Addictive Disorders and Substance Abuse

 

Remington C. Longstreth

Substance Abuse and Addiction Midterm Exam

American Military University

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  1. Explain, in terms a layperson could understand, the neurobiology of drug tolerance, dependence, and withdrawal.

Chronic substance use and abuse may stem from a variety of etiologies including neurobiological, social and historical. Neurobiological contributors are innumerable. The brain has an inherent reward circuit which promotes and encourages certain behaviors, including substance abuse. The euphoric effects of certain drugs make it tempting to the user to engage in repeated and even chronic use, even though there are dangerous and adverse health effects to substance abuse. Recreational use or experimentation with some illicit substances will have a neurobiological impact that can trigger strong cravings that can contribute to repeat use and even chronic abuse. Some studies suggest some are more neurobiologically prone to developing a substance use disorder (SUD) than others.

Another example is stress in daily life and its associated release of cortisol in the brain. Some studies suggest that those more susceptible to stress and therefore cortisol release, are more likelihood to engage in maladaptive coping mechanisms, such as illicit substance abuse. Cortisol is a hormone that can increase the euphoric effects of some drugs (Mack, 2016). This dynamic may be an appealing escape to a substance user under sever stress. Over time and with repeated use, substance abusers will experience neurobiological changes in the brain and feel a need to increase their drug intake to achieve the same euphoric feelings (Mack, 2016). This is the beginnings of developing a drug tolerance. Drug tolerance can lead to: dependence, withdrawal and a substance use disorder.

Drug tolerance is a feeling to take more of a drug to achieve the same high or effect (Mack, 2016). The evidence suggests that brain cell receptors are less reactive to drug effects with repeated and chronic use (Mack, 2016). Therefore, the user will need to increase their intake of the drug to feel the same levels of euphoria. For example, dopamine will be released at lower levels or with less intensity in a chronic opioid user, when compared to someone who has only used the substance once. Transmitters and receptors of brain cells will have a significant chemical reaction for a new user and a sluggish or insignificant reaction within the brain of the chronic abuser.

Drug dependence occurs when a patient needs a particular substance for normal daily functioning. For example, a chronic opioid user may experience tremors, anxiety, muscle cramps or diarrhea (Mack, 2016) when the user commits to abstinence. These are common feelings of withdrawal and if experienced, it can be said that the user has a drug dependence. The dependent user will naturally want to avoid the severe and painful withdrawal symptoms and continue drug usage, if treatment programs are not readily available.

Withdrawal is considered a syndrome with severe side effects similar to flu-like symptoms in other cases. For some opioid users, early states of withdrawal can include, yawning, agitation and anxiety (Mack, 2016). Later signs and symptoms of opioid withdrawal can include nausea, diarrhea and vomiting (Mack, 2016). One quick but maladaptive way to avoid withdrawal symptoms, is to continue to use the substance. Withdrawal symptoms can be painful and are also evidence that the individual has developed a dependence on the substance. Withdrawal, dependence and tolerance are all interfacing players on the same neurobiological stage – that is the brain. For example, withdrawal symptoms manifest when a patient has developed a drug dependence. Likewise, withdrawal only occurs after the patient has created a drug tolerance. In other words, tolerance is the precursor for both withdrawal and dependence.

 

Mack, A. H. (2016). Clinical Textbook of Addictive Disorders. New York: The Guilford Press.

 

  1. Choose one of the following areas and broadly recount its socio-historical path:
    1. Models of substance use
    2. Substance abuse treatments
    3. The social/self-help movements
    4. Treatment and prevention efforts

Treatment and prevention of substance abuse has been a human struggle for millennia. There are numerous modalities for treatment and prevention including: substance-focused strategies, Galenic medicine, pharmacological treatments, national government interventions, abstinence-oriented social movements, self-help groups and religious interventions (Mack, 2016). Substance-focused strategies have historically included a gradual reduction in the dosage of drug and isolation from the drug (Mack, 2016). A Civil War Physician named Benjamin Rush advocated for the latter of this strategy. Isolation from the drug could be within a drug-free zone, church or monastery. Isolation would also include separation from other substance users or abusers. The program would separate any environmental setting that would trigger cravings or encourage substance use.

Galenic medication models seek to identify the etiology of the substance use and abuse. Withdrawal symptoms would be sought and identified before a regimen for treatment could be prescribed. This program sought to tailor treatment for the individual and their particular struggle with the given substance. Galenic medication programs was developed by and named after the ancient Greek physician and philosopher, Aelius Galen.

Pharmacological treatments for substance abuse attempt to link medication to social situations. For example, the medication disulfiram is prescribed to those who have been diagnosed with alcohol abuse disorder. In social settings, disulfiram can help those with the disease to continue to abstain from drinking, where there may otherwise be social pressure (Mack, 2016). Likewise, opioid addicts can be prescribed naltrexone to ease the withdrawal symptoms of opioid dependence (Mack, 2016).

The national government has also attempted to prevent and treat substance use and abuse to little avail. The Harrison Act of 1914 sought to reduce opioid use in the United States (Mack, 2016). The prohibition period of the 1920s sought to eradicate the buying or selling of alcohol. However, these efforts were ultimately defeated in 1933 (Mack, 2016). The federal government also stood up multiple entities including the National Institute of Mental Health (NIMH), the National Institute on Drug Abuse (NIDA), the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) (Mack, 2016). In addition, the Nixon Administration wages a War on Drugs during the 1970s that has largely been viewed as costly and inefficient. Substance use still remains in the US and has steadily risen among adolescents in recent decades (Mack, 2016). Federal programs have also halted initiatives that have shown some success, including heroin dispensary clinics (Mack, 2016), due to political lobbying by conservative antidrug efforts.

Abstinence-oriented programs have historically been initiated by religious and cultural groups. Certain South Asian sects and Native American reservations have continued abstinence programs that were developed over two-thousand years ago (Mack, 2016). Health clubs are another group that promote abstinence as a social movement. In the social media and information age, there are numerous pages, websites, channels and other conduits of communication that encourage their members to remain on the wagon, issues guidance, advice and tips to staying sober through shared experience.

Self-help groups are another means of organization to fight against substance abuse. One of the best-known self-help groups is alcoholics anonymous (AA). Those who struggle with substance use and abuse can attend (AA) meetings to share their experience with others who are similarly situated. Some find the exercise helpful when an empathetic ear is listening to their experience. This network of social support reminds individuals that they are not alone in the fight against substance use and abuse. Other like-minded groups have benefitted from (AA) forging a pathway to sobriety. Today there are numerous self-help groups including: Narcotics Anonymous, Cocaine Anonymous, Overeaters Anonymous, Gamblers Anonymous and Emotions Anonymous (Mack, 2016). These organizations have assumed a welcoming posture and generally accept individuals who refer to themselves as an “addict” (Mack, 2016).

 

Mack, A. H. (2016). Clinical Textbook of Addictive Disorders. New York: The Guilford Press.

 

  1. In considering both psychological evaluations and laboratory assessments of substance use disorders, discuss the factors which you consider to be most pressing in determining which type(s) of assessment(s) to administer – those factors may be related to the client, to the substance being used, and/or to the assessment tools themselves.

In psychological evaluation of substance use disorders (SUDs), the most pressing factors are: the reliability and validity of diagnoses, severity of symptoms and treatment decisions. Diagnostic assessment is said to possess reliability if two diagnosticians come to the same diagnosis (joint reliability) or when a second test is administered and comes to the same conclusion (test-retest reliability) (Mack, 2016). Reliability has to be established before validity can be confirmed (Mack, 2016).

A psychological test is said to be valid if it measures what it claims to measure (Mack, 2016). For example, if a psychological test is said to determine a particular (SUD), then the subsequent diagnosis should be appropriate for the individual being tested. Compared to reliability, validity is more complex to establish with diagnostic assessments and instruments (Mack, 2016). There are many forms of validity including: face validity, content validity, concurrent validity, convergent validity and predictive validity. A diagnostic tool is said to possess face validity if the variable in question is measured with accuracy. Content validity exists where the instrument categorically covers all aspects of the phenomenon being measured. Concurrent validity allows a diagnostician or clinician to predict other symptoms, manifestation or characteristic of the measure being tested (Mack, 2016). Convergent validity exists where a diagnostician is able to predict the natural reaction or convergence of the internal measure being tested with external forces (Mack, 2016). Predictive validity refers to the clinician or diagnostician’s ability to predict future and natural courses of action during treatment and possible future behavioral proclivities of the patient (Mack, 2016). Observational assessment is only one tool for examining substance abuse disorders. Employers, clinicians and diagnosticians also have laboratory assessments at their disposal.

Laboratory assessments examine hair, saliva, urine or blood samples among other means. Laboratory assessments may be pleasing to the examiner who is searching for empirical evidence that an illicit substance is being used or abused. However, laboratory assessments are not without their limitations. Pressing factors of laboratory assessment include: accurate results, cost and prevention of drug use in the respective workplace. Unfortunately, it is possible to yield a false positive or negative in laboratory assessment. Preserving the integrity in the chain of custody is paramount. If the chain of custody is compromised or the integrity of the assessment is otherwise spoiled, then its deterrence effects, subsequent diagnosis and treatment options could be curtailed. For example, the military uses laboratory assessments to deter drug use and maintain order and discipline within formations. Secondly, if a soldier is falsely accused of having an illicit substance within their system, this could have unfair and adverse legal consequences to both the soldier and the unit.

Cost is also a concern vis a vis laboratory assessment. While urine tests are the least expensive, blood tests are the most expensive and can be a financial burden to some private companies or public monies. Taxpayers may foot the bill when law enforcement officials conduct laboratory assessment via blood tests with suspects of DUI investigations. The cost of the laboratory assessment not only varies by method of test, but also by the substance it seeks to identify. For example, steroid laboratory assessments are expensive. With the growing number of steroid variants on the market, laboratory assessments may fail to detect the substance. Costs can be compounded if false results are rendered or if an individual is combating the laboratory assessment with a doctored or manipulated specimen.

 

Mack, A. H. (2016). Clinical Textbook of Addictive Disorders. New York: The Guilford Press.

 

  1. Characterize the three specific factors you believe are most important for a basic understanding of each of the following substances of abuse.  Be sure to justify your choices using only about 100 words for each:
    1. Alcohol
    2. Nicotine
    3. Opioids
    4. Cannabis
    5. Hallucinogens & Inhalants
    6. Stimulants
    7. Cocaine
    8. Sedatives/Hypnotics & Benzodiazepines

The three most important factors to understand vis a vis alcohol are: 1) the effects; 2) comorbidity; and legal consequences. First, there is a litany of physiological effects from consuming alcohol. Effects include but are not limited to: brain damage, intoxication, delirium, anxiety, sexual dysfunction, sleep disorder, liver damage, gastrointestinal tract damage, pancreatic damage, cardiovascular dysfunction, cancer immune system degradation, musculoskeletal damage, skin problems and adverse effects to the fetus if the woman is pregnant (Mack, 2016).

Secondly, it should be noted that those with a dependence on alcohol are five times more likely to either use or abuse another drug. Bipolar I and II disorder is twice as likely to manifest among those individuals with an alcohol dependence (Mack, 2016). This latter groups of individuals are significantly more at risk to develop suicidal ideations or engage in suicidal behavior. Those with anxiety disorder may be particularly prone to developing alcohol use disorder.

Lastly, the public should be aware of the legal ramifications that may follow binge drinking alcohol or engaging in heavy drinking. While there is no clinical distinction for the onset of intoxication: legal intoxication is marked with 80 mg% (Mack, 2016). Clinically speaking, intoxication symptoms can generally be observed at 50 mg% (Mack, 2016). Individuals should not operate heavy machinery or a motor vehicle if they are intoxicated. This could lead to criminal charges, arrest, conviction and harsh sentencing. In addition to criminal consequences, an individual convicted of driving under the influence (DUI) is also subject to civil litigation.

The three most important factors to understand vis a vis nicotine are: (1) the effect; (2) comorbidity realities; and (3) treatment options. Physiological effects of nicotine are extensive and include but are not limited to: respiratory complications, cardiovascular disease, inflammation of veins and arteries and adverse effects on prefrontal cortical function (Mack, 2016). Comorbidity also exists for nicotine users. Those with psychiatric disorders are approximately twice as likely to use nicotine (Mack, 2016). This population is also more likely to be a heavy smoker when compared to the general public (Mack, 2016). One is considered a “heavy smoker” if they consume more than 25 cigarettes a day. Lastly, there are a variety of treatment plans available for those who want to quit nicotine use. Studies suggest that 70% of people who smoke want to quit and 50% have tried to quit at least once each year (Mack, 2016). Nicotine replacement therapy (NRT) currently has five variants on the market: transdermal patches, gum, nasal spray, inhalers and lozenges (Mack, 2016). There are also placebo and nonmedicated options such as bupropion slow release (SR) (Mack, 2016).

The three most important factors to understand vis a vis opioids are: (1) treatment options; (2) the dangers of prescribed opioids in pill form and (3) negative side effects. Treatment options include: methadone maintenance treatment (MMT), buprenorphine and naltrexone (Mack, 2016). Prescription and semi-synthetic opioids include: hydrocodone, oxycodone, oxymorphone, nalbuphine and diacetylmorphine (Mack, 2016). These drugs can be legally prescribed to patients who are suffering from severe physical pain. Unfortunately for some, the prescription medication can be addicting, leading to misuse and abuse. It is possible for some individuals to search the streets for heroin after their medical provide discontinues the prescription. Prescription opioids are the second most commonly used drug in the United States, trailing only cannabis (Mack, 2016). Individuals access these potent drugs through either a physician or family and friends. Studies suggest that opioid users or abusers are in search of the euphoric feeling it delivers, pain relief or to help with sleep. Lastly, there are an innumerable amount of negative side effects associated with opiate misuse including: fatal overdose, hepatitis, HIV and spontaneous abortion for pregnant women (Mack, 2016).

The three most important factors to understand in relation to cannabis are: risks, comorbidity and treatment options. First, the public perception within the United States is ever evolving, as the debate regarding the possession and use of cannabis is gravitating towards decriminalization. States including: Alaska, California, Minnesota, New York and Oregon et al. have decriminalized cannabis use under a varying threshold of grams. Colorado is another state that has decriminalized cannabis use and even allowed cannabis growers ands sellers to solicit the adult public in legitimate business forums. Colorado’s state government taxes cannabis sales and use and has allotted the revenue to improve schools, infrastructure and other civil programs. While the law is becoming more liberal and progressive compared to earlier decades, cannabis use is not without its negative side effects. In addition to the negative effects of smoking cannabis on the cardiovascular and respiratory systems, health concerns include: anxiety and depression. Some users suggest they consume cannabis to manage their stress. However, some studies suggest that cannabis users have a lower tolerance for stress and anxiety after they have consumed cannabis for a period longer than one year (Mack, 2016). This cycle may increase stress, anxiety and cannabis use. In addition, chronic cannabis users may also have difficulty in concentrating and performing executive functioning (Mack, 2016).

Secondly, comorbidity seems to exist within populations that use and abuse cannabis. There is some evidence that chronic cannabis use and panic attacks are related. These individuals seem to be more prone to them when compared to the general population. Those with posttraumatic stress disorder are three times more likely to have a dependence on cannabis. Furthermore, the evidence suggests that cannabis users have a disproportionate number of individuals with ADHD (Mack, 2016). There is also a statistical significance between psychosis and chronic cannabis use.

Treatment options for cannabis include: psychotherapy, lithium, valproate, antidepressants and buspirone (Mack, 2016). While lithium and valproate have yielded ambiguous results, there seems to be more promising effects with buspirone. The psychoactive cannabinoid in this substance is THC (Mack, 2016). Some studies have shown that the pill form of THC can be useful to treat cannabis dependence. There are also less adverse health effects when the illicit drug is taken in pill form, rather than smoked. The THC dosage in pill form can be controlled and slowly reduced, ultimately leading to cessation or abstinence.

The three most important factors to consider with regard to hallucinogens and inhalants are: (1) adverse health effects; (2) adverse psychiatric effects and (3) addictive nature. First, adverse health effects of hallucinogens include but are not limited to: unresponsiveness to pain, hyperreflexia, fatal overdose and hypertension. Adverse psychiatric effects include: psychotic, depressive spectrum disorders and bipolar disorder (Mack, 2016). Unlike other substances discussed, there is no legitimate medical use for hallucinogens because of their highly addictive liability (Mack, 2016).

Inhalants also carry adverse health effects including: permanent brain injury, cardiac dysfunction, intoxication, bone marrow damage, renal and sensory damages are all possible. Inhalant-induced disorders include: delirium, anxiety, mood disorders and psychosis (Mack, 2016).

The three most significant factors to understanding regarding stimulants are: (1) adverse health effects; (2) adverse psychiatric effects and (3) treatment options. Adverse health effects include: elevated blood pressure, dizziness, fever, sweating, rapid breathing, tremors et al. (Mack, 2016). Psychiatric effects of stimulants include: anxiety, mood and psychotic disorders. Treatment options for stimulants include: placing the individual in an environment of quiet and calm (Mack, 2016). More aggressive treatment options include the prescription of benzodiazepines or neuroleptics (Mack, 2016).

The three most important factors to understand associated with cocaine are: (1) negative health effects, (2) associated societal harms and (3) treatment options. Negative health effects of cocaine include: intoxication, fatal overdose, withdrawal, increased heart rate, increased blood pressure, tremors and reduction of appetite. Some social scientists in conjunction with law enforcement agencies, such as the DEA, have argued that the increased purity of street cocaine has led to an increase in familial and societal harm. Cocaine can lead to fatal overdose among users and abusers. Some users, in a desperate attempt to achieve the euphoria of cocaine, have committed violent crimes including robbery or burglary of an occupied dwelling. This speaks to the highly addictive nature of this substance. Treatment options include: behavioral treatment programs, cognitive behavioral therapy (CBT), motivational interviewing and family therapy.

The three most important factors of consideration regarding sedatives, hypnotics and benzodiazepines are: (1) an appreciation for the distinction between medical and nonmedical uses for the substance (Mack, 2016), (2) long-term effects of chronic use and (3) treatment regimens. Abuse of benzodiazepines or use or long-term use of benzodiazepine with the supervision of a medical provider can lead to personality change, memory loss and other adverse effects on the brain. All three substances have addictive qualities and lead to painful withdrawal symptoms. These substances should never be used without a prescription or without the supervision of a medical doctor. Mere possession of most of these substances are generally punishable as a felony within the United States. Treatment options of all three drugs have included anti-depressants, which have reduced the levels of anxiety among patients during withdrawal periods.

 

Mack, A. H. (2016). Clinical Textbook of Addictive Disorders. New York: The Guilford Press.

 

  1. Choose one of the following questions:
    1. Based on your reading and understanding of the traditional substance use disorders thus far, argue either for or against considering the “behavioral” addictions like pathological gambling to be “addictive” disorders.
    2. Discuss some of the primary clinical challenges of managing pain and addiction in a clinical population.

 

Pathological gambling can and should be considered an addictive disorder. Like substance use, the act of gambling can trigger the brain’s natural reward system. When a gambler wins a large pot of money in a game of high stakes poker, her mesolimbic dopamine is released (Mack, 2016), giving her an overall feeling of euphoria, better known as a “gambler’s high.” This euphoria will motivate her to continue to gamble. If the high is euphoric and consistent enough, an addiction could manifest. If an addiction is present, she could gamble even if it is causing distress or dysfunction in her personal or professional life. Substances do not always have to be consumed to contribute to neurochemical and ergo physiological changes in the brain over time. Sex is another act that can be considered a pathological or behavioral addiction. Like substance use disorders, these addictions can cause distress, dysfunction and legal effects and are worthy of psychotherapy or medication in extreme cases, just like substance use disorders are to be considered. Gambling disorder can cause various types of distress including, familial, financial, marital or legal. Some who engage in compulsive gambling have committed crimes to continue the behavior, such as: writing bad checks, stealing and embezzlement (Mack, 2016).

The latest edition of the Diagnostic and Statistical Manual already holds similar criteria for the diagnosis of gambling disorder, when compared to substance abuse disorders. The criteria includes repeated, but failed efforts to cease the behavior, tolerance and withdrawal. If one is to hold that neurochemical compounds precede or at least contribute to behavior, then this listed criterion suggests that there may be a neurochemical basis for gambling. Furthermore, there is some research to suggest that those who gamble compulsively may have less control to inhibit such behavior (Mack, 2016). These internal and external manifestations of behavior are not unlike substance abusers.

There are four additional parallels between pathological or behavioral addiction and substance addiction, and they are as follows: (1) a euphoric feeling during the act, (2) an increased urge to continue the act, (3) diminished control to refrain from committing the act and (4) repetitive or compulsive urges to engage in the activity (Mack, 2016). Moreover, gambling disorder, like substance use disorder, seems to start during adolescence for many. Like substance abuse, gambling disorder also has comorbidity, with alcohol dependence as the leading co-vice.

There has been some pharmacological success in the treatment of gambling disorder. Opioid antagonists are one substance medicinal approach that has shown efficacy when compared to placebos (Mack, 2016). Other agents such as some amino acids (N-acetyl cysteine) have shown positive progress in the reduction of gambling behaviors. Studies have also indicated that attending and completing psychotherapy for a gambling addiction is more effective than not attending treatment.

While treating gambling addiction as a disorder is controversial to some, it has shown an acute likeness to the effects of some substance abuse disorders. Behavioral addictions such as gambling disorder, have become known as addictions without the substance (Mack, 2016). Nevertheless, significant distress and dysfunction can manifest within the individual, family unit and society as a whole. Economic and violent crimes have been committed because of all the listed behavioral or substance addictions discussed in this paper. Therefore, behavioral addictions should be treated in the same vein as substance abuse disorders. Psychotherapy and medical means should be available and supported by health care providers and insurance companies when an objective, accurate, appropriate and professional diagnosis is reached by a legitimate professional if the field of psychology or psychiatry.

 

Mack, A. H. (2016). Clinical Textbook of Addictive Disorders. New York: The Guilford Press.

 

 

 

 

 

 

 

 

 

 

 

References

Mack, A. H. (2016). Clinical textbook of addictive disorders. New York: The Guilford Press.

 

 

 

 

 

 

Remington C. Longstreth

Substance Abuse and Addiction Midterm Exam

American Military University

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  1. Explain, in terms a layperson could understand, the neurobiology of drug tolerance, dependence, and withdrawal.

Chronic substance use and abuse may stem from a variety of etiologies including neurobiological, social and historical. Neurobiological contributors are innumerable. The brain has an inherent reward circuit which promotes and encourages certain behaviors, including substance abuse. The euphoric effects of certain drugs make it tempting to the user to engage in repeated and even chronic use, even though there are dangerous and adverse health effects to substance abuse. Recreational use or experimentation with some illicit substances will have a neurobiological impact that can trigger strong cravings that can contribute to repeat use and even chronic abuse. Some studies suggest some are more neurobiologically prone to developing a substance use disorder (SUD) than others.

Another example is stress in daily life and its associated release of cortisol in the brain. Some studies suggest that those more susceptible to stress and therefore cortisol release, are more likelihood to engage in maladaptive coping mechanisms, such as illicit substance abuse. Cortisol is a hormone that can increase the euphoric effects of some drugs (Mack, 2016). This dynamic may be an appealing escape to a substance user under sever stress. Over time and with repeated use, substance abusers will experience neurobiological changes in the brain and feel a need to increase their drug intake to achieve the same euphoric feelings (Mack, 2016). This is the beginnings of developing a drug tolerance. Drug tolerance can lead to: dependence, withdrawal and a substance use disorder.

Drug tolerance is a feeling to take more of a drug to achieve the same high or effect (Mack, 2016). The evidence suggests that brain cell receptors are less reactive to drug effects with repeated and chronic use (Mack, 2016). Therefore, the user will need to increase their intake of the drug to feel the same levels of euphoria. For example, dopamine will be released at lower levels or with less intensity in a chronic opioid user, when compared to someone who has only used the substance once. Transmitters and receptors of brain cells will have a significant chemical reaction for a new user and a sluggish or insignificant reaction within the brain of the chronic abuser.

Drug dependence occurs when a patient needs a particular substance for normal daily functioning. For example, a chronic opioid user may experience tremors, anxiety, muscle cramps or diarrhea (Mack, 2016) when the user commits to abstinence. These are common feelings of withdrawal and if experienced, it can be said that the user has a drug dependence. The dependent user will naturally want to avoid the severe and painful withdrawal symptoms and continue drug usage, if treatment programs are not readily available.

Withdrawal is considered a syndrome with severe side effects similar to flu-like symptoms in other cases. For some opioid users, early states of withdrawal can include, yawning, agitation and anxiety (Mack, 2016). Later signs and symptoms of opioid withdrawal can include nausea, diarrhea and vomiting (Mack, 2016). One quick but maladaptive way to avoid withdrawal symptoms, is to continue to use the substance. Withdrawal symptoms can be painful and are also evidence that the individual has developed a dependence on the substance. Withdrawal, dependence and tolerance are all interfacing players on the same neurobiological stage – that is the brain. For example, withdrawal symptoms manifest when a patient has developed a drug dependence. Likewise, withdrawal only occurs after the patient has created a drug tolerance. In other words, tolerance is the precursor for both withdrawal and dependence.

 

Mack, A. H. (2016). Clinical Textbook of Addictive Disorders. New York: The Guilford Press.

 

  1. Choose one of the following areas and broadly recount its socio-historical path:
    1. Models of substance use
    2. Substance abuse treatments
    3. The social/self-help movements
    4. Treatment and prevention efforts

Treatment and prevention of substance abuse has been a human struggle for millennia. There are numerous modalities for treatment and prevention including: substance-focused strategies, Galenic medicine, pharmacological treatments, national government interventions, abstinence-oriented social movements, self-help groups and religious interventions (Mack, 2016). Substance-focused strategies have historically included a gradual reduction in the dosage of drug and isolation from the drug (Mack, 2016). A Civil War Physician named Benjamin Rush advocated for the latter of this strategy. Isolation from the drug could be within a drug-free zone, church or monastery. Isolation would also include separation from other substance users or abusers. The program would separate any environmental setting that would trigger cravings or encourage substance use.

Galenic medication models seek to identify the etiology of the substance use and abuse. Withdrawal symptoms would be sought and identified before a regimen for treatment could be prescribed. This program sought to tailor treatment for the individual and their particular struggle with the given substance. Galenic medication programs was developed by and named after the ancient Greek physician and philosopher, Aelius Galen.

Pharmacological treatments for substance abuse attempt to link medication to social situations. For example, the medication disulfiram is prescribed to those who have been diagnosed with alcohol abuse disorder. In social settings, disulfiram can help those with the disease to continue to abstain from drinking, where there may otherwise be social pressure (Mack, 2016). Likewise, opioid addicts can be prescribed naltrexone to ease the withdrawal symptoms of opioid dependence (Mack, 2016).

The national government has also attempted to prevent and treat substance use and abuse to little avail. The Harrison Act of 1914 sought to reduce opioid use in the United States (Mack, 2016). The prohibition period of the 1920s sought to eradicate the buying or selling of alcohol. However, these efforts were ultimately defeated in 1933 (Mack, 2016). The federal government also stood up multiple entities including the National Institute of Mental Health (NIMH), the National Institute on Drug Abuse (NIDA), the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) (Mack, 2016). In addition, the Nixon Administration wages a War on Drugs during the 1970s that has largely been viewed as costly and inefficient. Substance use still remains in the US and has steadily risen among adolescents in recent decades (Mack, 2016). Federal programs have also halted initiatives that have shown some success, including heroin dispensary clinics (Mack, 2016), due to political lobbying by conservative antidrug efforts.

Abstinence-oriented programs have historically been initiated by religious and cultural groups. Certain South Asian sects and Native American reservations have continued abstinence programs that were developed over two-thousand years ago (Mack, 2016). Health clubs are another group that promote abstinence as a social movement. In the social media and information age, there are numerous pages, websites, channels and other conduits of communication that encourage their members to remain on the wagon, issues guidance, advice and tips to staying sober through shared experience.

Self-help groups are another means of organization to fight against substance abuse. One of the best-known self-help groups is alcoholics anonymous (AA). Those who struggle with substance use and abuse can attend (AA) meetings to share their experience with others who are similarly situated. Some find the exercise helpful when an empathetic ear is listening to their experience. This network of social support reminds individuals that they are not alone in the fight against substance use and abuse. Other like-minded groups have benefitted from (AA) forging a pathway to sobriety. Today there are numerous self-help groups including: Narcotics Anonymous, Cocaine Anonymous, Overeaters Anonymous, Gamblers Anonymous and Emotions Anonymous (Mack, 2016). These organizations have assumed a welcoming posture and generally accept individuals who refer to themselves as an “addict” (Mack, 2016).

 

Mack, A. H. (2016). Clinical Textbook of Addictive Disorders. New York: The Guilford Press.

 

  1. In considering both psychological evaluations and laboratory assessments of substance use disorders, discuss the factors which you consider to be most pressing in determining which type(s) of assessment(s) to administer – those factors may be related to the client, to the substance being used, and/or to the assessment tools themselves.

In psychological evaluation of substance use disorders (SUDs), the most pressing factors are: the reliability and validity of diagnoses, severity of symptoms and treatment decisions. Diagnostic assessment is said to possess reliability if two diagnosticians come to the same diagnosis (joint reliability) or when a second test is administered and comes to the same conclusion (test-retest reliability) (Mack, 2016). Reliability has to be established before validity can be confirmed (Mack, 2016).

A psychological test is said to be valid if it measures what it claims to measure (Mack, 2016). For example, if a psychological test is said to determine a particular (SUD), then the subsequent diagnosis should be appropriate for the individual being tested. Compared to reliability, validity is more complex to establish with diagnostic assessments and instruments (Mack, 2016). There are many forms of validity including: face validity, content validity, concurrent validity, convergent validity and predictive validity. A diagnostic tool is said to possess face validity if the variable in question is measured with accuracy. Content validity exists where the instrument categorically covers all aspects of the phenomenon being measured. Concurrent validity allows a diagnostician or clinician to predict other symptoms, manifestation or characteristic of the measure being tested (Mack, 2016). Convergent validity exists where a diagnostician is able to predict the natural reaction or convergence of the internal measure being tested with external forces (Mack, 2016). Predictive validity refers to the clinician or diagnostician’s ability to predict future and natural courses of action during treatment and possible future behavioral proclivities of the patient (Mack, 2016). Observational assessment is only one tool for examining substance abuse disorders. Employers, clinicians and diagnosticians also have laboratory assessments at their disposal.

Laboratory assessments examine hair, saliva, urine or blood samples among other means. Laboratory assessments may be pleasing to the examiner who is searching for empirical evidence that an illicit substance is being used or abused. However, laboratory assessments are not without their limitations. Pressing factors of laboratory assessment include: accurate results, cost and prevention of drug use in the respective workplace. Unfortunately, it is possible to yield a false positive or negative in laboratory assessment. Preserving the integrity in the chain of custody is paramount. If the chain of custody is compromised or the integrity of the assessment is otherwise spoiled, then its deterrence effects, subsequent diagnosis and treatment options could be curtailed. For example, the military uses laboratory assessments to deter drug use and maintain order and discipline within formations. Secondly, if a soldier is falsely accused of having an illicit substance within their system, this could have unfair and adverse legal consequences to both the soldier and the unit.

Cost is also a concern vis a vis laboratory assessment. While urine tests are the least expensive, blood tests are the most expensive and can be a financial burden to some private companies or public monies. Taxpayers may foot the bill when law enforcement officials conduct laboratory assessment via blood tests with suspects of DUI investigations. The cost of the laboratory assessment not only varies by method of test, but also by the substance it seeks to identify. For example, steroid laboratory assessments are expensive. With the growing number of steroid variants on the market, laboratory assessments may fail to detect the substance. Costs can be compounded if false results are rendered or if an individual is combating the laboratory assessment with a doctored or manipulated specimen.

 

Mack, A. H. (2016). Clinical Textbook of Addictive Disorders. New York: The Guilford Press.

 

  1. Characterize the three specific factors you believe are most important for a basic understanding of each of the following substances of abuse.  Be sure to justify your choices using only about 100 words for each:
    1. Alcohol
    2. Nicotine
    3. Opioids
    4. Cannabis
    5. Hallucinogens & Inhalants
    6. Stimulants
    7. Cocaine
    8. Sedatives/Hypnotics & Benzodiazepines

The three most important factors to understand vis a vis alcohol are: 1) the effects; 2) comorbidity; and legal consequences. First, there is a litany of physiological effects from consuming alcohol. Effects include but are not limited to: brain damage, intoxication, delirium, anxiety, sexual dysfunction, sleep disorder, liver damage, gastrointestinal tract damage, pancreatic damage, cardiovascular dysfunction, cancer immune system degradation, musculoskeletal damage, skin problems and adverse effects to the fetus if the woman is pregnant (Mack, 2016).

Secondly, it should be noted that those with a dependence on alcohol are five times more likely to either use or abuse another drug. Bipolar I and II disorder is twice as likely to manifest among those individuals with an alcohol dependence (Mack, 2016). This latter groups of individuals are significantly more at risk to develop suicidal ideations or engage in suicidal behavior. Those with anxiety disorder may be particularly prone to developing alcohol use disorder.

Lastly, the public should be aware of the legal ramifications that may follow binge drinking alcohol or engaging in heavy drinking. While there is no clinical distinction for the onset of intoxication: legal intoxication is marked with 80 mg% (Mack, 2016). Clinically speaking, intoxication symptoms can generally be observed at 50 mg% (Mack, 2016). Individuals should not operate heavy machinery or a motor vehicle if they are intoxicated. This could lead to criminal charges, arrest, conviction and harsh sentencing. In addition to criminal consequences, an individual convicted of driving under the influence (DUI) is also subject to civil litigation.

The three most important factors to understand vis a vis nicotine are: (1) the effect; (2) comorbidity realities; and (3) treatment options. Physiological effects of nicotine are extensive and include but are not limited to: respiratory complications, cardiovascular disease, inflammation of veins and arteries and adverse effects on prefrontal cortical function (Mack, 2016). Comorbidity also exists for nicotine users. Those with psychiatric disorders are approximately twice as likely to use nicotine (Mack, 2016). This population is also more likely to be a heavy smoker when compared to the general public (Mack, 2016). One is considered a “heavy smoker” if they consume more than 25 cigarettes a day. Lastly, there are a variety of treatment plans available for those who want to quit nicotine use. Studies suggest that 70% of people who smoke want to quit and 50% have tried to quit at least once each year (Mack, 2016). Nicotine replacement therapy (NRT) currently has five variants on the market: transdermal patches, gum, nasal spray, inhalers and lozenges (Mack, 2016). There are also placebo and nonmedicated options such as bupropion slow release (SR) (Mack, 2016).

The three most important factors to understand vis a vis opioids are: (1) treatment options; (2) the dangers of prescribed opioids in pill form and (3) negative side effects. Treatment options include: methadone maintenance treatment (MMT), buprenorphine and naltrexone (Mack, 2016). Prescription and semi-synthetic opioids include: hydrocodone, oxycodone, oxymorphone, nalbuphine and diacetylmorphine (Mack, 2016). These drugs can be legally prescribed to patients who are suffering from severe physical pain. Unfortunately for some, the prescription medication can be addicting, leading to misuse and abuse. It is possible for some individuals to search the streets for heroin after their medical provide discontinues the prescription. Prescription opioids are the second most commonly used drug in the United States, trailing only cannabis (Mack, 2016). Individuals access these potent drugs through either a physician or family and friends. Studies suggest that opioid users or abusers are in search of the euphoric feeling it delivers, pain relief or to help with sleep. Lastly, there are an innumerable amount of negative side effects associated with opiate misuse including: fatal overdose, hepatitis, HIV and spontaneous abortion for pregnant women (Mack, 2016).

The three most important factors to understand in relation to cannabis are: risks, comorbidity and treatment options. First, the public perception within the United States is ever evolving, as the debate regarding the possession and use of cannabis is gravitating towards decriminalization. States including: Alaska, California, Minnesota, New York and Oregon et al. have decriminalized cannabis use under a varying threshold of grams. Colorado is another state that has decriminalized cannabis use and even allowed cannabis growers ands sellers to solicit the adult public in legitimate business forums. Colorado’s state government taxes cannabis sales and use and has allotted the revenue to improve schools, infrastructure and other civil programs. While the law is becoming more liberal and progressive compared to earlier decades, cannabis use is not without its negative side effects. In addition to the negative effects of smoking cannabis on the cardiovascular and respiratory systems, health concerns include: anxiety and depression. Some users suggest they consume cannabis to manage their stress. However, some studies suggest that cannabis users have a lower tolerance for stress and anxiety after they have consumed cannabis for a period longer than one year (Mack, 2016). This cycle may increase stress, anxiety and cannabis use. In addition, chronic cannabis users may also have difficulty in concentrating and performing executive functioning (Mack, 2016).

Secondly, comorbidity seems to exist within populations that use and abuse cannabis. There is some evidence that chronic cannabis use and panic attacks are related. These individuals seem to be more prone to them when compared to the general population. Those with posttraumatic stress disorder are three times more likely to have a dependence on cannabis. Furthermore, the evidence suggests that cannabis users have a disproportionate number of individuals with ADHD (Mack, 2016). There is also a statistical significance between psychosis and chronic cannabis use.

Treatment options for cannabis include: psychotherapy, lithium, valproate, antidepressants and buspirone (Mack, 2016). While lithium and valproate have yielded ambiguous results, there seems to be more promising effects with buspirone. The psychoactive cannabinoid in this substance is THC (Mack, 2016). Some studies have shown that the pill form of THC can be useful to treat cannabis dependence. There are also less adverse health effects when the illicit drug is taken in pill form, rather than smoked. The THC dosage in pill form can be controlled and slowly reduced, ultimately leading to cessation or abstinence.

The three most important factors to consider with regard to hallucinogens and inhalants are: (1) adverse health effects; (2) adverse psychiatric effects and (3) addictive nature. First, adverse health effects of hallucinogens include but are not limited to: unresponsiveness to pain, hyperreflexia, fatal overdose and hypertension. Adverse psychiatric effects include: psychotic, depressive spectrum disorders and bipolar disorder (Mack, 2016). Unlike other substances discussed, there is no legitimate medical use for hallucinogens because of their highly addictive liability (Mack, 2016).

Inhalants also carry adverse health effects including: permanent brain injury, cardiac dysfunction, intoxication, bone marrow damage, renal and sensory damages are all possible. Inhalant-induced disorders include: delirium, anxiety, mood disorders and psychosis (Mack, 2016).

The three most significant factors to understanding regarding stimulants are: (1) adverse health effects; (2) adverse psychiatric effects and (3) treatment options. Adverse health effects include: elevated blood pressure, dizziness, fever, sweating, rapid breathing, tremors et al. (Mack, 2016). Psychiatric effects of stimulants include: anxiety, mood and psychotic disorders. Treatment options for stimulants include: placing the individual in an environment of quiet and calm (Mack, 2016). More aggressive treatment options include the prescription of benzodiazepines or neuroleptics (Mack, 2016).

The three most important factors to understand associated with cocaine are: (1) negative health effects, (2) associated societal harms and (3) treatment options. Negative health effects of cocaine include: intoxication, fatal overdose, withdrawal, increased heart rate, increased blood pressure, tremors and reduction of appetite. Some social scientists in conjunction with law enforcement agencies, such as the DEA, have argued that the increased purity of street cocaine has led to an increase in familial and societal harm. Cocaine can lead to fatal overdose among users and abusers. Some users, in a desperate attempt to achieve the euphoria of cocaine, have committed violent crimes including robbery or burglary of an occupied dwelling. This speaks to the highly addictive nature of this substance. Treatment options include: behavioral treatment programs, cognitive behavioral therapy (CBT), motivational interviewing and family therapy.

The three most important factors of consideration regarding sedatives, hypnotics and benzodiazepines are: (1) an appreciation for the distinction between medical and nonmedical uses for the substance (Mack, 2016), (2) long-term effects of chronic use and (3) treatment regimens. Abuse of benzodiazepines or use or long-term use of benzodiazepine with the supervision of a medical provider can lead to personality change, memory loss and other adverse effects on the brain. All three substances have addictive qualities and lead to painful withdrawal symptoms. These substances should never be used without a prescription or without the supervision of a medical doctor. Mere possession of most of these substances are generally punishable as a felony within the United States. Treatment options of all three drugs have included anti-depressants, which have reduced the levels of anxiety among patients during withdrawal periods.

 

Mack, A. H. (2016). Clinical Textbook of Addictive Disorders. New York: The Guilford Press.

 

  1. Choose one of the following questions:
    1. Based on your reading and understanding of the traditional substance use disorders thus far, argue either for or against considering the “behavioral” addictions like pathological gambling to be “addictive” disorders.
    2. Discuss some of the primary clinical challenges of managing pain and addiction in a clinical population.

 

Pathological gambling can and should be considered an addictive disorder. Like substance use, the act of gambling can trigger the brain’s natural reward system. When a gambler wins a large pot of money in a game of high stakes poker, her mesolimbic dopamine is released (Mack, 2016), giving her an overall feeling of euphoria, better known as a “gambler’s high.” This euphoria will motivate her to continue to gamble. If the high is euphoric and consistent enough, an addiction could manifest. If an addiction is present, she could gamble even if it is causing distress or dysfunction in her personal or professional life. Substances do not always have to be consumed to contribute to neurochemical and ergo physiological changes in the brain over time. Sex is another act that can be considered a pathological or behavioral addiction. Like substance use disorders, these addictions can cause distress, dysfunction and legal effects and are worthy of psychotherapy or medication in extreme cases, just like substance use disorders are to be considered. Gambling disorder can cause various types of distress including, familial, financial, marital or legal. Some who engage in compulsive gambling have committed crimes to continue the behavior, such as: writing bad checks, stealing and embezzlement (Mack, 2016).

The latest edition of the Diagnostic and Statistical Manual already holds similar criteria for the diagnosis of gambling disorder, when compared to substance abuse disorders. The criteria includes repeated, but failed efforts to cease the behavior, tolerance and withdrawal. If one is to hold that neurochemical compounds precede or at least contribute to behavior, then this listed criterion suggests that there may be a neurochemical basis for gambling. Furthermore, there is some research to suggest that those who gamble compulsively may have less control to inhibit such behavior (Mack, 2016). These internal and external manifestations of behavior are not unlike substance abusers.

There are four additional parallels between pathological or behavioral addiction and substance addiction, and they are as follows: (1) a euphoric feeling during the act, (2) an increased urge to continue the act, (3) diminished control to refrain from committing the act and (4) repetitive or compulsive urges to engage in the activity (Mack, 2016). Moreover, gambling disorder, like substance use disorder, seems to start during adolescence for many. Like substance abuse, gambling disorder also has comorbidity, with alcohol dependence as the leading co-vice.

There has been some pharmacological success in the treatment of gambling disorder. Opioid antagonists are one substance medicinal approach that has shown efficacy when compared to placebos (Mack, 2016). Other agents such as some amino acids (N-acetyl cysteine) have shown positive progress in the reduction of gambling behaviors. Studies have also indicated that attending and completing psychotherapy for a gambling addiction is more effective than not attending treatment.

While treating gambling addiction as a disorder is controversial to some, it has shown an acute likeness to the effects of some substance abuse disorders. Behavioral addictions such as gambling disorder, have become known as addictions without the substance (Mack, 2016). Nevertheless, significant distress and dysfunction can manifest within the individual, family unit and society as a whole. Economic and violent crimes have been committed because of all the listed behavioral or substance addictions discussed in this paper. Therefore, behavioral addictions should be treated in the same vein as substance abuse disorders. Psychotherapy and medical means should be available and supported by health care providers and insurance companies when an objective, accurate, appropriate and professional diagnosis is reached by a legitimate professional if the field of psychology or psychiatry.

 

Mack, A. H. (2016). Clinical Textbook of Addictive Disorders. New York: The Guilford Press.

 

 

 

 

 

 

 

 

 

 

 

References

Mack, A. H. (2016). Clinical textbook of addictive disorders. New York: The Guilford Press.

 

 

 

Remington C. Longstreth

Substance Abuse and Addiction Midterm Exam

American Military University

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  1. Explain, in terms a layperson could understand, the neurobiology of drug tolerance, dependence, and withdrawal.

Chronic substance use and abuse may stem from a variety of etiologies including neurobiological, social and historical. Neurobiological contributors are innumerable. The brain has an inherent reward circuit which promotes and encourages certain behaviors, including substance abuse. The euphoric effects of certain drugs make it tempting to the user to engage in repeated and even chronic use, even though there are dangerous and adverse health effects to substance abuse. Recreational use or experimentation with some illicit substances will have a neurobiological impact that can trigger strong cravings that can contribute to repeat use and even chronic abuse. Some studies suggest some are more neurobiologically prone to developing a substance use disorder (SUD) than others.

Another example is stress in daily life and its associated release of cortisol in the brain. Some studies suggest that those more susceptible to stress and therefore cortisol release, are more likelihood to engage in maladaptive coping mechanisms, such as illicit substance abuse. Cortisol is a hormone that can increase the euphoric effects of some drugs (Mack, 2016). This dynamic may be an appealing escape to a substance user under sever stress. Over time and with repeated use, substance abusers will experience neurobiological changes in the brain and feel a need to increase their drug intake to achieve the same euphoric feelings (Mack, 2016). This is the beginnings of developing a drug tolerance. Drug tolerance can lead to: dependence, withdrawal and a substance use disorder.

Drug tolerance is a feeling to take more of a drug to achieve the same high or effect (Mack, 2016). The evidence suggests that brain cell receptors are less reactive to drug effects with repeated and chronic use (Mack, 2016). Therefore, the user will need to increase their intake of the drug to feel the same levels of euphoria. For example, dopamine will be released at lower levels or with less intensity in a chronic opioid user, when compared to someone who has only used the substance once. Transmitters and receptors of brain cells will have a significant chemical reaction for a new user and a sluggish or insignificant reaction within the brain of the chronic abuser.

Drug dependence occurs when a patient needs a particular substance for normal daily functioning. For example, a chronic opioid user may experience tremors, anxiety, muscle cramps or diarrhea (Mack, 2016) when the user commits to abstinence. These are common feelings of withdrawal and if experienced, it can be said that the user has a drug dependence. The dependent user will naturally want to avoid the severe and painful withdrawal symptoms and continue drug usage, if treatment programs are not readily available.

Withdrawal is considered a syndrome with severe side effects similar to flu-like symptoms in other cases. For some opioid users, early states of withdrawal can include, yawning, agitation and anxiety (Mack, 2016). Later signs and symptoms of opioid withdrawal can include nausea, diarrhea and vomiting (Mack, 2016). One quick but maladaptive way to avoid withdrawal symptoms, is to continue to use the substance. Withdrawal symptoms can be painful and are also evidence that the individual has developed a dependence on the substance. Withdrawal, dependence and tolerance are all interfacing players on the same neurobiological stage – that is the brain. For example, withdrawal symptoms manifest when a patient has developed a drug dependence. Likewise, withdrawal only occurs after the patient has created a drug tolerance. In other words, tolerance is the precursor for both withdrawal and dependence.

 

Mack, A. H. (2016). Clinical Textbook of Addictive Disorders. New York: The Guilford Press.

 

  1. Choose one of the following areas and broadly recount its socio-historical path:
    1. Models of substance use
    2. Substance abuse treatments
    3. The social/self-help movements
    4. Treatment and prevention efforts

Treatment and prevention of substance abuse has been a human struggle for millennia. There are numerous modalities for treatment and prevention including: substance-focused strategies, Galenic medicine, pharmacological treatments, national government interventions, abstinence-oriented social movements, self-help groups and religious interventions (Mack, 2016). Substance-focused strategies have historically included a gradual reduction in the dosage of drug and isolation from the drug (Mack, 2016). A Civil War Physician named Benjamin Rush advocated for the latter of this strategy. Isolation from the drug could be within a drug-free zone, church or monastery. Isolation would also include separation from other substance users or abusers. The program would separate any environmental setting that would trigger cravings or encourage substance use.

Galenic medication models seek to identify the etiology of the substance use and abuse. Withdrawal symptoms would be sought and identified before a regimen for treatment could be prescribed. This program sought to tailor treatment for the individual and their particular struggle with the given substance. Galenic medication programs was developed by and named after the ancient Greek physician and philosopher, Aelius Galen.

Pharmacological treatments for substance abuse attempt to link medication to social situations. For example, the medication disulfiram is prescribed to those who have been diagnosed with alcohol abuse disorder. In social settings, disulfiram can help those with the disease to continue to abstain from drinking, where there may otherwise be social pressure (Mack, 2016). Likewise, opioid addicts can be prescribed naltrexone to ease the withdrawal symptoms of opioid dependence (Mack, 2016).

The national government has also attempted to prevent and treat substance use and abuse to little avail. The Harrison Act of 1914 sought to reduce opioid use in the United States (Mack, 2016). The prohibition period of the 1920s sought to eradicate the buying or selling of alcohol. However, these efforts were ultimately defeated in 1933 (Mack, 2016). The federal government also stood up multiple entities including the National Institute of Mental Health (NIMH), the National Institute on Drug Abuse (NIDA), the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) (Mack, 2016). In addition, the Nixon Administration wages a War on Drugs during the 1970s that has largely been viewed as costly and inefficient. Substance use still remains in the US and has steadily risen among adolescents in recent decades (Mack, 2016). Federal programs have also halted initiatives that have shown some success, including heroin dispensary clinics (Mack, 2016), due to political lobbying by conservative antidrug efforts.

Abstinence-oriented programs have historically been initiated by religious and cultural groups. Certain South Asian sects and Native American reservations have continued abstinence programs that were developed over two-thousand years ago (Mack, 2016). Health clubs are another group that promote abstinence as a social movement. In the social media and information age, there are numerous pages, websites, channels and other conduits of communication that encourage their members to remain on the wagon, issues guidance, advice and tips to staying sober through shared experience.

Self-help groups are another means of organization to fight against substance abuse. One of the best-known self-help groups is alcoholics anonymous (AA). Those who struggle with substance use and abuse can attend (AA) meetings to share their experience with others who are similarly situated. Some find the exercise helpful when an empathetic ear is listening to their experience. This network of social support reminds individuals that they are not alone in the fight against substance use and abuse. Other like-minded groups have benefitted from (AA) forging a pathway to sobriety. Today there are numerous self-help groups including: Narcotics Anonymous, Cocaine Anonymous, Overeaters Anonymous, Gamblers Anonymous and Emotions Anonymous (Mack, 2016). These organizations have assumed a welcoming posture and generally accept individuals who refer to themselves as an “addict” (Mack, 2016).

 

Mack, A. H. (2016). Clinical Textbook of Addictive Disorders. New York: The Guilford Press.

 

  1. In considering both psychological evaluations and laboratory assessments of substance use disorders, discuss the factors which you consider to be most pressing in determining which type(s) of assessment(s) to administer – those factors may be related to the client, to the substance being used, and/or to the assessment tools themselves.

In psychological evaluation of substance use disorders (SUDs), the most pressing factors are: the reliability and validity of diagnoses, severity of symptoms and treatment decisions. Diagnostic assessment is said to possess reliability if two diagnosticians come to the same diagnosis (joint reliability) or when a second test is administered and comes to the same conclusion (test-retest reliability) (Mack, 2016). Reliability has to be established before validity can be confirmed (Mack, 2016).

A psychological test is said to be valid if it measures what it claims to measure (Mack, 2016). For example, if a psychological test is said to determine a particular (SUD), then the subsequent diagnosis should be appropriate for the individual being tested. Compared to reliability, validity is more complex to establish with diagnostic assessments and instruments (Mack, 2016). There are many forms of validity including: face validity, content validity, concurrent validity, convergent validity and predictive validity. A diagnostic tool is said to possess face validity if the variable in question is measured with accuracy. Content validity exists where the instrument categorically covers all aspects of the phenomenon being measured. Concurrent validity allows a diagnostician or clinician to predict other symptoms, manifestation or characteristic of the measure being tested (Mack, 2016). Convergent validity exists where a diagnostician is able to predict the natural reaction or convergence of the internal measure being tested with external forces (Mack, 2016). Predictive validity refers to the clinician or diagnostician’s ability to predict future and natural courses of action during treatment and possible future behavioral proclivities of the patient (Mack, 2016). Observational assessment is only one tool for examining substance abuse disorders. Employers, clinicians and diagnosticians also have laboratory assessments at their disposal.

Laboratory assessments examine hair, saliva, urine or blood samples among other means. Laboratory assessments may be pleasing to the examiner who is searching for empirical evidence that an illicit substance is being used or abused. However, laboratory assessments are not without their limitations. Pressing factors of laboratory assessment include: accurate results, cost and prevention of drug use in the respective workplace. Unfortunately, it is possible to yield a false positive or negative in laboratory assessment. Preserving the integrity in the chain of custody is paramount. If the chain of custody is compromised or the integrity of the assessment is otherwise spoiled, then its deterrence effects, subsequent diagnosis and treatment options could be curtailed. For example, the military uses laboratory assessments to deter drug use and maintain order and discipline within formations. Secondly, if a soldier is falsely accused of having an illicit substance within their system, this could have unfair and adverse legal consequences to both the soldier and the unit.

Cost is also a concern vis a vis laboratory assessment. While urine tests are the least expensive, blood tests are the most expensive and can be a financial burden to some private companies or public monies. Taxpayers may foot the bill when law enforcement officials conduct laboratory assessment via blood tests with suspects of DUI investigations. The cost of the laboratory assessment not only varies by method of test, but also by the substance it seeks to identify. For example, steroid laboratory assessments are expensive. With the growing number of steroid variants on the market, laboratory assessments may fail to detect the substance. Costs can be compounded if false results are rendered or if an individual is combating the laboratory assessment with a doctored or manipulated specimen.

 

Mack, A. H. (2016). Clinical Textbook of Addictive Disorders. New York: The Guilford Press.

 

  1. Characterize the three specific factors you believe are most important for a basic understanding of each of the following substances of abuse.  Be sure to justify your choices using only about 100 words for each:
    1. Alcohol
    2. Nicotine
    3. Opioids
    4. Cannabis
    5. Hallucinogens & Inhalants
    6. Stimulants
    7. Cocaine
    8. Sedatives/Hypnotics & Benzodiazepines

The three most important factors to understand vis a vis alcohol are: 1) the effects; 2) comorbidity; and legal consequences. First, there is a litany of physiological effects from consuming alcohol. Effects include but are not limited to: brain damage, intoxication, delirium, anxiety, sexual dysfunction, sleep disorder, liver damage, gastrointestinal tract damage, pancreatic damage, cardiovascular dysfunction, cancer immune system degradation, musculoskeletal damage, skin problems and adverse effects to the fetus if the woman is pregnant (Mack, 2016).

Secondly, it should be noted that those with a dependence on alcohol are five times more likely to either use or abuse another drug. Bipolar I and II disorder is twice as likely to manifest among those individuals with an alcohol dependence (Mack, 2016). This latter groups of individuals are significantly more at risk to develop suicidal ideations or engage in suicidal behavior. Those with anxiety disorder may be particularly prone to developing alcohol use disorder.

Lastly, the public should be aware of the legal ramifications that may follow binge drinking alcohol or engaging in heavy drinking. While there is no clinical distinction for the onset of intoxication: legal intoxication is marked with 80 mg% (Mack, 2016). Clinically speaking, intoxication symptoms can generally be observed at 50 mg% (Mack, 2016). Individuals should not operate heavy machinery or a motor vehicle if they are intoxicated. This could lead to criminal charges, arrest, conviction and harsh sentencing. In addition to criminal consequences, an individual convicted of driving under the influence (DUI) is also subject to civil litigation.

The three most important factors to understand vis a vis nicotine are: (1) the effect; (2) comorbidity realities; and (3) treatment options. Physiological effects of nicotine are extensive and include but are not limited to: respiratory complications, cardiovascular disease, inflammation of veins and arteries and adverse effects on prefrontal cortical function (Mack, 2016). Comorbidity also exists for nicotine users. Those with psychiatric disorders are approximately twice as likely to use nicotine (Mack, 2016). This population is also more likely to be a heavy smoker when compared to the general public (Mack, 2016). One is considered a “heavy smoker” if they consume more than 25 cigarettes a day. Lastly, there are a variety of treatment plans available for those who want to quit nicotine use. Studies suggest that 70% of people who smoke want to quit and 50% have tried to quit at least once each year (Mack, 2016). Nicotine replacement therapy (NRT) currently has five variants on the market: transdermal patches, gum, nasal spray, inhalers and lozenges (Mack, 2016). There are also placebo and nonmedicated options such as bupropion slow release (SR) (Mack, 2016).

The three most important factors to understand vis a vis opioids are: (1) treatment options; (2) the dangers of prescribed opioids in pill form and (3) negative side effects. Treatment options include: methadone maintenance treatment (MMT), buprenorphine and naltrexone (Mack, 2016). Prescription and semi-synthetic opioids include: hydrocodone, oxycodone, oxymorphone, nalbuphine and diacetylmorphine (Mack, 2016). These drugs can be legally prescribed to patients who are suffering from severe physical pain. Unfortunately for some, the prescription medication can be addicting, leading to misuse and abuse. It is possible for some individuals to search the streets for heroin after their medical provide discontinues the prescription. Prescription opioids are the second most commonly used drug in the United States, trailing only cannabis (Mack, 2016). Individuals access these potent drugs through either a physician or family and friends. Studies suggest that opioid users or abusers are in search of the euphoric feeling it delivers, pain relief or to help with sleep. Lastly, there are an innumerable amount of negative side effects associated with opiate misuse including: fatal overdose, hepatitis, HIV and spontaneous abortion for pregnant women (Mack, 2016).

The three most important factors to understand in relation to cannabis are: risks, comorbidity and treatment options. First, the public perception within the United States is ever evolving, as the debate regarding the possession and use of cannabis is gravitating towards decriminalization. States including: Alaska, California, Minnesota, New York and Oregon et al. have decriminalized cannabis use under a varying threshold of grams. Colorado is another state that has decriminalized cannabis use and even allowed cannabis growers ands sellers to solicit the adult public in legitimate business forums. Colorado’s state government taxes cannabis sales and use and has allotted the revenue to improve schools, infrastructure and other civil programs. While the law is becoming more liberal and progressive compared to earlier decades, cannabis use is not without its negative side effects. In addition to the negative effects of smoking cannabis on the cardiovascular and respiratory systems, health concerns include: anxiety and depression. Some users suggest they consume cannabis to manage their stress. However, some studies suggest that cannabis users have a lower tolerance for stress and anxiety after they have consumed cannabis for a period longer than one year (Mack, 2016). This cycle may increase stress, anxiety and cannabis use. In addition, chronic cannabis users may also have difficulty in concentrating and performing executive functioning (Mack, 2016).

Secondly, comorbidity seems to exist within populations that use and abuse cannabis. There is some evidence that chronic cannabis use and panic attacks are related. These individuals seem to be more prone to them when compared to the general population. Those with posttraumatic stress disorder are three times more likely to have a dependence on cannabis. Furthermore, the evidence suggests that cannabis users have a disproportionate number of individuals with ADHD (Mack, 2016). There is also a statistical significance between psychosis and chronic cannabis use.

Treatment options for cannabis include: psychotherapy, lithium, valproate, antidepressants and buspirone (Mack, 2016). While lithium and valproate have yielded ambiguous results, there seems to be more promising effects with buspirone. The psychoactive cannabinoid in this substance is THC (Mack, 2016). Some studies have shown that the pill form of THC can be useful to treat cannabis dependence. There are also less adverse health effects when the illicit drug is taken in pill form, rather than smoked. The THC dosage in pill form can be controlled and slowly reduced, ultimately leading to cessation or abstinence.

The three most important factors to consider with regard to hallucinogens and inhalants are: (1) adverse health effects; (2) adverse psychiatric effects and (3) addictive nature. First, adverse health effects of hallucinogens include but are not limited to: unresponsiveness to pain, hyperreflexia, fatal overdose and hypertension. Adverse psychiatric effects include: psychotic, depressive spectrum disorders and bipolar disorder (Mack, 2016). Unlike other substances discussed, there is no legitimate medical use for hallucinogens because of their highly addictive liability (Mack, 2016).

Inhalants also carry adverse health effects including: permanent brain injury, cardiac dysfunction, intoxication, bone marrow damage, renal and sensory damages are all possible. Inhalant-induced disorders include: delirium, anxiety, mood disorders and psychosis (Mack, 2016).

The three most significant factors to understanding regarding stimulants are: (1) adverse health effects; (2) adverse psychiatric effects and (3) treatment options. Adverse health effects include: elevated blood pressure, dizziness, fever, sweating, rapid breathing, tremors et al. (Mack, 2016). Psychiatric effects of stimulants include: anxiety, mood and psychotic disorders. Treatment options for stimulants include: placing the individual in an environment of quiet and calm (Mack, 2016). More aggressive treatment options include the prescription of benzodiazepines or neuroleptics (Mack, 2016).

The three most important factors to understand associated with cocaine are: (1) negative health effects, (2) associated societal harms and (3) treatment options. Negative health effects of cocaine include: intoxication, fatal overdose, withdrawal, increased heart rate, increased blood pressure, tremors and reduction of appetite. Some social scientists in conjunction with law enforcement agencies, such as the DEA, have argued that the increased purity of street cocaine has led to an increase in familial and societal harm. Cocaine can lead to fatal overdose among users and abusers. Some users, in a desperate attempt to achieve the euphoria of cocaine, have committed violent crimes including robbery or burglary of an occupied dwelling. This speaks to the highly addictive nature of this substance. Treatment options include: behavioral treatment programs, cognitive behavioral therapy (CBT), motivational interviewing and family therapy.

The three most important factors of consideration regarding sedatives, hypnotics and benzodiazepines are: (1) an appreciation for the distinction between medical and nonmedical uses for the substance (Mack, 2016), (2) long-term effects of chronic use and (3) treatment regimens. Abuse of benzodiazepines or use or long-term use of benzodiazepine with the supervision of a medical provider can lead to personality change, memory loss and other adverse effects on the brain. All three substances have addictive qualities and lead to painful withdrawal symptoms. These substances should never be used without a prescription or without the supervision of a medical doctor. Mere possession of most of these substances are generally punishable as a felony within the United States. Treatment options of all three drugs have included anti-depressants, which have reduced the levels of anxiety among patients during withdrawal periods.

 

Mack, A. H. (2016). Clinical Textbook of Addictive Disorders. New York: The Guilford Press.

 

  1. Choose one of the following questions:
    1. Based on your reading and understanding of the traditional substance use disorders thus far, argue either for or against considering the “behavioral” addictions like pathological gambling to be “addictive” disorders.
    2. Discuss some of the primary clinical challenges of managing pain and addiction in a clinical population.

 

Pathological gambling can and should be considered an addictive disorder. Like substance use, the act of gambling can trigger the brain’s natural reward system. When a gambler wins a large pot of money in a game of high stakes poker, her mesolimbic dopamine is released (Mack, 2016), giving her an overall feeling of euphoria, better known as a “gambler’s high.” This euphoria will motivate her to continue to gamble. If the high is euphoric and consistent enough, an addiction could manifest. If an addiction is present, she could gamble even if it is causing distress or dysfunction in her personal or professional life. Substances do not always have to be consumed to contribute to neurochemical and ergo physiological changes in the brain over time. Sex is another act that can be considered a pathological or behavioral addiction. Like substance use disorders, these addictions can cause distress, dysfunction and legal effects and are worthy of psychotherapy or medication in extreme cases, just like substance use disorders are to be considered. Gambling disorder can cause various types of distress including, familial, financial, marital or legal. Some who engage in compulsive gambling have committed crimes to continue the behavior, such as: writing bad checks, stealing and embezzlement (Mack, 2016).

The latest edition of the Diagnostic and Statistical Manual already holds similar criteria for the diagnosis of gambling disorder, when compared to substance abuse disorders. The criteria includes repeated, but failed efforts to cease the behavior, tolerance and withdrawal. If one is to hold that neurochemical compounds precede or at least contribute to behavior, then this listed criterion suggests that there may be a neurochemical basis for gambling. Furthermore, there is some research to suggest that those who gamble compulsively may have less control to inhibit such behavior (Mack, 2016). These internal and external manifestations of behavior are not unlike substance abusers.

There are four additional parallels between pathological or behavioral addiction and substance addiction, and they are as follows: (1) a euphoric feeling during the act, (2) an increased urge to continue the act, (3) diminished control to refrain from committing the act and (4) repetitive or compulsive urges to engage in the activity (Mack, 2016). Moreover, gambling disorder, like substance use disorder, seems to start during adolescence for many. Like substance abuse, gambling disorder also has comorbidity, with alcohol dependence as the leading co-vice.

There has been some pharmacological success in the treatment of gambling disorder. Opioid antagonists are one substance medicinal approach that has shown efficacy when compared to placebos (Mack, 2016). Other agents such as some amino acids (N-acetyl cysteine) have shown positive progress in the reduction of gambling behaviors. Studies have also indicated that attending and completing psychotherapy for a gambling addiction is more effective than not attending treatment.

While treating gambling addiction as a disorder is controversial to some, it has shown an acute likeness to the effects of some substance abuse disorders. Behavioral addictions such as gambling disorder, have become known as addictions without the substance (Mack, 2016). Nevertheless, significant distress and dysfunction can manifest within the individual, family unit and society as a whole. Economic and violent crimes have been committed because of all the listed behavioral or substance addictions discussed in this paper. Therefore, behavioral addictions should be treated in the same vein as substance abuse disorders. Psychotherapy and medical means should be available and supported by health care providers and insurance companies when an objective, accurate, appropriate and professional diagnosis is reached by a legitimate professional if the field of psychology or psychiatry.

 

Mack, A. H. (2016). Clinical Textbook of Addictive Disorders. New York: The Guilford Press.

 

 

 

 

 

 

 

 

 

 

 

References

Mack, A. H. (2016). Clinical textbook of addictive disorders. New York: The Guilford Press.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Remington C. Longstreth January 28, 2018 PTSD Diagnosis Issues in the Military PSYC 590 Contemporary Issues in Psychology Dr. Riley

Remington C. Longstreth

January 28, 2018

PTSD Diagnosis Issues in the Military

PSYC 590 Contemporary Issues in Psychology

Dr. Riley

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The medical diagnosis of servicemembers in today’s military has cost the taxpayers of the United States billions of dollars each year. In recent history, there has been an increase in the amount of post-traumatic stress disorder (PTSD) diagnoses. Some critics of the Veterans Administration (VA) have suggested that government doctors have changed their diagnoses from PTSD to another pre-existing condition to save money. Pre-existing conditions are not medically covered by the VA. Other critics have suggested that the government has lowered the mental health standards of willing enlistees during war-time. These enlistees have deployed and experienced particularly traumatic events during war, only to be dismissed by military medical professionals at the end of their terms of service. This paper is a discussion of the ethical issues raised during PTSD diagnosis of servicemembers in the military.

PTSD is a psychological disorder that can follow extreme cases of trauma within the human experience. Symptoms of the disorder include but are not limited to: sleep trouble, vivid flashbacks, arousal, avoidance, anxiety, compulsive behavior and depression. The disorder interrupts normal daily functioning. The disorder is unique in that, it can only be developed by people who have been subjected to extreme psychological traumas such as war and torture. Less severe, albeit significant life stressors include: divorce, death, and financial loss. However, these events are not commensurate with PTSD, but are aligned with other maladjustment disorders.

PTSD was only included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) since 1980. The behavioral expressions of this disorder have long been recognized but were given other names such as: Vietnam Syndrome, shell shock, battle fatigue, railway spine, and the thousand-yard stare. It was not until the 1970s, with the research of Chaim F. Shatan, that PTSD began to manifest in psychological journals and other scholarly articles. Shatan was concerned with the psychological effects within servicemember who served in the Vietnam War – a political hot button issue. The political inceptions of our modern notion of PTSD will be discussed pater.

Irrespective of the name, those who have been diagnosed with PTSD describe their initial response to the initial shock or trauma as: numbness, having an out of body experience or an unreality, dulled responses to others, and in a dream-like state (Tuerk, 2009). The second phase of response is plagued with anxiety, compulsive checks (i.e. ensuring the door is locked 30-50 times a day), depression, nightmares and sleepless nights, vivid flashbacks and irritability. Treatments including prolonged exposure therapy and selective serotonin reuptake inhibitor (SSRI) have shown incremental progress within PTSD patients. The ethical concerns of PTSD diagnosis were not broached until the next major military campaign, in a post-Vietnam America, waged by President George W. Bush, in the aftermath of the September 11 attacks.

The Global War on Terrorism (GWOT) has deployed millions of servicemembers across the world in the last 17 years. Servicemembers have been subjected to the extreme psychological shock of war, kidnapping, torture and cruel imprisonment by our enemy combatants. If conservative estimates of PTSD are calculated through the strictest of diagnostic standards, the number of PTSD cases among servicemember will still reach the tens of thousands. These numbers have already overwhelmed the Department of Defense (DoD) and the VA.

War has consistently been deemed by medical professionals, as one pre-cursor or extreme stressor that can lead to PTSD. The axiom, “war is an extension of politics,” should be included in this discussion. President George W. Bush has encouraged public discourse of the modern PTSD phenomenon. President Bush refuses to use the term PTSD, instead calling the mental condition, “PTS,” because of the negative connotations that accompany the term “disorder.” More recently, President Donald J. Trump has publicly blasted the (VA) on the Presidential campaign trail because of their alleged mismanagement of the medical service of military veterans with PTSD. Medical professionals who work with servicemembers with PTSD should be cognizant of the socio-political influences of such rhetoric and remain sterile, scientific and objective in clinical settings. Some critics have blamed this socio-political intervention as the primary cause of the sky-rocketing bill that has been footed by the taxpayers. The same critics suggest our servicemembers are being reduced from heroic public servants to helpless and mentally instable victims. Others have suggested that the wave of PTSD cases can be empirically proven and is the result of an over-extended military. The debate between the two groups of thinking demonstrates one example of the subjective human endeavor that is psychological diagnosis.

Furthermore, there is no uniform standard for diagnosing servicemembers with PTSD. For example, branches within the military use the following measures and tests in PTSD diagnosis: PTSD module of the structured clinical interview (SCID), PTSD checklist military version, back depression inventory (BDI), brief trauma questionnaire (BTQ), combat experience scale and the life stressor checklist et al. These varying tests or measures and the absence of uniform standard measurements within the military, further subject servicemembers to the subjectivity of PTSD diagnoses. The differing diagnoses of servicemembers with PTSD have permanent legal and medical repercussions including medical separation from the military and loss of medical services and benefits upon separation.

Servicemembers are human beings and human beings have differential personality dispositions. Some servicemembers may have either adaptive or maladaptive psychological responses to the trauma of war. Modern warfare may also allocate heavy loads of shock and trauma to a particular military occupational specialty (MOS). For example, an Army Ranger, who conducts multiple raids against high value targets (HVTs), may be exposed to more psychological trauma when compared to an Airmen stationed in Arizona, who is responsible for remotely operating unmanned aerial surveillance (UAS) drones in combat zones. This is not to say that not all (MOSs) are exposed to the psychological traumas of war. War is chaotic and indiscriminate in its wrath. In weighing such considerations, there still does not exist a consensus within the medical profession or political spheres, as to how much coverage is necessary for patients with adaptive versus maladaptive psychological dispositions. Indeed, the nurture versus nature debate is still taking place in some corners of the psychological field of study.

The leaders within the United States Government and the medical community would save the servicemembers and the American people undue burdens if more uniformity was placed within the system that identifies and treats PTSD. Uniform tests and measures must be used across all branches of the military to ensure equal medical treatment of all servicemembers. Initial medical screenings during both peace and war times must be standardized. Lowering mental health standards during war-time may increase enlistments but will ultimately cost a priceless amount in human capital and an untenable amounts in tax appropriations.

The traumatic event or trigger of the patient should also be considered with empirical precision. Regardless of the human psychological propensities or dispositions, distinctions should be made in the witnessing of trauma and the first-hand experiencing of trauma. However, if the (DoD) determined that an individual was mentally fit to serve and does so with honor, then the government should pay for medical coverage of a patient who has received psychological trauma or traumatic brain injuries (TBIs). It should be illegal to reject medical claims of service for legitimate patients of such disorder or injury. To medically discharge a servicemember, who was seemingly without pre-existing conditions and allowed to serve, is immoral and unethical.

The distribution and availability of medical treatment for those with PTSD is lacking. The case load of PTSD cases in contemporary times is overwhelming for the (DoD) and (VA). PTSD’s recognition in DSM-III and the GWOT has brought the issue to pinnacle proportions. More healthcare facilities who specialize in this prevalent disorder should be erected. Political leaders should appropriate taxpayer monies toward this psychological epidemic. This politics of the issue is inherent because of taxpayer funding. However, elected leaders should allow the medical professionals to define and standardize the identification, treatment and facilitation of such a disorder. More legislative input from medical professionals is necessary to tip the issue back to the appropriate and psychologically-centric balance.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

 

Groves, C. (2015). Exploring issues related to PTSD versus personality disorder diagnoses with military personnel. Journal of Human Behavior in the Social Environment, 25(7), 731-745.

 

Tuerk, P. W., Grubaugh, A. L., Hamner, M. B., & Foa, E. B. (2009). Diagnosis and treatment of PTSD-related compulsive checking behaviors in veterans of the Iraq war: The influence of military context on the expression of PTSD symptoms. American Journal of Psychiatry, 166(7), 762-767.

 

Shen, Y., Arkes, J., Kwan, B. W., Tan, L. Y., & Williams, T. V. (2010). Effects of Iraq/Afghanistan deployments on PTSD diagnoses for still active personnel in all four services. Military Medicine, 175(10), 763-769.

 

Wickham, J. A. (2007). Diagnosis dilemma military’s influence infects PTSD cases. Army Times,
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Remington C. Longstreth January 7, 2018 Issues in Online Dating PSYC 590 Contemporary Issues in Psychology Dr. Riley

Remington C. Longstreth

January 7, 2018

Issues in Online Dating

PSYC 590 Contemporary Issues in Psychology

Dr. Riley

 

 

This essay is a discussion of: 1) the issues presented by online dating, 2) social media dating applications and their effect on human behavior and 3) psychological challenges posed by issues in online dating applications.

Online dating websites are now a mainstream method of finding dating partners, courtships, spouses, or sexual encounters. Online dating provides for the less mobile individuals (e.g. elderly, disabled, deployed, or rural) to instantly make virtual contact with potential partners around the world. Online dating applications also allow for instant gratification. The gratification could be casual sex or a long-term relationship. Either way, subscribers can scan thousands of attractive profiles in a short time-span, rather than wait on the forces of fate.  In some Asian countries where homosexuality and gay clubs are illegal, Tinder and Grindr have made social, dating or sexual encounters possible.

However, some dating sites are utilized by individuals who prey on the lonely or vulnerable. Fake profile pictures and personal backgrounds can easily be fabricated to pounce upon a potential partner. In more serious situations, scammers can create fake profile accounts to convince others to electronically transmit them money before ever meeting in person. This practice is referred to as “catphishing.” Catphishing is compromised of elements of online deception for financial gain.

Behavioral Psychologists are interested in how the environment effects human and nonhuman behavior. Online dating applications are one variable within the virtual realm that effects human behavior. Dating applications online have specific marketing strategies that are appealing to their respective customer base. For example, eHarmony advertises that their application is based in science and has “29 dimensions of compatibility” (Gupta, 2012) that are measured to allow longer-lasting relationships. Tinder occupies the other side of the social media spectrum, with a slogan of “Swipe Right,” referring to acceptance of another as a suitable companion. Tinder is socially known as a dating application that leads to casual sexual encounters, rather than long-lasting eHarmony types of courtships. “Tinderella” refers to a female Tinder user who seeking sexual activity. These labels carry negative connotations. Labels can have direct influences on overt behavior. However, some research suggests that Tinder users are simply seeking entertainment when subscribing to the application. Sexual motives in one such study was listed towards the bottom of a list in priorities (Timmermans, 2017).

Other specialized dating websites include “FarmersOnly.com” and “ChristianMingle.com.” Modern online subscribers have a variety of choices when entering the online dating arena. The unique marketing packages that are associated with the application may have an impact on the subscriber’s behavior. eHarmony subscribers may construct a profile that entails characteristics of the perfect wife or husband. These online profiles are created by the subscribers themselves and may be subjective or biased. Digital profiles with inherent bias could later contribute to self-deception and deception towards others. More research should be conducted on how each respective dating application online influence human behavior and interactions with romantic partners.

Personality theorists are interested in which personalities are more likely to engage in social dating applications online. Some research has indicated that introverted individuals are more likely to use dating applications online. Other research suggests that online dating application users are more extraverted than most. Tinder users in particular, seemed to have impulsive but social personalities with a motive for sex (Timmermans, 2017). Other motivations for using the app were “curiosity, belongingness, openness to experience, peer pressure, social approval et al” (Timmermans, 2017).

Psychological challenges posed by these issues in online dating including, but are not limited to: shame and financial loss from falling victim to “catphishing,” unrealistic expectations for potential mates, and possible deception to ourselves and others using false or outdated profile accounts. Some dating applications users who have fallen victim to catphishing do not report their financial loss to the authorities. In some situations, catphishing can lead to negative legal ramifications and socially ostracization.

In a bizarre and recent case, NBA basketball player Chris Anderson (also known as “Birdman”) fell victim to an intricate catphishing escapade. Unbeknownst to Anderson, he met an underage female in person after he was led to believe the female was an adult and reached out to him on Facebook. In reality, a “catfish” was posing as both Chris Anderson and “Paris,” with fake Facebook accounts. The catfish was acting as a virtual social intermediary between both unsuspecting victims. As a result of Anderson’s rendezvous with the minor, he was the target of a criminal investigation for child crimes. A police search warrant was also executed, and his Colorado residence was search by the authorities. Personal property such as cell phones and lap top computers were seized during the search. Anderson was released from the Denver Nuggets amidst the investigation and ostracized by the larger Denver community. The catfish extorted $3,000 from Anderson’s personal attorney in an attempt to avoid public embarrassment. The minor female involved was later interviewed as an adult by 60 Minutes on CBS. The female is known as “Paris” on social media applications. Paris stated she was blackmailed with nude photographs she thought she was sharing with Anderson. In reality, the catfish was receiving the photographs. This is an aggressive form of cyberbullying that included extortion and threats of physical violence. The catfish’s real name was Shelly Chartier, who later became known to be “The Ghost of Easterville.” Chartier was charged with possession and distribution of child pornography, personation, and extortion among other crimes. She was subsequently convicted and sentenced to 18 months in a Canadian prison. A warrant exists for her arrest within the United States, who can still seek extradition. Catphishing can be devastating to one’s life. The psychological distress that was endured by Chris Anderson and Paris must have been torturous.

Chartier is one individual who may be suffering from psychological conditions including agoraphobia and depression. Chartier was afraid to leave her house and refused to for over eleven years. Chartier was vicariously living her life through others. These maladaptive exhibitions of behavior led to her arrest, conviction, and sentencing to prison. Psychological therapy may have prevented anti-social tendencies that Chartier exhibited. Chartier may have also been addicted to social media applications such as Facebook. The internet served Chartier as a virtual social conduit to the real world. However, social interactions were not encouraged. Chartier dropped out of school when she was 12 years old to take care of her bed-ridden and invalid mother. Chartier would make for an interesting patient in psychological therapy.

Self-deception and deception of others can also be conducted while creating online profiles within dating applications. For example, members of a social dating site may post an outdated picture of their physical appearance. Users can also lie about their income, geographic location, education, goals, employment status et al. While presenting the best digital avatar version of our true selves may not reach the deceitfulness of a catfish, it may be self-deceiving towards potential romantic partners. One solution to such problems of outdated photographs is for websites to require users to upload a timestamped photograph when registering for the site. IT and security teams can review and validate legitimate and updated photographs before registration can be completed. This will help ensure users are given an accurate physical portrayal of their potential romantic partners. However, “filter” applications can also be uploaded to cell phones and contribute to the photo-shopped image users share in dating applications.  These “filters” are a digital form of make-up that can be used by the person taking a “selfie.” Snapchat filters are the best-known example of this application technique.

While face-to-face encounters in a public place are recommended for safety during first dates after extension social media interaction, they are not always possible to those who are hindered from travel. Other communication applications such as Skype or Facebook Messenger allow for conversations that can verify the identity of potential romantic partners. This is a much more effective and safer way to legitimize a long-distance and virtual relationship. These applications at a more human and three-dimensional aspect when compared to simply a profile picture or avatar.

Other challenges are posed to the elderly community in search for romantic partners online. Due to the recent advent of scams such as catphishing, elderly populations may be unaware of the dangers that exist in the online world. Other challenges are legal in nature. The catphishing phenomenon has largely been beyond the grasp of legally grappling. Some investigators may be befuddled when dealing with IP addresses, Google phone numbers, and jurisdictional complications that usually accompany such criminal or civil cases.

In summation, online dating has positives and negatives. It can create opportunities for individuals to meet a wider variety of courters. It can also allow scammers to present a false façade of a more appealing and marketable form of themselves. It also can be misused by criminals or cyberbullies to create a fake identity or steal the identity of another. Vulnerable dating applications users such as the elderly are particularly prone to being swindled in catphishing schemes that can lead to shame and embarrassment or financial loss. Users of dating applications must remain vigilant in protecting their emotions and informed on how to protect their finances, reputations and personal data.

 

 

References

Wiederhold, B. K. (2016). VR online dating: The new safe sex. Cyberpsychology, Behavior, and Social Networking, 19(5), 297-298.

McWilliams, S., & Barrett, A. E. (2014). Online dating in middle and later life: Gendered expectations and experiences. Journal of Family Issues, 35(3), 411-436.

Vandeweerd, C., Myers, J., Coulter, M., Yalcin, A., & Corvin, J. (2016). Positives and negatives of online dating according to women 50. Journal of Women & Aging, 28(3), 259.

Shekhar, S. (2017). The cost of love in the age of online dating. Gurgaon: Athena Information Solutions Pvt. Ltd.

Gupta, A., Murtha, R., & Patel, N. (2012). EHarmony: More than traditional internet dating. Journal of the International Academy for Case Studies, 18(1), 43.

Timmermans, E., & De Caluwé, E. (2017). To tinder or not to tinder, that’s the question: An individual differences perspective to tinder use and motives. Personality and Individual Differences, 110, 74-79.

McIntyre, M. (2016,). Easterville ‘ghost’ returns to old haunts: Cybercriminal out of jail and back home, but U.S. authorities may seek extradition. Winnipeg Free Press

Remington C. Longstreth January 21, 2018 The Death Penalty and Issues in Psychology PSYC 590 Contemporary Issues in Psychology Dr. Riley

Remington C. Longstreth

January 21, 2018

The Death Penalty and Issues in Psychology

PSYC 590 Contemporary Issues in Psychology

Dr. Riley

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Today, there are 31 states in the union with the death penalty. Nineteen states and the District of Columbia have abolished the practice. Opponents of the death penalty have broached numerous issues including: arbitrariness, racial and economic discrimination, deterrence, innocence, botched executions, The Eighth Amendment, and psychological issues of death row inmates. Psychological issues such as intellectual disability, mental disorders and illnesses will be the primary focus of this paper.

First, terms shall be discussed for clarity and distinction. Intellectual disability is a euphemism for mental retardation. Intellectual disability focuses on the biological attributes of the internal brain. Intellectual disability refers to a neurological disfunction of the brain. Cognitive characteristics such as learning will be hindered with this disability. Intellectual disabilities can be genetic or developed. Down Syndrome is an example of intellectual disability.

Next, mental disorders psychologically render an individual unable of normal functioning in their daily life. Mental disorders are powerful and can alter personality. Severe mental disorders such as bipolar disorder can lead to suicidal ideations. Schizophrenia is another example of a severe mental disorder that can cause significant disruptions for the person. Unlike intellectual disabilities, mental disorders may or may not affect cognitive functioning. It is possible for individuals to possess both mental disorders and superior cognitive abilities. John Forbes Nash Jr., as depicted by Russel Crow in “A Beautiful Mind,” is one such example.

Mental illness is a psychological state or condition that may not be permanent. Mental illness can be treated and cured by a medical professional. Mental illness may have negative effects on mood. Depression and anxiety are examples of mental illness. Mental illness also does not inhibit cognitive capacity. However, depression and anxiety are two forms of mental illness that can affect behavior.

These three forms of mental incapacitation are sometimes conflated. Legal authorities, such as the Supreme Court of the United States (SCOTUS), has also struggled in confusion to define what intellectual disability or mental retardation is. Subjective elements of intellectual disability include consistent scores in the low 70’s in IQ tests. The intellectually disabled cannot all be neatly placed within one category. The spectrum of intellectual disability adds to the complexity of the issue.

In 1972, the SCOTUS deemed the death penalty unconstitutional under The Eighth Amendment’s “cruel and unusual” clause. After a five-year moratorium, states began to tailor their death penalty laws and the applications of execution. For example, some states now only administer lethal injections of sodium thiopental. This application is perceived as more humane when compared to a firing squad or hanging.  In 1977, states began to reinstitute the death penalty as a form of punishment. Since 1977, a slow shift away from its practice as occurred within the United States. In Atkins v. Virginia (2002), the SCOTUS ruled the death penalty unconstitutional for the mentally disabled. The court left the definition of mental disability to the states. However, the complex definition of intellectual disability has given rise to more recent cases involving intellectually disabled murder convicts. In Hall v. Florida (2014), the SCOTUS ruled that Florida’s definition of mental disability was unconstitutional. According to Florida, all defendants with an IQ above 70 were deemed competent to stand trial and eligible for execution. This clear-cut definition did not allow for discretion to be applied by prosecutors and medical professionals in the eyes of the court.

In Virginia, Earl Washington Jr.’s wrongful conviction for the rape and murder of a 19-year-old woman is one of our country’s more infamous cases. Washington was on the spectrum of intellectual disability because his IQ score was 69. Under police coercion, Washington confessed to committing the rape and murder. Washington had a history of using extreme deference to figures of authority. Washington was subsequently convicted by prosecutors and sentenced to death. Washington spent nearly a decade on death row, with a total of 17 years behind bars. With the advent of DNA technologies, Washington was ultimately exonerated and deemed innocent by the State of Virginia. Today, Washington is married and a functioning member of society. He was also awarded over $2 million for his wrongful arrest, conviction, sentencing and service of sentence. In 2007, Kenneth Tinsley (the man guilty of the mentioned rape and murder) was arrested with DNA evidence placing him at the scene of the crime. Tinsley was later convicted and sentenced to life in prison. The Washington case highlights the mangled dynamic of psychology and the law.

While the law may be more clear-cut with respect to the death penalty and the intellectually disabled, it seems to become murkier when considering defendants with mental disorders. Courts within the United States have asked specific questions when determining whether to deem a defendant “competent” to stand trial. Timing is one consideration of the court. Questions such as: “Was the defendant sane at the time of their accused crimes?” and “Does the defendant have the ability to appreciate the gravity and consequences of the crime?” are broached.

In 2016, Texas executed Adam Ward. Ward was convicted of killing a code enforcement officer with a .45 caliber handgun. Ward was also diagnosed with bipolar disorder and was prescribed lithium at the age of four. In 2013, Florida executed John Ferguson. Ferguson was convicted of shooting and killing eight victims in separate incidents. Ferguson was diagnosed as schizophrenic and believed he would resurrect after lethal injection was administered. Opponents of the death penalty cite Ferguson’s lack of appreciation and understanding for the consequences of his actions. Andre Thomas was convicted of killing his estranged wife and sentenced to death in Texas. While in prison, Thomas removed both of his eyes and ingested one of them. Thomas is a diagnosed schizophrenic who currently sits on death row. These are just a few cases of many individuals with severe mental disorders who have been or will be executed by the state. The SCOTUS has a pattern of deferring these controversial and complex cases to the lower appellate courts or the respective states. Given the current state of affairs, most defense attorneys still have a high hurdle to jump when seeking not guilty verdicts for their clients who are mentally ill. If diagnosed patients of bipolar disorder and paranoid schizophrenia still sit on death row, depressed defendants will undoubtedly be deemed competent in murder trials.

The 14th Amendment of the Constitution provides for “equal protection of the laws.” The wide spectrum of intellectual disabilities, mental disorders and mental illnesses may contribute to a call for more amicus curiae briefs. Such briefs however are ad hoc and leave room for inequality among the states. Blanket abolishment by the SCOTUS is the only way to ensure all Americans are receiving equal treatment under the law. SCOTUS deferment to the individual states is grounded in the Tenth Amendment and our ideals of a republic, rather than a concentrated federal power.

With the court’s deflection, it seems the only way towards abolishment of the death penalty, will be up through the individual states. Out of the 31 states that have the death penalty, four of them have governor-imposed moratoriums (Washington, Oregon, Colorado and Pennsylvania). The legislatures of the rest of the union seem recalcitrant to change. Polling data seems to suggest that a shrinking majority of Americans still believe in the death penalty as a legitimate power of the state. In today’s political climate, state legislators are not politically privy to empower psychiatrists and psychologists with questions concerning the death penalty and psychology patients. This trend will continue as long as the tough-on-crime posture is politically appealing to voters. However, the long-reaching tentacles of the criminal justice system may inappropriately squeeze individuals who should be patients – not criminal defendants.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

Mangels, A. T. (2017). SHOULD INDIVIDUALS WITH SEVERE MENTAL ILLNESS CONTINUE TO BE ELIGIBLE FOR THE DEATH PENALTY? Criminal Justice, 32(3), 9-14. Retrieved from https://search-proquest-com.ezproxy1.apus.edu/docview/1965541414?accountid=8289

Bonnie, R. J. (2005). the death penalty and mental illness: Mentally ill prisoners on death row: Unsolved puzzles for courts and legislatures. Catholic University Law Review, 54, 1169-1313.

Ewing, C. P., & McCann, J. T. (2006). Minds on trial: Great cases in law and psychology. Cary: Oxford University Press.

Koch, L. W., Wark, C., & Galliher, J. F. (2012). Death of the American death penalty: States still leading the way. Lebanon: University Press of New England.

Baumgardner, F. R., Johnson, E., Wilson, C., & Whitehead, C. (2016). These lives matter, those ones don’t: Comparing execution rates by the race and gender of the victim in the U.S. and in the top death penalty states. Albany Law Review, 79(3), 797.

Lanier, C. S., & Acker, J. R. (2004). CAPITAL PUNISHMENT, THE MORATORIUM MOVEMENT, AND EMPIRICAL QUESTIONS: Looking beyond innocence, race, and bad lawyering in death penalty cases. Psychology, Public Policy, and Law, 10(4), 577-617.

Edds, M. (2003;2006;). An Expendable Man: The near-execution of Earl Washington, Jr. (1st ed.). New York: NYU Press.

 

 

 

 

 

 

 

Remington C. Longstreth February 04, 2018 Competency to Practice Psychology PSYC 590 Contemporary Issues in Psychology Dr. Riley

Remington C. Longstreth

February 04, 2018

Competency to Practice Psychology

PSYC 590 Contemporary Issues in Psychology

Dr. Riley

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Psychology, like all other professions, places value on defining the gold standard for competent professionals within their business. Defining quality and competence is crucial for the protection and preservation of Psychology. Incompetent psychologists can contribute to the army of critics who lambast the profession as a joke, pseudoscience or scam. The American Psychological Association (APA) has determined structure and standards are an essential element to a stable and professional continuum within civilized and modern society.

A Psychologist can be defined as an educated and state licensed individual, with a focus in psychology, who attempts to help individuals and society through application of psychological theories and practices. Within the United States, education, training and licensure requirements may vary. All states require practicing psychologists to pass an entrance exam. Some states require practicing psychologists to have earned a PhD, while other states only require a master’s degree. As a result of varying educational requirements, the competency of psychologists will also vary across the United States.

The APA has recently required respective sub-fields of psychology to define the core competencies of their specialty. The complex nature and vastness that is the profession of psychology, has also contributed to a variance of standards for competency. For example, the sub-field of educational psychology in the United States focuses on internal modules (i.e. education and training requirements to become an educational psychologist) of their professionals, while Clinical Psychologists favor external modules (i.e. outpatient procedures and responses to treatment). A competent Educational Psychologist, under such a competency model, would be highly educated with a collection of continued training certificates. A competent Clinical Psychologist, under such a competency model, would have successfully treated a large number of patients. Patient outcomes has been measured as empirical evidence and used to assess the effectiveness of Clinical Psychologists. This issue will be further discussed later.

Institutional and Organizational I/O Psychologists value an understanding of the culture within an organization or business. I/O Psychologists must understand the culture and conditions their clients are operating within to help them attain their organizational goals. Modern I/O Psychology focuses on specialized and continued training. For example, an I/O Psychologist who is acting as a coach for the CEO of Merrill Lynch needs to understand the basics of investments, emerging markets, dealers and brokers et al. With the exponential growth of social media applications, Media Psychologists may have the most challenging expectations for continued education that focuses on modern social internet apparatuses.

This is not to say that Psychology does not possess some uniformity of competence under the greater psychological umbrella. Most sub-fields of psychology cite knowledge, skills, professionalism, values and behaviors as components of a competent professional.

For a better understanding of what competence is, one should first identify what incompetence is within the profession. Canadian Prison Psychologist, Aubrey Rogerville, provides an acute profile in the incompetent practicing psychologist.

Rogerville’s behavior was brought to the attention of the local licensing board for professionals in psychology in Alberta, Canada. Colleagues of Rogerville complained that he: physically threatened colleagues, acted as an advocate of certain inmates, claimed special knowledge because of secret files that did not exist and lied to parole board members on legal matters during parole hearings for inmates. The litany of allegations compelled the local board to review the case. After an extensive investigation and multiple interviews, the board concluded that his behavior was concerning, but there was no legitimate reason to revoke his license to practice psychology.

Although Rogerville’s license was not revoked by his local board, his actions were unbecoming of a professional psychologist. Competence and professionalism within the field require ethical considerations such as truthfulness and objectivity during any legal proceeding. Psychologists are often invited to testify on the witness stand in court and under oath. A psychologist who intentional spreads misinformation, conflation, or who perjures themselves, cannot be considered competent. Other tenants of a practicing professional include professional relationships among colleagues. Rogerville physically threatened other psychologists within the correctional system. This is hardly the behavior of a competent professional in any field.

While it is easy to deem Rogerville as incompetent based on the totality of his behaviors over time, some defenders of Clinical Psychologists have questioned the use of patient outcomes as empirical evidence for their alleged lack of competence. For example, some Clinical Psychologists have devoted their careers to the service of high-risk patients. “High-risk” patients include those who have a pattern of suicidal behavior or ideations and drug abusers with a history of overdoses. The percentage of positive outcomes of high-risk patients in lower socioeconomic areas may not be as high when compared to lower-risk patients in high socioeconomic areas. Under such considerations, the Clinical Psychologist who serves in the conditions of the former, is not necessarily less competent than the latter.

Sports Psychologists work for professional sports teams, which are privately owned. While the Sports Psychologist works at the pleasure of the team owners, leading professionals within this sub-field have also tacked on both internal attributes of competence (education and training) and external attributes of competence. External attributes may include increasing the free throw percentage of an NBA basketball player who is struggling at the foul line. On a larger scale, external attributes could be the winning percentage of the NBA basketball team. NBA coach Phil Jackson employed his friend and Sports Psychologist, George Mumford, to use encouragement, counseling and other applications of psychology to increase Shaquille O’Neal’s free throw percentage when he played for the Los Angeles Lakers. O’Neal’s free throw percentage was increased from 48% to 62% in the 2002-03 season. According to Jackson, Mumford deserved some credit because of O’Neal’s free throw output. In Jackson’s eyes, Mumford was a competent Sports Psychologist.

In summation, competent and professional psychologists should have a solid initial foundation of education and training. The mark of a competent psychologist is one who not only has a depth of knowledge, education, and training, but strives for continuous training and is abreast of all the latest discoveries and discussions of their contemporaries. Furthermore, states and the APA should continue to strive for uniformity among standards of competence. This includes increasing the minimum education requirements of all practicing psychologists to that of a PhD. States should also attempt to require a standard amount of internship experience, under the supervision of a competent and licensed psychologist, before issuing licenses to psychologists in all specialties.

Just a few sub-fields of psychology were broached during this discussion. Psychology has an almost endless abyss of unmentioned sub-categories including, but not limited to: Social Psychology, Biosocial Psychology, Animal Psychology, Developmental Psychology, Cognitive Psychology, and Evolutionary Psychology. While it may be inappropriate to demand uniformity in education, training and skills of all psychologists, sub-categories of the field should strive for uniformity across the United States. This will reduce the critics of the profession, protect its integrity and preserve the study for generations to come.

 

 

 

 

 

 

References

McDaniel, S. H., Grus, C. L., Cubic, B. A., Hunter, C. L., Kearney, L. K., Schuman, C. C., . . . Johnson, S. B. (2014). Competencies for psychology practice in primary care. The American Psychologist, 69(4), 409-429.

Rodolfa, E., Greenberg, S., Hunsley, J., Smith-Zoeller, M., Cox, D., Sammons, M., . . . Spivak, H. (2013). A competency model for the practice of psychology. Training and Education in Professional Psychology, 7(2), 71-83.

Hunsley, J., Spivak, H., Schaffer, J., Cox, D., Caro, C., Rodolfa, E., & Greenberg, S. (2016). A competency framework for the practice of psychology: Procedures and implications. Journal of Clinical Psychology, 72(9), 908-918.

Roe, R. A. (2002). What makes a competent psychologist? European Psychologist, 7(3), 192-202.

Competency-based education for professional psychology: Moving from concept to practice. (2013). Training and Education in Professional Psychology, 7(4), 225-234.

                                                                                                       

Remington C. Longstreth

Exploitive Relationships

American Military University

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The fusion of professional and personal time at Starbucks and the contemplation of sharing a room with a supervisee is dancing with ethical disaster. The supervisee may feel as though their professional employment is contingent upon the personal relationship with their supervisor. Sharing a room also places the supervisee in a financially precarious position. Finally, sharing a hotel room with a supervisee, during a professional retreat, is highly inappropriate and clearly unethical. Section three (3) of the APA’s ethical codes, “Human Relations” (APA, 2017) immediately comes to mind. This section states that unfair discrimination, sexual and other harassment will not be tolerated (APA, 2017). Furthermore, the avoidance of harm to any party involved should be of the utmost importance (APA, 2017).

More specifically, there are at least three ethical issues within this scenario, according to the APA’s ethical codes. These ethical issues include: section (3.05) Multiple Relationships and section (3.08) Exploitive Relationships; section (6.04) Fees and Financial Arrangements; and section (7.07) Sexual Relationships with Students and Supervisees. “Multiple Relationships” is defined as holding more than one relational role with the same person (i.e. supervisor and friend) (APA, 2017). “Exploitive Relationships” exist where a supervisor uses their position of authority over another for personal or any other unethical benefit (APA, 2017). “Fees and Financial Arrangements” should be aligned with the law and understood by the supervisee (APA, 2017). “Sexual Relationships with Students and Supervisees” is a specific “multiple relationship” role and is strictly prohibited (APA, 2017).

Three courses of action to guard ethical parameters and maintain a professionally balanced relationship between the two parties are: (1) avoid conducting business outside of professional settings, such as Starbucks; (2) do not share a hotel room with a subordinate for any reason; (3) conduct an initial counseling regarding the appropriate roles and responsibilities of both the supervisor and supervisee. There should be a clear distinction between personal and professional environments for the comfort and effectiveness of both the supervisor and supervisee. Secondly, sharing a hotel room with a subordinate is a clear breach of this personal-professional line. Third, these parameters should have already been defined by the supervisor. The supervisee should also agree to such terms and conditions if they are in a position to freely do so.

With respect to multiple relationships, the supervisor should make it abundantly clear that any meeting, regardless of the location, is strictly for business or professional purposes (Barnett, 2014). A professional office should be used instead of outside locations such as Starbucks. Once the given business matters are handled, the supervisee should be and feel free to leave the office or any other location (Haydar, 2006). The supervisee should not at any time feel pressured or compelled to expend personal time with the supervisor. This would be an unethical exploitation by the supervisor.

Mixing personal and professional relationships with a supervisee can impair the objectivity, competence and effectiveness of both the supervisor and supervisee (APA, 2017). The supervisor must occupy and remain within the supervisory role when assessing the professional performance of the supervisee. It is the duty and obligation of the supervisor to remind the supervisee when inappropriate conduct is displayed and to consistently enforce ethical standards by means of word, documentation and deed (Cottone, 2005). The supervisor should be the personification of this ethical and professional dynamic. The supervisor must feel free to take necessary administrative action against the supervisee when necessary. A personal relationship can tip the professional balance into ethically murky waters. Dual relationships harbor a disservice to both the supervisee and the business, government agency or firm of the supervisor. If other subordinates view this unethical and personal relationship within a professional setting, they could perceive inequality or favoritism manifesting. It should be noted that the given scenario does not state whether there is more than one subordinate.

Secondly, exploitive relationships created by the supervisor are also unethical according to the APA ethics codes. The codes hold that the supervisor should not use their position of power or authority to personally, financially, or in any other unethical way, exploit the role of the supervisee. In this given scenario, the supervisee may feel coerced or compelled to remain at Starbucks well after the conclusion of business and for the personal enjoyment of the supervisor. On the other hand, the supervisor must never place him/herself in a professional position that can be exploited by the supervisee. For example, if the supervisor engages in embarrassing or unethical behavior with or in front of the supervisee, this could be used by the supervisee and against the supervisor. This could prevent the supervisor from administering equal treatment to the given supervisee in the future. The supervisor must not allow him/herself to be blackmailed or exploited by any supervisee. In this given scenario, it is suggested that the personal company is being enjoyed between the two parties. If enjoying the personal company also includes feelings of physical attraction or sexual intimacy, this could also make section (7.07) of the APA ethical codes applicable.

If the professional relationship evolves (or devolves) into a sexual relationship, or if any sexual conduct transpires between the two parties, then legal consequences could manifest. If the supervisor coerces, by means of his/her position of authority over the supervisee, then sexual harassment charges could be filed in civil court and/or charges of sexual battery could be brought against the perpetrator. Ethical codes are established in such professions to protect all parties from the slippery slopes that exist between unethical and illegal behavior (Frere, 2007).

Section seven (7) of the APA ethical codes outlines “Education and Training” (APA, 2017). A sub-section (7.07) on “Sexual Relationships with Students and Supervisees” (APA, 2017) has been enacted. It is unequivocally declared that supervisors should never engage in sexual conduct with students or supervisees who are within the same workplace or when the supervisor is likely to have some academic, administrative, judicial or legal authority over the supervisee (APA, 2017). In the given scenario, the supervisor is enjoying the company of the supervisee. This personal relationship may be escalated by entering into a financial agreement with the supervisee and sharing a hotel room during a professional retreat in Boston.

The sharing of a hotel room with a supervisee should be categorically avoided. Sharing a hotel room during a professional retreat can muddy financial matters between the supervisor and supervisee. Hotel rooms are used as personal, private and potentially intimate quarters for paying customers. Sharing a hotel room with a subordinate could be in violation of their privacy and confidentiality. Moreover, the supervisee should never be placed into a position where they personally owe the supervisor anything because their room expenses were covered by the supervisor. This could possibly be perceived by the supervisee and others, as an exploitive and unethical quid pro quo situation. The travel benefits and expenses of the supervisee should have already been explained during the hiring process of the supervisee. The supervisee should already understand the travel benefits they will enjoy and understand what travel benefits that will have to be paid out of pocket.

The best ethical solution to avoid such a scenario, is to hold an initial counseling with the supervisee. The initial counseling would highlight and explain the appropriate role of the supervisor and the relationship to the supervisee. It would also clarify expectations for both parties and explain the extent of financial benefits of employment with the supervisor. It would outline the extent of privacy and confidentiality of the supervisee (APA, 2017). If the roles or expectations did not remain within ethical, administrative and legal parameters, the appropriate action would occur to remedy the situation. It should also be explained that objective, swift and equal treatment of all supervisees would be protected both in and outside of the workplace. The authority of the supervisor should be explained and limited to the confines of professional settings.

The supervisor should also avoid entering into any social situations with the supervisee, that could be perceived by the supervisee or any other individual, as the cultivation of an exploitive or multiple relationship dynamic (Sanders, 2016). This includes refraining from conducting business at Starbucks or any other setting outside of a work environment. This also includes avoiding the sharing of hotel rooms or entering into any additional financial arrangements with the subordinate. All interactions between the supervisor and subordinate should be professional in manner. Exploiting the power of the higher rung within the hierarchical relationship is highly unethical and can be punished by administrative boards, civil or even criminal law. Such an interaction is not only dangerous to the subordinate, but also carries negative consequences to the psychological profession as a whole.

If the supervisor defines appropriate roles, establishes appropriate professional and financial relationships and avoids multiple, exploitive and sexual relationships: then he/she will be within the bounds of sections three, six and seven of the APA ethical codes. Occupying an ethical position beyond reproach will mitigate professional harm and damage to all parties involved. Walking a thin line between ethical and unethical behavior could quickly turn into illegal behavior subject to the jurisdiction of the criminal justice system. Additionally, entering into unnecessary personal or financial relationships with supervisees adds complexity to a profession that is already inherently complex. Supervisors must always feel free to supervise, while supervisees must feel free to execute the ethical, legal and professional intent of their boss.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

APA Ethical Principles of Psychologists and Code of Ethics (n.d.). Retrieved from https://apa.org/ethics/code/ethics-code-2017.pdf

Barnett, J., & Molzon, C. (2014). Clinical Supervision of Psychotherapy: Essential Ethics Issues for Supervisors and Supervisees. Journal of Clinical Psychology, 70(11), 1051–1061.

Cottone, R. (2005). Detrimental Therapist-Client Relationships—Beyond Thinking of “Dual” or “Multiple” Roles: Reflections on the 2001 AAMFT Code of Ethics. The American Journal of Family Therapy, 33(1), 1–17.

Frere, L., & Glenn, M. (2007). An exploratory study of multiple relationships, ethical decision making and the identification of potentially harmful relationships in college counseling centers. ProQuest Dissertations Publishing. Retrieved from http://search.proquest.com/docview/304800236/

Haydar, S., & Dalenberg, C. (2006). Dual relationships and the psychologist’s inner circle: Ethical decision making concerning multiple relationships with family and friends. ProQuest Dissertations Publishing. Retrieved from http://search.proquest.com/docview/304912072/

Sanders, R. (2016). Maintaining A Balance: The Challenge of Multiple Relationships for Christian Therapists. Journal of Psychology and Christianity, 35(4), 320–329.