Substance Abuse-Induced Dementia and Insanity

Substance Abuse-Induced Dementia and Insanity: Is Cause of the Mental Illness Relevant to Criminal Responsibility?


This paper reviews the evolving stances on voluntary intoxication, addiction and the insanity defense. It will review all sides of the debate of culpability of voluntary intoxication, the debate among the sciences, along with the more informed knowledge on addiction and a more inclusive stance on intervention when sentencing an offender with addiction. Unlike involuntary intoxication, or unknowingly ingesting a substance that would cause them to become impaired, voluntary or self induced intoxication defined as an individual taking or ingesting, injecting, or by other means a substance knowingly, that causes intoxication. It is not enough to be an addict just as it is not enough to be mentally ill for an insanity defense. The debate can sometimes seem similar to the chicken or the egg, especially if an individual has prior mental health issues. More relevantly, when does or can an individual’s addiction qualify or become plausibly applicable to involuntary intoxication. Neuroscience and psychology both play an important role in the questions at hand in this area.

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When looking at insanity as a defense, the first thing that comes to mind is compromise between the public and our justice system. A defense comprised of our society’s notion that criminals need to be punished, but the mentally ill should receive and are in need of treatment instead.  Most notably the first recorded definition being in an English legal dissertation in 1581. Using words such as madman, lunatic, and natural fool, and doing acts at the time of their lunacy, they were not culpable for their doings (Asokan, 2016).

The issues over recognizing and what constitutes insanity have been debated in courts for centuries, in 1724 a King Edward’s court judge, Justice Tracy, developed what he deemed the wild beast test. A defendant was considered insane if he/she lacked the mental abilities no greater than an infant, brute, wild beast or lunatic (Stoll, 2009).Justice Tracy’s concept of insanity was very narrow because it only pertained to those completely lacking mental processes or utilities. It was not until the M’Naghten case in 1843 that the concepts of insanity would become a tad wider in scope and become more of a common law, but not without controversy. M’Naghten was acquitted of murder after being evaluated by several medical professionals and found to have schizoid behavior, but under the Criminal Lunatics Act 1800, he was forced to be institutionalized for the rest of his life (Asokan, 2016). The M’Naghten rule was still restrictive to any person lacking reason, but does not recognize the lack of self restraint, yet it was responsible for other issues being raised concerning medical practitioners and their ability to assess the offenders state of mind during the time of the offense, as well as the importance of expert testimony. After the acquittal of M’Naghten, the public became angery over what they and the press considered being blatantly lenient because they felt that he didn’t look “mad” and seemed to carry himself in a rational manner (Dalby, 2006).  This would not be the last time an insanity verdict would cause an uproar. In 1981, John Hinckley’s attempted assassination of President Reagan, once again a not guilty by reason of insanity verdict, relying on the ALI’s Model Penal Code (which puts the responsibility on the jurors), and the jury finding there to be lacking burden of proof of the test, caused fear of criminals being able to escape punishment and made the public’s blood to boil. Congress almost immediately started their reformation and conceded the Insanity Defense Reform Act of 1984, re-establishing the M’Naghten test, incorporating the burden of proof to be on the defendant, and that an insanity defense can only be allowed if the defendant has clear and convincing evidence of having a severe mental disease or defect (Stoll, 2009).

Unlike involuntary intoxication, or unknowingly ingesting a substance that would cause them to become impaired, voluntary or self induced intoxication defined as an individual taking or ingesting, injecting, or by other means a substance knowingly, that causes intoxication, specifically in the Florida 2018 Statues, 3.6(d) Voluntary Intoxication, 775.051, is not a defense and evidence is not admissible to show lack of intent or insane. This Statue and the many others like it are seemingly, straight forward and pretty black and white, right? Well, not so much. Today most states still adhere to the basics of the Insanity Defense Reform Act 1984. In many states it is continuously evolving.  Arizona, for example, has taken on a guilty but insane statute, seemingly contradictory in terms but still, it’s close to the M’Naghten test yet genially combines the stigma and condemnation of the crime, while still trying to avoid the outcry of lenience (Stoll, 2009). In our court of law, there are two elements needed in order to find guilt beyond reasonable doubt, the wrongful deed (actus reus), or criminal intent (mens rea).The insanity defense, or not guilty by reason of insanity, submits that the defendant admits to the act, admits to the intent (mens rea), but was mentally incapable of appreciating the consequences and unable to resist or control their actions (actus reus), and there for has no culpability to their crime (Weiner & Otto, 2013). Involuntary intoxication is not included in this, nor is other conditions such as pedophilia, kleptomania, pyromania, and psychopathy. The guilty but insane statue mirrors diminished capacity.  This is when a defendant is acknowledged to have a mental impairment or defect and is incapable of having the intent to do harm; not considering the extent of guilt (Weiner & Otto, 2013), but rather basic guilt, therefore it is typically treated as reckless behavior and the defendant usually receives a lesser charge (manslaughter instead of murder).

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Science is ever evolving in the area of substance abuse and psychosis, although most court systems have not adapted to or even recognize the disease model of addiction (Davis, 2018). It is not enough to be an addict just as it is not enough to be mentally ill for an insanity defense. The debate can sometimes seem similar to the chicken or the egg, especially if an individual has prior mental health issues. More relevantly, when does or can an individual’s addiction qualify or become plausibly applicable to involuntary intoxication. Neuroscience and psychology both play an important role in the debate at hand in this area. Australian neuroscientist David Eagleman, contends that neuroscience is essential and can fundamentally change our customs of sentencing in our court system. He wants the courts to relinquish the idea of punishment, deeming it unjustified and retributive, and turn its attention towards the direct management of criminals by deterring these behaviours in order to protect the public. American psychologists Joshua Greene and Jonathan Cohen contend that neuroscience by revealing impairments in the process mechanics of human behavior will have us then thinking instead that we are all impaired and occasionally impulsive and unable rather than unwilling to abide to ethical accountability, in a sense, so therefore no one has the free will to choose their actions and consequently they do not deserve any just punishment for their criminal behavior (McCay, 2016).  It is widely recognized that addiction is associated with changes in the brain, but the controversy of this very complex and very multifaceted issue is in the naming and associating it as a disease. If we are go by the newest neurological understandings of addiction, then this becomes relevant in the court room because if in fact addiction is a disease, does that not involve a mental defect and the mental inability of appreciating the consequences and unable to resist or loss of conscious control of their actions (actus reus)? Those who would disagree do so on the grounds that, even though researchers agree that addiction has correlation with the brains processing abilities pertaining to memory, reward, and perception, and that the addict seems to have conditioned stimuli responses influenced by external and internal factors as well as by conscious and unconscious urges, it is still not fully agreed upon whether the addiction is a product of the pathology of a neurobiological ailment or maybe epigenetic processes, or even question maybe it is simply the brains manifestation taking form because of the addiction itself (Farisco, Evers, & Changeux, 2018). In other words, during an assessment, the forensic clinician must establish whether or not the offender was unable to control their criminal behavior or was a rational choice made by their real self (Blakey & Kremsmayer, 2018), to overrule a more moral decision, unconcerned with its outcome or consequences. In addition, in the courts are more concerned about these assessments not about the offender’s guilt, but more about their risk of reoffending and dangerousness (Gkotsi & Gasser, 2016). Some scholars argue that given this knew neuroscientific understandings of impulse control and rational tests, the insanity standards of today are outdated, and due to our society’s fear of crime and insecurity, the forensic clinician, both in treatment and in assessing or continuous re-evaluation, is put under more and more scrutiny. The law states that an individual is responsible for their action, irrelevant of its cause. Neuroscientific opinion of criminal behavior and lacking moral decision making is an individual’s biological flaw and can be treated with therapy and medication, thus continues to challenge forensic psychiatry and put it under pressure, as well as in ethical dispute (Gkotsi & Gasser, 2016).

In conclusion, with the question of should cause of mental illness relevant to criminal responsibility, the answer seems to be both yes and no. This is where our scientific and legal concerns tend to differ. The legal side and our society want culpability, and doesn’t make it its course to make known disorders or illness, and science is more interested in treatment than retribution (Asokan, 2016). I believe these two concerns could truly merge and form an ethical joint verdict and agreement. With more informed neuroscience concerning addiction and its potential of blurring the lines of voluntary intoxication, it is an opportunity for forensic clinicians to not only assess mental capacities using information gathered from the defendants past, their time of offense and current incarcerated behavior, as well as what type of substance is being abused along with its characteristics when being abused, but also suggest to the courts more effective interventions stemming from the mental health disorders associated with substance abuse, thus treating the defendant while incarcerated.  Punishment and treatment become more intertwined. A reformed Model Penal Code rule well-versed on substance abuse and its affects, allowing the judge the option to add a contingency management plan, aiding in reducing the chance of recidivism, as well as keeping the public safe.


Asokan, T. V. (2016). The Insanity Defense: Related issues. Indian Journal of Psychiatry, 58

Dalby, J. (2006). The Case of Daniel McNaughton: Let’s get the story straight. The American Journal of Forensic Psychiatry. 27. 17-32.

Davis, M. (2018). Addiction, Criminalization, and Character Evidence. Texas Law Review, 96(3), 619-653.

Farisco, M., Evers, K., Changeux, J., Medicinska fakulteten, Medicinska och farmaceutiska vetenskapsområdet, Uppsala universitet,  Centrum för forsknings- och bioetik. (2018). Drug addiction: From neuroscience to ethics. Frontiers in Psychiatry, 9, 595. doi:10.3389/fpsyt.2018.00595

Gkotsi, G. M., & Gasser, J. (2016). Neuroscience in forensic psychiatry: From responsibility to dangerousness. ethical and legal implications of using neuroscience for dangerousness assessments. International Journal of Law and Psychiatry, 46, 58-67.

McCay, A. (2016). Can neuroscience revolutionize the way we punish criminals?. London: Independent Digital News & Media.

Stoll, M.  (2009). Miles To Go Before We Sleep: Arizona’s “Guilty Except Insane” Approach to the Insanity Defense and Its Unrealized Promise. Georgetown Law Journal, 97, 1767.

The 2018 Florida Statues

Weiner, I. B., & Otto, R. K. (2013). The Handbook of Forensic Psychology (Vol. Fourth edition). Hoboken, New Jersey: Wiley.

Substance Abuse Treatment for Women Offenders: A Research Review

Adams, S, Leukefeld, C.G., & Peden, A.R. 2008. Substance Abuse Treatment for Women            Offenders: A Research Review. Journal of Addictions Nursing, 19, 61-75.             doi: 10.1080/10884600802111648

Finfgeld-Connett, D & Johnson, E.D. 2011. Therapeutic Substance Abuse Treatment for Incarcerated              Women. Clinical Nursing Research, 20(4), 462-481.              doi: 10.1177/1054773811415844

 This article written by Deborah Finfgeld-Connett and E. Diane Johnson looks at the importance of substance abuse treatment being gender-specific when it comes to incarcerated individuals.

Lanza, P.V. & Menéndez, A.G. 2013. Acceptance and Commitment Therapy for drug abuse in              incarcerated women. Psicothema, 25(3), 307-312.               doi: 10.7334/psicothema2012.292 In this article, the authors set out to test the hypothesis that Acceptance and Commitment Therapy (ACT) would be beneficial in treating substance abuse in incarcerated women. This is a very important hypothesis, in that treatment for substance abuse in incarcerated persons has not been addressed as often as one would hope. In the research that has addressed this issue, the findings most often seem to be from an all-male inmate population. This study included 31 participants, all women, who were diagnosed with a substance use disorder, were convicted of a sentence of more than 6 months, and voluntarily agreed to participate in the study. Lanza and Menendez collected data on the participants for 3 years between 2009 and 2012 at the specific prison. The participants were assigned to one of two groups: ACT (Acceptance and Commitment Therapy) or CG (control group), and all were given a 75-minute assessment at the beginning of treatment. The treatment itself consisted of 16 weeks of 90-minute weekly sessions and took place in separate groups of 4 female inmates per group. The participants would self-report their drug use throughout treatment while also completing a urinalysis to confirm that they were accurately reporting. The participants in the control group were only given the self-reporting and urinalysis check-ups throughout the 16-week period. Post-treatment, the participants in the ACT group showed a significant difference when it came to abstinence from substances compared to the control. The most interesting finding according to the authors, was that at the 6-month follow-up, 43.8% of the ACT group was able to maintain their abstinence compared to the 18.2% in the control group. This study reported that the conclusions were consistent with other findings regarding ACT and substance abuse treatment. Perhaps the most interesting and beneficial finding was the 6-month follow-up. It is so important to give individuals who are incarcerated a fighting chance at overcoming addiction. While 12-step programs are extremely popular, ACT may be able to give inmates struggling with addiction the coping skills to overcome triggers, address their own struggles, and learn new ways of dealing with stressors. Though this study only looked at a population of 31 inmates, the findings were extremely compelling and interesting. It is important to know that one major limitation of this study is that it did not test for comorbidity, which is important to address when looking at treatment methods and outcomes. It is also important that we as a country look at the most beneficial ways to help inmates struggling with substance use to overcome their addiction. By teaching coping skills that will aid them in daily life outside of prison, they may have a much higher chance of avoiding relapse and potential incarceration.

Fernandez, P., Menendez, A.G., Rodriguez, F., & Villagra, P. 2013. Long-term outcomes of Acceptance              and Commitment Therapy in drug-dependent female inmates: A randomized controlled trial.              International Journal of Clinical and Health Psychology, 14, 18-27.

 This study is also looking into the use of Acceptance and Commitment Therapy (ACT) as a treatment for substance use disorders in incarcerated women. This study however, does not solely look at ACT as a treatment method, but set out to compare ACT and Cognitive Behavioral Therapy (CBT) in long-term efficacy. This research looks at an important aspect of treatment comparisons; their effectiveness long-term. For an incarcerated population, the most efficient treatment long-term could dramatically increase their quality of life during and after serving their sentence, potentially keeping them away from the possibility of future incarceration once their time has been served.

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 This study included 37 participants, all were female inmates who had been diagnosed with current substance abuse or dependence, and most were incarcerated for drug-oriented crimes. Data for this study was collected over a 2-year period between 2010 and 2012. Each participant underwent a 90-minute assessment prior to treatment. Both of the treatment interventions occurred simultaneously in 90-minute sessions over a 16-week period in groups. The Psychologist providing the ACT treatment outlined the main goals throughout treatment as: identifying ineffective strategies, understanding that control is the problem, acceptance and willingness to change, as well as values and commitment. The Psychologist providing the CBT treatment identified their main goals for treatment as: recognizing behavioral patterns, analyzing different drug use/abuse situations, identifying negative emotional states, cognitive restructuring, alternative behaviors, and relapse prevention.

The results of this study were very interesting as the researchers continued to track the progress of the participants for up to 18 months post-treatment. The findings showed a significant difference in abstinence between the CBT group and the ACT group. It was found that the ACT group had 27.8% abstinence immediately after treatment, 84.6% 12 months post-treatment, and 85.7% at 18 months post-treatment. This was calculated to be significantly higher than the CBT treatment, as that group had percentages of 15.8% immediately after treatment, 54.5% 12 months post-treatment, and finally just 50% at 18 months post-treatment. One of the important things to notice when looking at these findings is that both CBT and ACT seem to be efficacious as they both showed significant increases in abstinence up to 18 months post-treatment. However, in this specific study, ACT presented with significantly higher rates of abstinence than did CBT.

Some limitations of this study include the presence of other disorders that may have gone unnoticed throughout treatment and may have potentially had an impact on the outcome of treatment. Another limitation could potentially be that these treatments were given by different therapists, and though the treatment consists of following protocol, there is a significant importance of the therapeutic relationship in both of these treatment methods. However, the findings in this article present very interesting evidence into treatments for incarcerated women struggling with SUD’s. While CBT is a very popular and efficacious therapy used to treat substance use in individuals, ACT seems to have a long-lasting and possibly higher positive impact on incarcerated women specifically.

Garcia, P.F., Lamelas, F.R., Lanza, P.V., & Menendez, A.G. 2014. Acceptance and Commitment Therapy Versus Cognitive Behavioral Therapy in the Treatment of Substance Use Disorder with Incarcerated Women. Journal of Clinical Psychology, 70(7), 644-657.doi: 10.1002/jclp.22060

The objective of this study was to compare Acceptance and Commitment Therapy (ACT), Cognitive Behavioral Therapy (CBT), and a control group to understand the differences in efficacy between the two therapies when it comes to treating incarcerated women with substance use disorders (SUD’s). This study looks deeper into the differences seen at post-treatment regarding both therapies that may help to give insight into what needs to be incorporated into future therapies in order to see the highest level of abstinence post-treatment for incarcerated women.

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The participants of this study consisted of 50 incarcerated women in a state prison who met the diagnostic criteria for currently having an SUD. They also were individuals serving a sentence of 6 months or more. All of the participants were given an assessment involving a questionnaire prior to treatment, an assessment immediately after treatment, and then a follow-up 6 months post-treatment. The data was collected over a span of 3 years from 2009 to 2012. All participants participated in 16 weeks of group sessions lasting 90 minutes each. The CBT group focused on altering the behavior resulting from their negative schemas and understanding how that may affect their behavior in relation to their SUD. The ACT group was focused more on how they could respond to events in a novel way while trusting themselves, becoming empowered, and taking back control of their behaviors. The control group received mental health assessments at the same time as both experimental groups and they would receive treatment after the 6-month follow-up had been complete.

The results were seen to show a significant difference between the ACT group and the control. At post-treatment, the CBT group was reported to have 15.8% abstinence, the ACT group 27.8%, and the control group 7.7%. At the 6-month follow-up, the CBT group was at 26.7%, the ACT group was at 43.8%, and the control was at 18.2% abstinence. The ACT group had the highest percentage of abstinence at both post-treatment and the 6-month follow-up compared to the CBT group as well as the control. The study also found that 86% of the participants assessed displayed criteria for at least one other mental disorder. One very important finding was looking at anxiety and avoidance in the participants. It was seen that anxiety was progressively decreasing throughout the course of treatment for both the ACT and CBT groups, however, the CBT group change at post-treatment seemed to fade when observed at the 6-month follow-up while the ACT group’s change was maintained. ACT also showed that anxious and depressive symptoms significantly decreased over the course of treatment compared to the other groups.

Some of the limitations of this particular study involve the sample size as well as the environment. This study was completed using inmates from one specific prison, it may be much more beneficial to use a variety of inmates over many different prisons to determine whether or not there is a significant difference based on the specific prison environment. Again, the therapies were completed by two different psychologists, and as the therapeutic relationship is very important in both treatments, it may have influenced the study in some way. The study was stronger than some of the previous studies discussed because of the use of resources to determine whether or not the inmates were presenting with comorbid disorders. These studies are very beneficial to incarcerated persons in the way that they pave the way for improvement in not only the incarcerated individuals with SUD’s, but our justice system as well. It is easy to lock people up, release them, lock them up again, etc. but if we could just provide them with the resources to make this change in themselves, there is potential to decrease the number of re-incarcerations.

Effective Counseling Interventions for Adolescents with Substance Abuse

Effective Counseling Interventions for Adolescents with Substance Abuse

        Substance abuse is an unhealthy pattern that continuously causes problems nationwide as it can lead to medical, psychological, financial and legal consequences (Butler Center for Research, 2016). Substance abuse has been a growing concern during adolescent development due to an inability to recognize the consequences of using harmful substances (Much, 2001). According to Muck et al. (2001), adolescents are more likely to progress rapidly from casual use to substance dependence. Adolescents are a vulnerable population that are at a higher risk of developing a Substance Use Disorder (SUD, (American Psychiatric Association, 2013). In comparison to adults, adolescents need more intense interventions because of the complexity of their problems and where they are in the stages of the change model. Due to the likelihood of dependence and the need for a more intensive approach, it is essential to find effective interventions and to explore the role the counselor plays during this process. Interventions that have shown efficacy are Cognitive Behavioral Therapy (CBT), forms of family therapy (MST, FFT, MDFT, BSFT) and Therapeutic Communities (TC), (Muck et al., 2001).   

Literature review

        Adolescents are less likely to seek treatment due to their inability to distinguish casual substance use from addiction. Adolescents are also more likely to be referred to some form of therapy making their lack of motivation to change aconcern since they aren’t actively seeking treatment (Muck et al., 2001). According to Pallonen (1998), adolescents who smoke cigarettes are typically in the same stage when they are contemplating quitting and before making any commitment to change. Pallonen (1998) discusses the importance in creating an intervention that targets adolescents who are in the precontemplation stage which is when adolescents show more resistance and are less likely to admit their problematic substance use. Adolescents who are in the preparation stage are the ones who will typically participate in an intervention that will lead them to recovery. One of the counselors main goals is to make a note of what stage an adolescent is in which helps them decide which intervention is more beneficial for the adolescent.

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         Although the type of intervention that is used with the adolescent is important, the therapeutic relationship is essential in creating positive change. Auerbach. May, Stevens and Kiesler (2008) conducted a study to see how the client and counselor relationship perceptions impact the treatment outcome. For this study, the Working Alliance Inventory (WAI) and Impact Message Inventory Circuplex IMI-C were given to both the counselor and the client during week two of treatment. The results of the treatment indicated that when the client and counselor felt both affiliation and friendliness, they believed there was a good working alliance which correlates with the outcome of treatment (Auerbach et al., 2008). Although this is just one study and Auerbach et al. (2008) mention that there are limitations, the results serve as a good basis for future research and indicates the importance of a healthy rapport.

 The intervention that is most commonly used and that has shown the most effectiveness with individuals suffering from addiction is the 12-step program. The 12-step program is based on Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), and is typically faith based (Taylor, 2010). This kind of intervention can be done in groups and it can also be done individually with counselors and with family members (Muck et al., 2001). Counselors who work in the substance abuse field are often recovering users themselves so they serve as a role model for the adolescents. Adolescents might be able to connect more with a counselor who has been through relatable struggles and this will lead to more effective outcomes (Auerbach et al., 2008).

The 12-step model that this intervention follows helps guide adolescents to create change step by step, which begins with deciding to change and ends with ways to maintain the change. According to Muck et al. (2001), those who complete the 12-step program are more likely to remain abstinent from using a substance 6 months after treatment. It seems that compared to those who don’t complete the program, those who do complete the program are more likely to remain abstinent after one and even two years. 12-step programs are now offered in residential and outpatient settings making it more convenient and accessible to those looking for treatment.

Another frequently used intervention by counselors is Cognitive Behavioral Therapy (CBT), which can also be referred to as cognitive therapy, or behavioral therapy (Muck et el., 2001). The purpose of CBT  is to change a learned behavior by altering cognitions and by using interventions that modify addictive behavior. Counselors help adolescents unlearn the addictive behavior and aim to find positive outlets that help the adolescent cope with stressors (Muck et al., 2001). According to Dingle, Gleadhill and Baker (2008), CBT for young substance abusers involve teaching skills, trying to identify the consequences of substance use and aiming to figure out what caused the substance abuse to manifest.

CBT is all about teaching adolescents how to use coping strategies and how to change the thoughts and behaviors that are attached to addiction. The skills that are taught to the adolescent during CBT will allow them to avoid substance use when they encounter situations that are high stress for them (Dingle, Gleadhill, Baker, 2008). In CBT counselors help adolescents face their addictive behavior and come up with steps that lead to positive behavior change. According to Dingle, Gleadhill and Baker (2008), research shows that CBT is effective in treating a range of addictive behaviors. Some of these addictive behaviors include misusing alcohol, tobacco, stimulants, opiates and other drugs.

CBT is a unique intervention because it not only targets behavior but it also targets the adolescent’s thoughts (Muck et al., 2001). Unhealthy cognitions can lead to negative behavior so if cognitions are targeted and cognitive restructuring is used, it will help adolescents refrain from using the substance (Sussman,Skara, and Ames, 2008). Some of the skills that are taught during CBT include nonverbal communication, alcohol refusal, conflict resolution and problem solving skills. These skills are then practiced in either a group or an individual setting so that the adolescent can see how the skill can be used (Muck et al., 2001). It is important to use situations that the client might find themselves in during role play and practice so that they can apply it in their every day lives. CBT has shown great efficacy when it comes to treating adolescents especially those with more severe substance use.

While CBT aims to change negative cognitions and behaviors during intervention, Family Therapy looks at the substance abuse as something that is stemming from a family distortion (Sussman et al., 2008). The goal of family therapy is to determine how the family is playing a role in the adolescent substance use (Taylor, 2010). When a counselor conducts family therapy, he or she is able to directly observe some of the behaviors of the family and how family functioning is demonstrated so that they can better assist the adolescent. According to Taylor (2010), there are three parts to the family, which are “the person’s family of origin, the nuclear and the extended family”. When there are distortions in these three areas and lack of communication including limits by the parents, there is room for the adolescent to seek substances to divert pain, fear, anxiety, etc.

In general, the goals of family therapy are to engage with the adolescent and the family so that the family can help intervene in the adolescents substance use (Taylor, 2010). The role of the counselor is to coach the family members on confronting the adolescent and to teach them about the risks that the substance of choice can cause. Family therapy is similar to CBT in the sense that with family therapy the counselor is also teaching coping skills as well as parenting skills (Taylor, 2010). The difference is that the family is incorporated into the intervention and is also being taught skills that will benefit the adolescent. Four family therapy approaches that have shown efficacy with adolescent substance abuse are BSFT, FFT, MDFT and MST (Baldwin et al., 2012).

Brief Strategic Family Therapy (BFST) is a brief intervention that not only targets the substance abuse but other conduct problems that may take place at home or at school (Taylor, 2010). BSFT follows three principles that include: considering that what affects one person affects another, influences that family interactions have and that this intervention is meant to “change patterns of family interactions” (Taylor, 2010). The role of a counselor during this intervention is to change the negative interactions of the family members and to really hone in on the positive interactions, as these are the interactions that will aid the adolescent in changing and maintaining change. This intervention is essential for those that are having other problems besides the substance use as it targets behavioral problems as well.

Another form of family therapy that is useful for adolescent substance abuse is Functional Family Therapy (FFT). The purpose of FFT is to improve family functioning and family interactions so that it can help change dysfunctional behaviors (Alexander & Robbins, 2010). Much like when using CBT, the purpose of FFT is to use behavioral and cognitive interventions that match the relational functioning of the family. The role of the counselor in FFT is to change behaviors within the family so that they can have a healthier relationship. When there is an adolescent suffering with substance abuse, the goal of the counselor is to uncover what is triggering the adolescent to use and if there are any dysfunctions in the family that need to be fixed. FFT like CBT also uses skills and role-playing to get the family to change their behavior (Alexander & Robbins, 2010). FFT is also done in three phases where the counselor builds alliance and motivation then teaches skills and finally generalizes them.

Multidimensional family therapy (MDFT) is much like FFT because it too has its own phases (Liddle et al., 2001). For the first month of MDFT it is crucial for the therapist to build alliance with the family and to also engage them. During this month, anyone that is part of the family system is included in the therapy. For this intervention in particular, individual characteristics are observed from each family member along with the adolescent that is abusing a substance. During the process of MDFT the therapist pulls out themes that match to each individual so that there can be a basis for treatment (Liddle et al., 2010). The goal with the adolescent for this therapy is to explore every aspect of the adolescents life and how they interact with the other family members as well as when they are in community settings. The other phases include problem solving and finding other ways to cope that does not include using substances.

Multisystemic Therapy (MST) is a more intensive form of family therapy (National Institute of Justice, 2011). The goal of MST is to advise families on how to keep track of adolescent behaviors while still using rewards and punishments. Using rewards and punishments are effective ways to help reduce or increase a behavior that the adolescent is exhibiting. The concentration for this form of therapy is on the involvement youth has in addictive behavior and how it can be changed with behavior that is more prosocial (National Institute of Justice, 2011). Since this form of therapy is more intensive, the therapist has a smaller caseload and is also available at all times for the families. This intervention was shown to be effective in regards to decreasing substance use behaviors in adolescents (National Institute of Justice, 2011) but is typically not used until the other forms of therapy have been attempted.

Although MST is a more intense form of family therapy, Therapeutic communities (TCs) are “reserved for adolescents with the most severe substance abuse and related problems” (Muck et al., 2001). This intervention is inpatient and the adolescents can stay an average of 15 months. Some adolescents can get out in as early as 6-12 months if they exhibit good behavior and follow the program as it should be followed (Muck et al., 2001). The purpose of this program is to provide the adolescent with a safe space where they can learn skills and goals in regards to their behavior with substance abuse. This program is also highly structured where each day is planned and is filled with individual therapy, peer groups, recreation, jobs and occupational training. TC has shown to be effective with adolescents who complete the program (Muck et al., 2001).


 Overall, programs such as the 12-step program, BSFT, MST, FFT, MDFT and TC have shown to be effective in adolescents that complete the program. Although there has been significant evidence that point to these programs being effective with adolescents, there are still limitations to how the programs were found to be effective and what they were compared to. According to (Muck et al., 2001) a limitation to the studies that were looked at is the level of substance use by the adolescent. If a study was conducted with adolescents who have low levels of substance abuse and it’s compared to a study where there is criterion, it makes less sense to compare the two and use them to show efficacy. According to Baldwin et al. (2012) “studies are limited in comparing the models side by side”. This makes it difficult to determine which model is most effective. 

 According to Baldwin et al. (2012), the most significant limitation is that some interventions have shown efficacy but we do not have enough training available for the interventions. Not having enough training, limits the amount of clinicians or counselors that can use these interventions because they can only be trained by working in a setting where multiple people are using this intervention. These trainings are also very costly and a lot of practitioners may not have the funds to receive these forms of therapy (Baldwin et al., 2012). Auerbach et al. (2008) mention that while their study showed effectiveness between how the client and the counselor perceive the relationship, the results are promising and it can serve as a basis for future research. The limitation that is mentioned the most is how the studies are compared and what is truly the most effective form of substance abuse treatment for adolescents. Although a lot of studies have been conducted, more research is needed to show evidence based approaches.


 Substance abuse continues to be a growing concern for the vulnerable adolescent population so it is essential to know which treatment interventions are most effective. Counselors play such a significant role in the treatment of adolescents with substance abuse because they are the ones that teach the adolescents the necessary skills to stop addictive behaviors. The different forms of family therapy while very similar help target family functioning which might be the genesis of the adolescents substance abuse.  CBT helps adolescents change their cognition and create plans to change their behaviors. 12-step programs are widely available making it easily accessible to those in need. TC is a more intensive option that is needed for those adolescents who are more severe. All of these interventions have shown to be effective and can be used by counselors to target substance abuse in adolescents making for more efficient outcomes.


American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, D.C: American Psychiatric Publishing.

Alexander J.F., Robbins M.S. (2011) Functional Family Therapy. In: Murrihy R., Kidman A., Ollendick T. (eds) Clinical Handbook of Assessing and Treating Conduct Problems in Youth. Springer, New York, NY

Auerbach, Stephen M., May, James C., Stevens, Martha, & Kiesler, Donal J. (2008). The interactive role of working alliance and counselor-client interpersonal behaviors in adolescent substance abuse treatment. International Journal of Clinical and Health Psychology, 8(3), 617-629.

Baldwin, S., Christian, S., Berkeljon, A., & Shadish, W. (2012). The effects of family therapies for adolescent delinquency and substance abuse: A meta‐analysis. Journal of Marital and Family Therapy, 38(1), 281-304.

Butler Center for Research. (2016). Adolescent substance misuse trends shown by a

recent nationwide study. Retrieved from:

Dingle, G. A., Gleadhill, L., & Baker, F. A. (2008). Can music therapy engage patients in group cognitive behavior therapy for substance abuse treatment? Drug and Alcohol Review, 27, 190-196. Doi: 10.1080/09595230701829371

Liddle, H., Dakof, G., Parker, K., Diamond, G., Barrett, K., & Tejeda, M. (2001). Multidimensional family therapy for adolescent drug abuse: Results of a randomized clinical trial. The American Journal of Drug and Alcohol Abuse, 27(4), 651-688.

Muck, R., Zempolich, K. A., Titus, J. C., Fishman, M., Godley, M. D., & Schwebel, R. (2001). An overview of the effectiveness of adolescent substance abuse treatment models. Youth and Society, 33(2), 143-168.

National Institute of Justice. (2011). Program profile: Multisystemic therapy-substance abuse. Retrieved from:

Pallonen, U. (1998). Transtheoretical measures for adolescent and adult smokers: similarities and differences. Preventive Medicine, 27(5), A29-A38.

Sussman, S., Skara, S., & Ames, S. (2008). Substance abuse among adolescents. Substance Use & Misuse, 43(12/13), 1802-1828. Doi: 10.1080/10826080802297302

Taylor, O. (2010). Predictors and protective factors in the prevention and treatment of adolescent substance use disorders. Journal of Human Behavior in the Social Environment, 20(5), 601-617.


Case Study on Robin Williams: Substance Abuse and Depression


This paper is a case study done on actor and comedian Robin Williams. Williams had presented signs of major depressive disorder along with his existing substance abuse. Williams has also been diagnosed with Parkinson’s affecting his ability to maintain his career, giving him more intense depressive symptoms. Williams needs a mix of psychoanalytically therapy over a long period of time to target the reasons of his depression as well as shorter term cognitive-behavioral therapy to encourage him and teach him how to better maintain his life and disorder. This combination, along with staying away from drugs and alcohol, should set Williams on a path to recovery.

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Robin Williams is a 63-year-old male comedian, actor, and voice actor. Williams has been diagnosed with Parkinson’s disease but may exhibit signs of Lewy body dementia, both of which affect the brain and nervous system. He also had heart surgery that required recovery time away from his shows and movies. No familial history of mental illness found. Williams married 3 times, first to Valarie Velardi (ending in divorce due to infidelity and substance abuse by Williams), then to Marsha Garces (also ending in divorce), and finally Susan Schneider as a current spouse. Williams has two sons, Cody and Zachary, and one daughter, Zelda. Williams has an extensive history of multiple substance abuse, including alcohol and cocaine. He faced bullying and loneliness as a child and faces loneliness, failed relationships, and substance abuse as an adult. Williams faced a tough time breaking through in acting and recently had the show “The Crazy Ones” canceled. His main goal was to be a comedian and actor in his younger years, this is the way he connected/connects with people. Another goal was to beat addiction after the birth of his first son, Zachary. Williams stayed sober for close to two decades, but relapsed and has struggled up to this point. Williams has turned to substances and focus on his work and shows to cope with his losses and hardships through the years. Cycling also helped Williams kick addiction for a while as a replacement. Williams weaknesses were women and alcohol, leading him down a disastrous road of infidelity and addiction.

Williams has exhibited symptoms such as trouble sleeping, constipation, loss of the sense of smell, intense anxiety, tremors, difficulty thinking and concentrating, loss of interest in activities, difficulty making decisions, and suicidal thoughts. Feelings of sadness, paranoia, guilt, and worthlessness. Williams believes there is something medically wrong with him and has underwent many tests and scans, tried physical therapy and yoga, tried medication, and attempted self-hypnosis. Williams suffered from low self-esteem and emotional neglect from his parents at a young age. Other than being diagnosed with Parkinson’s the scans and tests indicated no other medical conditions.

Williams exhibits symptoms and signs of severe depression (major depressive disorder), code F33.2. This diagnosis was reached because DSM-V (2013) states “Depression (major depressive disorder) is a common and serious medical illness that negatively affects how you feel, the way you think and how you act.” Symptoms displayed that show signs of depression are feeling sad, feeling worthless or guilty, loss of interest in activities, trouble sleeping, difficulty thinking, difficulty concentrating, difficulty reasoning or making decisions, and suicidal thoughts. This display of 8 total symptoms lines up with depression. Williams diagnosis of Parkinson’s disease complicated the process of finding a mental diagnosis. Symptoms such as trouble sleeping and cognitive changes (difficulty thinking, concentrating, or reasoning) fit under both diseases and were displayed by Williams. Depression fits in the Axis I category of mood disorders, which includes: major depressive disorder, bipolar disorder I and II, seasonal affective disorder (SAD), and cyclothymic disorders. Williams does not suffer from any type of disorder that falls under Axis II, seeing as though they are personality disorders. Axis III has had serious impact on Williams. Williams health greatly affects his mental illness. Parkinson’s disease is currently untreatable and is neurodegenerative, meaning it affects specific neurons in the brain. Symptoms include delusions or hallucinations, sleep disorders, and speech impairments. It also shares symptoms with Lewy body dementia, which also has no cure. There is suspicion Williams was misdiagnosed with Parkinson’s. Either of the listed diseases coupled with major depressive disorder will be disastrous. Williams will eventually have to give up acting and comedy shows, the things he clings to and enjoys most. Williams history of substance abuse (alcohol and cocaine) also makes his illness more intense. Substance abuse allows Williams thoughts of guilt and worthlessness spiral into suicidal thoughts, becoming even more dangerous. Axis IV has not affected Williams as greatly as Axis III. Williams bullying and emotionally neglect as a child and then two failed marriages while being in and out of rehab has taken its toll. Williams has had ample time and reasons for his mind to wander to dark thoughts and places. On the Axis V scale, Williams scores somewhere between 30 and 40. Williams has stated he feels as though he is going crazy and is almost unable to function completely, though still maintains personal hygiene.

Psychoanalytically, this problem can be solved through the release of repressed experiences or emotions from the unconscious. Bringing those thoughts out is seen as a healing method when needed. The psychoanalytical approach was created by Sigmund Freud, who believed that people could be cured through the unconscious by gaining insight into it. These mental disturbances would be seen as an issue in the unconscious that should be brought forward in an effort to correct them. Generally, these issues spur from traumatic occurrences or issues during the developmental period (childhood). It is fairly normal for depression to be treated with a psychoanalytical approach through therapy. In this form of therapy Robin will recall memories, experiences, etc. throughout his life while notes are taken in an effort to bring out the unconscious causes of the illness. This involves a regular therapy schedule for however long Williams needs to attend. Williams will respond well to this therapy seeing as though he doesn’t have trouble talking about his past and all of his experiences throughout life. Talking through these should allow Williams an idea of what events brought about or triggered the illness. Psychoanalytical therapy should prove to be effective in his treatment, as it is in other cases of depression. Williams will become more comfortable with his past and trauma that he has endured, such as the overdose of John Belushi, and able to determine how to control bouts with depression. This therapy should set Williams on a long-needed path to recovery. However, recovery will potentially take years for Williams to see great results. The brain’s natural defense mechanisms make this therapy a long process over several years, though it is one of the most effective. Techniques used in this therapy to aid in bringing out unconscious thoughts include inkblots, interpretation, parapraxes, resistance analysis, free association, and transference analysis. Several of these rely on interpretation by the analyst/therapist present or Williams himself. This paired with a more encouraging short-term therapy will pair well.

Through the Cognitive-Behavioral approach this problem can be resolved by talk through sessions, potentially with the help of other therapies such as medication. It helps teach how to manage stressful situations throughout life more effectively. Cognitive-Behavioral therapy focuses more on solutions to the illness rather than roots of said illness, which is how psychoanalytical therapy would approach major depressive disorder. The cognitive-behavioral approach encourages a change of behavior that is needed. The approach stresses the idea that perceptions and thoughts will influence a person’s overall behavior. One’s reality may be warped because of their perception. This type of therapy may help with multiple mental illnesses and the symptoms that come with them (major depressive disorder, phobias, eating disorders, PTSD, sleep disorders, etc.), help to prevent relapse, determine how to manage emotions properly, help overcome emotional traumas throughout life, and help find was to cope with stressful situations. Therapy sessions can be one-on-one or group therapies where Williams will learn about his mental illness and gain knowledge on coping, stress management, and relaxing. Williams will need to be open to any questions asked and to sharing his past. Williams may be asked to do activities or “homework” to build on his knowledge from therapy so it can be applied to his life easier. Therapy will be shorter term, 10-20 sessions in total. Williams should respond well to this type of therapy as well, seeing as though there is no issue about sharing his past and experiences. The addition of medication to this therapy is not a logical idea due to his past addiction to substances. Williams has been surprisingly open to any questions about his past up to this point. Cognitive-Behavioral therapy will work better in conjunction with psychoanalytical therapy, since it is long-term therapy. Williams should have the best possible results with a combination of these two therapies approaches because one will target the root of his issue and solve it while the other will encourage him to learn about his disease and how to better manage his life with said disease.



Psychosocial Implications of Substance Use and Addiction


This research paper will address Substance Use and Addiction, and the psychosocial implications associated with it.  This paper will also address the prevalence, incidence, symptoms, signs, investigations, and ethical considerations of substance use and addiction.



Substance addiction can be defined as a behavior that creates physical and psychological pleasure; however, the cost to the individual visibly outweighs the benefits. Substances, such as psychoactive drugs, that affect the brains pleasure zones will often result in dependence; these substances include anything from alcohol and nicotine, to a variety of legal and illegal drugs (Fleury et al., 2014; Babor, 2011).

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There is a numerous amount of psychological information on substance use and abuse, however, there is not one individualized theory focused on addiction.  Addiction is defined as a condition of being habitually or compulsively occupied with, or involved in something (Pinel, 2014). Substance addiction is often described as an unmanageable, compulsive act that is carried out even when it threatens the individual’s health and wellbeing; the individual often negates to see the potential harmful social consequences that follow the addictive behavior (Matusow & Rosenblum, 2014). The word addict carries with it a negative stigma that is born from the perception of society. Addicts are often perceived as uncaring, unreliable and unstable individuals; this perception does not necessarily apply to all addicts. Some individuals can function and manage their lives in such a way that no one is aware of their substance dependence; these individuals are referred to as functioning addicts (Smith, et al., 2014).

Theoretical Underpinnings

The Disease Model of Addiction

Psychological research has resulted in a theoretical model of addiction as a disease. The addiction model has neutralized the negative connotations associated with substance addiction and helps to encourage substance users to partake in addiction treatments and self-help meetings (Smith, et al., 2014). Consequently, the disease model has a limited view on the various treatment methods; it does not take into consideration the reality of the everyday life that substance users face. Moreover, the disease model neglects to address the social issues that arise from substance use and addiction (Fleury et al., 2014 and Smith, et al., 2014). When deciding on a treatment plan individualized for the substance user it is important that all treatment and intervention methods are thoroughly examined. Another psychological theory on substance use is the psychodynamic model. The psychodynamic model implies that addictive behavior is brought on due to the relationship between external events and the unconscious psychological processes of which the user stays oblivious (Klostermann & O’Farrell, 2013). The psychodynamic model has been successful in shedding light onto the importance of early childhood development and parental influences as possible origins of addictive behavior (Klostermann & O’Farrell, 2013).

The Behavioral Model of Addiction

Unlike the previously discussed theories on substance use, behavioral models of addiction base themselves upon the theory that the continued use of a substance will create elation, which in turn will intensify the need for the substance use to continue (Babor, 2011;Fleury et al., 2014;Goodwin & Sias, 2014). The need to ease withdrawal symptoms can be explained by reinforcing contingencies, however, the substance user will experience negative reinforcement due to taking the dose to help ease the pain (Fleury et al., 2014). Although the feeling of elation explains the continued use of the substance, it does not explain why some individuals are able to stop while other individuals become addicted. The social learning theory delves into this issue by explaining how social and psychological factors influence the emotional quandaries individuals find themselves in when they are using the substance (Fleury et al., 2014). Psychologists argue that the social learning theory explains human behavior by analyzing the continuous collective interaction between behavioral, cognitive and environmental factors; this theory looks at how an individual’s self-control and decision processes are affected (Babor, 2011; Fleury et al., 2014; Goodwin & Sias, 2014).

The Social Model of Addiction

The social learning theory focuses on an individual’s personal experiences from families, friends and other individuals. How individuals learn and perceive substance use, whether positive or negative, will affect the learning process and this in turn affects their behavior (Babor, 2011). Cognitive behavioral treatment, a popular addiction treatment bred from both the social learning theory and other behaviorist theories, helps substance user’s deal with wanting to make new life changes, managing their cravings, thoughts and develop new problem solving skills (Babor, 2011;Fleury et al., 2014;Goodwin & Sias, 2014).

The social model also takes into account the comorbid psychopathologies associated with addiction. These psychopathologies include depression, major depressive disorder, generalized anxiety disorder, panic disorder, trauma, oppositional defiant disorder, and conduct disorder, (Goldston, et al., 2009). These comorbid psychopathologies are categorized into internalizing and externalizing, with the former being more strongly connected to addiction (Verona & Javdani, 2011).

Numerous studies indicate that depression and hopelessness are directly linked to adolescent substance use; depression was present in 90% of the cases in which there was comorbidity (Goldston, et al., 2009). Substance use acts emerge as a result of a vulnerable personality (psychopathology, increased traumatization, high harm avoidance, etc.) and additional stressors, as well as the presence and interaction between internalizing and externalizing factors. Stressors can precipitate an individual’s emotional distress, which may be alleviated by their social support, family connectedness, and coping behaviors. Comorbid psychopathologies, as well as substance use, weakens these effective coping behaviors and increase exposure to stressors, ultimately increasing the risk of substance use (Ruchkin, et al., 2003).

Substance Use and Abuse

Illegal substance use and underage alcohol consumption is a prevalent issue within society today. Early experimentation with drugs and alcohol have an influencing role on how individuals view substance use in the future; individual that have a positive experience will be more susceptible to use again. Individuals who are social, or recreational, substance user also have the potential to become addicts due to their psychological state and what substance they are using. Individuals who are deemed “social users” can control what substances they take and the amount they use, however, social users still share the risk of having their substance use interfere with their home and work lives. When the individual begins to lose control of their consumption and how much they are consuming, they begin to become less of a social user and more of an addict. Once the individual cross the line from social user to addict, their primary focus is on how and when they can use again. Addiction is no different whether you are addicted to a substance, alcohol, or food (Pinel, 2014).

All drugs affect the brain chemical balance, no matter what the substance, this is known as the brains reward system. When analyzing the brain of a non-addict it is different from that of an addict. When an individual uses a substance there is a surge of dopamine and other pleasure messengers, however, these quickly desensitize due to the adaptivity of the brain; this adaptation results in withdrawal symptoms.  Short-term substance use does not affect the brains chemical makeup contrary to long-term substance use (Pinel, 2014). If an individual continues to abuse substances permanent neurological changes begin to affect the chemical makeup of the brain; these changes in the brain affect behavior and/or the ability to make rational decisions (Pinel, 2014). These chemical changes in the brain results in the individual’s persistent substance usage in hopes to achieve the “high.” Individuals may become addicted primarily to help deal with withdrawal symptoms (physically dependency), stress issues or simply to avoid everyday reality (psychological dependency) (Pinel, 2014).

Research suggests that addiction runs in families; however, it may not be merely a function of the parent-child relationship or imitation, but rather an inherited trait. In 1998, Statham and colleagues conducted a twin study in which the heritability quotient was 55%. Serotonin metabolism and receptivity is the focus in the attempts to pinpoint the mechanism through which genes affect behavior (Wenar & Kerig, 2006). Others argue that an individual’s biological genes make up may have a role to play regarding a person’s addiction. If this is the case, then if an individual’s parents were alcoholics or drug addicts then they would be at a greater risk of following the same path resulting in the individual becoming an addict them self. This could possibly prove that in a minority of cases addiction could be genetic. The individual will not necessarily be born a drug addict or alcoholic, but is however, more at risk of becoming involved in substance use later in their life.

Additionally, research suggests that genetics plays a role in an individual’s susceptibility to addiction (Fleury, et al., 2014).Once a substance user decides to cross over the line of being in control of their thoughts and actions to achieve the “high” they become addicts; they have no self-control and the chemical effect on the brain has made the “high” unachievable. The individual’s lack of ability to control their substance use is now looked at as the disease of addiction. It is, however, achievable for the brain to recover from long-term substance use. For this to be achieved it involves long term abstinence from the use of chemical changing substances (Matusow & Rosenblum, 2013).


If there is to be progress in the disease from the abuse of drugs and alcohol, continuing to educate society about the possible dangers using can have not only to themselves, but also to their family and friends. By continuing to do this we will have a better chance of witnessing a decline in the abuse of drug and alcohol substances and by large an improvement in everyday living. Abstinence as previously mentioned is the only viable treatment program regarding the disease model of addiction. However, there are suggestions that in the process of recovery relapses are all too common (Matusow & Rosenblum, 2013).

Ethical Considerations

To help fully appreciate addiction there must be a more integrated approach which will take the different processes into consideration. Smith, et al. (2014) states that there are five stages that individuals will go through when experiencing behavioral changes. The first stage is when the individual is ignorant or unaware that they have a problem and have no wish to change. Stage two looks at the individual and how they begin to consider changing their behavior but have not yet made any attempts to do so. Stage three focuses on the acceptance that there may be a problem and begins to make changes. The fourth stage is when the individual begins to put their plans into action to help change their behavior. The final stage is when the changes made are maintained and the individual is dedicated in making lifestyle changes to allow this to be maintained (Smith, et al., 2014). A successful addiction treatment should encompass both the biological factors as well as the behavioral and social factors that influence individuals. Although there is no concrete theory and treatment on substance use and addiction, much improvement has been made in understanding this complex disease.


Babor, T. F. (2011). Substance, not semantics, is the issue: comments on the proposed addiction criteria for DSM-V. Addiction, 106(5), 870-872.

Fleury, M. f., Grenier, G., Bamvita, J., Perreault, M., & Carón, J. (2014). Predictors of Alcohol and Drug Dependence. Canadian Journal Of Psychiatry, 59(4), 203-212.

Goodwin, J. g., & Sias, S. M. (2014). Severe Substance Use Disorder Viewed as a Chronic Condition and Disability. Journal Of Rehabilitation, 80(4), 42-49.

Klostermann, K., & O’Farrell, T. J. (2013). Treating Substance Abuse: Partner and Family Approaches. Social Work In Public Health, 28(3/4), 234-247.

Matusow, H., & Rosenblum, A. (2013). The Most Critical Unresolved Issue Associated With: Psychoanalytic Theories of Addiction: Can the Talking Cure Tell Us Anything About Substance Use and Misuse?. Substance Use & Misuse, 48(3), 239-247.

Pinel, J. (2014). Biopsychology Plus NEW MyPsychLab with eText-Access Card Package (9th ed). Upper Saddle River, NJ: Pearson

Smith, J. L., Mattick, R. P., Jamadar, S. D., & Iredale, J. M. (2014). Deficits in behavioral inhibition in substance abuse and addiction: A meta-analysis. Drug And Alcohol Dependence, 1451-33.


Parental Substance Abuse and the Negative Impact It Has on Children

An investigative report into parental substance abuse and the negative impact it has on children in the United Kingdom




Executive Summary

Terms of reference






Executive Summary

Substance misuse among parents is a major issue for many young children who are in their development stage of growing up. This report will aim to find an understanding of why parents use drugs and what the worst-case scenario would be for children if their parents have an overdose. This report will also contain a conclusion to why parents use drugs and alcohol. The contents will also show official Government statistics along with findings of substance misuse. Secondary research was conducted.


 Terms of reference

Helen Evans (Communications Lecturer, Edinburgh College) instructed Zen Hayat (Scottish Wider Access Wider Programs student) to produce a schematic report to investigate parental substance abuse and the effect it has on children in the United Kingdom. The report is to be submitted on the 20th February 2019.




3.1  Research into substance misuse among parents and it’s impact on children in the United Kingdom

3.2  Analysis of statistics to find out how many children are affected by parental overdose



4.1  The impact of substance misuse on children


4.1.1        Many children will feel unloved and emotionally abused if their parents are substance abusers, while the child is in development stages of life, difficulties can arise behaviourally, emotionally and problems with initiating and sustaining relationships with loved ones.

4.1.2        A child may take on caring responsibilities for either parents or younger siblings.

4.1.3        Regards to caring for their parents children may also gain a bad attendance record at school resulting in poor academic performance.

4.1.4        Exposure to criminal activities and may be taken away from their parents if social services or child protection services where to intervene.

4.1.5        Children may start offending themselves and increase the risk of misusing drugs or alcohol.


4.2  Why parents misuse substances


4.2.1        Parents may use substances due to different reasons, one example would be losing a close friend or relative that has impacted on his/hers life.

4.2.2        Parents may use drugs as a gateway from escaping reality, stress and even pain from daily day to day problems.

4.2.3        Adults may be pressured to misuse drugs by certain Individuals or an ex-partner, which makes the parent addicted to the substance and lose interest in supporting their own child.





4.3  Figures

4.3.1        It is estimated that around 250,000 to 300,000 young teenagers and young adults are living with drug and alcohol dependent parents, many children are at high risk of emotional and physical neglect and can damage their crucial stages of development.

4.3.2        Many young people come from poor economical backgrounds with a third coming from middle class backgrounds. Majority of victims who transition to adulthood live a happy life, continuing their education onto university or as some individuals may in habit drug using themselves and possibly consider treatment.

4.3.3        It is to be believed that around 100 young teenagers and adults phoned Childline services every week in need of support of parents who were misusing drugs and alcohol.

4.3.4        It was estimated in the years between 2017 to 2018  268,390 adults contacted drug and alcohol rehabilitation services.

4.3.5        Around 25,593 parents with a total of 46.109 children reported themselves to services for safeguarding their children while getting treatment for their misuse of substances.


Overall this report has conducted reasons why parents of young adults and children tend to misuse drugs and alcohol and why this is problematic for today’s youth. Children are suffering of emotional and physical abuse and missing out on crucial stages of development and tend to occur problems with transitioning to adulthood. Children are even missing out on basic English and writing skills which altogether can alter the perception of the future for children or become mature at a very young age. Parents tend to misuse drugs in secret to avoid being suspected if children were to find out and inform a teacher at an education centre/school, this could leave the caring responsibility of the children to the social services and may not see there parents again if they were to continue misusing drugs and alcohol. There is evidence to support the claim that many children do suffer long term from witnessing their parents committing illegal activity in the household, with many young adults living a happy life substance free, where as others may start producing criminal activity which could impact heavily on any younger children who are in the care of parents who are substance abusers. It is believed that a reduction rate of one third of parents from 25,593 have stopped using substances and went back into caring for their children from seeking help from rehabilitation services.



 Rehabilitation and other services are available to all adults who are seeking advice and to help stop their problem with substances.

6.2  More services should be available to children who undergo caring responsibilities and to prevent them going down the same route as their parents.

6.3  Children should be allowed to move in with next of kin if the situation at home is a safety concern for the child.

6.4  Other types of methods of looking after children should be proposed other than taking children away from their substance using parents if they have caring responsibilities.



       HEDY CLEAVER, IRA UNELL, JANE ALDGATE. (2011). CHILDREN’S NEEDS – PARENTING CAPACITY Child abuse: Parental mental illness, learning disability, substance misuse and domestic violence . Available: Last accessed 25th Feb 2019.

Emilie Smeaton. (2011). Dealing with parental substance misuse. Available: Last accessed 25th Feb 2019.

Angus Bancroft, Sarah Wilson, Sarah Cunningham-Burley, Kathryn Backett-Milburn, Hugh Masters. (2004). The effect of parental substance abuse on young people. Available: Last accessed 25th Feb 2019.


Is Sugar Addiction a Substance Use Disorder?

An Examination of Sugar Addiction as a
Substance Use Disorder
In the last decade, many studies have supported the addictive nature of sugar. In this examination of sugar addiction, we explore the parallels with substance abuse disorder and highlight the effects on the brain and body as well as the psychological and biological risk factors that may make an individual vulnerable to sugar addiction. We theorize that defining sugar addiction as a substance abuse disorder in a future version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) will change policy to improve public health, and minimize the costs of metabolic disorders like diabetes, obesity, and heart disease on the economy.
Keywords: sugar addiction, substance use disorder, dopamine,
impulsivity, obesity
Worldwide obesity rates are rapidly rising. In 2016, an estimated
30% of Americans over the age of 18, and almost 20% of young adults were overweight
or obese, as defined by a body mass index (BMI) greater than 30 (Centers for
Disease Control and Prevention, 2016); and they are projected to increase to
80% by 2023 (Wang, Beydoun, Liang, Caballero, & Kumanyika, 2008). Between 29%
and 47% of obese individuals meet the criteria for binge eating disorders (BED)
(McCuen-Wurst, Ruggieri, & Allison, 2017). However, we suggest in this review
of the literature that the food addiction model is a more appropriate mechanism
when looking at correlates and causes of the development of eating disorders
and metabolic disorders, including insulin resistance, diabetes, and obesity. The
DSM-5 criteria for BED is limited in that it focuses largely on behavior, distress
and shame caused by the eating disorder, and lacks acknowledgment of the
neurobiological vulnerabilities and effects (American Psychiatric Association,
2013a). Alternatively, the food addiction model proposes that food, especially
highly palatable, processed foods that are high in sugar, fat and/or salt are
addictive (Davis & Carter, 2014), and therefore may be the underlying cause
of BED and metabolic disorders, including obesity. For this examination, we mainly
focus on the addictive nature of sugar, as the majority of food addiction
studies have shown that sugar intake is more addictive than fat or salt, and highlight
the numerous biological and psychological parallels to substance (Avena,
Bocarsly, Rada, Kim, & Hoebel, 2008; Avena, Rada, & Hoebel, 2008; Davis,
Loxton, Levitan, Kaplan, Carter, & Kennedy, 2013; Hoebel, Avena, Bocarsly,
& Rada, 2009; Hone-Blanchet & Fecteau, 2014; Ifland, Preuss, Marcus,
Rourke, Taylor, Burau, Jacobs, Kadish, & Manso, 2009; Page & Melrose,
2016; Tran & Westbrook, 2017; Wong, Dogra, & Reichelt, 2017).

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It is well known that addictive drugs activate the
dopaminergic reward pathway. The mesocorticolimbic pathway, which includes the
ventral tegmental area (VTA), nucleus accumbens (NAc) and the frontal cortex,
is especially implicated in the reinforcement of the use of these substances.
These areas release high levels of dopamine, which produce a euphoric state,
and help form “liking” motivations and positive associations toward the
addictive substances. However, as the drug is repeatedly consumed, tolerance
builds in the body, and “liking” becomes “wanting,” resulting in reduced
pleasure, and physiological dependence that necessitates increased consumption
(Reeve, 2015).
Food addiction studies have shown that while a variety of
foods lead to the release of dopamine, sugar activates the dopaminergic pathway
in a way that mirrors addictive substances, and leads to bingeing, tolerance, cravings,
dependence, and subsequent withdrawal symptoms when deprived (American
Psychiatric Association, 2013b; Avena et al., 2008; Davis & Carter, 2014;
Davis et al., 2013). As sugar is over-consumed, tolerance grows and bingeing
with increased amounts of sugar are needed to obtain the same pleasurable
effect. This is suggested to be due to the down-regulation of dopamine
receptors (Avena et al., 2008; Davis, Patte, Levitan, Reid, Tweed, &
Curtis, 2007; Hoebel et al., 2009; Ifland et al., 2009, Loxton & Tipman,
2017). Thereafter, “wanting” or cravings are suggested to be due to the
imbalance of hormone signals that results in high anticipation and high
sensitivity to sugar when it is consumed. In a study conducted by Lindqvist,
Baelemans, and Erlanson-Albertsson (2008), rats that were given a sugar
solution showed a 40% increase in ghrelin, the hormone that triggers appetite;
in contrast to a significant decrease in leptin and peptide YY, two hunger-suppressing
hormones; and a significant down-regulation in mRNA expression of additional hunger-suppressing
peptides. This imbalance of appetite hormones and gene expression were
hypothesized to have resulted in bingeing and tolerance, as demonstrated by a doubling
of the drink consumption compared to control-group rats given water. Lastly, animal
studies on sugar addiction have shown that sugar withdrawal mimics opioid
withdrawal, and presents with depression and anxiety when deprivation of sugar
occurs (Avena et al., 2008; Avena, Rada, & Hoebel, 2008; Hoebel et al.,
2009; Hone-Blanchet & Fecteau, 2014; Ifland et al., 2009). The numerous
studies in sugar addiction that overlap with the different stages of substance
use disorders provide strong biological support for sugar addiction to be classified
as a substance use disorder.
Further adding to the biological susceptibility of sugar
addiction, Davis et al. (2013) found enhanced dopamine transmission was due to
six genetic mutations linked to the dopamine reward pathway; and that association
between increased dopamine signaling and multilocus genetic profile scores was
significantly higher in participants with high reward sensitivity and high risk
for food addiction. These neurological changes and genetic vulnerabilities support
tolerance and dependence that may result from a frequent flooding of dopamine and
a reduction of receptors as seen in substance use disorders.
Likewise, psychological traits like impulsivity and poor
emotional regulation, have been found in both substance use disorders and sugar
addiction. Impulsivity, as it relates to immediate gratification and deficits
in behavioral inhibition, was positively correlated with sugar addiction.
However, sensation-seeking, as an impulsive personality trait, was negatively
associated with sugar addiction, and theorized to be due to the lack of arousal
and stimulation from eating food; “those who are risk seeking and reward-driven
might seek out experiences involving greater levels of arousal and stimulation
(Pivarunas & Connor, 2015; VanderBroek-Stice, Stojek, Beach, vanDellen,
& MacKillop, 2017). Poor emotional regulation and low distress tolerance
were also positively associated with sugar addiction, and the consumption of
sugar was hypothesized to activate the pleasure center countering the negative
emotional state and further reinforcing the reward of sugar intake behavior (Kozak
& Fought, 2011; Pivarunas & Connor, 2015).
Equally important in the comparison between sugar addiction
and substance use disorders are the detrimental effects on the brain and body’s
functions, such as cognitive impairment and metabolic disorders. Reversible cognitive
impairments in decision-making, motivation, spatial or place-recognition memory
were recently identified in studies with rats (Tran & Westbrook, 2017; Wong,
Dogra, & Reichelt, 2017). However, in a study conducted by Page and Melrose
(2016), high levels of circulating sugar and insulin levels dulled food cues, reducing
hypothalamic activity, and negatively affecting neural food processing, which
over time increased the risk for insulin resistance, type 2 diabetes, and
obesity. A separate study found that the overconsumption of sugar increased
levels of free fatty acids, triglycerides and cholesterol in the blood (Lindqvist,
Baelemans, & Erlanson-Albertsson, 2008), which are confirmed risk factors for
developing in heart disease and strokes in humans (National Institute of
Health, 2005; American Heart Association, 2017). The relationship between sugar
addiction’s detrimental effects and long-term illness are apparent in the
literature, and is analogous to the relationship between substance use and
Current treatment options for food or sugar addiction are
limited to exercise, which addresses biological pathways; and mindfulness,
which emphasizes psychological processes. Exercise serves as a protective
treatment against metabolic disorders and food addiction via increases in brain-derived
neurotropic factor (BDNF), a neurotransmitter that plays a major role in
neuroplasticity, and in the regulation of food intake, physical activity, and
glucose metabolism (Codella, Terruzzi, & Luzi, 2017). Whereas, mindfulness
addresses the dual process model of health behavior, which states that there
are interactive automatic (implicit) and controlled (explicit) psychological processes
that result in addictive behavior. Implicit, automatic processes include
intentions, approach and avoidance tendencies, and emotions, meanwhile explicit,
controlled processes include reflective action (Hagger, Trost, Keech, Chan,
& Hamilton, 2017; Tang, Posner, Rothbart, & Volkow, 2015). In 2017, Kakoschke,
Kemps, & Tiggemann showed that a two-pronged approach-modification protocol
successfully retrained participants to avoid unhealthy food by 1) reducing the
approach bias toward unhealthy food, and 2) increasing the approach bias toward
healthy food. Another study showed a high approach tendency for healthy food
buffered against the stress of hunger and wanting for unhealthy food (Cheval,
Audrin, Sarrazin, & Pelletier, 2017). Mindfulness was also found to
regulate emotional reactivity to internal and external cues (Fisher, Mead,
Lattimore, Malinowski, 2017). Unfortunately, available treatment options have
low generalizable, replicable success as they fail to provide a streamlined approach
to sugar addiction and/or address neurobiological vulnerabilities and negative
Neither sugar nor food addiction is currently defined in the
DSM-5. The only consistent measure of food addiction is the Yale Food Addiction
Scale (YFAS), a survey developed in 2009, and it is used in studies reliably as
its questions are based on DSM-IV addiction criteria (Gearhardt, Corbin,
Brownell, 2009; Gearhardt, Corbin, Brownell, 2016). As mentioned earlier, food
addiction and BED are not reciprocal disorders, therefore acknowledging sugar
addiction as a substance use disorder in a future DSM may increase evidence-based
research that strongly implicates genetic and brain pathways, which may lead to
early prevention, reduced stigmatization and diverse treatment options that address
the psychological as well as neurobiological vulnerabilities through
medication, and even gene therapy. Further research and government regulation can
also limit the pseudo-science funded by sugar and packaged goods companies. For
example, in reviewing the literature, two studies were found that denied sugar
and its addictive properties (Benton, 2010; Markus, Rogers, Brouns, &
Schepers, 2017); they were funded by Coca-Cola and the World Sugar Research
Organization. Similar to the studies conducted by the tobacco industry, the
information countering sugar addiction can be confusing and deceptive to
consumers. Government regulation of the sugar industry, like the tobacco
industry can result in a decrease of sugar addiction and its harmful health effects.
Lastly, there is also a large benefit to public health and the economic costs in treating sugar addiction like a substance use disorder. The costs to treat diabetes, a disease directly related to increased blood sugar levels and insulin resistance was $245 billion in 2012 (Centers for Disease Control and Prevention, 2017). These costs do not include comorbid diseases like obesity, hypertension, and hyperlipidemia. Obesity alone is projected to cost upwards of $957 billion by 2030 (Wang et al., 2008). Therefore, prevention of these life-long metabolic disorders by addressing the addictive properties of sugar can potentially reduce the burden on global health and economic systems in a great way. References
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Descartes’ Theories on Substance Dualism

In this essay, I will argue and conclude that Descartes is not successful in showing that there is a real distinction between the mind and body.
Substance Dualism is the position that the mind is a separate substance and exists independently of the body and possesses mental properties through the change of which it persists. For Descartes, the mind/soul is a res cogitans, a thinking thing. A substance is something which can exist independently of other substance, which possess properties and which persists through property change.
Although we now very easily critique Descartes’ arguments, Princess Elisabeth of Bohemia critiqued them during Descartes’ lifetime, and they discussed these problems.
The main issue she raised was the interaction problem.  The interaction problem is the issue of how mental states can have physical effects, so how can the non-physical cause the physical.
The interaction problem is actually a problem because in order for x to cause y, ie something cause something else, it needs to be moved. In order for it to be moved, it needs to be pushed, and this pusher logically needs to be able to be causally extended, and a mental state cannot push and does not have extension.
This objection is the first of four reasons I will be addressing, in order to conclude that Descartes is not at all successful in showing a distinction between mind and body.
Throughout the sixth meditation, Descartes presents a number of arguments for his position. One such argument, the conceivability argument, can be outlined as follows:

I have a clear and distinct idea of myself as something that thinks and isn’t extended,
I have a clear and distinct idea of body as something that is extended and does not think
If I have a clear and distinct idea thought of something, God can create it in a way that corresponds to my thought.
Therefore, God can create mind as something that thinks and isn’t extended and body as something that is extended and does not think.
Therefore, mind and body can exist independently of one another.
Therefore, mind and body are two distinct substances.

We can understand the first two premises as the claim that it is conceivable that the mind and the body are distinct. It is not a logical contradiction to say “the mind and body are distinct”in the same way in which it is a logical contradiction to say “being a bachelor and being an unmarried man are distinct”.
If it is conceivable that the two are distinct, then there must be a possible world in which they are distinct. But if it is possible for the mind and the brain to be distinct then they must really be distinct since it would be impossible to say the mind and brain are identical if they can exist independently in some possible world in the same way as it would be impossible to say a bachelor is not an unmarried man in a possible world.
Conceivable distinctness therefore seems to entail the possibility of distinctness, and the position that the mind and brain can possible be distinct things is “substance dualism”. This argument is therefore an argument for substance dualism.
However, it is actually far from clear that conceivability entails any kind of possibility. In case of an identity there is no possible world in which the M can come apart from B if M = B, There is no possible world in which a bachelor is not an unmarried man. Similarly, if water is H2O there is no possible world in which water could not be H2O. However, although it is not be conceivable to you that there can be bachelors that are not unmarried as long as you understand the meaning of the word bachelor, it might seem conceivable that water could be something else than H2O. This, however, is probably because the identity between water and H20 is an a posteriori identity (and hence the necessity that obtains could be an a posteriori necessity) and not an a priori identity as the identity between bachelor and unmarried man. So although it might seem as if it is conceivable that the mind and the body can exist separately, it doesn’t follow that it is actually possible that they can exist separately if the identity between mind and brain is an a posteriori identity.

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It can be argued that the conceivability argument misapplies Leibniz’ law of indiscernibles and makes an intensional fallacy. Just because I can conceive of two things as separate it doesn’t follow that they are separate – only that I do not know that they are the same thing. You cannot draw ontological conclusions about how the world is and what exists in it from epistemological premises of what you can or cannot doubt or conceive.
A typical issue that faces substance dualism is the problem of other minds. The problem of other minds is the question of how we can realize that there are minds known to man other than our own. We each experience, or introspect, our own minds directly, from ‘inside’ yet our insight into other individuals’ minds is altogether different. We can’t encounter other individuals’ mental states. It appears that all we need to go on is other individuals’ conduct which is communicated through their bodies.

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This is a test for substance dualism in that if minds and bodies are independent of each other, then how might I derive from seeing a body that there is a mind ‘connected’. Different bodies could all be machines, modified to act as they do, yet without any mental states. If there are no other minds, at that point my brain is the special case that exists. This is solipsism and therefore the test to substance dualism is, how would we prove that solipsism is false?
It could be argued that we can infer the existence of minds from behaviours:

This behaviour has a mental cause
That behaviour has a mental cause
The third behaviour has a mental cause
Therefore, many behaviours have a mental cause
Other people exhibit the same types of behaviour as cited above
Therefore, those behaviours also have mental causes
Therefore, other people have minds.

However, the argument still does not fully refute the objection to substance dualism as it relies on mental causation and thus suffers from the interaction problem. We can also object that the belief that other people have minds is not a hypothesis, nor do we infer, on the basis of evidence, that they have minds. The whole way we think about other minds is mistaken.
Another of Descartes’ arguments to be found in the sixth meditation is the divisibility argument. It can be formalised as follows:

The mind has no parts within itself – it is either there or not.
The body does have parts. You can remove arms, legs etc.
Only that which has parts can be separated.
Therefore the mind cannot be separated.
Therefore the body can be separated.
Therefore, mind and body are entirely distinct types of thing.

This is by far the strongest of Descartes’ arguments for his cause, but there are still some objections to counter and ultimately devalue it.
First of all, we have the objection that not all things that the mental is divisible in some sense. For example, cases of mental illness such as bipolar or schizophrenia could suggest that the mind can be divided. In these cases it seems that some parts of the mind are unable to interact with others. Furthermore, there is a distinction drawn between consciousness and subconsciousness, and these in themselves could be separate “parts”.
Further still, not everything thought of as physical may be divisible, because when you break things down eventually you will get to the smallest possible thing that cannot be broken down any further for example an atom: you cannot have half an atom, or half a proton, neutron, etc.
Overall, these objections severely discredit the divisibility argument, which makes it a useless tool in Descartes’ arsenal.
In conclusion, it does not seem that Descartes is successful in proving that there is a real distinction to be made between mind and body. Based on the strong objection from Princess Elisabeth, the interaction problem, as well as the problem of other minds and the weakness of his conceivability argument, along with the objections to his divisibility argument, it seems logical to conclude that Descartes is unsuccessful in this regard.

Descartes, R. (1986). Meditations on First Philosophy. Cambridge [Cambridgeshire]; New York: CAMBRIDGE University Press.
Dualism (Stanford Encyclopedia of Philosophy). (2019). Retrieved from
Lacewing, M. (2015). Philosophy for A2. [Place of publication not identified]: Routledge.
Lacewing, M. (2019). Substance Dualism. Retrieved from
Other Minds (Stanford Encyclopedia of Philosophy). (2019). Retrieved from

Health Promotion for Substance Misuse: Alcohol

Table of Contents


Epidemiological Statistics

Health Inequalities and Alcohol Dependence

Population Experiencing Severe Disadvantages

Assessment, Plan and Commission of Intervention

Role of Nursing


Substance Misuse: Alcohol

The term “health promotion” can be defined as the way to develop objectives that address the association of biology, health status, health services, individual behaviour and social factors. It requires careful assessment of the patients with respect to their strengths, weaknesses and past experiences that they have already had in order to improve wellbeing. In this case, the goal is to improve the wellbeing of the consumers of alcohol and helping them to reduce its consumption. Steps to decrease and prevent the use of alcohol and similar drugs can have a magnificent effect on the health and safety in the community (Whiteford, et al. 2013). It is not necessary that all the approaches will work equally. It is shown by the researchers that education on the own can only impact to a small extent against the problems and norms raising due to drinking. To strengthen the impact of education, the culture of the organisation that supports the wellbeing of the consumers of alcohol and the public around that along with the practices and policies that are comprehensive, well-established, well-promoted and clear. An effective policy helps the people to get a clearer idea of what is unacceptable and acceptable. A framework is provided by it for the prevention and early intervention to tackle the potential problems experienced by the public (Williams, et al. 2014). A path is established by it eventually in order to make sure that objectives associated with the public relationships, productivity and safety are achieved. By only having the policies cannot make sure the safety and wellbeing of the population (Williams, et al. 2014).

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The resistance can also be created by the process from the top to bottom for establishing the policies. The rights of the citizens are also infringed by the policies sometimes and sometimes these are implemented unevenly and dishonourably but not all the times. The suggestions and highlight of the keys issues encountered in the developments and implementation of the alcohol policies are given in this rationale. It is determined that the implementation of alcohol policies includes several stakeholders (Whiteford, et al. 2013). Therefore, essential information regarding the use of health promotion, preventions of abuse and limitation to the misuse of substance are covered and the role of health nurses and health and safety coalitions in the UK is elaborated.  The responsibility of PHE (Public Health England) is to make sure the harms triggered by the consumption are prevented and reduced as much as possible. The awareness on the effect of dependency on alcohol is provided by PHE. The delivery and commissioning of the intervention that is evidence-based are supported by it in order to address the hazardous impact of alcohol dependency among adults (Williams, et al. 2014).

Epidemiological Statistics

There exist approximately 1.5 million adults in the UK who are having the same level of dependency on alcohol. However, all of those do not require interventions. Some of them will get better with a short intervention. It is defined by the NICE (National Institute for Health and Care Excellence) that consumption of drugs is a pattern that can potentially cause problems like physical illness, depression and road accidents (Williams, et al. 2014). Heavy drinkers can become dependent on the drug usage which is characterised by tolerance, continuous drinking and craving despite the consequences according to NICE (Whiteford, et al. 2013). A report of public by CMO (Chief Medical Officer) states that drinking can be associated with a threat to health independent of the level of consumption. Adults are suggested to keep their drinking within 14 pegs a week in order to prevent liver diseases or even cancer. It was found in an assessment in which 67 factors of disability and death were included that alcohol ranks third on the table to cause disability and death just below obesity and smoking (Whiteford, et al. 2013).

The evaluation of CMO indicated that all alcohols can possibly cause cancer. The risk of cancers like breast, mouth, liver, stomach and bowel can be increased by drinking regardless of the level of consumption. A recent review of CoC (Committee on Carcinogenicity) supported this evaluation on the risk of cancer by alcohol. In addition to that, it is also demonstrated by the epidemiological surveys that there exist strong relation of the attendees to get mental health services with the use of alcohol. It has been reported by a community of mental health patients that over 40% of the problems were related to the alcohol usage last year (Williams, et al. 2014). There exist a strong relation of the suicide with the misuse of alcohol. It was found by the inquiry of National confidential into suicide by the people suffering from mental issues that there was a strong relation of alcohol misuse with 45% of the suicides among them between 2002 and 2011 (Abuse and Administration, 2016).

Health Inequalities and Alcohol Dependence

Even though the potential threat to wellbeing is indicated by the volume of alcohol consumption, the relationship is affected by other factors.

The dependency of alcohol in the UK is more common in men than women with 6% to 2% respectively (Inchley and Currie, 2013. This differences in gender can be same globally and it is one of the key dissimilarities based on gender in social behaviour. The effect of excessive drinking is greater for the ones with lower income and the ones suffering from the deprivations. The reason for this is not easily understandable because people with lower income do not appear to consume alcohol as much as compared to people with higher incomes. The higher risk can be related to the impact of other threats impacting lower socio-economic people (Rehm, et al. 2013). The areas with the highest rate of mortality are situated in North West mostly while the lowest rates are situated in the south of England. The mortalities associated with the alcohol were found to be 53% inclined from the year of 2013 (Rehm, et al. 2013). In Blackpool during the year of 2013, mare 80 death was found to be related with the alcohol per 100,000 population while in Wokingham, Berkshire the figures were 33 per 100,000 (Abuse and Administration, 2016).

Hospital admission rates due to alcohol also vary regionally. For the least deprived docile, the rate of admissions to the hospital are almost 70% lesser in 2013 to 2014. The North West saw the highest number of admissions to hostel caused by alcohol with 551 per 100,000 population while the lowest rate was witnessed in the south-east with 383 (Abuse and Administration, 2016).

Population Experiencing Severe Disadvantages

There is visible incline in the overlap of population experience severe disadvantages such as homelessness, offending behaviours, alcohol and drug misuse and poor mental health (Inchley and Currie, 2013. Alcohol abuse is a more common cause of death among the homeless people makes around 35% of all deaths (Barry, et al. 2013). It was found by a study that life quality in England was even worse than reported by the people with low salaries particularly in terms of mental health (Barry, et al. 2013). Factors related to the alcohol in England are found over several domains in PHOF (Public Health Outcomes Framework) such as improvement in determinants of health, prevention of premature mortality, improvement and protection of health (Barry, et al. 2013).

Assessment, Plan and Commission of Intervention

Wellbeing boards and local councils and health are responsible for planning an intervention to misuse of alcohol.

Environmental health

Social care

Public health

Licensing standards

Clinical treatment services

Housing strategy

Consumers are placed at the heart of intervention by this. Treatment is a crucial way in which the council will plan and deliver interventions (McGorry, Bates and Birchwood, 2013). This comes after the conditions of public health grant. Boards of wellbeing and health will take into account the ways in which services in the hospital are integrated with the standardised systems and will arrange joint funding for the public health (McGorry, Bates and Birchwood, 2013). JSNA (Joint Strategic Needs Assessment): Local data on alcohol harm is provided by the JSNA in order to plan and commission the intervention. It includes commissioning community alcohol treatment services as well as hospital services (McGorry, Bates and Birchwood, 2013. Quality governance guidance for council commissioners of alcohol and drug services: Councils are required to provide quality arrangements during services according to the public health grant. NDTMS: A little or restricted access to the confidential data is provided to the commissioners in order to help planning and improving services. Reports are provided in an annual and monthly basis. Detailed information is provided by them on the clients in drug treatment and structured alcohol from the National Drug Treatment Monitoring System (NDTMS) (McGorry, Bates and Birchwood, 2013.

Role of Nursing

The nurses are required to comply with the guidance provided by NICE on alcohol use. The nurses have to support the people dependent on alcohol in order to sustain fast recovery. The service users need to be engaged in a stable accommodation by the nurses. There might be alcohol dependents who do not seem to be ready for the intervention, nurses should work with the cooperation of other services in order to address the requirements of drinkers resistant to change. Nurses should provide information to the family members as well regarding the treatment. Nurses are entitled to comply with the Care Act 2014 and are required to comply with the guidance provided by the government if there exist safeguarding issues against treatment.

Nurses are required to see their role as health promoters at the time of treatment. The drinking habits of the patients should be assessed by the nurse when it same appropriate at the time of admission. This cannot be done thoroughly enough to make the nurses able to bring effectiveness in the treatments in case the sufferer seems to be excessively addicted to alcohol. The treatment out of the specialist units includes clomethiazole and multivitamins in order to tackle withdrawal by reducing the role of nursing to only dispensing. Serious consequences will trigger if these issues are not addressed properly in the future. The alcohol consumers these days are most likely to be the patients in coming days and the number of them will surely be remarkable.

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Issue of Substance Abuse in Pregnancy


Substance abuse is a mental illness that refers to the unsafe or misuse use of psychoactive substances, including alcohol and illicit drugs (World Health Organization [WHO], 2018). Psychoactive substance use can lead to dependence syndrome. Dependence syndrome includes behavioural, cognitive, and physiological sensations that develop following frequent use. Such syndromes include the urge to consume, difficulties with regulating substance use, continual use despite consequences, increased tolerance, and states of withdrawal (WHO, 2018). Furthermore, substance abuse during pregnancy is more prevailing than conceptualized, with up to 25% of child bearing women using illicit drugs. Substance abuse is significantly more common among women of reproductive ages than women in other populations. That being said, the average pregnant woman will take approximately four to five drugs during the duration of their pregnancy whereas 82% of those women take prescribed substances and 65% use nonprescription substances, including illicit drugs and alcohol (Wilson & Thorp, 2018). This paper will discuss substance abuse in pregnancy in relation to perinatal nursing. The incidence, physiology, morbidity and mortality with respect to the effects on the newborn and plan for labour and delivery, emotion and psychological support, discharge and follow up plans, in addition to nursing interventions, roles, and special considerations will be discussed.


Maternal substance abuse has reached levels of critical concern in North America over the past years. Wendell (2013), depicted that women currently represent 30% of the user population, with a majority of child bearing aged women. Substance abuse among the pregnant population varies significantly and is reflective of social status and income, race, age, cultural beliefs and norms, education and methods of screening for substance abuse (Cook et al., 2017).  In addition, multiple risk factors for substance abuse include previous addictions, history of psychotic illness, history of physical or sexual abuse and environmental pressures (Wendell, 2013). According to Wendell (2013), the 2010 National Survey of Drug Use and Health reported an increase in the use of illicit drugs and alcohol among pregnant women.  Trends suggest that tobacco, followed by alcohol, cannabis, cocaine, are by far the most commonly abused by this population (Cook et al., 2017). In Canada, new mothers reported that during their pregnancy 10.5% smoked cigarettes, 10.5% drank alcohol, and 1% used street drugs. However, one year later, the Perinatal Health Report revealed data depicting an overall increase in alcohol consumption and signifiant increases in smoking and drug use (Cook et al., 2017). These not so shocking trends are consistent with those observed in the United States, North America, and worldwide (Cook et al., 2017).


Alcohol and illicit drugs have a significant impact on the human body. A significant number of health concerns arise from substance abuse. Liver problems as a result of alcohol consumption, respiratory impairment and lung cancers related to smoking, HIV/AIDS and hepatitis from injecting drugs, are a few examples supporting the impact that such substances have on the body (Center for Substance Abuse Treatment [CSAT], 2009). According to CSAT (2009), women who partake in substance abuse may have physiological problems related to gynecology. Impairments may be seen in women’s menstrual cycles, with cramping and changes with the duration and volume of menstruation. On the other hand, women who use illicit drugs can experience amenorrhea, misleading them regarding the signs of pregnancy or withdrawal (CSAT, 2009). Women’s substance use also poses risks to the unborn fetus, although the total damage that substance abuse has on a fetus is not fully studied and known. Fetal brain development is the most studied and the greatest life-threatening effect of substance abuse during pregnancy (Wang, 2014). A constant misuse of alcohol and illicit drugs during the first half of the pregnancy is likely to harm the wiring and connections of the brain which allows for the optimal brain development, maturity, and ability to learn (Wang, 2014).

Morbidity and Mortality: The Effects on newborn & plan of care for Labour and delivery

Substance abuse, both drugs and alcohol, during pregnancy is associated with mother and fetus mortality and morbidity. There is a strong correlation between substance use and a high-risk pregnancy and delivery. Substances such as opioids, smoking, and alcohol have proven increased risks of preterm labour, early onset delivery, poor or lack of fetal growth and development, and stillbirths (Whiteman et al., 2014). Increased hospital stays postpartum, exceeding five days, is common for mothers of substance abuse. In addition, during their extended stay, mothers of substance abuse are more likely to experience the complications, as significant as death (Whiteman et al., 2014).

Maternal complications vary from one mother of substance abuse to another. Some complications may include respiratory, cardiovascular, neurological, psychoses, human immunodeficiency virus and/or metabolic. Bacterial infections, hypertension, seizures, vitamin deficiencies and malnutrition are the most common complications from the list above (Wilson & Thorp, 2008).

  Obstetric and fetal complications include placenta previa, abruption of the placentae, and even rupture of membranes (Wilson & Thorp, 2008). In other cases, poor growth of the fetus may occur due to the lack of maternal nutrition adequate oxygen supply. Most mothers dealing with substance abuse often deliver prematurely and pose long term developmental effects on the baby (Wilson & Thorp, 2008).

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Effects of substance abuse on the fetus and baby depend on the substance being smoked, snorted, inhaled, injected, swallowed or absorbed through the mucus membrane (Thorpe, 2008). Substances include congenital abnormalities, neonatal medical complication, and neurobehavioral alterations. Wilson and Thorp (2008), suggests that specific neonatal medical complications include sudden infant death syndrome (SIDS), neonatal abstinence syndrome (NAS), and respiratory distress syndrome.

 The plan for labour and delivery includes a comprehensive approach that is inclusive of communication, education, compassion, respect, and holism free of judgement. It is imperative that a full support of staff, resources, and tools are present during all phases of labour to support mother, baby, and the family overcoming upcoming challenges and barriers leading to a healthy delivery, post-partum period, and discharge (Whiteman et al., 2014).

Emotional and Psychological Support

They most vital component to caring for a mother with substance abuse is directing treatment and control during prenatal, intrapartum, and postpartum periods towards counselling. Counselling is to be provided by those who have acquired extensive learning and training in the treatment of substance misuse and abuse in addition to pregnancy and determinants of health (Brady, McCauley, & Back, 2015). Counsellors and substance abuse treatment programs use a variety of techniques and modifications that include motivational interviewing, identification of triggers, stress reduction, medication, cognitive behavioural therapy, positive reinforcement of abstinence and contingency management of support groups (Gopman, 2014). Furthermore, Gopman (2014) articulates the importance of alternative therapies such as massage, acupuncture, yoga, which were studied and found to be effective in grounding and stabilizing the mind. Women who are child bearing and suffer from substance abuse are encouraged to develop and participate in social networks that are separate and beyond their bad acquaintances with respect to drug use, thus redirecting them from the pressures that come with their personal relationships (Cook et al., 2017). 

Discharge and follow up plan

There are many considerations and learning topics that need to be identified prior to a discharge after birth. Significantly, there are a far greater number of considerations that need to be identified and discussed for a woman who is dealing with the issue of substance abuse. Pain management, preventing relapse, breast feeding guidance, newborn development and assessment as well as transition to primary care are specific areas of discharge and follow up planning that need to be addressed (Gopman, 2014).

Pain Management Postpartum

Both vaginal and caesarian births are accompanied by significant pain and discomfort postpartum. Keeping the history of a substance abuser in mind, pain medications are to be selected and used with severe caution. Non-Steroidal Anti-inflammatory Drugs, such as acetaminophen, is the most commonly prescribed medication in effort to relieve pain related to vaginal births (Gopman, 2014). Opioids may be the drug of choice when a significant increase in pain is felt in association with caesarian deliveries. Patients with a tolerance for opioids may have more difficulty controlling pain. It is suggested to allow for a higher or more frequent dosing of an opioid early on post-op, however quickly decreasing the need for opioid use to prevent relapse (Gopman, 2014). A discussion is critical to allow for the appropriate medications to be prescribed and so patient can understand the expectations and use of the prescription upon discharge. A follow up shortly after discharge is crucial to observe and track pain management related to drug use (Gopman, 2014).

Preventing Relapse

 After a delivery of a baby, substance abuse mothers may quickly have the urge to use. These mothers have a high risk for relapse as there is no longer a concern that  exposure to drugs and alcohol will impact maternal and fetus health (Gopman, 2014). This population also has significant relapse rate due to the increased amounts of stress derived from postpartum depression, lack of sleep, hormone imbalances, and demands of parenting (Gopman, 2014). For the substance abuse mothers, close follow ups and early postpartum visits are crucial in preventing chances of relapse.

Breast Feeding Support

Breast feeding is a topic that raises many concerns and questions for the lay postpartum women. However, educating to a substance abuse mother is critical for the wellbeing of both mother and newborn (Gopman, 2014). Methadone and buprenorphine are acceptable forms of synthetic analgesic drugs that enable substance abuse mothers to breastfeed while controlling their addiction. It is proven that the amount of drug used is unlikely to negatively effect the baby and just as unlikely to prevent or treat neonatal abstinence syndrome (NAS). Breastfeeding and skin to skin contact may in fact diminish some symptoms of NAS (Gopman, 2014). Breastfeeding may also be a motivating for mothers, thus keeping clean of substance abuse (Demirci, Bogen, &Klionskyb, 2015). Patients in this predicament need education regarding opioid replacement and health conditions such as Hepatitis C that may influence a women’s decision/ability to breastfeed safely. Some users also need to be made aware of how to properly feed their newborn prior to discharge if abstinence is not of interest, thus breastfeeding is unsafe (Demirci, Bogen, &Klionskyb, 2015).

Newborn Development and Guidance

Recovery from substance abuse requires additional support to assure stability, health, and safety for both mother and newborn. Environmental resources that include parental and newborn care, substance abuse treatment, child development support that facilitate ongoing participation and trust are crucial in making sure that mother and baby are progressing and developing as they should be. Parenting classes and support groups provide opportunities for families to share knowledge and experiences with this matter (House, Coker, & Stowe, 2016).

Transition to Primary Care

Access to primary care services out of hospital is of utmost importance for women with substance abuse to attain. Encouraging women to seek visits with a current provider or a non-obstetric provider is an important message after delivery or potential loss of fetus (Gopman, 2014). The goal of this is to facilitate a smooth transition of care where the mother and fetus can have trust, respect, and compassion facilitated in an environment that can provide ongoing health care to a developing fetus and recovering or addicted mother.

Nursing interventions and roles and Special Considerations

Nursing has an imperative role in the prevention, treatment, and interventions for those who are dealing with substance use in pregnancy. As per Stone (2015), early recognition, intervention, and screening are the most effective tools and strategies that help an individual recognize the issue of substance abuse before the misuse of substances progresses.

Nurses have the role and duty to provide non-judgmental, compassionate, and ethical care that is client centered and holistic. In fact, pregnant women with substance abuse disorders often fear stigmatization, shame, and judgement, therefore decline prenatal and postnatal care (McKeever, Spaeth-Brayton, & Sheerin, 2015). Identifying pregnant women with substance abuse is an ongoing challenge for nurses as well as other members of the interdisciplinary team, as these women have distinct care and treatment needs (Stone, 2015). An important topic that needs to be addressed for nurses and health care members caring for women’s who display these issues is recognizing the need for multidisciplinary management to promote and ensure positive maternal and fetal health outcomes as well as compliance with substance abuse treatment (McKeever et al., 2015). Nurses must advocate for the education and resources that this population requires, so that they can become active partners in their care (McKeever et al., 2015). It is reported that pregnant women dealing with substance abuse were seeking nurses who showed the ability to listen, hear, and respond to their concerns, while keeping them safe and build a trusting relationship (Stone, 2015). It is vital that nurses initiate and influence patients to partake in education and support services regarding the latest on perinatal addiction and pregnancy. Therefore, special considerations like those listed above are required by nurses and interdisciplinary team members in order to provide safe, ethical and compassionate care from prenatal to postnatal for this population (McKeever et al., 2015).


In conclusion, it is evident that substance abuse in pregnancy is significant issue in North America today. To understand substance abuse in pregnancy, the incidence, physiology, morbidity and mortality with respect to the effects on the newborn, plan for labour and delivery, psychological support, discharge, nursing interventions, roles, and considerations are components that need to be understood. After a comprehensive review of scholarly literature, it is clear that further education, support groups, screening, and public health access and supports need to be introduced. Such interventions will greater enhance the provision and care for addicted women and women trending towards addiction during pregnancy. Due to the fact that substance abuse is a global issue, municipal, provincial and national leaders must work together to provide supports and resources to mothers who abuse substances prior to conception or during their pregnancy. They are both crucial and essential in helping control, support, and reduce the number of pregnant women with substance abuse issues. All in all, it is imperative that perinatal nurses fulfill their duty to provide treatment by initiating early recognition, screening, and treatment programs for such individuals. It is the goal of nurses and multidisciplinary teams to put a stop to the increasing trend of this epidemic.


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