Moneta Sinclair, EdD, LPC Solomon E. Stretch, MA, NCC, CAMS 2013 This presentation is meant to educate participants on particular concepts and interpersonal tools that can address those concepts. Contact Information Moneta Sinclair, EdD, LPC Solomon Stretch, MA, NCC, CAMS Positive Impact, Inc. 60 Eleventh St., NE, Atlanta, GA 30309 (404) 589-9040  Understand addiction and attachment  Understand similarities in the neurobiology of addiction and attachment  Learn interpersonal characteristics that assist in forming a working alliance The American Society of Addiction Medicine (ASAM; 2011) A chronic neurological disorder Involves many brain functions A devastating imbalance in reward circuitry Impairs experience of pleasure A “bio-psycho-socio-spiritual” illness Damaged decision-making (effecting learning, perception, and judgment) Persistent risk and/or recurrence of relapse; the unambiguous implications are that  People with addictions have no control over their addictive behaviors and  Total abstinence is, for some people with addictions, an unrealistic goal of effective treatment 9% of all new HIV infections occur among injection drug users; 3% among MSM/IDU Effects of drugs/alcohol alters judgment; people engage in impulsive and unsafe sexual behaviors contributing to spread of HIV as well as lowering adherence to treatment Untreated mental/substance use disorders (M/SUDs) is among top 5 predictors of poor adherence to HIV/AIDS treatment Strict drug regimens o effectiveness of an individual’s antiretroviral therapy o drug-resistant strains of HIV Drug resistance - loses its effectiveness forever Cross-resistance - further limiting options 8  Morphine enhances susceptibility of the immune cells to HIV infection (Wang et al., 2005)  Crack and Methamphetamine Can increase amount of HIV virus in brain cells by ~57% Increase viral replication, associated with more rapid declines in CD4 counts (Baum et al., 2009)  Powdered cocaine, marijuana, or alcohol - Behaviors  Ritonavir increases potency of MDMA (X) to fatal degree  Clinicians need to screen all HIV+ patients for ongoing or recurrent drug and alcohol use and abuse Feeling anxious about going to a party? Having difficulty approaching a potential lover? Stressed out about meeting new friends? Worried about not appearing perfect to others? Why? http://www.youtube.com/watch?feature=player_ detailpage&v=a7nbmjkImHQ Addiction is hypothesized to function as a compensatory means to modulate effects and treat distressful psychological states Drugs of abuse (and process addictions) produce a relief from psychological suffering Drug psychopharmacology & preference CNS depressants – alcohol and sedative/hypnotics (e.g., barbiturates, benzos) Psychostimulants – e.g., cocaine, meth, caffeine, nicotine Opiates – analgesics, e.g., heroin, morphine Cannabis - paradoxical by simultaneously producing stimulating, sedating and mildly psychedelic properties, often dependent upon individual and/or circumstance Addiction/Dependency Recurring compulsion to engage in some specific activity, despite harmful consequences Devotion, attachment, dedication and inclination 3 Cs  Control  Compulsion Consequences A Biopsychosocial Approach Biological Psychological Sociological Process Addiction vs. Substance Addiction Similarities Differences Often intertwined  Sex and/or Love Addiction  Eating Disorders  Self-Injurious Behavior  Exercise  Gambling  Shopping  Video games  Stealing  Serial killer  Relationships Encompasses fields of psychology, evolution, and ethology Interpersonal dynamics A means of survival An affectional bond Safe Haven Need for safety, security, and protection “Addiction is a disorder in self-regulation. Individuals who become dependent on addictive substances cannot regulate their emotions, self-care, self-esteem, and relationships. “ Dr. Phillip Flores “Addiction represents an intemperate relationship with an activity that has adverse biological, social, or psychological consequences for the person engaging in these behaviors.” Dr. Howard Shaffer, Assoc. Professor of Psychiatry, Harvard Medical School Not everyone with an insecure attachment style will become addicted Unfortunately, most individuals with addiction issues probably have an insecure attachment style Please respond honestly to the questionnaire. It is intended for your personal awareness… Unless you REALLY want to share your results 4 Category Model (Bartholomew & Horowitz, 1991) Positive (Low Anxiety) View of Self Negative (High Anxiety) Cell II Positive SECURE PREOCCUPIED (Low Avoidance) Positive View of Self & Others Negative View of Self & Positive View of Others View of Others Cell I Negative (High Avoidance) Comfort with Intimacy & Autonomy Preoccupied with Relationships Cell IV Cell III DISMISSING-AVOIDANT FEARFUL-AVOIDANT Positive View of Self & Negative View of Others Negative View of Self & Others Fearful of Intimacy & Socially Avoidant Highly Self-Reliant and Avoidance of Close Relationships Trusting, lasting relationships Good self-esteem Comfortable sharing feelings with close others Seeks social support Increased resilience to loss, trauma, stress Better strategies for self-regulation and selfsoothing Preoccupied: Negative/Positive Fearful: Negative/Negative Dismissive: Positive/Negative Preoccupied and Fearful: Negative/+&Fearful and Dismissive: +&-/Negative Disorganized: +&-/+&Lyddon & Sherry (2001) Reward system stimulation: Likes, wants, needs Pleasure Compulsion Reliance Serotonin Controls moods by helping with sleep, calming anxiety, and relieving depression Dopamine Controls the drive to acquire something (rewards) Dopamine overstimulation and disruption  Early interpersonal interactions with the primary caregiver positively or negatively impact the structural organization of the brain and its expanding adaptive functional capacities, including coping with stressors and emotions (Schore, 2001)  Emotional pain associated with rejection evolved as a survival mechanism to keep us attached to a larger group and effects same part of brain as physical pain – opioid receptors (Panksepp, 2003).  Parent-child contact contribute to the secretion of two hormones relevant to attachment and addiction  Bottom up approach – emotions influence thinking Oxytocin – Love Hormone Reduces anxiety and stress Promotes feelings of calmness and security in interpersonal relationships Opioids – Pleasure Hormones Natural morphine-like chemicals created in the body Reduces pain awareness Creates feelings of elation The Limbic System: Self- and Species- Preservation Sensory Perception Regulatory System Thought Processes & Impulse Control Dopamine & Serotonin Pathways Emotions Memory & Learning We don’t have different relationships with different people. We have the same relationship with different people.  Wounded healers  Compulsive caregiving (Dismissive style) Directive Vulnerable to burnout Clients as a secure base  Preoccupied Want to be the supervisor’s favorite Reluctant to challenge clients  Fearful Tests the supervisor’s and/or clients’ caring or trustworthiness On your own: http://personality-testing.info/tests/ECR.php The quality of the professional alliance is the most robust predictor of treatment success Safran & Muran, 2000 A grief reaction Distress activates the behavioral attachment system for survival The prime opportunity to begin to establish safety and alliance Difficult to be simultaneously attached to an addiction and to people Need to be active therapist (vs. Rogerian) and a Safe Haven Neuroplasticity and Earned Security Empathy and attunement Convey understanding and respect Challenge and interpret as necessary Acknowledge our mistakes and repair ruptures Genuine concern for their well-being Bear witness and honor their journey Set realistic, healthy boundaries Allow them to get mad at us Structure, consistency, and boundaries Volunteers to demonstrate Randomly choose an attachment style Briefly review the characteristics Role play an interaction with the professional and a client with an addiction Audience guesses your attachment styles Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a four-category model. Journal of Personality and Social Psychology, 61(2), 226-244.  Baum, MK, Rafie, C, Lai, S, et al. (2009). Crack-cocaine use accelerates HIV disease progression in a cohort of HIV-positive drug users. Journal of Acquired Immune Deficiency Syndrome, 50, 93-99. Bordin, E. S. (1994). Theory and research on the therapeutic working alliance: New directions. In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, research, and practice (pp. 13-37). New York: Wiley. Flores, P. J. (2004). Addiction as an attachment disorder. Northvale, NJ: J. Aronson Press. Hill, C. E., & Knox, S. (2009). Processing the therapeutic relationship. Psychotherapy Research, 19(1), online at: http://dx.doi.org/10.1080/10503300802621206 Khantzian, E.J. (1997). The self-medication hypothesis of drug use disorders: A reconsideration and recent applications. Harvard Review of Psychiatry, 4, 231-244. Lyddon, W. J., & Sherry, A. (2001). Developmental personality styles: An attachment theory conceptualization of personality disorders. Journal of Counseling & Development, 79, 404-414. Panksepp, J. (2003). Feeling the pain of social loss. Science, 302(4643), 237-239. Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatment guide. New York: Guilford Press. Shore, A. N. (2001). Effects of a secure attachment relationship on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal, 22(1–2), 7–66. Wang, X., Tan, N., Douglas, S.D., Zhang, T., Wang, Y.J., Ho, W.Z. (2005). Morphine inhibits CD8+ T cell-mediated, noncytolytic, anti-HIV activity in latently infected immune cells. Journal of Leukocyte Biology, 78 (3), 772–776. Wei, M., Russell, D. W., Mallinckrodt, B., & Vogel, D. L. (2007). The experiences in Close Relationship Scale (ECR)-Short Form: Reliability, validity, and factor structure. Journal of Personality Assessment, 88, 187-204. Your lights are on, but you're not home. Your mind is not your own. Your heart sweats, your body shakes, another kiss is what it takes You can't sleep, you can't eat, there's no doubt, you're in deep Your throat is tight, you can't breathe. Another kiss is all you need Whoa, you like to think that you're immune to the stuff, oh yeah It's closer to the truth to say you can't get enough You know you're gonna have to face it, you're addicted to love You see the signs, but you can't read. You're runnin' at, a different speed You heart beats, in double time Another kiss, and you'll be mine a one track mind You can't be saved Oblivion is all you crave If there's some left for you You don't mind if you do