcoholic process the patient is denying. Portions of the denial can deal with having lost control over drinking behavior, causing pain to the family, or recognition that the problems the alcoholic is experiencing are related to his drinking. Unlike the Prochaska Model of Change, the Denial Rating Scale (DRS) is not used later in the treatment process. It contains eight levels, which are actually mind states. Level 1 has no recognition of any problems related to drinking. Level 2 realizes the problems, but does not relate them to alcohol consumption. Level 3 realizes the problems are related to drinking, and Level 4 understands loss of control in the past of drinking behaviors. Level 5 shows the patient afraid of the loss of control and wanting help. Level 6 is an acceptance of the disease, but doesn’t believe sobriety will be a problem. Level 7 patients work hard at maintaining sobriety in order to achieve Level 8, which is a change in lifestyle.
Harm Reduction Approach
As an alternative treatment model to abstinence, the Harm Reduction approach is based on three goals: to reduce the negative consequences of excessive intake of alcohol, to allow controlled amounts of alcohol consumption, and to encourage participation in services that act outside traditional treatment programs (Marlatt & Witkiewitz, 2002). Research conducted by Mark and Linda Sobell employed an inpatient alcohol treatment program with male patients using moderate drinking goals (Sobell & Sobell, 1973). Their findings showed that moderate drinking by chronic alcoholics is an effective treatment for some patients; further research has supported these conclusions (Davies, Scott & Malherbe, 1969; Foy, Nunn & Rychtarik, 1984; Sanchez-Craig, Annis, Bronet & MacDonald, 1984). In addition, the health problems associated with excessive drinking are seen most often in heavy drinkers, but least often in men who drink no more than two drinks daily and women who drink no more than one drink daily.
The Harm Reduction approach to treatment is more attractive to people who want to continue drinking, but don’t want the consequences. Also, by surrendering to a treatment program and attending Alcoholics Anonymous meetings, they may encounter the stigma associated with admitting they have a problem with alcohol. The World Health Organization (1996) takes the broad view that treatment options in a step manner should be based on individual needs. A public education program on a national level is the first step, followed by brief treatment periods for people without severe problems. If the intervention is not effective, stronger methods may be needed.
One of the more controversial methods of Harm Reduction is the use of drugs that cause physical reactions when combined with alcohol (Marlatt & Witkiewitz, 2002). Antabuse causes an increased heart rate, nausea, and sweating. ReVia blocks the positive feelings provided by drinking alcohol. Acamprosate reduces the urges to drink by an alcoholic. Antidepressants can help people who drink because they are depressed.
Motivational Interviewing Approach
Rollnick & Miller (1995) define Motivational Interviewing as“ . . . a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence” (p. 325). The methods of Motivational Interviewing came about through a realization that empathetic therapists had more positive outcomes in treating alcoholics (Miller & Baca, 1983). The techniques used in the approach addressed the behavior of the therapist during treatment. These techniques included specific responses to speech patterns of the patient, encouraging the sort of speaking that is motivational by the client, and empathetic responses to ambivalence. Treasure (2004) presents the stages as: 1) express empathy with reflexive listening techniques to demonstrate understanding, 2) bring out ways to show the client the discrepancy between his values and behavior, 3) avoid confrontation, and 4) promote the idea to the patient that change is possible. In contrast to confrontational styles used in the past, the goal of Motivational Interviewing is to promote the client to express the desire for change rather than the therapist push him to want it.
In the course of developing the process for motivational interviewing, a “drinker’s checkup” (DCU) was created to evaluate the components present in interventions that were brief rather than long-term (Miller & Sovereign, 1989). A randomized trial showed the DCU resulted in a sharp decrease in drinking behavior when combined with motivational interviewing, but a similar result was discovered when the DCU was administered without the therapy. In other words, motivational interviewing is not necessary to decrease inappropriate drinking behavior after the DCU is taken; the DCU itself is the impetus for change.
Evaluation of motivational interviewing in clinical trials showed that a single session prior to entering treatment for drug abuse doubled the rate of abstinence three to six months after treatment and increased retention and motivation (Brown & Miller, 1993). Miller and Rose (2010) reported that over 200 trials of motivational interviewing also showed improved results for medical problems such as management of diabetes and rehabilitation following a heart attack. The addition of the therapeutic approach of motivational interviewing to other treatments created a synergistic effect that resulted in improved outcomes.
This patient is a candidate for the use of Harm Reduction therapy and Motivational Interviewing methods of treatment based on his cultural traditions that support alcohol consumption and his resistance to the acceptance of his disease. Research has indicated that allowing the client to drinking in small amounts with meals will prove beneficial for his diabetes and hypertension. After taking the DRS test, it was determined the patient is at Level 4, realizing his drinking has been out of his control in the past. In addition to therapy, education will continue to address his diabetes and high blood pressure with referral to his family physician. The synergistic effect on motivational interviewing is expected to enhance the results of that education.
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