28 Rosemary Crouch1 and Lisa Wegner2 1 School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa 2 Department of Occupational Therapy, Faculty of Community and Health Sciences, University of the Western Cape, Bellville, South Africa This chapter will cover the whole spectrum of drug and alcohol use, abuse and disorders. The use of any addictive substance which alters a person’s life has implications as far as occupational performance is concerned and has become a major public and professional concern in almost every country of the world. Most countries are experiencing an increase in drug/alcohol use particularly amongst the youth. The developing countries are particularly vulnerable to the increase in drug/alcohol use, placing demands on the health system, as well as on society and the economy. Wilcock (1992, p. 3) stated that ‘Alcoholism is the most treatable, untreated disease!’ This also applies to drug abuse such as the abuse of cannabis and cocaine, and there are a number of factors contributing to this fact, the most important one being ‘denial’. This defence mechanism is a major factor in the illnesses and often prevents an addict from seeking help until it is too late. There are many reasons for this, one of which is that alcoholism and drug dependence is still seen as a social disgrace in most cultures and that stigma prevents the addict from acknowledging his/her problem. Drugs such as cannabis and cocaine can be socially acceptable, but in some religions, a drug such as alcohol is not condoned at all. It is important to understand, as an occupational therapist, that the treatment of drug/alcohol abuse requires a particular approach and way of thinking or attitude towards the illness/disease. The occupational therapist should see it as a primary concern in many patients/clients. It is often neglected, particularly by the medical team, and is often considered secondary to other illnesses such as HIV/AIDS and cancer. The developing countries are particularly vulnerable to the increase in drug/alcohol use and abuse. A study of the prevalence of substance use amongst South African adolescents reported that cannabis had almost doubled since 1990 (Flisher et al. 2003). The average age of people treated for cannabis use is 19–24 years, and the majority are male (National Institute on Drug Abuse 2012). A report by the director of the Medical Research Council’s Alcohol and Drug Abuse Research Group revealed that between 1996 and 2003 treatment demands for cannabis and heroin use increased by 11% and 6%, respectively (Parry 2003). The age of patients admitted to treatment centres decreased, reflecting an increase in drug use by adolescents and even children. These are worrying statistics given the lack of accessibility to intervention by much of the population. Many social events can be associated with an increased risk of drug/alcohol use including individual, family, social, genetic and contextual factors (Gilvarry 2000). In South Africa, much of the population lives in disadvantaged areas lacking in resources. Social problems such as poverty, violence, crime and gangsterism further compound the situation. Adolescents living in these areas tend to experience relatively high levels of boredom in their leisure time (Wegner et al. 2006). Opportunities to become involved in healthy leisure activities are restricted by the lack of resources within the environment (Wegner 2011). This situation increases the potential for substance use and other risk behaviours to occur. The illness of drug/alcohol dependence is very often of primary concern (particularly in the rural areas and crowded urban areas of a country like South Africa) as it can be the basic reason why a person behaves in a certain way. Drug/alcohol use is often the root cause of many motor vehicle and industrial accidents, child and wife/husband abuse, divorce and the destruction of relationships, violence and criminal acts, drowning and other problems such as physical illnesses (liver disease) and cognitive impairment. Unemployment is also a factor caused by drug/alcohol abuse, and often, the unemployed person becomes heavily involved in drug/alcohol use. The illness affects the economy of a country through loss of working hours and medical costs as a result of the excessive use of drugs/alcohol and contributes greatly to poverty. It should not be overlooked that in a country such as South Africa, there is a large emerging middle class society as well as a substantial higher income group that uses drugs/alcohol to excess. Most social events involve the use of alcohol or cannabis and often cocaine and heroin. Drug/alcohol use refers to the general use of any type of drug/alcohol and usually starts on an experimental basis. Experimentation can lead to drug/alcohol abuse, where individuals use drugs/alcohol despite knowing that the effects are harmful and dangerous. With repeated use over time, drug/alcohol dependence or addiction can occur. This is when individuals need to use increasing amounts of the drug/alcohol to achieve the same effect (otherwise known as tolerance) and feel unable to perform daily tasks without using the drug/alcohol (APA 2013). Withdrawal symptoms may be experienced if the drug/alcohol is not used for some time. From an occupational perspective, people use drugs/alcohol to enable, avoid or enhance occupation, as a coping mechanism and to alter perception (Chacksfield & Lancaster in Creek 2002). Drugs/alcohol can be broadly classified according to the different effects they produce in the human body. Drugs are commonly consumed by smoking, inhalation, oral ingestion or injection. For the classification of Commonly Abused Drugs, please refer to the DSM-5 (APA 2013). Intervention with people with drug-/alcohol-related disorders is a complex and lengthy process. Individuals can receive inpatient or outpatient treatment at government or private medical facilities, where the length of treatment may range from two weeks to six months, or even longer in some cases. It depends on the economic status of a family, and often, short-term treatment is the only option. In this case, the client is encouraged to keep in touch with society as soon after the ‘dry-out’/detoxification period as possible. Detoxification is considered a medical emergency and should only take place under close medical or nursing supervision. Treatment of the drug/alcohol dependent has only just begun after detoxification. Developing insight into the condition, skills training, lifestyle change, treatment of underlying conditions such as depression, counselling and ongoing support are the essential ingredients for the next phase of recovery. This is where the role of the occupational therapist is so important. This type of treatment is ‘therapeutic’ or ‘rehabilitative’ in nature. Intervention can also be ‘preventative’, where the focus is on increasing awareness about drugs/alcohol and their harmful effect and enables people to stay drug-/alcohol-free. Prevention programmes usually occur in community settings such as clinics, libraries and schools. Support and advice are available in South Africa from Narcotics Anonymous (NA) (2012), the Alcoholics Anonymous (AA) (2013) and Nar-Anon (Nar-Anon Family Groups South Africa 2013). NA and AA are non-profit fellowships of recovering dependents who meet regularly to help each other ‘stay clean’. Nar-Anon provides support for family and friends affected by drug/alcohol abuse. Many local religious organisations also offer assistance regarding drug/alcohol addiction. Refer to the DSM-5 (APA 2013, p. 198) for the definitions of both alcohol abuse and alcohol dependence. A description of these disorders is as follows: Substance abuse. Substance abuse is a maladaptive pattern of substance use which results in recurrent and serious life consequences, which are directly related to the repeated use of the substance. The possible consequences are: Substance dependence. Substance dependence is the resultant combination of cognitive, behavioural and physiological symptoms which are caused by the individual continuing to use the substance despite these problems. The continued use of the drug/alcohol is maintained resulting in tolerance, withdrawal and compulsive drug-/alcohol-taking behaviour. ‘Craving’ occurs when the person is withdrawn from the substance. The criteria for this disorder are: Defence mechanisms that are frequently used by the drug/alcohol dependent are denial, intellectualisation, selective recall and euphoric recall, repression, projection, rationalisation and minimising. All of these defence mechanisms are used in order to protect the drug/alcohol dependent from being attacked and hurt by others. The defences become an integral part of coping (Wilcock 1992). All drug/alcohol dependence is a relapsing illness. Relapse is a process, not an event, and is often part of the rehabilitation process but is an unpopular concept and frustrating for professionals and family alike. Even friends expect the client to be completely healed when he/she leaves a treatment centre. Treatment of the drug/alcohol dependent is a lifelong process. It should be noted that the occupational therapist may also encounter the addict/dependent client in various treatment settings, for example, in the orthopaedic or general medical unit or the psychiatric hospital. Here, the client’s drugging/alcoholic illness may be complicated by other conditions such as multiple fractures from a motor vehicle accident, heart complaints, diabetes, anxiety or depression. A large proportion of mental illnesses in many countries are complicated by drug/alcohol use. The occupational therapist is trained to treat the client in totality and should always take serious note of the drug/alcohol pathology, as this may be the focus for either primary or secondary intervention. Most importantly, the occupational therapist encounters the drug/alcohol addict/dependent at a grass-roots level where no facilities are available. The versatility of the training of occupational therapists worldwide makes him/her ideal for taking part in the intervention of the client within his/her own environment, taking into consideration the performance areas, the performance components and the performance contexts (American Occupational Therapy Association 1994). These areas are well defined in Chacksfield and Lancaster (in Creek 2002, p. 519). Various theories of occupational performance and occupational therapy provide a sound basis for this intervention The occupational performance approach is concerned with the dynamic interaction between the person, the context and his/her occupations (Watson 1997). Occupational performance refers to the hierarchy of roles, tasks and activities that allows the individual to organise his/her daily occupations (Watson in Christiansen & Baum 1997). The occupational performance approach is a useful way of planning intervention for clients with drug-/alcohol-related disorders. The case studies illustrate how theory is applied in practice. Wilcock (1998) describes three factors, which cause a breakdown of health, and it can be seen that these factors are very applicable to the person with an addiction or dependency: Without a doubt, addressing these three issues can provide a sound basis for intervention by the occupational therapist. The responsibility for leading a sober life is the sole responsibility of the client, but the occupational therapist can assist in supporting attempts to address these three issues so that major change can take place. There must be a commitment to change, and a lot of effort needs to ‘go into changing the activity profile and developing a healthy, balanced lifestyle that fills the void left by not taking drugs. Skills and knowledge learnt in treatment must be put into use’ (Wilcock 1992, p. 51). Creek (2002) builds on the theories of White (1971), which are also applicable to the recovering drug/alcohol dependent. Whilst the drug/alcohol dependent’s life was intent on living a lifestyle centring on activities which revolved around the use of the chosen drug/alcohol, he/she now finds that he/she has an intrinsic drive to realise potential ‘and exert an influence on the environment. It is drive which leads to the development of competence, as the individual tests his capacities on the outside world and gains confidence in his ability’ (Creek 2002, p. 41). It is important to look at the models of treatment of drug/alcohol dependency that are commonly used throughout the world in order to understand where occupational therapy is most effective. Effective practice is always based on sound theoretical models. Models of intervention which have proven success include the well-known Twelve-Step Method of Alcoholics Anonymous and the Minnesota Model, which is used by the AA worldwide, even in the remotest areas. This programme can be found in Chacksfield and Lancaster in Creek (2002, p. 521) or literature obtained from the AA. The Stages of Change Model developed by Prochaska and Di Clemente (in Miller & Heather 1986) is frequently used. The Stages of Change Model assists the multidisciplinary team to understand the client’s behaviour according to which stage he/she is in and to select appropriate treatment goals and activities for that stage. The client can be an active participant in the process of identifying his/her stage and setting realistic goals. The Stages of Change Model recognises that addicts move through six stages in their efforts to change their behaviour (Connors et al. 2001). Individuals who are using drugs/alcohol often tend to have limited insight into the damaging effects of drugs/alcohol on their occupational performance. This may be combined with a desire to conceal the drug/alcohol use from families and employers. Often, an individual gets referred for treatment after an incident such as an accidental overdose, or a warning from the school or employer triggers the individual or a family member to seek help. Clients can be referred for treatment by the usual referral sources including doctors, social workers, occupational therapists, psychologists, nurses, teachers, employers and family members. The courts may also refer people who have been involved in criminal activities associated with their use of drugs/alcohol. The occupational therapist needs a firm but empathetic, supportive and understanding approach to the drug-/alcohol-dependent client. His/her attitude should be positive and motivated towards complete sobriety and integration of the client back into normal society again. No team member who has a hardened and non-empathetic view towards drug/alcohol dependence can be included. The occupational therapist working in a team, usually with a social worker, nurse and doctor, must fully understand that the person with this illness may never use the drug/alcohol again. There is controversy as to the controlled use of addictive substances, and the decision of the team is decisive (Wanjek 2007). Clients may initially undergo a period of detoxification depending on the drugs/alcohol used. Assessment by the multidisciplinary team starts at this time. The occupational therapist’s role is to assess the impact of drug/alcohol use on the client’s occupational performance and the extent of the dysfunction in his/her life. This can be done by drawing up the client’s occupational performance profile (Watson 1997). The American Occupational Therapy Association’s Uniform Terminology for Occupational Therapy (2002) should be taken into account. Assessment should be client centred, where the occupational therapist assists the client to identify the level of dysfunction within his/her performance areas and role fulfilment. It is important to consider the client’s past, present and intended future performance. The occupational therapist assesses the relevant performance components related to the client’s deficits in the performance areas. With drug-/alcohol-related disorders, the components that are commonly affected are cognitive integration, psychosocial skills and psychological components, but the client’s physical status should also be assessed. Assessment of context includes temporal factors such as age and stage of development, as well as social, cultural, environmental and physical factors. The occupational therapist should consider how the client’s particular context affords him/her opportunities for performance, as well as how it demands particular behaviours from the client (Kielhofner 2002). The occupational performance profile can be compiled by means of the following methods of assessment. It may be necessary to adapt some of the methods according to the time available for assessment and the intervention context: The following assessment is useful in determining the extent of the problem and was devised at Riverfield Lodge Rehabilitation Centre, South Africa, in 1991. It was developed specifically for use with alcoholics but is relevant to most drug/alcohol dependents (Table 28.1). Table 28.1 Psychological behavioural signs of alcoholism (Wilcocks et al. 1992). If working in the community or in short-term units, the assessment of clients should be quick and efficient and can take place during both group and individual sessions. Assessment also continues when treatment begins. The following assessment tools can be used: Important aspects of the client, which should also be assessed by the occupational therapist, include: Problems that are frequently found in the drug-/alcohol-dependent client are:
Substance Use and Abuse: Intervention by a Multidisciplinary Approach Which Includes Occupational Therapy
Introduction
The South African context
Drug/alcohol use and abuse
The theory of occupational therapy as an integral part of intervention and rehabilitation of the drug/alcohol dependent
The occupational performance approach
Models of intervention and occupational therapy
Occupational therapy intervention
Assessment
By using the Canadian Occupational Performance Measure (COPM) (Law et al. 1998), the occupational therapist can assess which aspects of the performance areas the client considers important, as well as the client’s satisfaction with his/her task performance. This facilitates the establishment of meaningful goals for intervention.
yes
no
Using alcohol to enhance moods or as a ‘pick up’ when down
Using alcohol to boost confidence
Drinking faster than, or more than, others
Consistently drinking more than was originally intended
Finding that alcohol is having a negative impact on social, emotional, physical or occupational functioning and, in spite of this, not being able to stop or control this
Missing deadlines or important meetings
Drop in work performance
Forgetting things and not being able to concentrate
Being supersensitive to constructive criticism
Drinking alone
Deterioration in relationships with colleagues, spouse and friends
Feelings of remorse or guilt over drinking
Using drinking as a central activity in life
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Acute Psychiatry and the Dynamic Short-Term Intervention of the Occupational Therapist
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Understanding Persons with Personality Disorders: Intervention in Occupational Therapy
Sensory Integration in Mental Health
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