3. Criteria Substance Abuse/Addictions - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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Mine, Yours, and Ours, Addiction and Compulsivity in Couples and Couple Therapy
Chapter 3: CRITERIA FOR SUBSTANCE DEPENDENCE & APPLICATION TO OTHER ADDICTIONS


The following are from the DSM IV (APA, 1994, page 181) criteria for substance dependence with the words "behaviors or relationship" in italics inserted after the term "substance use."  In the newest version, DSM V (APA, 2013) there have been some technical differences for diagnosis that do not change the concerns of this book.  The therapist will find that adding or substituting behavioral and interpersonal addictions to substance maintains the accuracy and appropriateness of the list of diagnostic criteria.  This becomes useful in working with someone who may resist the addiction label.

A maladaptive pattern of substance use (behaviors or relationship), leading to clinically significant impairment or distress, as manifested by three  (or more) of the following, occurring at any time in the same 12-month period:

(1) tolerance, as defined by either of the following:
(a) a need for markedly increased amounts of the substance (behaviors or relationship)  to achieve intoxication or desired effect
(b) markedly diminished effect with continued use of the same amount of the substance (behaviors or relationship)

(2) withdrawal, as manifested by either of the following:
(a) the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)
(b) the same (or a closely related ) substance (behaviors or relationship) is taken to relieve or avoid withdrawal symptoms

(3) the substance (behaviors or relationship) is often taken in larger amounts or over a longer period than was intended

(4) there is a persistent desire or unsuccessful efforts to cut down or control substances (behaviors or relationship) use

(5) a great deal of time is spent in activities necessary to obtain the substance (behaviors or relationship) (e.g., visiting multiple doctors or driving long distances), use the substance (e.g. chain-smoking, weekend trips to gamble at casinos, frequent traveling out of town to visit partner), or recover from its effects

(6) important social, occupational, or recreational activities are given up or reduced because of substance use (behaviors or relationship)

(7) the substance use (behaviors or relationship) is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (behaviors or relationship) (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption, (continuing relationship despite recurrent experiences of hurt and abandonment, depression and anxiety)

Addiction needs to be revealed in therapy.  Many clients will agree to couple therapy only after getting the partner to agree not to bring problematic use or behavior or addiction up as an issue.  For example, Marilyn was not supposed to bring up Daryl's affairs, especially when they were supposed to be dealing with their son's behavior.  Dyson was not supposed to mention Samantha's childhood molestation or her cutting.  It is not unusual when the therapist has elicited revelation of compulsive behavior or addiction from one partner that the other confesses that he or she had been warned not to talk about it.  Only if the therapist can skillfully bring this out can he or she now speak of it.  Holding addiction or compulsivity secret will basically compromise the integrity of the therapy.  Clients normally will not reveal this secret "agreement" (which is normally a coerced or forced agreement) at all unless the therapist asks probing questions.  The questions that lead to uncovering possible substance abuse will not be a direct question whether the individual has a drinking, drug, or addiction/compulsion problem.  The questions should be about the amount of alcohol or drug use, alcohol or drugs of choice, situations of use, emotional atmosphere when use occurs, and family history of use.  The exploration of family history of use, abuse, or dependence can be a roundabout way to get to individual use.  The addict or compulsive person often does not have the foresight to include family history of use (parents, aunts, uncles, siblings, cousins, and grandparents) into the "agreement" he or she has forced upon his or her partner.  The addict or substance abusing partner will often reveal use or abuse in both his or her family and the addict's family.  The therapist should also look for controlling behavior in the couple's dynamic or family history.  Controlling behavior patterns can be an indicator of hidden addiction issues.

Minimizing of alcohol or drug use or history may be common.  The addict tends to distort the truth, as opposed to outright lying.  "Yeah, I have a beer or two after work.  No big deal."  The therapist needs to ask specifically, "How many do you have after work, one or two… or three… or what?"  After work may turn out to be after work and before dinner!  "How many do you have with dinner?"  One or two.  "Do you drink after dinner?  How many?" One or two.  Now simple addition takes it from one or two to a half or a whole (more likely) six-pack an evening.  "And, do you drink during the day."  Another one or two at lunch, and one or two in the afternoon if it's really hot.  With simple mathematics, the therapist can see that the total number gets closer to a 12-pack case a day habit, for example.  Getting full disclosure may not occur readily or early in therapy.  The therapist can return to it as is therapeutically astute.  While essential to the integrity and success of therapy, getting an individual or the couple to reveal and own addiction immediately is not essential.  Getting full disclosure and ownership of addiction is a developmental process that takes incremental change to eventually get to a critical mass of acceptance.  Using his or her clinical judgment, the therapist can refer to criteria used for diagnosis without initially referring to addiction.

Sexual addiction, for example can be discussed referencing tolerance, as defined by either of the following using terminology borrowed from the DSM:

a need for markedly increased sexual frequency (instead of amounts of the substance) to achieve intoxication or desired effect

markedly diminished effect with continued use of the same frequency or type of sex.

Internet addiction, for example can be discussed referencing withdrawal, as manifested by either of the following:

the characteristic withdrawal syndrome for the stopping or curtailing Internet addiction

the same Internet behavior is taken to relieve or avoid withdrawal symptoms

Gambling addiction, for example can be discussed

as gambling occurs in larger amounts of time or money gambled or over a longer period than was intended

there is a persistent desire or unsuccessful efforts to cut down or control gambling

a great deal of time is spent in activities necessary to gambling (e.g., visiting multiple bookies or casinos or, frequent traveling out of town to visit partner), or recover from its effects

An eating disorder or food addiction, for example can be discussed'

important social, occupational, or recreational activities are given up or reduced because of eating compulsions or food addiction

eating compulsions or food addiction is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the eating compulsions or food addiction (e.g., current eating compulsions or food addiction despite recognition of eating or food-induced depression, or recognition that unhealthy medical consequences were made worse by eating compulsions or food addiction.

The therapist can ask about the partners' behaviors and choices about use or behavior to see if they constitute problematic use or behavior.  When the addict and partner discuss the behavior in ways that fit the criteria, the therapist is alerted to the possibility of addiction.  The therapist can then introduce how their choices, behaviors, and experiences reflect a diagnosis for addiction.  This approach is often important for non-substance addiction or behavioral addiction, since the behavior does typically have a negative stigma as alcohol or illicit drug use.  The distinction between behavior and problematic behavior is subjective to the individual, couple, and their circumstances.  Both partners may be genuinely ignorant that the individual's behavior is addiction in action.

ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
phone: (510) 614-5641
fax: (510) 889-6553
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