Treatment of Alcoholism - Research Paper Example

 The purpose of this assignment is to research the problem of alcoholism and to apply the knowledge gained to the case-study of Mr. JG (hereafter JG). The essay will deal with a number of aspects of the treatment of alcoholism: The importance of the therapeutic relationship The development of an education program that encompasses the needs of all parties involved Look at the factors that will produce positive outcomes Identification of the differences/similarities between adolescent behavior that that which occurs in substance abusers Explain treatment options that are available to alcoholics The overarching theme of this analysis is that effective management for the alcoholic patient will result in positive outcomes for both the patient and the family. Question 1 Describe the importance of developing a therapeutic relationship with a patient, as identified in the case study. Explain how you would develop such a relationship A therapeutic relationship has been described as an intervention tool that is used to assist the patient in reaching treatment goals: an evolving process that occurs between the nurse and the patient, with the primary focus always being the patient and his needs (Boyd 2005, p.175). As Boyd continues, the therapeutic relationship is based upon self-awareness and communication between the nurse and the patient. The nurse must both identify and acknowledge the effects of her own beliefs, motivations and biases and their effect on the patient. For example, the gender and past life experiences of the nurse may make empathy, which is vital to develop for the therapeutic relationship to be successful, really succeed. For example JG was physically and mentally abusive towards his wife. Many nurses may have difficulty empathizing with this aspect of JG’s behavior. Empathy does not of course imply support, but rather the ability to genuinely put oneself within the situation of the patient. Thus understanding of the why and how of the abuse would be essential to helping JG work through the reasons for the abuse and help to avoid it in the future. If the nurse is not able to cross the boundary between distaste and/or condemnation of JG’s behavior into empathy then he/she might not be able to help JG. As Stein (2005, p.51) puts it, self-awareness on the part of the nurse clears the way for an honest and non-judgmental nurse-patient relationship. To be succinct, within the therapeutic relationship, self-awareness on the part of the nurse leads to self-awareness on the part of the patient. And self-awareness, especially within the substance abuse patient, is essential for improvement and eventual cure. The initial contact is the ideal time for a spontaneous start to the therapeutic relationship. Ironically, many nurses miss this time, preferring to wait for a more “appropriate” moment to establish the genuine nurse-patient relationship (McAllister 2004, p. 575). Thus the initial contact should not be taken up with bureaucratic and polite procedures, but rather should be a starting point for conversation, facilitating awareness and insight into issues, allowing solutions to be identified (McAllister 2004). Thus genuine rapport between the nurse and the patient, both as professional/client and as people needs to be created. If it does not occur in this opening meeting then the chance of a genuinely productive therapeutic relationship may be lost. As McAllister suggests, the initial contact is the time where roles are defined, rapport is established and expectations are created. Part of this initial meeting, as well as the ongoing relationship, requires effective communication between the nurse and the patient. Communication can be verbal or non-verbal, with or without empathetic linkages. Verbal communication includes the crux and implication of what is said together with how it is said. The nurse needs to be aware of the educational level of the patient and thus the expectation of comprehension within that patient. Thus as JG has a rather low education level, the nurse should expect to need to explain the treatment in fairly simple terms. The nurse cannot expect as much interaction with and contribution to the therapy as migh6t occur with a highly educated patient. Non-verbal communication is also important. While often discounted, body language, gestures and expressions are perhaps as important as actual words in communicating with a patient. The patient and the nurse may come from different cultural backgrounds where non-verbal communication may connote a variety of different meanings. Thus a culture in which touching is commonplace will have a different view of a lack of touching than a more standoffish group. The reverse is also true. Both verbal and non-verbal communication are essential for developing a sense of rapport. Rapport develops by displaying a caring, warm, friendly approach by having a non-judgmental attitude and coming to a mutual understanding (Boyd 2003, p.180). Validation is also a part of rapport: it involves immediate feedback from the patient following observation by the nurse on how a patient is feeling or what they thinking. One important therapeutic exercise is the adoption of a realization of personal space. This is a useful concept, because the various boundaries and types of personal space are common among different cultures (Stein-Parebury 2005, p.139). The areas of personal space are as follows: Public area: 3.6 meters < Social Area: 1.2 – 3.6 meters Personal Area: 46 cm – 3.6 meters Intimate Area: 15-46 cm. In nursing it is vital to protect the personal zone of the patient. In order for effective communication to occur it is essential to establish a zone which is comfortable for both the nurse and the patient. Lastly, it must be noted that many patients are very vulnerable on admission to a facility or at the start to therapy. They often mistake professional caring for personal or romantic friendship (Boyd 2005, p.181). The actual nature of the relationship needs to be clarified promptly and certainly in order to avoid embarrassment and damage to the therapeutic relationship. Some degree of identification with the nurse may be inevitable within the patient, but this should be kept strictly within the bounds of professional ethics. Alcohol abuse also effects partners and families. Develop an education program that aims to assist partners in this area. Include an outline of the topics to be covered and rationales for each topic. Overall the education program should seek to give knowledge to the family of the patient that they would not otherwise have, while being sure that this knowledge is relevant to the individual case. Thus the education program should not be a generic type of fact-based course that would be taken by a student seeking to become a mental health professional, but rather one tailored to the unique characteristics, challenges and opportunities offered by the individual patient that the family is trying to help. 1. Alcohol Withdrawal: Signs and Symptoms Alcohol withdrawal occurs when a person who is dependant on alcohol stops drinking, it usually occurs between 6 – 24 hours after the last drink (Treatment Protocol Project 2000b, p. 479). Symptoms of alcohol withdrawal can include restlessness, anxiety, sweating, fast heart rate, high blood pressure, nausea, vomiting, tremors, seizures and delirium tremens (also known as the “DT’s”). The DT’s can consist of loss of insight, hallucinations, confusion, loss of insight and disturbed sleep. Alcohol withdrawal can be life threatening and it is important to seek help during this time (Treatment Protocol Project 2000, pp. 479 - 480). The rationale for including this topic is that alcohol withdrawal syndrome is a potentially life threatening condition that can cause death. Knowledge of the signs and symptoms of alcohol withdrawal can lead to early intervention thus avoiding a possible life-threatening situation (Boyd 2005, p. 535). The family may well have longer and more complete contact with JG than the nurse, and so they should be able to identify when he is going through withdrawal. 2. The Use of Medications: Action, Dosage, Frequency and Effects Once again the idea that knowledge is power is at work here. Medications such as diazepam, or valium, control the symptoms of alcohol withdrawal by producing sedation and decreasing anxiety (Boyd 2005, p. 535; Treatment Protocol Project 2000a, p. 141). The importance of using Valium in alcohol withdrawal is to decrease the risk of seizures that can occur in the first 48 hours following the last drink (Boyd 2005, p. 535). Dosage for valium is usually in the range of 5mg to 10 mg given every 2 – 4 hours, if delirium occurs higher doses may be given and monitoring is required to prevent overdose (Boyd 2005p. 535). Adverse effects of diazepam use include day time drowsiness, dizziness and can be dangerous if taken with alcohol (Treatment Protocol Project 2000a, pp. 141 - 143). The rationale for including this topic is that diazepam is an important component of an alcohol withdrawal treatment plan to manage potentially life threatening seizures, knowledge of the use for this drug will assist the family to monitor the effectiveness of treatment for adverse effects from alcohol withdrawal (Boyd 2005, p. 535). Emphasis will be laid on the particular medications that JG will be taking and their likely effects on him. The family should not be overloaded with information about the huge array of drugs that are available to all alcoholics, but rather the specific drugs that are being used with JG. This information will be practical and of obvious use to them. 3) Coping Strategies Within this category of the education program the family will learn to cope with their own reaction to a highly stressful and what will be at times frightening situation. Coping is the skill used to manage the emotions that are created by a situation; it is usually an automatic process that occurs depending on the level of stress involved (Boyd 2005, p. 781). Two methods of coping are the problem based and emotion-focused methods. The problem-based method of coping looks at the problem and changes the effect from that problem; the emotion-focused method allows the person to reinterpret the situation allowing an alternate tact on the issue (Boyd 2005, p. 781). The rationale for including this topic is knowing alternate methods of coping can assist the spouse to better manage stressful situations thus avoiding unnecessary confrontations and they can also assist in helping their spouse deal with stressful events (Boyd 2005, p. 781). In the particular case of JG, the wife has been abused (both physically and mentally) by him, and may feel resentment towards him. The spouse needs to learn how to cope with these emotions, enabling her to move beyond them into a stage where she can help with JG’s recovery process. The education program needs to stress that these emotions are not ‘wrong’, but are rather a natural reaction to being hurt. However, it must be just as clear that the emotions should play as little role as is feasible within the treatment program. 4) Structured Problem Solving While risking becoming too intellectual and moving too far away from the actual case of JG, this type of approach may work if the family is receptive to it. Structured problem solving assists the family to apply problem-solving skills to manage problems and meet goals in everyday life (Treatment Protocol Project 2000a, p. 39). The six step method of problem solving identifies the problem, looks at possible solutions by brainstorming ideas, evaluates those solutions, chooses the best solution, makes plans for how the solution will be worked out and to review the effectiveness of the solution so adjustments or alternate solutions can tried (Treatment Protocol Project 2000a, pp. 40 - 41). The rationale for including this topic is the skills will assist the family to deal with issues by constructively looking at a range of solutions to everyday issues that impact on relationships whilst assisting the alcoholic to find alternative ways of dealing with problems rather than turning to alcohol (Treatment Protocol Project 2000b, p. 492). 5) Safety Plan The goal of the safety plan is to assist the spouse to recognise the signals of impending danger. Increased drinking and subtle changes in behaviour can indicate that the person is loosing control, being able to notice these changes and have a plan to leave will assisting in avoiding potentially dangerous situations (Boyd 2005, p. 848). The rationale for including this topic is for self protection of the spouse, thinking rationally and recognizing the signs that precede abusive situations will allow time for an action plan to be initiated thus avoiding abuse (Treatment Protocol Project 2000a, p. 39). Positive outcomes for the recovery of substance abuse are dependant on several different factors. Identify factors that will promote positive outcomes. Factors leading to positive outcomes for JG include, cognitive function, readiness to change drinking behaviour, effective coping strategies, self efficacy, spousal and family attitudes and adherence to pharmacotherapy. Intact cognitive functioning leads to positive outcomes as information retention paves the way for the development of new coping methods thus preventing relapse (Ciracaulo, Piechniczek-Buczek & Iscan 2003, p. 386). Substance abuse outcome can depend on the willingness of the person to change their substance taking behaviour (Treatment Protocol Project 2000b, p. 481). Successful treatment outcomes may depend on what stage the person is at, Prochaska & DeClemente (cited in Treatment Protocol Project 2000b, p. 481) discuss the five stages of change, these stages reflect the persons willingness to change their substance abuse behaviour. The first stage is the precontemplative stage, this stage occurs when the individual is not thinking about changing, the next stage is the contemplative stage and occurs when the individual is aware of the problems caused by the substance abuse but are not ready to initiate change. The next stage is the preparation stage and occurs when the individual is preparing to change behaviour, the following stage is referred to as the action stage and begins when treatment is underway and the last stage occurs following treatment that put into place strategies for ongoing behaviour changes to successfully deal with relapse of substance abuse behaviour (Treatment Protocol Project 2000b, p. 481). Effective coping strategies relate to the ability of the person to have mechanisms in place in respond to stress and stressful situations. Stress has been shown to play a role in increasing alcohol use, seeking treatment and precipitating relapse, although stress can be seen to be a factor in predicting outcome, having effective coping plans can be a greater positive outcome predictor (Ciracaulo, Piechniczek-Buczek & Iscan 2003, p. 386). A form of coping strategy called substitute dependencies such as self help or religious groups can be seen as an indicator in positive outcomes, in this case the self help and religious groups are used for support through difficult periods (Ciracaulo, Piechniczek-Buczek & Iscan 2003, p. 387). Self efficacy refers to the ability of the person to believe they can effectively deal with the situation at hand and maintain abstinence, psychosocial factors such as marital status and education can influence self efficacy (Ciracaulo, Piechniczek-Buczek & Iscan 2003, p. 388). Maintaining self efficacy in situations where resisting alcohol is difficult has been shown to improve long term abstinence (Demmel & Rist 2005, p. 5) Cognitive behaviour therapy can lead to increased self efficacy, thus improving outcome (Ciracaulo, Piechniczek-Buczek & Iscan 2003, p. 388). Spousal and family attitudes, refers to the approach of family members and spouses as well as the emotions expressed on a regular basis. Abstaining from drinking requires support, reassurance and understanding from spouses and family, outcomes improve with positive comments, affection and emotional connection (Ciracaulo, Piechniczek-Buczek & Iscan 2003, p. 388). Pharmacotherapy such as naltrexone has been linked to improved outcomes in some studies where there are elevated craving levels. Those who have an early onset and family history of alcoholism have been shown to respond positively to pharmacotherapy and when behavioural methods are employed (to assist with medication adherence) outcome has improved (Ciracaulo, Piechniczek-Buczek & Iscan 2003, p. 390). Normal adolescent behaviour can be similar to that associated with substance abuse. How would you differentiate this normal behaviour from possible substance abuse or dependence? Adolescence marks a time in life where young people trial the things that signify adulthood such as alcohol, smoking, sex, driving and drug use. Some risk taking behaviour is considered normal (even healthy); exploration of life contributes to personal growth whilst the adolescent finds his or her identity (Carr–Gregg, Enderby & Grover 2003, pp. 1 - 2). Usually, for most adolescents, experimentation does not result in major problems though for some experimentation leads on to dependence (Usher, Jackson & O’Brien 2005, p. 209). Carr-Greg, Enderby & Grover (2003, p. 6) cites the inner self, the family, the school and the peers as being the areas of influence in the adolescent. Firstly the inner self; this includes temperament, self-esteem plus mental and general health. Secondly, the family, this includes family dynamics, relationships, culture and spirituality. Thirdly, the school; including sporting and academic success and peer and teacher interactions, lastly the peers, this includes friendships, activities, social and antisocial groups (Carr-Gregg, Enderby & Grover 2003, pp. 6 – 10). Significant social factors attributed to adolescent substance abuse include, peer influence, false perception that alcohol reduces tension, community traits and dense population and high levels of crime. These social factors can induce reality avoidance and abnormal behaviours resulting in substance use (and abuse) (Boyd 2005, p. 530). The main difference between dependence and abuse of a substance is the person with an abuse problem does not experience loss of control (even though there may be accompanying medical and social issues), whereas a person who is dependent on a substance will have a compulsion to use a substance even when there are harmful ramifications and are usually in a state of denial about the effects this has on themselves and other people (Mersy 2003, p. 2). Substance dependence is associated with the overriding need to take a substance along with the inability to control that need, difficulty in controlling its use, as well as associated problems because of continued substance use (Treatment Protocol Project 2000b, p. 476). Withdrawal symptoms occur as a result of cessation, toleration occurs due to ongoing intake of substance resulting in the need to increase substance amounts to have the same effect (Boyd 2005, p. 560). Similarities in the catalysts for drinking can be seen between the older person and adolescent. Dysfunctional family interactions, between parent and child or between spouses are linked to alcohol use and result in avoidance behaviour that exacerbates the original problems (Jacob, Leonard & Haber 2001, p. 842). Poor scholastic or employment performance can initiate or worsen drinking, the adolescent in this case may drink to rebel against the system (Usher, Jackson & O’Brien 2005, pp. 209 – 210) and the older person will often drink to avoid the problem (Wiscott, Begovic & Kopera-Fry 2002, p. 254). After JG is free of withdrawal symptoms he expresses interest in obtaining treatment for his addiction. What are his options? How would you describe them to him? Options for treatment of alcohol addiction include twelve step programs such as Alcoholics Anonymous, cognitive and cognitive behavioural therapy, improving coping skills, group therapy and early recovery, individual and family therapy (Boyd 2005, pp. 555 – 559) and harm minimization (Plant 2004, p. 905). Harm minimization refers to reducing the harm to individuals and communities from alcohol abuse, a reduction in drinking is the aim with abstinence being seen as a separate option, this allows a reduction in the risks from alcohol (NSW Health DATE, p. ; Plant 2004, p. 90). Alcoholics Anonymous (AA) is a support group that assists people with alcohol addiction providing support both through meetings and on an individual basis. These meetings can be open, allowing any interested person (with or without a drinking problem) to attend or closed meetings, specifically for AA members or those who wish to abstain from drinking. The AA participant will usually have a sponsor that has been sober for a minimum of one year that provides ongoing support (Feillin, Reid & O’Connor 2000, p. 821). AA and other 12 step programs are based on twelve steps or principles that are followed through on a daily basis, providing hope by example, encouraging support seeking from others and listening to others, encourages friendships and sharing of experiences with sober individuals and has a spiritual element to improve your standard of life (Boyd 2005, p. 555). Research shows that high levels of attendance to these meetings whilst undergoing other forms of therapy often results sustained abstinence thus improving outcomes (Research refines alcoholism: Treatment options 2000, p. 57). Cognitive and cognitive behavioural therapy is based on counselling sessions that use a range of techniques to identify and examine the reasons behind the substance abuse applying behavioural and cognitive approaches to change destructive thinking (Carroll & Onken 2005, pp. 1452 – 1454). Motivational enhancement therapy uses motivational approaches for the patient in order to obtain sobriety, achieved by the patient recognising and using their inner strengths to sustain sobriety (Fiellin, Reid & O’Conner 2000, p. 821). Motivational therapy explores all aspects of behaviour, general satisfaction with life (linking to role of behaviour) and assisting the person to prepare for change. This is a type of brief therapy that builds up over time and is seen in general practice settings (Treatment Protocol Project 2000a, pp. 34 – 35). Improving coping skills is a relapse prevention strategy, usually attended as group therapy. This type of therapy looks at learning new skills or behaviours that assist with management of alcohol cravings such as problem solving, awareness and management of anger and negative thinking, drink refusal skills, improving social alliances and relaxation training. Role playing is a key aspect to this therapy, with group members giving feedback to the methods used, enhancing new skills learnt (Boyd 2005, p. 558). Group therapy sessions focus on the ongoing recovery process, with the focus staying on abstinence from alcohol, looking at the here and now (not at past issues). These groups help reduce isolation, offer a sense of hope, help each other learn by example, a place to exchange information, to change unrealistic behaviours and provide an arena for family like interaction. Problem solving techniques are employed to continue sobriety (Boyd 2005, p. 558). Individual therapy can be used as an adjunct to group and family therapy, it is provided by a counselor. There are three stages, the first stage addresses the dynamics surrounding the issues, improves motivation to stay sober. The second phase uses cognitive behavioural therapies to address urgent concerns and the third phase focuses on relationships and independence, often touching on childhood issues. Counselors assist in the continued focus of goals and use problem solving techniques to deal with ongoing issues (Boyd 2005, p. 559). Family therapy can be brief or long term, can occur in conjunction with other therapies such as individual therapy, helps stabilise relationships and promotes abstinence from alcohol. Family therapy allows families to identify problem behaviours and issues as a result of alcohol dependance. Behavioural couples therapy is an example of family therapy, the aim is to improve marital communication, to decrease domestic violence and verbal abuse by isolating and addressing the trigger factors that decrease family functioning (Boyd 2005, p. 559). To conclude, Mr JG will be assisted by the nurse to manage his alcohol detoxification by providing an environment which is patient focused, non judgmental and empathetic whilst being respectful of personal boundaries which ultimately results in the establishment of rapport. This allows for effective communication between all parties and results in a therapeutic relationship. The education of partners assists in managing the effects of alcohol abuse on families by identifying the symptoms of alcohol withdrawal. Developing coping and planning skills assist partners to identify alternate solutions to issues thus alleviating stress and providing some focus in the area of available options to alcoholism treatment and support. Positive outcomes for Mr. JG will depend on factors such as self-efficacy, present coping abilities, family attitudes and cognitive function. Substance use is normal in the adolescent with alcohol being an easily accessible substance; experimentation is a learning tool that contributes to personal growth, whereas in the adult substance use and abuse occurs to sustain an ongoing need for a substance resulting in tolerance requiring increased amounts to sustain the same effect. There are many treatment options available, abstinence is not the only option available, harm minimization is an option endorsed by NSW Health that reduces the harm to communities and individuals from the harmful effects of alcohol. Ultimately issues caused through substance abuse affect not only the individual but families, friends, co-workers and the community as a whole, abstinence requires a great deal of support and as a health professional the nurse is in the position of assisting the person with a substance addiction through detoxification, presenting treatment options for addiction that will assist in addressing the personal and social issues that accompany substance abuse. Reference Page Al-Anon 2004, Fact Sheet for Professionals: Information about Al-Anon and Alateen, Al-Anon Family Group Headquarters Inc., Virginia Beach, U.S.A., pp. 1 – 2, Viewed 1 October 2005, . Australian Government Department of Family and Community Services 2004, Families & friends affected by the drug or alcohol use of someone close, NSW Department of Health, Sydney, pp. 25 – 27, viewed 1 October 2005, . 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Feillin, D, Reid, C & O’Connor, P 2000 ‘Outpatient management of patients with alcohol problems’, Annals of Internal medicine, vol. 133, no.10, p. 821, viewed 22 September 2005, . Reference Page Jacob, T, Leonard, K & Haber, J 2001, ‘Family interactions of alcoholics as related to alcoholism type and drinking condition’, Alcoholism: Clinical and Experimental Research, vol. 25, no. 6, p. 842, viewed 1 October 2005, . Mc Allister, M, Matarasso, B, Dixon, B & Shepperd, C 2004, ‘ Conversation starters: re – examining and reconstructing first encounters within the therapeutic relationship’, Journal of Psychiatric and Mental Health Nursing, vol. 11, pp. 575 – 576, viewed 2 September 2005, . Mersy, D 2003, ‘Problem – orientated diagnosis: Recognition of alcohol and substance abuse’, American Family Physician, vol. 67, no. 7, p. 2, viewed 29 September 2005, . Moyle, W 2003, ‘Nurse-patient relationship: A dichotomy of expectations’, International Journal of Mental Health Nursing, vol. 12, no. 2, p. 1, viewed 2 September 2005, . Plant, M 2004, ‘The alcohol harm reduction strategy for England’, BMJ, vol. 328, p. 905, viewed 3 October 2005, . Research refines alcoholism: Treatment options, 2000, Alcohol, Research and Health, vol. 24, no. 1, p. 57, viewed 24 September 2005, . Stein-Parbury, J 2005, Patient & person: Interpersonal skills, 3rd edn, Elsevier, Churchill Livingston, Marrickville NSW, pp. 51 – 139. Treatment Protocol Project 2000a, Management of Mental Disorders, 3rd edn, vol. 1, World Health Organization Collaborating Center for Mental Health and Substance Abuse, Sydney, pp. 34 – 143. Reference Page Treatment Protocol Project 2000b, Management of Mental Disorders, 3rd edn, vol. 2, World Health Organization Collaborating Center for Mental Health and Substance Abuse, Sydney, pp. 476 – 492. Usher, K, Jackson D & O’Brien, L 2005, ‘Adolescent drug abuse: Helping families Survive, International Journal of Mental Health Nursing, vol. 14, pp. 209 – 210, viewed 3 October 2005, . Welch, M 2005, ‘Pivotal moments in the therapeutic relationship’, International Journal of Mental Health Nursing’, vol. 14, p. 165, viewed 28 September 2005, . Wiscott, R, Begovic, A & Kopera-Fry, K 2002, ‘ Binge drinking in later life: Comparing young-old and old-old social drinkers’, Psychology of Addictive Behaviours, Vol. 16, no. 3, p. 254, viewed 18 September 2005, . Read More